rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
11117,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,150,D,0,1,6TSD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to act upon a resident's wish to change her advance directives. Resident #54, who was determined to possess the capacity to understand and make her own medical decisions, upon admission indicated she wished to receive cardiopulmonary resuscitation (CPR) in the event of cardiac or [MEDICAL CONDITION] arrest. Shortly after admission, she decided she did not want to receive CPR, and the facility failed to act upon her request for do not resuscitate (DNR). Resident identifier: #54. Facility census: 101. Findings include: a) Resident #54 Record review, on [DATE], revealed Resident #54 was admitted to the facility on [DATE]. Review of her interdisciplinary progress notes (by nursing) revealed an entry, dated [DATE], stating the resident was a ""full code at this time"", meaning the resident was to receive CPR in the event of cardiac or [MEDICAL CONDITION] arrest. A physician's orders [REDACTED]. Review of a subsequent entry in the interdisciplinary progress notes (by social services), dated [DATE], revealed, ""POST (physician's orders [REDACTED]. Code status DNR."" This form was completed by the resident and Employee #133, but there was no physician's signature on it. Interview with Employee #80 on [DATE], and with other staff reviewing the resident's medical record on [DATE], confirmed the facility had not followed through to ensure the resident's request for DNR was confirmed by an order signed by the attending physician. .",2014-08-01
5787,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2014-10-07,151,D,0,1,U60O11,"**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 allow one (1) of thirty-one (31) residents reviewed to exercise his rights. The facility restricted access to his power wheelchair without evaluating the resident's physical and cognitive ability to use the power wheelchair. Resident Identifier: #111. Facility census: 132. Findings Include: a) Resident #111 On 09/24/14 at 3:30 p.m., during an interview with Resident #124, during Stage 1 of the Quality Indicator Survey (QIS) process, she voiced a concern. She said her husband, Resident #111, had left the facility in his power wheelchair at 2:00 a.m. a few weeks earlier. She reported the facility would no longer allow him to use his power wheelchair. She said staff told her that her husband could have his power wheelchair back when they could trust that he would not leave the facility. At 3:00 p.m. on 10/06/14, during a review of the facility's unusual occurrences, the elopement of Resident #111 was identified. The report stated on 08/04/14 the resident left the facility around 2:00 a.m. in his power wheelchair. When found by the police, no injuries were identified. The report further stated the power wheelchair was removed from the resident's possession for his safety. On 10/06/14 at 3:45 p.m., during an interview with Resident #111, the resident was observed self propelling in a manual wheelchair in his room. Upon inquiry as to the wheelchair in which he was seated, he said he had a power wheelchair, but the facility took it away from him. When asked why, he said because he had been a bad boy. He explained that during the summer he left the facility late one night, and had taken a road trip. He said he knew what he had done, and he knew it had been the wrong thing to do. The resident said he had just wanted to have some control over his life, and at that time, that was how he took control. He said because he had left the facility in the middle of the night, the facility had taken his chair away from him as punishment. He said he was told he might get it back if they could trust him. He also stated staff told him that by leaving the facility during the night, the place could get shut down. He further said he had no intention of leaving the facility again. The resident said he was aware he can no longer live alone or take care of himself. He said he was dependent on staff for his medications and care in regards to his tube feeding and all areas of his needs. He said he can be very ornery, and it often got him into trouble, or gives the wrong impression. He said even though he can propel himself around the facility using his feet in the a manual wheelchair, he would prefer to have his power wheelchair, and has asked staff a number of times to allow him access to his chair. He said his power wheelchair was more comfortable, as it was padded, and he could sit for longer periods of time, and move about the facility easier. He said he knew the facility took the chair from him because they thought he might leave again, and even though he and his wife have assured staff he would not attempt to leave, he had yet to have his chair returned to him. The resident further stated, if he was inclined to leave the facility again, he could do it in the manual wheelchair, but he had no intention of leaving again. Resident #111 said Employee #222 (called by name), the assistant administrator, runs the show, and she would know if he would again be able to have access to his power wheelchair. At 9:00 a.m. on 10/07/14, a review of medical records for Resident #111 revealed he was admitted to the facility on [DATE]. On 05/21/14 the physician signed the determination of capacity, stating the resident demonstrated capacity to make decisions. On 08/06/14, after the resident's road trip, the physician made a new determination of capacity which indicated the resident demonstrated incapacity to make medical decisions. The Quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 08/25/14, indicated no behaviors were identified in Section E (Behaviors). There was no evidence of therapy evaluations regarding the resident's power wheelchair, or his ability to safely use the power wheelchair. A Behavior Management program was implemented on 08/14/14. The behavior indicated was exit seeking. Less restrictive procedures included: TLC (tender loving care) and reassurance. Restrictive procedures were listed as [MEDICAL CONDITION] medications. There was no mention of his power wheelchair. On 10/07/14 at 9:45 a.m., Employee #222, licensed social worker (LSW), and assistant administrator, was interviewed. Upon inquiry as to the status of Resident #111's power wheelchair, she said she took the power wheelchair for his safety. She said she had had many conversations with the resident regarding his elopement and comments he had made since the elopement. The assistant administrator said the facility's therapy department was currently testing all residents who had or wanted power wheelchairs for safety and awareness concerns. She said Resident #111 was to be tested in a few weeks, and she anticipated his power wheelchair would be returned to him at that time. Upon inquiry as to any concerns regarding the resident's ability to safely operate his power chair prior to the elopement, she said there had been none. She said the resident had safely and without incident operated his power wheelchair throughout the facility. When made aware both the resident and the resident's wife viewed the restricted access of the power wheelchair as punishment, rather than a safety measure, Employee #222 had no comment. She said the resident had asked for the return of his power wheelchair several times, saying the manual chair was work, and he was retired and did not want to work. The assistant administrator provided a motorized chair permit form that is given to residents requesting power wheelchairs. The form stated, A motorized chair is a privilege - not a right. When asked the rationale behind the wording, privilege - not a right, she said, Every resident thinks they should have a power chair paid for by the facility. Upon inquiry as Resident #111 having had his power wheelchair prior to admission, she said the form would be used as a permit to use the power wheelchair in the facility. She said it was her intention that he would more than likely get his chair back in a few weeks, because the weather was getting colder. At 11:00 a.m. on 10/07/14, during an interview with both the administrator and the assistant administrator, the status of Resident #111's power wheelchair was discussed. Also discussed was the lack of supporting documentation for the decision to restrict the resident's access to his power wheelchair. Upon inquiry as to whether the resident had attempted to leave the facility since the occurrence in August, they said, No. The assistant administrator said the resident left his unit and went to another floor one (1) time without notifying staff. Both the administrator and the assistant administrator reported, the resident had taunted staff by saying he would leave if he wanted. Both agreed, he was physically capable of exiting the building in the manual wheelchair, but he would be moving at a slower pace. On 10/07/14 at 11:30 a.m., upon inquiry, Employee #74, a licensed practical nurse (LPN) on the resident's unit, said the resident was able to make his needs known and effectively communicated with the staff.",2018-07-01
6351,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,151,D,0,1,OMIN11,"Based on resident interview, record review, review of complaints and grievances, and staff interview, the facility failed to ensure one (1) of two (2) residents, reviewed for the right to exercise rights, was afforded the opportunity to exercise her rights about how she lived in the facility. The resident was not able to exercise her right to privacy in her room. Resident Identifier: #24. Facility Census: 61. Findings Include: a) Resident #24 During an interview with Resident #24, at 10:30 a.m. on 05/28/14, she was asked, Are residents able to exercise their rights? Resident #24 responded with, That's a hard one, I would say no. The resident said she paid the facility $6,000 a month for her private room and she did not have any privacy in her room. She stated there were two (2) occasions the previous week when she came into her room and found other residents of the facility in her bathroom. She stated the interventions the facility attempted did not work. For example, she stated they were supposed to keep her door closed, but it was often left open by the staff. The resident said she also might not get it closed at times, because it was sometimes difficult to shut. The resident stated she felt she was not able to exercise her right to privacy because others went in and out of her room when she was not in there. The facility grievances and complaints were reviewed. This review revealed a Grievance/Complaint Report, dated 02/24/14, for Resident #24. The resident told Employee #61, the social service supervisor (SSS), that housekeeping said her dentures were found on the floor of her room when they went in to mop the floor. Resident #24 also told Employee #61 her bed had been getting messed up. Under the section for documentation of the facility's follow-up was, SW (social worker) suggested putting safest knob back on door, make sure door is closed. Resident #24 said they have tried those things as well as a stop sign on the door. Under the section titled, resolution of grievance/complaint was documented, Staff will continue to monitor situation, staff will redirect any resident seen entering Resident #24's room. Review of the resident's current care plan revealed there were no interventions to keep the resident's door closed, or any other interventions to maintain her privacy. An additional Grievance/Complaint form was completed on 02/26/14, after the resident council meeting on 02/26/14. It was indicated as a concern from Resident Council. This form also named Resident #24 as the complainant. The concern was, Other residents coming into rooms, mostly during the day. Under the section titled, Resolution of Grievance/Complaint the following was documented: Staff to monitor Resident who roams into others rooms and redirect. Employee #61 had signed both of the forms as the person who completed the forms. Employee #61, SSS, was interviewed at 12:43 p.m. on 05/30/14. She stated Resident #24's room was close to the nurses' station and staff redirected wandering residents when they attempted to go into her room. She stated they did not put any mechanical interventions in place to prevent other residents from entering Resident #24's room. Employee #61 stated keeping the door closed was suggested and should be done. She confirmed there were no interventions on Resident #24's care plan related to keeping her door closed or any other interventions to keep other residents out of her room. The SSS said she was not aware this was still a problem because Resident #24 had not mentioned it to her in a while. She stated she should add keeping the resident's door closed to the care plan, and fix it so the aides could see it on the Kiosk. The SSS said she would follow-up more closely with the resident in the future to ensure her concern was resolved.",2018-04-01
8036,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,151,D,0,1,8KXK11,"Based on resident interview, staff interview, observations, and a review of Resident Council minutes for the months of April, May, June, and July 2012, it was determined the facility failed to notify the Resident Council of the implementation of a new non-smoking policy. This practice affected three (3) of three (3) residents who smoke in this facility. Interviews conducted with Residents #217, #68, and #150, revealed the facility had decided to implement a non-smoking policy both in the facility and on the grounds. It was also discovered during a review of Resident Council minutes this new rule had not been taken to the Resident Council prior to imposing the new policy and presenting the three (3) smoking residents with the notification. Resident identifiers: #217, #68, and #150. Facility census was 127. Findings include: a) Resident #127 During an interview with Resident #217, on 08/16/12 at 10:15 a.m., the resident stated the facility had informed the residents who smoked this facility was to become a non-smoking campus - meaning there would be no smoking allowed on the facility property. The resident further indicated the facility nursing home administrator (NHA) (Employee #116) had provided the residents who smoke a written announcement of the new policy with the effective date of 09/10/12. This notified them they would have to stop smoking on that date. Resident # 217 stated she did not want to stop smoking. The resident stated smoking was the last and only pleasure she had left in life and she could not give it up. During the interview, it was discovered there were three (3) smokers in this facility. b) Residents #68 and #150 Interviews conducted with Resident #68 and Resident #150, on 08/21/12 at 2:30 p.m., found they had also been given the non-smoking notice and informed they could receive assistance with giving up smoking. Both Residents #68 and #150 stated they did not want to quit smoking. It was observed the announcement of the new smoking policy had been distributed in the public and resident areas of the facility. c) During a review of the Resident Council Minutes for the months of April, May, June, and July 2012, it was discovered the new smoking policy had not been presented to the Resident Council. An interview with the Resident Council President (Resident #120), on 08/22/12 at 9:30 a.m., revealed the facility had not brought the new non-smoking policy to the Resident Council prior to making a new rule. During an interview with the NHA, on 08/22/12 at 2:00 p.m., it was confirmed this smoking change had not been taken to the resident council prior to making the non-smoking policy.",2016-10-01
8446,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2012-06-22,151,E,0,1,NISF11,"Based on resident/staff interview and record review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained/promoted by the facility for 9 of 9 residents attending the group meeting (R10, R18, R27, R41, R56, R63, R64, R72, and R74) and 1 additional sampled resident (R43.) Findings include: 1. A group interview was conducted on 06/19/12 at 2:00pm with 9 residents whom the facility identified as alert, oriented, and credible historians. Interview with the group revealed 9 of the 9 residents wanted to vote; however, the facility had not assisted them with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. 2. An individual interview was conducted with R43 on 06/19/12 at 12:35pm. The resident stated, I'm looking forward, to the coming presidential election. He indicated he was registered to vote and revealed he voted in every presidential election since he was old enough to vote. Review of the Recreation History and Assessment Long Stay form dated 06/24/11 for R43 revealed the Activities Director (AD) identified R43 as a Registered Voter. An interview with the Social Services Director (SSD) on 06/21/12 at 4:30pm revealed the facility had no system in place to get the voter information from the AD to the SSD. Interview on 06/21/12 at 3:30pm with the Social Services Director (SSD) revealed she obtained absentee ballots for any residents who asked for them, but did not have a system to assure that all residents who were capable and interested were informed of their right to vote and provided with assistance as needed. Further interview with the SSD on 06/21/12 at 4:30pm revealed she had discussed voting in resident council meetings, and information about voting should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of assistance with voting had not been discussed.",2016-06-01
8467,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2012-05-11,151,E,0,1,HIO211,"Based on interview, the facility failed to ensure that residents were provided the opportunity to exercise their rights as a citizen. Voting rights were not maintained for 2 of 19 sampled residents (R54, R58) and 9 additional residents (R8, 16, 19, 36, 57, 61, 71, 81, and 84.) Findings include: During a group interview with residents identified by the facility as alert and oriented on 05/08/12 at 3:00pm, only 2 of the 13 residents stated they were registered to vote and had voted since their admission to the facility. Upon further conversation, it was determined that neither of the 2 residents who voted had been assisted to do so by the facility. R64 had a Personal Computer (PC) and independently utilized the PC to register to vote, and R26 stated his sister assisted him to register. All of the other 11 residents (R8, 16, 19, 36, 54, 57, 58, 61, 71, 81, and 84) interviewed in group said they would like to vote. All present agreed the facility Social Worker (SW) had never approached any of the attendees concerning voter's registration or educated them on their right to vote either by absentee ballot or at the nearest polling place. On 05/11/12 at 10:21am, the SW stated she personally assisted several residents to register and to vote. The only residents she could identify as having voted in the last 8 years were R64 and R26. She was unable to provide the names of other alert and oriented residents she had assisted with the voting process. She stated she was unable to provide any evidence to prove she had educated the residents on how to continue to exercise their voting rights once they were admitted to the facility.",2016-06-01
8873,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2012-05-25,151,E,0,1,ZX7V11,"Based on interview and Resident Council Meeting Minutes review, the facility failed to ensure residents were provided the opportunity to exercise their rights as a citizen related to voting. Voting rights were not maintained nor promoted for 6 of 12 residents identified by the facility as alert and oriented. (R26, 32, 34, 45, 77, and 79.) Findings include: A group interview was conducted on 05/22/12 with 12 residents whom the facility had identified as alert, oriented, and credible historians. Interview with the group revealed that 6 of the 12 residents wanted to vote; however, the facility had not assisted them, either help with voter registration, making arrangements for transportation to the polls, or obtaining absentee ballots. Interview with R32 revealed, They used to help you, in making arrangements to vote, and R34 added, No one approached me. Interview on 05/23/12 at 2:40pm with the Social Services (SS) Director revealed that Activities staff was currently responsible for assisting with voting. She related that she used to attend the Resident Council meetings, and would provide information about voting to the residents. The SS Director related that if the need for assistance with voting was still being discussed in Resident Council, information about it should be included in the minutes of the meetings. Review of all Resident Council meeting minutes for 2012 revealed the topic of need for assistance with voting had not been discussed. On 05/22/12 at 3:10pm, interview with the Activities Director (AD) revealed that some residents in the facility were registered to vote, and several had sent in absentee ballots in the last election, two weeks prior to the survey date. She added that residents are asked upon admission if they are interested in voting. Further interview with the AD on 05/22/12 at 3:35pm revealed that she had checked the records of each of the residents present in group who had related they were interested in voting. She confirmed both R34 and R45 were registered to vote, and stated staff had not approached them to see if they preferred an absentee ballot or to be transported to their local polling place. The AD related that other residents in the group were not registered to vote at the time of their admission assessment, and there was no documented evidence of further discussion with the residents regarding assistance with their voting process.",2016-03-01
9140,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2012-04-26,151,D,0,1,JRXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to allow one (1) of thirty-three (33) residents the opportunity to exercise his resident rights, and gave the resident a thirty (30) day notice for refusing care and treatment. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 had refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97, the treatment nurse, in an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. No evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. The resident further stated, he had friends who worked at the facility, and he did not want them to provide his care. The resident stated, I went to school with some of them and some of them date my friends. During an interview, on the afternoon of 04/25/12, with Employee #83 (evening shift nurse), it was found Resident #78 had acquaintances who worked at the facility. She stated He does not want particular people taking care of him because he knew them. No evidence could be found the facility had made any attempts to provide care in a manner which maintained the resident's dignity. On 04/11/12, the facility issued Resident #78 a thirty (30) day notice stating they had no choice, but to give him a thirty (30) day notice related to his refusals of care and treatment. The letter further stated the facility would look for alternative placement that better suited the resident. During an interview with Employee #100 (administrator), on 04/24/12 at 5:57 p.m., he stated the facility had several meetings with Resident #78, but did not have documentation related to these meetings. He further added Resident #78 may have stated he did not want to go to another nursing home. 04/11/12 at 5:57 p.m., Employee #100 was asked for information related to education provided to Resident #78 on the risks and benefits of treatment. He stated, I'm sorry, it's not documented. On 04/24/12 at 3:37 p.m., Employee #78 (social worker/admission coordinator) was asked if he had met with Resident #78 related to his care and treatment. He stated, No, I have not had a lot of contact with him. He further added he was present when the facility gave Resident #78 a thirty (30) day notice for refusal of care. Review of the social worker notes identified only three (3) notes written from 02/14/12 through 04/23/12. On 02/29/12, Employee #78 wrote a note stating the following, Had been refusing care related to pain, but this has been corrected and he is participating more now. According to the social service note dated 02/29/12 Resident #78 was having no issues at that time.",2016-02-01
10608,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,151,D,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to allow one (1) of eight (8) sampled residents the right to exercise her rights as a resident of the facility. This resident was not permitted to choose how she wished to live her everyday life and receive care. The facility cleaned the resident's room without permission and did not allow the resident to refuse a medication when she clearly stated she did not want the medication. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. This was an infringement on the resident's rights which led to the following infringement on the resident's rights: - On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. - On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, ""You're not giving me no shot."" The resident was walked to her room, all the while screaming ""No, no, no."" Nurse's notes described the resident as ""shaking all over"" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because ""she does not like how it makes her feel."" It should be noted that [MEDICATION NAME] was one (1) of the medications the resident had refused to take by mouth. The resident's rights were violated when the resident refused [MEDICATION NAME] by mouth and was forced to take the same medication by injection. On 06/13/11, the facility again attempted to violate this resident's rights. Nurse's notes, on 06/13/11 at 05:55 (5:55 a.m.) revealed another telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". Nurse's notes continued with, ""... Unable to give resident shot. Became very agitated and belligerent and defensive. Not enough staff available @ this time to assist. She refuses to have [MEDICATION NAME]."" Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed that a discussion should have been held with the resident regarding cleaning of her room. Additionally, Employee #171 confirmed the resident should have been afforded the right to refuse the [MEDICATION NAME], and staff violated the resident's rights when they did not allow the resident to refuse the injection of [MEDICATION NAME] on 06/10/11. .",2015-01-01
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
2959,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2017-09-28,152,D,0,1,BKPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on records review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of death had a health care decision maker. Resident Identifier: #4. Facility census: 61. Findings include: a) Resident #4 Resident #4 was admitted to the facility on [DATE] for palliative care. The Minimum Data Set (MDS) with Assessment Reference Date (ARD) of 08/02/17, Section C, Cognitive Patterns, gave a Brief Interview for Mental Status (BIMS) score of 00. Medical records review for Resident #4 revealed a Personal Care Pre-Admission Screening Form dated 07/21/17 which stated (Individual #1) and (Individual #2) were the Medical Power of Attorneys. A Designated Surrogate form dated 04/06/16 stated (Individual #2) was designated as surrogate. The Designated Surrogate form was not signed by a physician. According to facility records, (Individual #1) was designated by the facility as first emergency contact and Medical Power of Attorney. (Individual #2) was designated as second emergency contact and alternate Medical Power of Attorney. During an interview on 09/27/17 at 3:55 p.m., the Center Executive Director was shown the Personal Care Pre-Admission Screening Form dated 07/21/17 and the Designated Surrogate form dated 04/06/16. The Center Executive Director was unable to produce a document appointing a health care decision maker. She stated the Pre-Admission Screening Form dated 07/21/17 might have been the document the facility believed appointed the Medical Power of Attorney.",2020-09-01
4550,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2016-11-22,152,D,0,1,EZR311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, staff interview, and review of West Virginia State Nursing Home Licensure Rule 64-13, the facility failed to ensure the legal surrogate designated in accordance with State law only exercised the resident's rights to the extent provided by State law. This was found for one (1) random resident reviewed for capacity to make informed medical decisions. Resident identifier: #10. Facility census: 55. Findings include: a) Review of the medical record for Resident #10, began on 11/15/16 at 2:45 p.m., revealed she was [AGE] years of age, and admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions. b) Record review found Resident #10 was determined by the attending physician to lack the capacity to make informed medical decisions upon her admission. The determination was reversed on 08/02/16 at which time the attending physician determined she possessed the capacity to make informed medical decisions. c) Pertinent social services notes were found as follows (typed as written): --05/11/16 at 1:02 p.m. a Social Service Note stated: Quarterly MDS (minimum data set assessment) Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter is acting as her MPOA (Medical Power of Attorney). BIMS (Brief Interview for Mental Status) score of 14 this review. A dx. (diagnosis) of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident denies any s/s (signs and symptoms) of an altered mood this review. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR (do not resusitate.) --08/08/16 at 10:36 a.m. a Social Service Note stated: Annual residents rights review mailed out in June, but the signed acknowledgement form has not yet been returned. Overview of residents rights re-mailed to the responsible party at this time. --08/12/16 at 11:53 a.m. a Social Service Note stated: Annual Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter is acting as her MPOA. BIMS score of 13 this review. A dx. of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident currently reports little energy at times following [MEDICAL TREATMENT] treatments. She also does continue to request the use of ear muffs r/t (related to) a fear that bugs will get in her ears. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR. --09/19/16 at 12:40 p.m. a Social Service Note stated: Residents rights review again mailed for signature. --11/10/16 at 2:21 p.m. a Social Service Note stated: Quarterly Review: The resident is alert with confusion at times secondary to Dementia. She has been deemed to lack capacity. Her daughter, (name) is acting as her MPOA. BIMS score of 13 this review. A dx of Depression is present with orders in place for [MEDICATION NAME], anti-depressant medication. The resident currently reports only minimal s/s of an altered mood. She does continue to request the use of ear muffs r/t a fear that bugs will get in her ears. A care plan remains in place to address her impaired decision making and risk for increased s/s of an altered mood. No behavioral issues noted. Code status reviewed as DNR. Long term placement needed. d) Multiple interviews with Resident #10 throughout the survey from 11/14/16 through 11/17/16 found she was able to describe and discuss pertinent details regarding her care being provided both in the facility and also by an outside contractor for [MEDICAL TREATMENT] services including dates, times, and procedures. e) Review of West Virginia State Code of regulations 64-13-4.3.f stated, After a resident has been determined to lack capacity to make health care decisions a nursing home shall reevaluate the resident's capacity to make health care decisions at least annually. Regulation 64-13-4.3.g states: If the resident regains his or her capacity to make health care decisions, the powers of the legal representative shall cease immediately. f) During an interview with social worker #70, on 11/21/16 at 10:12 a.m., she confirmed the determination had been changed, but she was unaware this had taken place. The facility continued to consider the legal representative as the decision maker and the person to be notified.",2019-09-01
5099,RALEIGH CENTER,515088,1631 RITTER DRIVE,DANIELS,WV,25832,2015-04-10,152,D,0,1,CRGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure residents' health care surrogate appointments were completed and implemented in accordance with State law. For Resident #66, the physician's determination of capacity failed to include the reason for the incapacity, the expected duration of incapacity, and evidence the resident was informed of who would be making her decisions. For Resident #21, the facility allowed a person who was not appointed as the health care surrogate to complete advance directives for the resident. This was found for two (2) of two (2) residents while reviewing for participation in planning care. Resident identifiers: #66 and #21. Facility census: 66. Findings include: a) Resident #66 At 11:10 a.m. on 04/06/15, during stage 1 of the Quality Indicator Survey (QIS), Resident #66 stated she did not have any input into her care at the facility. She did not understand why the facility was allowing her daughter to make medical decisions for her. The resident stated she did not want her daughter involved, because she could speak for herself. She gave the following example: I had a feeding tube. I had been eating for months by mouth, eating food that looks like baby food. I wanted my feeding tube removed and they didn't listen so I took it out myself a few weeks ago. Review of the medical record, on 04/07/14, found the resident's daughter was appointed the resident's health care surrogate decision maker on 12/09/12 during a hospitalization . This form indicated the appointment was temporary and was the result of a [MEDICATION NAME] hemorrhage. Record review, on 04/07/15, found the facility's physician completed a determination of capacity on 02/05/13, after the resident was admitted to the nursing home. The capacity statement noted the resident lacked capacity to make medical decisions. The nature of the incapacity and the [DIAGNOSES REDACTED]. The form indicated the resident was to be informed of the person who would be making health care decisions for her during her incapacity. This information was not documented on the incapacity form. The resident's last full minimum date set (MDS), with an assessment reference date (ARD) of 02/05/15, found the resident's score on the brief interview for mental status (BIMS) was a fifteen (15), the highest possible score, indicating she was cognitively intact. The resident's initial admission MDS, with an ARD of 02/02/13, found the resident's score on the BIMS was a six (6), indicating severe impairment. The medical record contained no further evaluations of the resident's capacity, since the 02/05/13 evaluation. A progress note entered in the medical record by the activity director on 02/25/15 found, . She is becoming more independent in communicating her needs and decisions daily. At 2:30 p.m. on 04/07/15, the social worker, Employee #59, verified the 02/05/13 physician's determination of capacity was the only one completed since the resident was admitted . When asked if the facility had completed the determination of capacity as directed on the form, Employee #59 replied, No. The West Virginia Health Care Decisions Act, 16-30-7, of the West Virginia Legislative Code requires: . (b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. (c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decision-maker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED].> b) Resident #21 On 04/06/15 at 11:04 a.m., during an interview with the resident's husband, who was appointed as her medical power of attorney (MPOA), the MPOA said staff did not inform him of his wife's condition. The MPOA became visibly upset when discussing the matter. The MPOA stated, The facility staff thinks I have no sense, they always call our daughter instead of telling me Review of Resident #21's medical record, on 04/07/15 at 2:30 p.m., revealed Resident #21 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 06/13/13, the attending physician determined Resident #21 lacked the capacity to make informed medical decisions. Further record review found a State of West Virginia Medical Power of Attorney (MPOA) completed on 05/09/11. According to that document, Resident #21 appointed her husband as her representative to act on her behalf to give, withhold, or withdraw informed consent regarding health care decisions. On admission to the facility, the facility allowed the resident's daughter to sign all admission documents, including the Physician order [REDACTED]. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #52's husband was her MPOA and should have completed her admission papers. They further confirmed the husband should be informed of the resident's condition.",2019-03-01
6377,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,152,E,0,1,35BV11,"Based on staff interview, observation, review of facility policy, family interview, and resident interview, the facility failed to ensure four (4) of four (4) residents reviewed for rights were afforded the opportunity to exercise their rights. Residents were not free to exercise their rights regarding the use of side rails. Resident identifiers: # 98, #71, #29, and #2. Facility census: 77. Findings include: a) During the survey, residents and family members expressed serious concerns regarding the facility's decision to discontinue the use of side rails. The residents who expressed concern were those who used the side rails for turning and repositioning. An interview with Employee #1 (director of nursing), on 06/24/14 at 9:30 a.m., revealed the side rails were discontinued on 06/11/14 at the request of the medical director. Review of a new policy regarding side rails, which the facility implemented on 06/11/14, revealed the statement, No Resident will have side rails, unless the resident has capacity. Capacity to make health care decisions and the right to use side rails are not one and the same. The decision to discontinue the side rails was not discussed with the resident to judge how well the resident understood the facility's concerns with the use of side rails and/or how the resident used the side rails. Each of the residents for whom concerns were raised were deemed to not have capacity to make health care decisions. The facility also did not allow the person appointed under State law to act on the resident's behalf regarding the use of the side rails. 1) Resident #98 On 06/23/14 at 1:47 p.m., during an interview with Resident #98 and his wife, who acts as the resident's medical power of attorney (MPOA), the MPOA said a couple of weeks ago a facility staff member informed them the resident could no longer use his side rails. The MPOA became visibly upset when discussing the matter. The MPOA stated the facility staff member said, State says we can't use side rails because someone may get their head caught in them. The two (2) 1/4 side rails on the resident's bed were secured in the lowered position with two (2) zip ties on each side rail. The MPOA said Resident #98 could turn and reposition himself independently when the side rails were in the up position. Without the side rails, the resident had to call staff to assist him to turn and reposition. The MPOA said recently the resident had an itch on his back, and they had to use the call light to get staff to help him turn so he could scratch his back. She said the resident was upset by this and told her he did not want to have to push his button every time he had an itch. During the interview, the resident asked if he would again be able to use his side rails. The resident and his wife/MPOA said they were not consulted in the decision regarding discontinuation of the use of the side rails. 2) Resident #71 On 06/25/14 at 3:30 p.m., Resident #71 was observed in her bed. Her side rails were in the down position secured with two (2) zip ties on each side rail. The resident said she wished she still had her side rails because she used them to position herself in the bed. She asked if she would ever get them back. During a telephone conversation, on 06/25/14 at 5:00 p.m., with the MPOA for Resident #71, the Resident's MPOA said she received a letter stating the side rails would no longer be allowed to be used by the residents. She thought the letter came from the State. She said her mother was very upset about losing her side rails, as she was able to turn and reposition independently while in bed. She said her mother no longer feels safe in bed, and now requires assistance to turn and reposition. The MPOA said it was her opinion, as well as her Mother's opinion that she (the resident )could do more and felt safer with the side rails. She said she wanted her mother to once again be able to utilize her side rails. 3) Resident #29 During an interview on 06/17/14 at 4:20 p.m., Resident #29 said her side rails were removed about a week ago. She said she was informed by staff that she could no longer use them. On 06/25/14 at 11:20 a.m., Resident #29 said she almost fell getting out of bed that morning because she did not have her side rail to assist her. Several times during the conversation, she expressed a fear of falling. The resident said she used to be able to get out of bed herself using the side rail and the arm of her recliner. She said she no longer attempts to get out of bed, without staff, due to a fear of falling. The resident said when she had her side rails, she was not fearful of falling. She said her anxiety was higher now because she cannot have her side rails. During a telephone interview with the resident's MPOA, on 06/25/14 at 11:31 a.m., the MPOA said she really believed Resident #29 needed her side rails. She voiced fear for the risk of injury to the resident was greater without the side rails than with the side rails. The MPOA said when she talked with the administrator and expressed her desire for the resident to have side rails, the administrator told her, State says side rails cannot be used, and I just can't go against State rules. The MPOA said the facility made a decision to discontnue the use of side rails regardless of the resident's or the MPOA's wishes. She said she thought the decision made the resident require staff assistance in areas in which she did not previously need assistance. The MPOA also said the entire situation had made the resident's anxiety worse. 4) Resident #2 On 06/11/14 the facility implemented a policy which stated No Resident will have side rails, unless the resident has capacity. An interview with Resident #2, on 06/20/14 at 9:10 a.m., she demonstrated she could raise the bed, but was not able to reposition in bed or raise the head of the bed due to the controls being on the lowered secured side rail. Observation of the resident's side rails revealed the side rails were secured in the lowered position. An interview on 06/24/14 at 9:30 a.m. with the director of nursing revealed there was no assessment completed for Resident #2 prior to implementing the policy and discontinuing the resident's side rails. She stated she had ordered two (2) devices to assist with bed mobility, but they had not yet arrived. She verified the side rails were discontinued prior to the alternative devices being in place. An interview with the medical director on 06/25/14 at 8:00 a.m. revealed residents were to be assessed by physical therapy and alternate bed control and positioning devices were to be in place prior to the discontinuation of the bed rails. She confirmed the facility had not completed the physical therapy evaluations. She also said the facility had not received the positioning devices they ordered.",2018-04-01
6526,EASTBROOK CENTER,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2015-02-17,152,D,1,0,O5Z211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the person appointed by the court to act on the resident's behalf exercised the rights of a resident, who was adjudicated incompetent by a court of law. The facility allowed Resident #126 to leave the facility for several hours with family members on three (3) separate occasions. There was no evidence to support the court appointed guardian gave consent for the visits with family members. This was true for one (1) of seven (7) residents whose closed records were reviewed for the care area of admission, transfer, and discharge. Resident identifier: #126. Facility census: 125. Findings include: a) Resident #126 Medical record review, on 02/16/15 at 1:00 p.m., found this fifty-eight (58) year old resident was admitted to the facility on [DATE]. The circuit court appointed the Department of Health and Human Services (DHHR), Adult Protective Services (APS) to act as guardian for the resident on 10/17/13. A representative of the DHHR completed the admission paper work at the time of the resident's admission. Review of the admission social services assessment contained no information of any family members. The only contacts listed for the resident on the admission record was the DHHR. On the afternoon of 02/16/15 at 3:30 p.m., Assistant Director of Nursing #106, provided a copy of the occasions the resident had been out with family members. She explained each resident did not have their own individual sheet and she had to review all daily sheets for every resident to compile a list of occasions when this resident went out with family members. Review of the information, provided by Employee #106 found the resident had been out of the facility on 11/27/14, 12/24/14, and 01/14/15 with family members. Review of the medical record, on 02/16/15 at 4:00 p.m., found no documentation the resident was signed out by family on 11/27/14. There was no evidence the resident was assessed upon return and no evidence the DHHR was contacted or aware of the resident's out of the facility visit with family. Further review of the medical record found a nurse's note, written at 10:00 a.m. on 12/24/15, Resident out of facility with family member (name of member), will return later this evening. This was the only note written on 12/24/15. There was no indication of the time the resident returned, no indication the resident was assessed upon his return from the visit, and no indication the DHHR was contacted regarding the visit. A social service entry, written on 01/02/15 noted, I spoke with DHHR (name of worker). I explained the behaviors that resident has been exhibiting. (Name of worker) stated that (name of resident) had been out of the facility and visited with his brother from (name of another state). She felt that the behaviors may be from something inappropriate he was exposed to when he was out of the facility with his brother. She stated that she does not want him going out of the facility with his family until further notice On 01/14/15 a nursing entry, written at 1:18 p.m., noted, Resident was compliant with AM (morning) PO (by mouth) meds. (medications) with encouragement from his brother that was present at the time, resident was signed out by brother at 9:10 a.m. to attend funeral service for a family member. At 11:00 p.m. on 01/14/15, a nurse wrote, Resident lying quietly in bed with eyes closed. Took medications without difficulty. No complaints of pain or s/s (signs and symptoms) of behavior issues. Record review found no evidence the DHHR was contacted prior to any of the resident's family outings. Written correspondence from the DHHR, dated 01/21/15, confirmed they had not granted permission for the resident to attend a funeral on 01/14/15. At 4:15 p.m. on 02/16/15, the facility's administrator was asked if she had any evidence the resident's guardian, the DHHR, gave permission for the resident to visit with family members out of the facility. The administrator stated it was all verbal permission. She said the DHHR worker later denied she granted permission for the resident to attend the funeral on 01/14/15. She said she had learned a valuable lesson and the next time everything would be in writing. The administrator also said the DHHR worker was always aware the resident had visits with family members and had encouraged the visits. The administrator stated she had nothing in writing to verify the DHHR granted permission for the resident's visits with family. On 02/17/15 at 12:18 p.m. the administrator provided copies of a documented telephone conversation the DHHR, written on 01/14/15 at 4:08 p.m. The documentation included, .Discussed with (name of DHHR worker) telephone conversation several days we had regarding (name of resident) going to brothers funeral. Worker gave permission on the basis that (name of resident) would take morning medication. Relayed information to staff. However, worker now saying she did not give permission The administrator was unable to provide evidence the resident's guardian, the DHHR, gave permission for the resident to attend the funeral of his brother prior to his departure at 9:10 a.m. on 01/14/15. This note was written after the resident went to the funeral.",2018-02-01
7013,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2013-08-29,152,D,0,1,30TC11,"**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 evaluated for capacity to make medical decisions, according to the law. The medical record contained two (2) conflicting statements regarding the resident's capacity to make health care decisions. Both statements were completed by the same physician. This was true for one (1) of twenty (20) residents reviewed during Stage 2 of the quality indicator survey. Resident identifier: #177. Facility census: 73. Findings include: a) Resident #177 Medical record review found the resident was admitted to the facility on [DATE]. Further review of the medical record, on 08/26/13, found two (2) conflicting statements of determination of capacity for health care decision-making in the resident's medical record. The first determination of capacity was completed by the facility physician on 07/07/13. It indicated the resident did not have capacity to make medical decisions based on cognitive loss and an inability to understand or make medical decisions. The expected duration of incapacity (long term or short term) was not completed by the physician. A second determination of capacity, dated only July 2013, indicated the resident had capacity to make medical decisions. This was completed by the same physician. The physician did not document the exact day this capacity determination was completed. The director of nursing (DON), Employee #23, was interviewed on 08/26/13 at 2:00 p.m. After she reviewed the conflicting statements for determination of capacity she verified she did not know if the resident had capacity or did not have capacity to make medical decisions. The DON reviewed the physician's progress notes in an attempt to determine when the undated determination of capacity form was completed. She presented a copy of the physician's progress note, dated 07/04/13, which contained the following information: His daughter was in today . She would also like to have him declared as demonstrated incapacity to allow her to make all medical decisions. The physician then documented, The patient was examined by me and was oriented to person, place and time. I explained that his daughter would like to make all medical decisions for him and he agreed to this arrangement. The DON did not know why the resident was then determined to have incapacity by the same physician on 07/07/13, just three (3) days after the physician stated the resident was oriented to person, place and time. She could not find a physician's progress note or any notes to explain the decision made by the physician on 07/07/13. The facility's social services director, Employee #27, was interviewed on 08/26/13 at 2:35 p.m. She stated she believed the resident had capacity upon admission. She did not know when the capacity statement was signed by the physician. She thought the determination of capacity was made before the determination of incapacity, but she was not sure. Employee #27 completed a social history and initial assessment of of the resident on 07/05/13. The resident's Brief Interview for Mental Status (BIMS) score was 11, which indicated the resident's cognition was moderately impaired. Further review of the medical record found the admission coordinator, Employee #89, wrote a progress note on 06/28/13, the day of admission, . resident was without capacity. Employee #89 stated, on 08/29/13 at 10:47, she never found any written evidence the resident had been evaluated for determination of capacity prior to or on 06/28/13, I just took the daughter's word that he lacked capacity. On 08/26/13 at 2:45 p.m., the DON agreed the conflicting statement of capacity resulted in the facility's inability to determine if the resident did or did not have capacity to make medical decisions on 08/26/13 at 2:45 p.m.",2017-09-01
7171,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2014-07-16,152,D,1,0,1X1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to establish a resident who had been determined to lack the capacity to make health care decisions had a legally appointed individual, appointed under State law, to act on her behalf to help exercise her rights on admission to the long term care facility. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injuries to both feet, right hip, coccyx, both ears, and left hip. The 5 foot 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care, and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her health care decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital (07/01/14) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on 07/02/14, revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived by ambulance and indicated Son #2 and his wife were notified. There was no evidence of an attempt to contact Son #1, the resident's medical power of attorney (MPOA). The nurses' notes revealed Son #1 was in to visit the resident on the evening of her admission (07/06/14). The nurses' notes revealed the APS worker visited the resident on 07/08/14. During a review of the clinical record for Resident #61, at 9:00 a.m. on 07/10/14, a full-sized red paper was found on the opening of the chart. This document indicate the resident's code status, should her heart or breathing stop, was Do Not Resuscitate (DNR). Further review failed to find documented evidence of a Physician's Orders for Scope of Treatment (POST) form or any document indicating who the legally responsible person was for Resident #61. The resident had been deemed to lack the capacity to form her own health care decisions by the attending physician, who had also written an order for [REDACTED]. During an interview with Employees #119 and #131 (both Licensed Social Workers) at 10:00 a.m. on 07/10/14, they were asked to provide evidence that Resident #61 had a legally appointed health care surrogate. Employee #131 stated the daughter-in-law was making decisions, but she acknowledged the absence of a HCS document. She stated Son #2 and his wife had gone on vacation and said they would take care of that on their return. When asked about the status of Son #1, they stated they had been unable to reach him and he had not contacted them. They were asked about the status of the APS investigation and both acknowledged they had not contacted APS since the resident's admission. They stated the contact had been made at the hospital and they had not heard anything. They were not aware the APS worker had been to the facility to interview the resident. A review of the entire record revealed only one entry of an attempt to reach Son #1 since admission, and it was by the director of nurses (DON) on 07/10/14. At 11:35 a.m. on 07/14/14, Resident #61 was observed meeting her son (Son #1) in the hall next to the South Nurses' Station. Both were happy to see the other and greeted each other warmly. Both were being pushed in wheelchairs. They continued to the dining room and were observed sitting next to each other during the meal, where he stayed to visit her while she ate. During an interview with Employee #131 at 2:00 p.m. on 07/14/14, she stated she had contacted APS and confirmed an investigation was pending. She had also contacted the attending physician who informed her he was the family doctor for both the resident and Son #1, who was also sick. When asked why there was still no evidence of a legally designated responsible party, no Physician's Order for Scope of Treatment (POST) form, or no signed admission forms/consents of any kind on the chart, she stated she had been waiting for Son #2 to return from vacation and had been unable to reach Son #1. She also pointed out the front sheet on the record had been changed and Son #2 and his wife were no longer entered as HCS designees. Review of the medical record on 07/14/14, revealed Employee #131 had contacted APS at 12:06 p.m. on 07/10/14 as stated. A note written by Employee #131 at 1:34 p.m. on 07/10/14, stated, SS (social services) spoke with resident's physician who stated that he has MPOA (Medical Power of Attorney) paperwork on resident. At 2:20 p.m. on 07/14/14, Employee #131, accompanied by the DON, produced a HCS form dated 07/07/14 and signed by Son #2 on 07/14/14 (today) appointing him HCS. She also had a copy of the MPOA form dated 07/03/2012 naming Son #1, which, per the time stamp, had been received via fax at 12:29, on 07/10/14. Employee #131 stated she had called a local attorney and he said if they could not reach the MPOA, the physician could revoke the MPOA due to the neglect allegation made to APS and re-assign the HCS to Son #2 because he was the successor representative on the MPOA document. The DON had no comment when informed Son #1, accompanied by his son, was in earlier and visited with the resident throughout lunch. Employee #131 did agree there had been no information from APS confirming the allegation investigation had been completed and/or substantiated; and there was no evidence of documentation by the physician of revocation of the MPOA, although he had signed the HCS form on 07/07/14. During an interview with Employee #131, the Administrator, and the DON at 2:15 p.m. on 07/15/14, the Administrator reported they had contacted Son #1 and he had immediately come into the facility and informed them he intended to remain the MPOA. He also authorized a DNR status for the resident. They acknowledged the resident had been in the facility since 07/06/14 (9 days) without a legally appointed responsible party.",2017-07-01
7390,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,152,D,0,1,PDFH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to ensure a legally appointed healthcare decision-maker was in place for a resident the facility decided was unable to make her own health care decisions. This was found for one (1) of thirty-two (32) Stage 2 sample residents. Resident identifier: #2. Facility census: 62. Findings include: a) Resident #2 This resident's medical record was reviewed on 08/13/13 at 1:07 p.m. While reviewing the record, it was noted there were inconsistencies related to who was making healthcare decisions for this resident. This [AGE] year old resident was admitted to the facility on [DATE], transferred to another facility on 11/29/11, and was subsequently readmitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions on 06/28/13. Her Brief Interview for Mental Status (BIMS) score, as assessed on 07/02/13, was 14, indicating she was cognitively intact. (The highest possible BIMS score is 15.) An interview was conducted with the social worker (SW), Employee #18, on 08/14/13 at 9:29 a.m. She confirmed Resident #2 was determined to have capacity at the facility where she resided prior to her admission. The resident was determined to possess the capacity to make informed healthcare decisions by a physician. The SW said the resident had acted as her own decision-maker there. According the SW, since the resident was determined to lack capacity to make healthcare decisions upon her admission, a person needed to be selected to make health care decisions on the resident's behalf. An appointment of a Health Care Surrogate was necessary, but had not been completed. The resident's cousin was willing to assume this responsibility according to the social worker. In the meantime, Resident #2's choices related to refusal of care and other treatment were documented as being followed without question or counseling regarding the impact of those decisions, even though the facility had determined she was unable to make healthcare decisions for herself. Her cousin had already signed all consents and admission documents authorizing the facility to admit and treat Resident #2, although she had no legal basis for doing so. The administrator, Employee #33, was interviewed on 08/14/13 at 4:12 p.m. The situation regarding the lack of any legal authority to make medical decisions for Resident #2 was discussed. She confirmed Resident #2 was determined by her physician to lack the capacity to make medical decisions upon admission, but there was still no documented legal designation of any other person to make decisions on her behalf. The resident's cousin was permitted to sign all the admission documents and consents without the authority to do so. This had been the situation from admission on 06/27/13, until it was identified during the survey on 08/14/13.",2017-05-01
8079,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2013-10-22,152,D,1,0,KE9711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's legal representative was permitted to make medical decisions on behalf of one (1) of five (5) residents reviewed. The health care surrogate (HCS) for Resident #66 was unaware of the facility's decision to transport the resident to an out of state facility for treatment of [REDACTED]. Resident identifier: #66. Facility census: 121. Findings include: a) Resident #66 Medical record review found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Upon admission to the facility, the resident had HCS which was appointed during her stay at the referring hospital. Further review of the medical record revealed the resident was transferred and admitted to an out of state hospital's psychiatric unit for treatment of [REDACTED]. On the day of discharge (09/30/13), only three (3) entries were recorded in the resident's computerized medical record. -- The first entry was written at 2:15 p.m., (Name of health care surrogate) aware of new order to send resident to (name of hospital) for evaluation. -- The second entry was made at 3:59 p.m. by a facility social worker, Employee #80 which stated, A referral was made to (name of facility), there are no openings at the current time, requested documents will be faxed for review. A referral was made to (another name of a facility) documents will be faxed for review. A referral was made to (name of a third facility) documents will be faxed for review. Two (2) of these three (3) referrals were made to out of state facilities. -- The third entry, on 09/30/13 was made at 4:12 p.m., (Name of ambulance service) here to transport resident to (name of the state). Resident and family aware. (Note: The resident's legal representative was not a family member.) On 10/21/13 at 12:05 p.m., the director of nursing (DON) was asked how the HCS was notified regarding the transfer of Resident #66. The DON stated the facility corresponded with the HCS surrogate by e-mail. She provided a copy of the e-mail correspondence on 09/30/13. The DON stated the resident had exhibited inappropriate sexual behaviors over the weekend which prompted the transfer on Monday, 09/30/13. The e-mail message sent to the HCS at 12:45 p.m. on 09/30/12 was, (Resident's initials) new order for psych consult at (name of hospital) in (name of state). The HCS was interviewed by telephone on 10/21/13 at 2:30 p.m. The HCS stated the e-mail did not explain the resident was being admitted to an out of state facility on 09/30/13. She said she believed a psych consult would be completed in house by a psychiatrist, as that was the procedure in the past. She was also unaware the resident was exhibiting any inappropriate sexual behaviors. The HCS stated she had been told the resident had a crush on a male resident. She did not believe a crush, was inappropriate. Further review of the medical record found Employee #60, a facility social worker, had contacted four (4) other area nursing homes in an attempt to make placement arrangements for Resident #66 on 07/31/13. According to the documentation in the medical record, the other facilities did not accept placement of the resident. Employee #60 was interviewed on 10/21/13 at 1:00 p.m. She stated the resident had displayed inappropriate sexual behaviors for some time, but she did not know the actual behaviors that occurred on 09/30/13 because she was not working that day. She stated she had made referrals to other nursing homes for the resident in July 2013, when the sexual behaviors started. Employee #60 was asked to provide verification the HCS was made aware of the placement arrangements and of the inappropriate sexual behavior exhibited by the resident. At the close of the survey on 10/22/13, no further information had been provided. Employee #80, another facility social worker, was interviewed on 10/22/13 at 2:48 p.m., regarding her note written on 09/30/13 at 3:59 p.m. She stated she was told in morning meeting on Monday, 09/30/13, the resident had exhibited sexual behaviors over the weekend and she needed to call some facilities for placement. She verified she did not contact the HCS regarding her efforts at placement. Employee #80 stated she was just calling other facilities because she was told to follow up on referrals made by another social worker. During the telephone interview, on 10/21/13 at 2:30 p.m., the HCS stated she was unaware of referrals being made to other facilities until she spoke with the DON via telephone on 10/02/13. She said she called the facility because the hospital had contacted her about Resident #66. She said she had just become aware the facility was also contacting out of state facilities for placement, and her HCS appointment would not even be recognized in an out of state facility. On 10/22/13, the DON and the administrator were interviewed at 9:30 a.m. The DON verified the facility could not produce evidence the HCS was notified the facility was seeking alternative placement at other facilities and she could not find evidence the HCS was notified of the resident's inappropriate sexual behaviors which the facility stated had occurred. The DON also acknowledged the facility had not documented the sexual behaviors exhibited by the resident that resulted in the resident's hospitalization .",2016-10-01
8112,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2013-10-25,152,D,1,0,CYPC11,"Based on record review and staff interview, the facility failed to follow the directives of a person acting on behalf of an incapacitated resident. The family and Medical Power of Attorney (MPOA) informed staff they did not want a resident to receive an influenza vaccination. The facility administered the influenza vaccine without having consent to do so. This was evident for one (1) of six (6) residents reviewed for the facility's annual influenza vaccination program. Resident identifier: #29. Facility census: 61. Findings include: a) Resident #29 Review of the medical record revealed that family members did not want Resident #29 to receive an influenza vaccine. On 07/22/13, the resident's Medical Power of Attorney (MPOA) signed an influenza immunization form. By signing, this form, they acknowledged having received educational materials on the risks and benefits that may result from accepting or declining the influenza vaccine. The MPOA did not sign consent giving permission for the resident to receive the vaccine. A nursing progress note, dated 08/16/13, was reviewed. The resident's family/MPOA called and spoke with the nurse. The MPOA requested that the orders for flu vaccine and pneumonia vaccine be discontinued. On 10/23/13 at 2:30 p.m., the Director of Nursing (DON) produced a copy of the Medications Administration History for October 2013. She verified that a nurse administered the influenza vaccine to the resident's left deltoid muscle on 10/08/13 at 11:00 a.m. A nursing progress note, dated 10/09/13, conveyed that a nurse called the spouse of the MPOA and told her that the resident had received the flu vaccine with no adverse reaction. During an interview with the DON, on 10/23/13 at 2:30 p.m., she acknowledged that the resident was given the flu vaccine without consent of the MPOA.",2016-10-01
8435,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2013-06-18,152,D,1,0,RXW311,"Based on record review and staff interview, the facility failed to follow the instructions that were given for allowing a resident to be taken out of the facility without permission from the legal guardian. Resident #50 was identified as a protected person and had a court appointed guardian/conservator. Written instructions were provided to the facility to indicate who was allowed to take the resident out of the facility. The facility did not follow the instructions and allowed the resident to leave the facility with a person who was not authorized to take the resident out of the facility. The court appointed guardian was not made aware the resident had left the facility. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 It was recorded in this resident's medical record this resident had been determined by the Court to be a protected person. The Court had appointed a legal guardian to make decisions on the resident's behalf on 09/24/07. A review of the medical record, on 06/18/13, revealed a note that Resident #50 was not to leave the facility with anyone in his family. According to the note, he was only to leave with his court appointed guardian or her husband, whose name was specified. During an interview with the Administrator (Employee #83), it was verified that Resident #50 went out of the facility on 06/06/13 with an unauthorized person and went to his legal guardian's house without permission from the legal guardian. The facility had no knowledge of him leaving the facility until he returned. It was confirmed the facility did not follow the instructions of the legal guardian and failed to notify the responsible party that the resident wanted to go out of the facility with someone other than the individuals she had specified. The facility also failed to follow practices for signing out residents when they leave the facility.",2016-06-01
8640,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,152,D,0,1,5VE911,"Based on record review and staff interview, the facility failed to ensure the individuals making financial decisions for two (2) of three (3) sampled residents had the legal authority to do so. Review of Resident #11's financial file found a family member was being permitted to act as the resident's financial power of attorney in the absence of documentation to demonstrate this individual had the legal authority to do so. The physician appointed a health care surrogate (HCS) to make health care decisions on behalf of Resident #2, and the facility permitted this individual to also make financial decisions on behalf of the resident; such authority is not conferred by State law to a HCS. Facility census: 89. Findings include: a) Resident #11 Review of the financial file for Resident #11 revealed there was no documentation to indicate the individual making financial decisions on behalf of this resident who had the legal authority to do so. There was notice in the file by the facility, asking a family member to provide the necessary paperwork to prove they were the resident's financial power of attorney, but no such documentation had been supplied as yet. -- b) Resident #2 Review of the financial file for Resident #2 revealed he had been making his own financial decisions at the time of admission, but his status had changed such that he was no longer able to do so. The physician appointed a HCS to make health care decisions on behalf of the resident, but State law does not confer the authority to a HCS to also make financial decisions. -- c) The above concerns were discussed with Employee #29 (the business office manager) at 1:05 p.m. on 8/10/11.",2016-04-01
8752,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-03-13,152,D,1,0,MS9D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure that for residents who had been determined to lack the capacity to make informed medical decisions, a legal surrogate was designated in accordance with State law to exercise the resident's rights to the extent provided by the law. This was found for two (2) of four (4) residents whose records were reviewed. Resident identifiers: #116 and #117. Facility census: 115. Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 3/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. He was seventy (70) years old. His [DIAGNOSES REDACTED]. He was determined by a physician to lack the capacity to make informed healthcare decisions on 02/27/13. He was admitted to the facility for skilled therapy services designed to strengthen him, and improve his ability to assist with activities of daily living (ADLs) to allow him to return home with his son and daughter-in-law. There was an indication in the admission paperwork that a health care surrogate (HCS) had been appointed. Further review found a form entitled West Virginia Health Care Surrogate Designation, which had been faxed to the facility on [DATE] from the admitting hospital. The form indicated the resident's sister had consented over the telephone to act as the resident's HCS on 02/18/13. The cause of Resident #116's incapacity to make his own decisions was not completed. The expected duration of his incapacity to make his own decisions was not completed. The person that the physician intended to appoint as HCS was not named. There was a signature in the space marked attending physician, but the signature was not dated. During an interview, on 03/13/13 at 8:45 a.m., the administrator, Employee #38, stated that a new health care surrogate appointment form containing all the information required by the West Virginia Health Care Decisions Act ?16-30-1 should have been completed by the facility following the facility's determination upon admission that Resident #116 continued to lack the capacity to make informed health care decisions. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. Resident #117 was a fifty-nine (59) resident who was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. During the review of the medical record, questions arose regarding Resident #117's capacity to make informed medical decisions and also regarding sufficient appropriate provisions to ensure that an authorized decision maker was in place. Resident #117 signed his physician's orders [REDACTED]. He indicated his wishes for emergency medical interventions and end of life care on 03/07/12. He then signed all admission paperwork, including an authorization to provide medical treatment on 03/08/12. The attending physician determined the resident was incapable of making informed medical decisions on 03/08/12. There was no medical power of attorney (MPOA), health care surrogate (HCS) appointment, or any other evidence that a legal and appropriate decision maker was in place. Social services notes, dated 03/14/12, stated (typed as written): Resident was deemed incapable of making self-decisions by physicians but no reason given. Physician consulted to reevaluate. Resident has no MPOA or HCS on chart. A social services note dated three (3) months later, on 06/13/12, stated (typed as written): HCS completed and waiting for physician signature. No HCS was found in the medical record. After discussion regarding this issue on 03/12/13 at 3:47 p.m., the administrator presented a health care surrogate appointment form that had been completed on 02/03/12, while the resident was in the hospital. She said, and the FAX transmission date confirmed, that this form had never actually been in the record or available to staff, as it was just faxed to the facility on [DATE]. What was found in the medical record was a determination made at the hospital 26 days later on 02/29/12. This document indicated Resident #117 did possess the capacity to make informed medical decisions, which would have negated the health care surrogate's authority. The social worker for Resident #117, Employee #37, was interviewed on 03/12/13 at 2:40 p.m. He was asked about the HCS status of Resident #117 following his admission. He said he could not speak to that as he only began his employment at the facility in September 2012. He said he thought there was a surrogate form on the chart, but was not sure. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She confirmed that she was not able to provide any additional documentation regarding the completion of a health care surrogacy form following the determination that Resident #117 lacked the capacity to make informed medical decisions on 03/08/12.",2016-03-01
9081,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-02-21,152,D,1,0,RESW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a person making health care decisions had the legal authority to do so under state law, ?16-30-1, the West Virginia Health Care Decisions Act. The facility allowed a person to make health care decisions prior to having documentation to support the person had the legal authority to do so for one (1) of four (4) sampled residents. Resident Identifier: # 94. Facility Census: 107. Findings include: a) Resident #94 Medical record review, conducted at 1:45 p.m. on 01/25/13, revealed a Durable Power of Attorney (DPOA) for Resident #94. The DPOA did not provide legal authority for the person named as the DPOA to make health care decisions for Resident #94, because it was not signed by Resident #94. Therefore it was not a legally binding document. If the DPOA had been signed by the resident and was legally binding it still did not contain a health care decision clause giving permission for the person to make health care decisions for Resident # 94. This document was placed on the medical record by the facility staff, therefore the facility felt it was a legally binding document. The facility staff was not aware the document was not signed by Resident #94, until it was pointed out during the by the survey. There were no other documents within the medical record which gave anyone the legal authority to make health care decisions for the resident. The medical record revealed a Physician order [REDACTED]. This form was signed by a person other than Resident #94 on 10/21/09. The person signing the form signed in the signature box labeled, Signature of Patient/Resident, Parent of Minor, or Guardian/MPOA Representative/Surrogate(Mandatory). Also contained in the medical record of Resident # 94 was a form titled, Resident admission agreement/consent to treatment. This form was also signed by the same person who signed the POST form. This form was also dated 10/21/09, on the line labeled Legal Representative. There was no documentation contained on the medical record giving the person signing these forms the authority to do so. The medical record review further revealed a Physician's Determination of Capacity dated 10/28/09 which revealed Resident #94 demonstrated incapacity to make medical decisions as of 10/28/09. This determination of capacity was completed one (1) week after the facility allowed someone else to sign the POST form and the consent for treatment. An interview was conducted with the Nursing Home Administrator (NHA), Employee #119, and the master's level social worker, Employee #73 at 2:10 p.m. on 01/24/13. They both reported they thought the resident had a Health Care Surrogate (HCS) appointed to make her health care decisions. They both confirmed the HCS appointment was not on the medical record at the time of the interview. They looked at the resident's financial file and was able to locate a HCS appointment for this resident. The HCS did appoint the person who had signed the POST form and the consent to treat, as the HCS decision maker for Resident #94. This HCS appointment was signed by the Physician on 10/28/09 which was one week after the facility allowed this person to make health care decisions for the resident. The NHA and Employee #73 both felt the resident may have had a HCS appointment prior to entering the facility, but was unable to provide evidence which would suggest they had seen the HCS appointment prior to allowing this person to make health care decisions for Resident #94. On 01/28/13 the NHA provided a HCS appointment document which appointed the person allowed by the facility to make health care decisions for Resident #94 as her HCS decision maker on 10/12/09. The NHA reported they contacted the hospital and they were able to fax her this document. The time and date the form was faxed was printed at the top of the page which was 01/24/13 at 6:06 p.m This document was received by the facility after the the presence of such a document was unable to be located in the facility. There was no evidence to suggest the facility had this document in their possession prior to allowing the now appointed HCS to make the medical decisions for this resident. Had the facility had this document in their possession they would not have reappointed the same person as HCS decision maker on 10/28/09.",2016-02-01
9429,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2011-07-28,152,D,0,1,TF5T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview it was found that the Physician order [REDACTED]. This was evident for 1 (one) of 37 stage II sampled residents. Census: 57 residents currently in facility. Findings include: A) Resident #51 Review of the medical record for this resident revealed that there had been a previous POST form completed with a physician signature and date of 12/29/09. It stated the resident would want: Do Not Resuscitate (DNR), comfort measure only, antibiotics, IV (intravenous fluids)for a trial period and no tube feedings. Another POST form was noted which was dated by staff on 1/26/11. This document had listed that the resident would want DNR, no antibiotics, no IV, no tube feedings. It was not signed nor dated as to when the physician would have reviewed this information with the resident or responsible party and informed them of this change in treatment that would be provided. Spoke with director of nursing on 7/26/11 at mid afternoon regarding the lack of the signature and date by the physician. There was no further details submitted to the surveyor as of exit on 7/28/11",2015-11-01
9596,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-10-05,152,D,1,0,D8F011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the West Virginia Code, the facility failed to ensure a third evaluation of the resident's ability to make health care decisions was completed after the facility obtained two conflicting statements regarding the resident's ability to make health care decisions. The unresolved conflict resulted in various individuals making health care decisions for the resident. This was true for one (1) of six (6) medical records reviewed for resident rights exercised by a representative. Resident identifier: #81. Facility census: 89. Findings include: a) Resident #81 Review of the medical record found the resident's physician had determined the resident demonstrated capacity to make medical decisions on 07/17/12. Further review of the medical record found the local Department of Health and Human Services (DHHR) had completed the admission paper work on 07/19/12, two (2) days after the resident's physician determined the resident had the capacity to make his own medical decisions. The DHHR had also completed a, West Virginia Physician order [REDACTED]. The admissions director, Employee #56, was interviewed at 10:00 a.m. on 10/2/12. He stated the resident had lacked capacity upon admission. On 10/02/12 at 10:25 a.m., the facility social worker, Employee #62, presented a physician's determination of capacity from a local hospital, dated 06/27/12, which determined the resident lacked capacity to make medical decisions and appointed the DHHR as the resident's health care surrogate. According to the West Virginia Code (16-30-22), .shall have two physicians, one of whom may be the attending physician, or one physician and a qualified psychologist, or one physician and an advanced nurse practitioner, certify that the principal has regained capacity. Further review of the physician's orders [REDACTED]. The director of nursing (DON), Employee #88, and the corporate nurse, Employee #89, were made aware of the above situation on 10/04/12 at 10:30 a.m. The DON stated she thought another physician had examined the resident and had found he had capacity to make medical decisions, but this physician had not documented the findings on a determination of capacity form. No further information / explanation was provided regarding the inconsistent contacting of either the DHHR, the resident, or a family member when changes in condition occurred.",2015-10-01
9692,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,152,D,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to ensure each resident's health care decisions were made by the individual appointed by the resident. Additionally, determination of the resident's incapacity did not clearly indicate the nature of the incapacity. This was true for one (1) of thirteen (13) sampled residents. Resident identifier: #17. Facility census: 72. Findings include: a) Resident #17 1. Review of the resident's medical record found the resident had appointed Individual #1 as her first choice to be her medical power of attorney representative (MPOA). She had appointed Individual #2 as the successor MPOA should Individual #1 be unable, unwilling, or disqualified to serve. Further record review found Individual #2 had signed the physician's orders [REDACTED]. However, no evidence was found in the medical record indicating Individual #1 was unwilling or unable to serve, or that he had been disqualified. On the morning of 01/07/10, Employee #95 was asked whether something had happened to Individual #1, as Individual #2 had been making the resident's health care decisions. She said she did not know but would find the answer. At 9:20 a.m. on 01/07/10, Employee #95 said she had contacted Individual #2, who said she had been making the resident's health care decisions because Individual #1 had been working a lot of overtime. 2. This resident was admitted on [DATE]. A Physician Determination of Capacity had been completed on 12/10/09, by a physician other than the resident's primary physician. The form contained the following sentence: In my opinion this patient HAS ___ or LACKS ___ sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The physician placed a checkmark in the blank beside Lacks. In a section directing Please check the nature of the incapacitation as evidenced by:, the evaluator recorded: Disorientation to person, place, and time. The word place had been circled. There was no check placed by Inability to understand or make medical decisions. This was discussed with Employee #95, who agreed it appeared the physician had indicated the resident was disoriented to place, which would not necessarily mean she was unable to understand the implications of health care decisions.",2015-10-01
9834,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2012-08-02,152,D,1,0,K6SZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to aenure a resident who was alert and oriented was provided the opportunity to make her own health care decisions. Resident #85 had expressed that she did not want cardiopulmonary resuscitation (CPR) and two days later, her medical power of attorney (MPOA) changed this decision without the legal authority to do so and without evidence the resident was involved in this decision. The resident's family was also permitted to sign her admission paperwork without evidence the resident was involved in her admission or in decisions regarding her care at this facility. This practice was evident for one (1) of nine (9) sampled residents. Resident identifier: #85. Facility Census: 84. Findings include: a) Resident #85 Resident #85 was admitted to the facility on [DATE]. Her advance directives were reviewed and it was determined she had appointed a medical power of attorney on [DATE], just two (2) days prior to her admission to this facility. At the time of this resident's admission, on [DATE], the resident completed a cardiopulmonary resuscitation (CPR) form to express her wishes if she were to suffer a [MEDICAL CONDITION], respiratory arrest, or if death was imminent. She directed the facility withhold CPR and all life saving measures. The resident signed this form along with her representative who she had appointed her MPOA. Review of the medical record found that this resident was examined by the physician on [DATE]. It was recorded in the history and physical that she was alert and oriented times four (x 4). There was no incapacity statement found in the medical record to establish this residtn was not able to make her own medical decision and to activate her medical power of attorney. Further review of the medical record found that on [DATE], the appointed MPOA completed and signed a new CPR form stating ""I want CPR"". This form did not have the resident's signature on it and was completed only by the family with no evidence the resident had been involved in this decision or was even aware her CPR status had been changed. The Director of Nursing (Employee #67) was interviewed on [DATE] at 9:00 a.m. She revealed that she could not find a capacity statement for this resident. She also verified the admission papers had been signed by the power of attorney without evidence there was legal authority to allow her to sign these forms and without evidence the resident had requested the family be allowed to do so. .",2015-08-01
10023,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,152,D,0,1,4T1611,". Based on medical record review and staff interview, the facility failed to ensure the rights of one (1) of twelve (12) sampled residents, who had been determined to lack capacity to make informed health care decisions, were exercised by an individual appointed in accordance with State law. The physician appointed two (2) individuals to serve jointly as Resident #49's health care surrogate (HCS); however, WV State Code 16-30-8 allows a physician to appoint only one (1) HCS. Additionally, the facility allowed a family member who had not been appointed to the role of HCS to make health care decisions on Resident #49's behalf. Facility census: 50. Findings include: a) Resident #49 Medical record review revealed the physician appointed two (2) persons to serve jointly as Resident #49's HCS, to make health care decisions for this resident. In addition, record review also revealed health care decisions were being made by the resident's mother, who was had not been appointed to serve as HCS. In an interview with the administrator and the person in charge of resident funds (Employee #5) at 2:15 p.m. on 02/10/10, they acknowledged understanding the State law only allows for the appointment of one (1) person to serve as HCS for an incapacitated individual, and they acknowledged the resident's mother was not the resident's legal representative. They state they would see that all staff was made aware of this. According to WV Code 16-30-8. Selection of a surrogate.: ""(a) If no representative or court-appointed guardian is authorized or capable and willing to serve, the attending physician or advanced nurse practitioner is authorized to select a health care surrogate."" ""(b)(1) Where there are multiple possible surrogate decisionmakers at the same priority level, the attending physician or the advanced nurse practitioner shall, after reasonable inquiry, select as the surrogate the person who reasonably appears to be best qualified."" This State law does not allow for the simultaneous appointment of more than one (1) person to serve jointly as HCS for an incapacitated individual. .",2015-07-01
10115,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,152,D,0,1,9ELI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the individual acting on behalf of an incapacitated resident had the legal authority to make health care decisions. The facility had not obtained documentation to validate the appointment of a health care surrogate for the resident. One (1) of eighteen (18) residents on the sample was affected. Resident identifier: #40. Facility census: 99. Findings include: a) Resident #40 The resident was admitted to the facility on [DATE]. According to documentation in the resident's medical record, a health care surrogate had been appointed for the resident. An individual, other than the resident, had signed documents regarding health care decisions. However, there was no evidence the health care surrogate appointment had been validated. On 10/21/09 at 4:00 p.m., the social worker (Employee #23), when asked whether a copy of the health care surrogate appointment had been obtained, said she had asked the appointed individual to bring in a copy, but he had yet to do so. It was suggested a copy might have been received with the documents provided by the hospital at the time of transfer. Employee #23 checked, but was unable to locate a copy of the surrogate appointment. On 10/22/09 at 8:10 a.m., Employee #23 provided a copy of the health care surrogate appointment that had been faxed to the facility at 8:09 a.m. that morning. The facility had not obtained verification of the health care surrogate appointment for nearly a month after the resident was admitted . .",2015-06-01
10182,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2009-10-08,152,D,0,1,XHIH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure determinations of incapacity were documented in accordance with State law for two (2) of thirteen (13) sampled residents. One (1) resident's determination of incapacity did not indicate the expected duration of incapacity, nor was there evidence the physician informed this alert resident that a surrogate decision-maker would be acting on her behalf. Another resident's determination of incapacity also did not note the expected duration of incapacity. Resident identifiers: Resident identifiers: #18 and #36. Facility census: 59. Findings include: a) Resident #18 The medical record of Resident #18, when reviewed on 10/05/09, disclosed the resident's physician had, on 02/05/09, determined she lacked the capacity to understand and make her own informed medical decisions. The resident had been admitted to the facility on [DATE] and had posessed capacity until this time. The physician's documentation did not indicate this alert resident had been informed that her medical power of attorney representative (MPOA) would be making medical decisions of her behalf, as required by State law. The documentation also did not include the length of time the physician expected the resident to lack this capacity. b) Resident #36 The medical record of Resident #36, when reviewed on 10/05/09, disclosed the resident's physician had determined she lacked the capacity to understand and make her own informed medical decisions. The physician's documentation did not indicate this alert resident had been informed that her MPOA would be making medical decisions of her behalf, as required by State law. In an interview on 10/07/09 at 3:30 p.m., the director of nursing (Employee #69) agreed the was no evidence to reflect physician had informed the resident that her MPOA would be making her medical decisions, as required by State law. c) According to W.V.C. 16-30-7. Determination of incapacity.: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2015-06-01
10580,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2009-07-30,152,D,0,1,OPXH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the legal surrogate, of one (1) of thirteen (13) residents reviewed, exercised the resident's rights in accordance with State law. Resident #24 had designated a medical power of attorney representative (MPOA) to make health care decisions for her in the event she should lack the capacity to do so. The MPOA was making health care decisions on the resident's behalf, although there was no determination of incapacity in her record to reflect she was incapable of making these decisions for herself. Resident identifier: #24. Facility census: 60. Findings include: a) Resident #24 The medical record of Resident #24, when reviewed on 07/27/09, disclosed this [AGE] year old female had been admitted to the facility on [DATE], following hospitalization after a fall resulting in a subdural hematoma and cervical fracture. Review of the resident's admission documents, as well as the physician's orders [REDACTED]. The resident's medical record contained no document stating she herself did not have the capacity to make her own health care decisions. The facility's director of nursing (DON), when interviewed related to these findings on 07/29/09, confirmed that, although the resident was indeed unable physically and mentally to make her own decisions, there was no determination of incapacity completed by the attending physician for this resident. .",2015-01-01
10605,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,152,E,1,0,0VZD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and review of State law, the facility failed to determine a resident's capacity according to State law (WVC 16-30 - West Virginia Health Care Decisions Act) for six (6) of eight (8) sampled residents. Resident identifiers: #38, #40, #17, #35, #9, and #5. Facility census: 38. Findings include: a) Residents #38, #40, #17, and #35 1. Resident #38 A review of Resident #38's medical record revealed the resident was determined to be incapacitated due to bilateral hearing impairment and dementia. - 2. Resident #40 A review of Resident #40's medical record revealed the resident was determined to be incapacitated due to dementia. - 3. Resident #17 A review of Resident #17's medical record revealed the resident was determined to be incapacitated due to dementia. The form was not dated as to when the determination of capacity had been made. - 4. Resident #35 A review of Resident #35's medical record revealed the resident was determined to be incapacitated due to dementia. - 5. According to WVC 16-30-7. ""Determination of incapacity. ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..."" - 6. On 09/28/11 at 12:12 p.m., an interview with the director of nursing (DON - Employee #169) and the social worker (SW - Employee #188) revealed the above residents' determinations of capacity were based on a medical [DIAGNOSES REDACTED]. Both employees agreed that, just because a resident was hard of hearing, this did not necessarily mean the resident lacked the capacity to understand and make informed health care decisions. -- b) Resident #9 1. Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions. The document signed by the physician contained no date of the determination. ""Dementia"" was written across the areas on the form on which documentation was supposed to include ""nature of incapacity"" and ""cause of incapacity"". (The documentation of ""dementia"" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) - 2. According to WVC 16-30-7: ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. The section on the facility's form regarding this requirement required the indication of ""yes"" or a ""no."" Neither ""yes"" or ""no"" was marked. - 3. During an interview on 09/29/11 at 10:30 a.m., the acting DON confirmed this determination of incapacity did not describe why the resident could not make her own health care decisions, did not contain a date, and did not indicate the resident had been informed of being deemed incapacitated to make health care decision by the physician. -- c) Residents #5 Medical record review, on 09/28/11, revealed this resident's physician determined the resident did not possess the capacity to make health care decisions on 11/23/10. ""Dementia"" was written across the areas on the form on which documentation was supposed to include ""nature of incapacity"" and ""cause of incapacity."" (The documentation of ""dementia"" in itself did not provide a description of the how this condition impacted this resident's ability to make informed health care decisions.) During an interview on 09/29/11 at 10:30 a.m., the DON confirmed this resident's determination of incapacity did not describe why the resident could not make her own health care decisions. .",2015-01-01
10680,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-09-13,152,D,1,0,8CVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the medical record and staff interview, the facility failed to assure documentation was obtained to verify who had authority to make health care decisions on behalf of the resident. On numerous occasions throughout the medical record of Resident #56, the facility referred to the resident's daughter as the resident's medical power of attorney representative (MPOA) and allowed her to make medical decisions for the resident; however, the medical record failed to contain any documentation showing the resident had designated the daughter as his MPOA. Furthermore, the facility also failed to obtain an evaluation of the resident's capacity to understand and make informed health care decisions when it was determined the resident had severe cognitive impairment. This was true for one (1) of ten (10) sampled residents. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Medical record review revealed this [AGE] year old male was admitted to the facility on [DATE]. Active [DIAGNOSES REDACTED]. Further review of the medical record found an admission minimum data set assessment (MDS) with an assessment reference date (ARD) of 02/13/11. The results of the brief interview for mental status (BIMS) contained in this MDS revealed a score of ""5"", indicating the resident's cognitive performance was severely impaired. A quarterly MDS, with an ARD of 07/28/11, revealed a BIMS score of ""9"", indicating the resident's cognitive performance was moderately impaired. (A BIMS score of ""0"" to ""7"" indicates severely impaired cognitive performance; a score of ""8"" to ""12"" indicates moderately impaired cognitive performance; and a score of ""13"" to ""15"" indicates a resident is cognitively intact.) The medical record contained no further documentation to reflect the facility had assessed the resident's cognitive status. The medical record also contained no documentation to reflect the physician had completed an assessment of the resident's capacity to make medical decision when the facility became aware of the resident's severely impaired cognitive performance as indicated by the results of the BIMS on 02/13/11. Further review of the medical record revealed an absence of documentation to reflect the resident had ever designated his daughter to serve as his MPOA. Additionally, there was no evidence to reflect the physician had appointed the daughter to serve as the resident's health care surrogate after having made a determination that the resident was unable to make his own informed health care decisions. On numerous occasions throughout the resident's stay the resident's daughter had been contacted and had been allowed to make medical decisions for the resident. The following are some examples of such occasions: - On 02/09/11, the daughter completed the admission agreement which dictated the responsibilities of the resident and facility as terms for the condition of the stay. - On 04/09/11, nursing staff had referred to the daughter as ""MPOA"" when she was called concerning the resident's new orders. - On 05/10/11, the daughter had been allowed to determine the resident should not endure surgical procedure for a hernia. - On 08/15/11, the daughter had been allowed to decide whether the resident could attend an appointment for an eye exam. - The daughter was listed as the contact person for the resident on the admission information. - A grievance / concern form, completed by the corporate social worker on 05/11/11, referred to the resident's daughter as the ""MPOA"". From all indications, the facility's staff believed the daughter was the resident's MPOA and contacted her to make medical decisions for the resident during his stay at the facility. During an interview with the director of nursing (DON) on the afternoon of 09/12/11, she was unable to locate documentation to prove the resident's daughter was legally appointed to serve as his health care decision maker. She verified the resident's capacity should have been evaluated by the resident's physician but could find no evidence this had been completed. On the morning of 09/13/11, the DON provided a capacity statement completed by the resident's physician on 09/12/11. The physician had determined the resident lacked capacity to make medical decisions due to early dementia and the lack of inability to process information. The physician also provided a written statement, dated 09/13/11, which contained the following information: ""(name of resident) was admitted to (name of facility) in February of 2011. I am confident that I did a Determination of Capacity at that time and that he was deemed incompetent."" In summary: The facility failed to produce an evaluation of the resident's capacity to make health care decisions when they knew (or should have known) the resident had cognitive impairment. Further, the facility failed to verify that the daughter, who was allowed to make health care decisions, was the legally appointed individual designated to make medical decisions on behalf of the resident. .",2015-01-01
10711,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,152,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the determination of incapacity, for one (1) of twenty-one (21) sampled residents, was documented in accordance with State law. Resident #106's record lacked any information regarding the cause or nature of the incapacity as required by W.Va. Code 16-30-7(b). Additionally, there was no evidence the resident was notified of the determination of incapacity as required by W.Va. Code 16-30-7(c). Resident identifier: #106. Facility census: 138. Findings include: a) Resident #106 According to the medical record, the resident was admitted to the facility on [DATE]. A ""Physician's Determination of Capacity"" form, completed by the attending physician on 04/23/08, indicated the resident ""Demonstrates INCAPACITY to make medical decisions"" for a ""Short term"" duration. The form listed ""sequelae of [MEDICATION NAME] toxicity"" without additional explanation as to the nature or cause of the resident's incapacity. Additionally, no evidence could be found the physician informed this conscious resident of the determination of incapacity or of the fact that a surrogate decision-maker would be acting on the resident's behalf. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged, after reviewing the resident's determination of incapacity, the documentation was incomplete. b) Per W.Va. Code 16-30-7. Determination of incapacity. ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10755,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,152,E,0,1,667111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, a review of the West Virginia Health Care Decisions Act, and staff interview, the facility failed to ensure, for three (3) of thirteen (13) sampled residents, a legal surrogate was appointed in accordance with State law for residents lacking the capacity to understand and make their own informed health care decisions. Determinations of incapacity were made solely based on a [DIAGNOSES REDACTED]. Resident identifiers: #50, #33, and #47. Facility census: 75. Findings include: a) Resident #50 On 06/24/09 at approximately 2:00 p.m., review of Resident #50's medical record revealed a physician's determination of capacity form indicating Resident #50 lacked the capacity to understand and make informed health care decisions. However, the cause of the incapacity had not been recorded on the form. b) Resident #47 On 06/23/09, review of Resident #47's medical record revealed a physician's determination of capacity form indicating Resident #47 lacked the capacity to understand and make informed health care decisions due to having a [DIAGNOSES REDACTED]. c) Resident #33 Review of Resident #33's medical record, on 06/23/09, revealed the physician determined she lacked the capacity to understand and make her own health care decisions; however, the cause of her incapacity was not recorded. d) According to '16-30-7. Determination of incapacity., ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10804,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,152,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to ensure the rights of residents were exercised by an individual appointed in accordance with State law. One (1) resident, who been determined to lack capacity prior to admission, had a health care surrogate appointed while in the hospital. Documentation indicated some staff was aware of this; however, others were a party to completion of a medical power of attorney document (MPOA), which would not be valid as the resident had not been deemed to have the capacity to make the appointment. Additionally, the MPOA had been witnessed by two (2) facility staff members, which was prohibited by the facility's policy. Two (2) residents, who were found to have capacity, had health care decisions made by others. Three (3) of the fifteen (15) current residents on the sample were affected. Resident identifiers: #6, #81, and #46. Facility census: 86. Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. 1. Review of the resident's medical record found a document entitled ""Health Care Decision Making"" that listed the resident's representative as Individual A and noted he was the resident's health care surrogate (HCS). At the bottom of the document, ""Surrogate Decision Maker for Health Care"" was marked as being the resident's advance directive. A date of 08/17/09, initialed by Employee #58, had been entered as the date the HCS document had been obtained. A ""Physician order [REDACTED]. This form had been prepared by Employee #20, a registered nurse. This was further evidence some staff was aware the resident had previously had a health care surrogate appointed due to a determination of incapacity. 2. A copy of a ""State of West Virginia Medical Power of Attorney"" was also found in the resident's medical record. The form was dated 08/24/09 and signed by the resident. This form named Individual A as the resident's MPOA representative. There was no indication why the MPOA had been completed, given that the resident had a HCS appointed and needed only to be reviewed by the physician. 3. A ""Physician Determination of Capacity"" had been completed by the resident's physician on 08/25/09. The physician determined the resident lacked capacity to make health care decisions, because she lacked the capacity to appreciate the nature and implication of healthcare decisions. 4. To execute an MPOA, a resident must have capacity. This document had been completed, although her hospital records documented she lacked the capacity to make such an informed decision as this. Additionally, the day after it was signed, her attending physician at the facility also determined that she lacked capacity. 5. The MPOA, executed on 08/24/09, had been witnessed by facility staff - Employees #86 (the assistant director of nursing) and #89 (the food services director). The facility's policy entitled ""Health Care Decision Making"" includes: ""GHC (Genesis Health Care) staff will not act as witnesses to signing of any forms or documents concerning health care decision making .... "" 6. A copy of the HCS appointment from the hospital was found with the records the hospital had sent to the facility. There was also a ""Determination of Capacity"" form dated 08/05/09, where the physician had noted the resident demonstrated incapacity to make medical decisions based on his examination of her in the hospital. The incapacity was expected to be long term. 7. The social worker who had completed the ""Health Care Decision Making"" form (which noted the resident had a HCS) was not available. The director of nursing was asked if she was aware of what had prompted the completion of the MPOA document when the resident had a HCS from the hospital in place. She did not know why this had been done. She agreed the MPOA document would not have been valid, since the resident had determinations of incapacity before and after the MPOA document was executed. b) Resident #81 This resident's medical record contained a form entitled ""Consent for Treatment and Release of Information"". The form had the resident's name written on it and a date of 09/11/09. It was apparent this had been written by the same nurse (Employee #54) who also signed the form and dated her signature 09/11/09. The resident's MPOA representative had signed the document, which authorized medical care but also authorized disclosure of information to the resident's daughters, the resident's son, and two (2) in-laws. The determination of the resident's capacity was not completed until 09/15/09, at which time, he was determined to possess the capacity to make his own health care decisions. There was no indication why the resident's MPOA representative had signed the document, nor was there evidence the document had been reviewed with the resident to see whether he agreed. c) Resident #46 Medical record review, on 090/2/09, revealed this resident was admitted to the facility on [DATE]. Upon admission, the person whom this resident had appointed as her MPOA representative signed for the resident to be resuscitated in the event of cardiopulmonary arrest. There was no evidence of the resident's involvement in this decision. This was verified by the social worker at 4:00 p.m. on 09/22/09. At the time the MPOA signed for resuscitation, the resident had not been determined to lack the capacity to make informed health care decisions. In fact, on 09/09/09, the physician evaluated the resident and determined she did possess the capacity for medical decision making. .",2014-12-01
10838,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,152,D,0,1,L59911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure the determination of capacity for a resident was made in accordance with Chapter 16, Article 30 of the West Virginia State Code, prior to allowing another individual to make health care decisions on behalf of the resident. The cause, nature, and duration of the incapacity were not identified for one (1) of the twelve (12) residents on the sample. Resident identifier: #28. Facility census: 48. Findings include: a) Resident #28 Review of the medical record for this resident found determinations of capacity dated 02/13/08 and 03/17/09. Both of the assessments identified the resident as lacking capacity to make health care decisions. The ""Physician's Determination of Capacity"" dated 02/13/08 had an ""X"" in the box by ""[MEDICAL CONDITION]"" in the section for ""Nature"". (""[MEDICAL CONDITION]"" means the resident was unable to speak but would not necessarily mean the resident was unable to communicate and/or make medical decisions.) In the section for the cause of the incapacity, ""ASCVD"" ([MEDICAL CONDITION] cardiovascular disease) had been written. Again, this [DIAGNOSES REDACTED]. Additionally, the box by the section indicating the resident had been informed that someone else would be making her health care decisions was not checked. On the same form, another section for ""Periodic Capacity Review"" had been completed on 03/17/09. An ""X"" had been placed in the box by ""Demonstrates INCAPACITY to make medical decisions."" It had not been marked to indicate the resident was informed of the decision, and nothing had been checked or written for the nature and cause of the incapacity. The West Virginia Health Care Decisions Act, ?16-30-7. Determination of incapacity., states: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-12-01
10864,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2009-12-11,152,D,0,1,IPRG11,"**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 eleven (11) residents received a re-evaluation in their capacity status after a determination of short term incapacity had been made in 02/06/09. Resident identifier: #51. Facility census: 61. Findings include: a.) Resident #51 On 12/08/09 at approximately 9:30 a.m., medical record review for Resident #51 revealed she lacked the capacity to understand and make her own medical decisions. This determination occurred on 02/06/09, at which time the physician selected ""short-term"" for the duration incapacity and listed [MEDICAL CONDITION] cardiovascular disease as the cause. The physician identified as the nature of incapacity that the resident could not process information. The physician's determination of capacity form allowed for periodic capacity review; however, the facility had not completed the periodic review for this resident. On 12/08/09 at approximately 9:45 a.m., Employee #87 (registered nurse) indicated the resident received treatment from a psychiatrist who comes to the facility. She provided copies of the psychiatrist's progress notes which reflected no change in the resident's mental capacity. On 12/08/09, the physician re-evaluated the resident, at which time he determined the resident now possessed the capacity to understand and make her own medical decisions. .",2014-11-01
10943,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,152,D,0,1,HO2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ascertain a capacitated resident's wishes with respect to advance directives, allowed a medical power of attorney representative (MPOA) to make a health care decision on behalf of the resident without the legal authority to do so, and failed to identify and resolve conflicts between physician's orders [REDACTED]. Resident identifier: #4. Facility census: 61. Finding include: a) Resident #4 Review of Resident #4's medical record, on 06/17/09, revealed she was admitted to the facility on [DATE], with admitting orders signed by the physician for ""Advance Directives: DNR (do not resuscitate)."" Review of the ""Physician Determination of Capacity"", dated 01/11/09, revealed the resident had the capacity to understand and make her own informed health care decisions. The ""staff member involved"" with the completion of Resident #4's Advanced Directive Acknowledgment Form (Employee #63) marked an ""X"" at Item 6 indicating, ""Do not perform cardiopulmonary resuscitation"", and recorded, ""Per conservation with POA (power of attorney) 01/09/09 2:50 PM."" There was no signature of the form from the person making this health care decision on behalf of Resident #4, and there was no indication that Resident #4, who had the capacity to make this decision herself, was consulted regarding this matter. The ""physician acknowledgement"" of the form was signed by the physician on 01/09/09. Review of the resident's history and physical, dated and signed by the physician on 01/12/09 at 3:50 p.m., revealed: ""CODE STATUS: FULL RESUSCITATION in the event of cardiopulmonary arrest, including intubation with mechanical ventilation and/or cardioversion pending her POST form and official DNR status. Will get further details from the long-term care unit."" Review of the Physician order [REDACTED]. The form had been signed by the resident's MPOA - not the resident, and the MPOA's signature was not dated. The physician had signed and dated the form on 01/18/09. Interview with the director of nursing (DON), on the afternoon of 06/17/09, confirmed there was conflicting information regarding the resident's advances directives. The DON said the facility would need to ascertain the resident's desires with respect to resuscitation status and honor her wishes. .",2014-11-01
11021,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,152,D,0,1,53ZE11,"Based on record review and staff interview, the facility failed to assure a resident, who had been determined to lack the capacity to understand and make informed healthcare decisions, had his decisions made by a legal surrogate designated in accordance with State law. The facility had Resident #92 sign an informed consent form authorizing the administration of the influenza vaccine, even though he had been determined to lack the capacity to make such healthcare decisions. Resident identifier: #92. Facility census: 121. Findings include: a) Resident #92 Medical record review revealed the attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on 07/28/08. This determination was validated by a second determination made by a psychologist on 08/01/08. Further record review revealed Resident #92 had signed an informed consent form authorizing the administration of the influenza vaccine on 10/22/08. No other signature was on the form. During an interview with the social worker at 11:45 a.m. on 02/04/09, she acknowledged, after reviewing the chart, that Resident #92 should not have been asked to sign this form, as the resident did not have the capacity to understand and make healthcare decisions at that time. (Note: After the fact, on 11/19/08, the resident's attending physician reversed this and determined the resident had the capacity to formulate healthcare decisions. However, at the time the resident signed the vaccination consent form, he did not.) .",2014-09-01
11048,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2009-06-25,152,E,0,1,OJEL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for four (4) of twenty-eight (28) sampled records, to ensure legal surrogates were designated in accordance with State law for residents who have been determined to lack the capacity to understand and make their own health care decisions. Additionally, the facility failed to ensure the correct legal surrogate was identified in the medical record and contacted when health care decisions needed to be made. Resident identifiers: #3, #113, #131, and #19. Facility census: 128. Findings include: a) Resident #3 Medical record review, completed on 06/24/09, revealed the face sheet (demographic sheet) identified the resident's son was his medical power of attorney representative (MPOA). Review of the resident's MPOA document revealed the wife was the primary MPOA and the son was the successor MPOA. Further review revealed, on 11/19/08, the facility sent a notice to the resident's son, informing him of an upcoming care plan meeting. When interviewed on 06/24/09 at 11:20 a.m., the social worker (Employee #22) identified that the correct legal representative was the wife and the medical record face sheet was incorrect. Shortly after this interview, the face sheet was corrected. b) Resident #113 Medical record review, on 06/23/09, revealed Resident #113 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 03/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to a ""[MEDICAL CONDITION]"" ([MEDICAL CONDITION] - stroke). The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The facility's director of nursing (DON - Employee #82), when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. c) Resident #131 Closed medical record review, on 06/25/09, revealed Resident #131 was determined by his physician to lack capacity to make an informed choice regarding medical decisions on 02/27/09. Documentation on the form entitled ""Physician Determination of Capacity"" stated the resident lacked capacity due to the [DIAGNOSES REDACTED]. The determination of incapacity was based solely on a medical condition and did not provide information to describe what components of the disease interfered with his ability to understand and make informed health care decisions. The DON,when provided this information on 06/25/09, was unable to provide any additional documentation by the resident's physician to describe the nature of the resident's incapacity. d) Resident #19 Medical record review for Resident #19 revealed the physician's determination of capacity stated Resident #19 demonstrated incapacity to understand and make informed medical decisions and indicated, with a check mark, the [DIAGNOSES REDACTED]. There was NO further information regarding cause or nature, as required by State law. During an interview with the social worker (Employee #128) at 11:00 a.m. on 06/24/09, he confirmed the physician had not filled in all the required information on the determination of capacity form. e) Per W.Va. Code 16-30-7. Determination of incapacity: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ""(c) If the person is conscious, the attending physician shall inform the person that he or she has been determined to be incapacitated and that a medical power of attorney representative or surrogate decisionmaker may be making decisions regarding life-prolonging intervention or mental health treatment for [REDACTED]. .",2014-09-01
11116,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,152,D,0,1,6TSD11,"Based on record review and staff interview, the facility failed to ensure that the persons making healthcare decisions for two (2) of thirteen (13) sampled residents, who had been determined to lack the capacity to make such decisions for themselves, were appointed in accordance with State law. Resident identifiers: #45 and #60. Facility census: 101. Findings include: a) Resident #45 A review of Resident #45's medical record revealed a copy of a document appointing the resident's son as her medical power of attorney representative (MPOA). Review of the resident's advance directives, consents for vaccination, and other legal documents revealed these healthcare decisions had been made by the resident's daughter as evidenced by her signatures on these documents. During an interview with the director of nursing (DON) at 5:15 p.m. on 04/28/09, she stated the son was the MPOA of record, but the facility accepted the daughter's signature because she was the one who came in most often. b) Resident #60 A review of Resident #60's medical recordrevealed the individual who gave consent for a do not resuscitate order and for use of psychoactive medications, and who made other healthcare decisions for Resident #60 was not the person designated by the resident to serve as MPOA. During an interview with the DON at 5:15 p.m. on 04/28/09, she acknowledged that the person making the resident's healthcare decisions was not the resident's legally appointed MPOA.",2014-08-01
11154,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,152,D,0,1,OCKG11,"Based on record review and staff interview, the facility allowed a resident to sign legal documents for health care decisions on the same day the resident's physician determined he did not possess the capacity to understand and make informed health care decisions and no one had been designated to serve as health care surrogate for the resident. Additionally, the physician failed to record the cause and duration of Resident #50's incapacity. This was evident for one (1) of thirteen (13) sampled residents. Resident identifier: #50. Facility census: 50. Findings include: a) Resident #50 Record review revealed Resident #50 had a determination of incapacity statement signed by his attending physician at the facility. Record review also revealed that, on the same day the incapacity statement was signed by the physician, Resident #50 had signed the following documents: acknowledgment for bed rail use; acknowledgment of resident rights and privacy notice; immunization acknowledgment for declination of influenza vaccine; advance directives acknowledgment form; and permission to release information form. Interview with the social worker (Employee #8), on 08/12/09 at 2:00 p.m., revealed the resident had recently been admitted to the facility on her day off; he was accompanied by one (1) of his children. Employee #8 said, on the following day, she contacted one (1) of his children, who agreed to come in that day and speak with her, but the daughter did not appear. The next day, the physician assessed Resident #50 and determined he lacked the capacity to understand and make health care decisions. Employee #8 spoke her plans to have a yet-to-be assigned health care surrogate co-sign his legal documents, and she was in the process of making phone calls and going down the long list of family members to identify who was willing and able to serve as his health care surrogate. Interview with the social worker, on 08/12/09 at approximately 6:00 p.m., revealed she was still in the process of calling family members to determine who was able and willing to be the resident's health care surrogate, noting that it was a very large family which made the process more difficult. She explained that, prior to his admission to the facility, the transferring facility led her to believe the resident had capacity. Also at this time, it was brought to the attention of staff that the physician did not record the cause(s) of his incapacity. Employee #8 said the physician wrote the cause was ""to be determined"". Review of Resident #50's determination of incapacity form found physician documentation indicating the duration of his incapacity was ""to be determined"" (as to whether it was short term or long term), and nothing was recorded to address the cause of his incapacity. .",2014-08-01
11211,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,152,D,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify the nature of incapacity for one (1) of twenty-one (21) sampled residents determined by the physician to lack the ability to understand and make informed health care decisions. Resident identifier: #3. Facility census: 116. Findings include: a) Resident #3 Review of Resident #3's determination of incapacity statement, dated 10/28/09, revealed the physician identified the resident lacked decision-making capacity due to the [DIAGNOSES REDACTED]. During interview with the director of nursing (DON) the morning of 12/02/09, she stated the facility's practice is for the physician to note not only the [DIAGNOSES REDACTED]. When informed of Resident #3's incapacity statement, which noted only the diagnosis, she said she would bring this to the physician's attention for correction. According to W.V.C. 16-30-7. Determination of incapacity.: ""(a) For the purposes of this article, a person may not be presumed to be incapacitated merely by reason of advanced age or disability. With respect to a person who has a [DIAGNOSES REDACTED]. A determination that a person is incapacitated shall be made by the attending physician, a qualified physician, a qualified psychologist or an advanced nurse practitioner who has personally examined the person. ""(b) The determination of incapacity shall be recorded contemporaneously in the person's medical record by the attending physician, a qualified physician, advanced nurse practitioner or a qualified psychologist. The recording shall state the basis for the determination of incapacity, including the cause, nature and expected duration of the person's incapacity, if these are known. ..."" .",2014-07-01
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
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
6917,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2014-10-08,153,B,1,0,KVTV11,"Based on review of the facility's policies and procedures, the facility failed to ensure the policies established for accessing medical records was in compliance with this regulation. The current facility policy had the potential to result in residents and/or the legal representative being denied access to medical records within 24 hours (excluding weekends and holidays) as required. This practice had the potential to affect any resident/responsible party who exercised the right to access clinical records. Facility Census: 81. Findings include: a) Review of the facility's policy titled Request for Medical Records, last reviewed 2013, revealed in section 6, . the documents should be produced within five (5) days of receipt of the notification that the request for a medical record is valid.",2017-10-01
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
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
2612,WILLOW TREE HEALTHCARE CENTER,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2017-08-17,154,E,0,1,OM4311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of the risks and benefits of receiving psychopharmacological medications in advance of administering them to cognitively impaired residents. This affected two (2) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #46, and #118. The facility census was 101. Findings include: a) Resident #46 On 08/17/17 at 9:32 a.m., review of the resident's medical record revealed [REDACTED]. Review of current physician orders [REDACTED]. Review of the medical record on 08/17/17 at 11:15 a.m. revealed Resident #46 lacked capacity to make her own medical decisions and her daughter was indicated as the resident's responsible party and emergency contact. Concurrent review of the resident's plans of care revealed a current plan of care with a revision dated of 03/29/17 for the resident's use of [MEDICAL CONDITION] drug for dementia. The care plan problem stated the use of [MEDICAL CONDITION] drug use placed the resident at risk for drug related [MEDICAL CONDITION], gait disturbance, cognitive impairments, behavior impairment, activities of daily living decline, decline in appetite, and abnormal involuntary movements. The care planned interventions included antipsychotic side effects list #1 not limited to: [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (stiffness of neck), [MEDICATION NAME] symptoms: dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased falls/dizziness, cardiac abnormalities ([MEDICAL CONDITIONS], irregular heart rate), anxiety/agitation, blurred vision, sweating/rashes, headache, [MEDICAL CONDITION]/hesitancy, pseudo-parkinsonism: cogwheel rigidity, bradykinesia, tremors, appetite change/weight change. Educate resident/family/POA about risk versus benefits of medication/side effects/adverse effects. Further review of the medical record found no evidence the resident's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications. Interview on 08/17/17 at 10:30 a.m. with the Director of Nursing verified there was no evidence Resident #46's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications and had given consent for the continued use of the medications. b) Resident #118 Review on 08/16/17 at 1:54 p.m. of the resident's medical record revealed the resident was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. Concurrent review of current physician orders [REDACTED]. Review of the medical record on 08/16/17 at 1:57 p.m. revealed Resident #118 lacked capacity to make her own medical decisions and her granddaughter was indicated as the resident's responsible party and emergency contact. Concurrent review of the resident's plans of care on revealed a current plan of care with an initiation date of 11/09/16 for the resident's use of an anti-depressant. The care plan interventions included to administer medications as ordered. (MONTH) cause day time drowsiness, confusion, loss of appetite in the morning, increased risk of falls and fractures, dizziness. Observe for possible side effects. Further review of the resident's plans of care revealed a plan of care for the resident's use of use of [MEDICAL CONDITION] drugs. The plan of care identified the medication placed the resident at risk for drug related [MEDICAL CONDITION], gait disturbance, cognitive impairments, behavior impairment, activities of daily living decline, decline in appetite and abnormal involuntary movements. Interventions with initiation date of 03/22/17 stated sedative/hypnotic side effects not limited to: [DIAGNOSES REDACTED]: [DIAGNOSES REDACTED] (stiffness of neck), [MEDICATION NAME] symptoms: dry mouth, blurred vision, constipation, [MEDICAL CONDITIONS], sedation/drowsiness, increased falls/dizziness, cardiac abnormalities ([MEDICAL CONDITIONS], irregular heart), anxiety/agitation, blurred vision, sweating/rashes, headache, [MEDICAL CONDITION]/hesitancy, weakness and hangover effect. Educate resident/family/POA about risk vs benefits of medication/side effects/adverse effects. Further review of the medical record found no evidence the resident's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications. Interview on 08/17/17 at 10:30 a.m. with the Director of Nursing verified there was no evidence Resident #118's responsible party was educated/informed about the risk versus benefits of the resident's use of the [MEDICAL CONDITION] medications and had given consent for the continued use of the medications",2020-09-01
3893,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,154,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was given information in advance sufficient enough for her to make a knowledgeable health care decision in regards to a fluid restriction which her attending physician at the hospital (who was also her attending physician at the facility) had recommended upon her discharge from the hospital on [DATE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178 Findings include: a) Resident #170 A review of Resident #170's medical record at 9:00 a.m. on 09/23/16, found a discharge summary completed by Resident #170's attending physician while she was at the hospital. The discharge summary completed on 08/22/16 included her attending physician recommended a fluid restriction due to her status as a [MEDICAL TREATMENT] patient and her [DIAGNOSES REDACTED]. The same physician was also her attending physician at the facility. During an interview with the corporation's Chief Medical Officer Medical Doctor (CMO-MD) #271 at 10:20 a.m. on 09/23/16, when asked why Resident #170, a [MEDICAL TREATMENT] patient, was not ordered a fluid restriction upon her return from the hospital on [DATE], he replied not every one on [MEDICAL TREATMENT] needed a fluid restriction. He indicated that people in the community very seldom ever restrict their fluid. He proceeded to state the risk and benefits related to not watching her fluid intake was explained to the resident, but she was alert and orientated and able to make her own decisions. Therefore, she had the right refuse the fluid restriction which is why she was not currently ordered a fluid restriction. CFO-MD #271 was then asked if the conversation explaining the risk and benefits related to her refusal of a physician recommended fluid restriction was documented in her medical record. He informed the surveyor that this information did not need to be in the medical record because she was alert and orientated and able to make her own decisions. Review of the State Operations Manual Appendix PP - Guidance to Surveyors for Long Term Care Facilities found the following, 483.10(d)(2) - The resident has the right to be fully informed in advance about care and treatment and of any changes in that care or treatment that may affect the resident's well-being; Interpretive Guidelines 483.10(d)(2) Informed in advance means that the resident receives information necessary to make a health care decision, including information about his/her medical condition and changes in medical condition, about the benefits and reasonable risks of the treatment, and about reasonable available alternatives. At 4:04 p.m. on 09/23/16 the NHA was asked to provide any information that showed Resident #170 was informed about the physician recommended fluid restriction. The Director of Nursing (DON) was also asked at 5:16 p.m. on 09/23/16 to provide the same information. The DON stated she would check with the NHA and let us know. At 5:30 p.m. on 09/23/16, the medical records director reported the DON had told her to let the surveyors know there was no documentation in the medical record related to Resident #170's recommended fluid restriction. During an interview at 4:15 p.m. on 09/23/16, when asked if anyone at the facility had ever talked to her about a fluid restriction Resident #170 said a doctor, who she described as CMO - MD #271, had just been in a little while ago and asked her about a fluid restriction. She stated, I told him that I would not mind being on a fluid restriction if it was what was best for me. She then stated, Then he (she was referring to CMO - MD #271) said not to worry about it because I really did not need one. She then stated, I just want to do what is best for me. When asked if anyone at the facility had ever spoken with her about a fluid restriction prior to that time she stated, No that was the first time they ever mentioned it. On 09/23/16 Resident #170's attending physician declined to be interviewed by the surveyor. The NHA indicated that he was going out of town and was too busy to talk to us.",2020-04-01
5100,RALEIGH CENTER,515088,1631 RITTER DRIVE,DANIELS,WV,25832,2015-04-10,154,D,0,1,CRGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for resident rights was informed of his health status and needs. The resident's daughter, and not the resident, who had capacity to make health care decisions, was informed of the resident's health status. Resident identifier: #76. Facility census: 66. Findings include: a) Resident #76 On 04/06/15 at 11:04 a.m., the resident voiced concerns that staff did not involve him in his plan of care. He stated, I want my daughter involved and notified; however, I want to be notified first. Medical record review, on 04/06/15 at 1:20 p.m., found Resident #76 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. On 11/29/14, Resident #76's attending physician determined he had capacity to make informed health care decisions. Review of nurse's notes since admission found Resident #76's daughter was notified of his condition instead of the resident. An interview with Employee #42, Director of Admissions (DOA) and Employee #59, Social Services (SS), on 04/08/15 at 1:15 p.m., confirmed Resident #76 should be notified and involved in his plan of care. On 04/08/15 at 2:00 p.m., after intervention during the survey, Employee #42 spoke with Resident #76. The resident voiced his concern of not being allowed to be involved in his plan of care. In-service documentation, provided on 04/08/15, confirmed Resident #76 had capacity to make health care decisions and wished to actively participate in his care process.",2019-03-01
5644,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2015-07-29,154,D,0,1,DSPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's reasonable available alternatives; including the option of palliative care. Resident identifier: 98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed Resident #98 was a [AGE] year-old male initially admitted to the facility on [DATE]. He was determined by his physician to lack the capacity to make health care decisions and his brother was his medical power of attorney (MPOA). Resident #98 was designated to be a Full Code, meaning he was to be resuscitated should he stop breathing or his heart stop. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED]. The [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers. On readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable and 11 deep tissue injuries (DTIs) and the treatment goal stated by the NP/Physician was, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a full code; had recent cognitive changes and scored 0/15 on his brief interview for mental status (BIMS); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA. During an interview with the resident's brother/MPOA at 9:35 a.m. on 07/21/15, he said he knew the resident had been getting worse for the past few months. When asked what the plan of care was at present, he stated they wanted him to eat more and be able to get out of bed more. The resident, observed during the conversation was very frail and thin, with pale skin. He was lying on one side with his knees drawn up. He was awake but did not respond when spoken to. During an interview with Social Worker (SW) #145 at 2:00 p.m. on 07/23/15, she was asked if there had been a discussion with the MPOA about changing the code status, or about the use of palliative care or Hospice when the resident's health status deteriorated. She stated she had no knowledge of this and referred to SW #154, who was unavailable at that time. At 10:50 a.m. on 07/27/15, SW #154 was interviewed and also asked the same questions. She stated she had spoken to the MPOA and he had refused hospice, but would have to review her notes. At 11:45 a.m. SW #154 returned after reviewing the record and stated she had been unable to find written evidence of the MPOA being informed of available palliative or hospice care. At 4:30 p.m., on the same day, SW #154 stated she had informed the resident's brother/MPOA of the option of hospice/palliative care and had entered it into the record.",2018-09-01
5711,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2014-11-19,154,D,0,1,H5V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview, and staff interview, the facility failed to ensure a resident was fully informed in language that she could understand of her total health status, including but not limited to, her medical condition and, in advance, about care and treatment and of any changes in that care or treatment that may affect her well-being. The facility failed to inform a resident they documented as having the capacity to make informed medical decisions that they had honored her medical power of attorney's decision to change her treatment to comfort measures only. This was found for one (1) randomly reviewed resident. Resident identifier: #147. Facility census: 110. Findings include: a) Resident #147 The medical record review for Resident #147, on 11/12/14 at 1:20 p.m., revealed she was most recently admitted to the facility on [DATE] and subsequently re-admitted on [DATE]. She was determined by a physician to possess the capacity to make informed medical decisions on 05/07/14. b) A physician's determination of capacity completed at the acute- care hospital on [DATE] just prior to resident #147's admission to the facility stated she possessed the capacity to make informed medical decisions. The initial determination of capacity made after her admission to the facility was on 05/05/14 and determined she lacked the capacity to make informed medical decisions, and the duration of her incapacity was long term. There was no nature or cause of her incapacity recorded. Another determination of capacity was completed at the facility on 05/07/14 as a periodic capacity review. Besides the reasons provided on the form for capacity review, which were Significant Change, Annual, and Readmission, a fourth reason, Tiebreaker, had been hand-written and was checked. This tiebreaker assessment determined she possessed the capacity to make informed medical decisions. There were no other physician's determinations of capacity found in the medical record. c) Pertinent progress notes were found as follows: -- The social service note dated 05/09/2014 at 8:07 a.m. stated: Resident admitted to facility from (acute care hospital) on 05/03/14. Resident is a DNR (do not resuscitate) and has a DNR order, DPOA, and LW posted on her chart. Resident has capacity and is oriented to person, place, time, and situation. Resident refused to participate in MDS/SW assessment(s). Resident's PHQ-9-OV score is 2. Resident receives an ATA medication with no reported adverse reactions. Resident is short term in the facility and will return to (assisted living facility) after completion of nursing/rehab goals. Resident's PCP is Dr. (name). Care plan reviewed/revised as needed. -- 06/12/2014 11:05 a.m. social services note stated: SW met with resident's daughter/POA and son in law, (name) and (name), to talk about placement plans for this resident. Resident is not appropriate to return to (assisted living facility) due to her high level of care needs. (medical power of attorney) has requested that resident remain in the facility for LTC. Facility is able to offer resident a LTC bed at this point in time, family accepted offer. (Son-in-law and daughter) then met with the business office to discuss the financial side of things involved with the transition. -- 07/14/2014 2:44 p.m. nutrition/weight Note: Call placed to resident's DPOA (durable power of attorney)/daughter, (name) notifying of 65 weight loss within one month and noted meal refusals. Per (name), she has noted that her mother does not seem to be interested in eating her usual favorites that she herself has brought in for resident, she states that she believes her mother has given up and states that she is agreeable to her mother being evaluated by psychiatrist if ordered by MD. Spoke with PA-C (physician's assistant) in facility notifying him of conversation with daughter and order received for psych evaluation due to noted weight loss with declination of meals. (Name) notified of same. -- 07/15/2014 3:18 p.m. social services note: SW met w/POA (name) to complete POST (physician orders [REDACTED]. POST form completed with following options: comfort measures, no IV fluids, no feeding tube. Resident is a DNR. Hospice offered and declined at this time. (Name) states she will notify SW if she changes her mind. POST out for MD signature. (Name) also informed SW that if resident should pass while in facility to have body sent to (Name)'s funeral and they have instructions to send body to funeral home in (another state). -- 07/16/2014 8:54 a.m. social services note: POA (power of attorney) also stated psych. (psychiatric) consult not necessary at this time. -- 07/16/2014 1:46 p.m. social services note: POST form signed by MD. POA aware. -- 07/18/2014 5:16 p.m. general progress note: Dr. (name) PA, (name) in to see resident and dc'd meds. and put resident on comfort measures. POA, (name) made aware. No pain or distress made aware. 08/6/2014 12:35 Care Plan Progress Note: Significant change. Weight loss, hand fed, incontinence, refusals to eat, behaviors. Alert. She has no hearing, communication problems. No vision impairment with glasses. When staff speaks with her she answers with curt, sharp almost angry sound in voice and does not care to carry on a conversion with them. Episodes of refusing 5 meals during ARD. ADL status verified by speaking with staff, observation, review of P[NAME]. Due to issues with screw in her hip per note of 6/19/14 she is a hoyer lift for transfers. She has episodes of yelling out, and at times does not know what she wants. She prefers to be in bed most of the time. Therapies discontinued. She is not motivated to assist with ADLs. Incontinent of urine and stool. Most medications have been discontinued without adverse effect. No pain per resident. No falls. Her dentures are loose and per resident not using them. When asked if she would like to see a dentist her response was as follows. They don't fit anymore and I ain't spending no D--- money on them No pressure areas. Excoriation under breast (pink currently, slightly damp. Use of prn antianxiety medication. Displays episodes of yelling out, and verbalizes increased anxiety. No adverse effects noted. --08/7/2014 8:00 a.m. Social Services Note: Resident is a significant change. Please refer to assessments for details. Resident is a DNR (do not resuscitate) hand has a DNR order, DPOA, POST form, and LW (living will) on her chart. Resident has capacity and is oriented to person and place. Her BIMS (brief interview for mental status) score is 3 and PHQ-9 (patient health questionnaire) score is 0. Resident is LTC (long term care) in facility r/t (related to) physical care needs. Care plan reviewed/revised as needed. 08/27/2014 16:34 Social Services Note: Alerted to the fact that resident was yelling at/with roommate's spouse. SW offered resident a room change because she does not like the fact that her roommate rambles without reason at times. SW offered resident a room change but she refused a move at this time. SW explained that if she is not getting along with her roommate she always has the right to move. Resident again refused to move. Resident stated that she agrees to be cordial with roommate and spouse from this point forward. SW stated that if she changes her mind and would like to move rooms to please alert staff. Resident agreed to do so. d) There was no documentation found to suggest Resident #147 had ever expressed she now wished to defer all decisions regarding her care to her medical power of attorney. e) Resident #147 was interviewed on 11/18/14 at 1:00 p.m. She was asked if anyone had spoken to her about her wishes for her continued care and advance directives. She replied absolutely not. f) Staff interviews 1. A member of the activities staff was interviewed on 11/18/14 at 11:47 a.m. they were asked about their interactions with resident #147 during documented one to one visits for socialization. They said they felt resident #147 understood the intent of conversation and questions during their visits. Although she occasionally refused to engage in conversations, when she did, she understood what was being communicated and answered questions appropriately. 2. The administrator was interviewed on 11/18/14 at 2:40 p.m. The situation regarding Resident #147 was discussed. She expressed understanding about the issues, including apparent contradictions in the record regarding Resident #147's capacity status, and agreed that if there is no additional evidence available, there is a concern with the resident's right to be informed of a change in her capacity, the recognized decision maker, and/or of her complete medical condition. No further documentation was presented during the survey. Although the medical record continues to show Resident #147 has the capacity to make informed medical decisions, the facility has honored the medical power of attorney's decisions placing her on comfort measures only, declining hospice care, and canceling an appointment for a psychiatric consultation.",2018-08-01
6078,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,154,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to fully inform residents who had been determined to possess the capacity to act as their own decision-maker, in a language that he or she could understand, of identified concerns regarding his or her total health status, including their cognitive status and psychosocial status as initiated in their individualized care plans. Residents were not informed of care plans established for behaviors. This was found for four (4) of four (4) residents who had voiced multiple documented complaints during 2013. Resident identifiers: #19, #62, #25, and #57. Facility census: 100. Findings include: a) Review of complaints, concerns, and abuse/neglect reporting began on 01/08/13 at 9:00 a.m. This review was continued and expanded on 01/20/14 as part of the extended survey protocol. 1) Resident #19 Review of the complaint/concern files identified this resident had thirty (30) documented concerns in 2013 to date. According to the documentation regarding these issues, the facility had attempted to resolve all of the resident's issues. The facility had not dismissed any of the resident ' s concerns as being unfounded or untrue. The high number of concerns filed by this resident prompted review of her medical record. This review the resident's physician had determined she possessed the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score, as assessed on 12/17/13, was 15, indicating she was cognitively intact. She was acting as her own decision-maker. Review of her care plan, on 01/16/13 at 1:00 p.m., found she had a focus item for being at risk for changes in behavior problems related to making false accusations towards staff. The goal for this problem was (typed as written), Will remain free of behavioral disturbances daily thru next review. Interventions implemented toward meeting this goal were (typed as written): 1. Anticipate needs and provide care as able. 2. Provide emotional support as needed. Further review of the resident's medical record found there were no behaviors identified on the resident's minimum data set assessments. There was no evidence of any targeted behaviors being quantitatively monitored. There was no evidence of any behaviors, other than the frequency of her complaints. The record review found no basis for establishing the goal of (typed as written), Will remain free of behavioral disturbances daily thru next review. b) Following the review of Resident #19's medical record, patient liaison, Employee #176, was asked on 01/20/14 at 11:48 a.m., to provide a listing of residents who had voiced the most complaints and concerns in 2013. She provided the requested information a short time later, which indicated the following: 1) Resident #62 This resident had eleven (11) complaints/concerns/grievances documented. Resident #62 had been determined by a physician to possess the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 01/09/14 was 15, indicating she was cognitively intact. She was acting as her own decision-maker. She was currently president of the resident council. Review of her care plan, on 01/16/13 at 1:10 p.m., found she had a focus item for being at risk for behavior symptoms related to fabrications of staff refusing care/frequently making accusations toward staff and other residents. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Resident refuses psychiatric evaluation. 4. Use consistent approaches when giving care. 2) Resident #25 A review of the closed medical record for Resident #25 revealed she had been determined by a physician to possess the capacity to make informed medical decisions. This was verified in each of her care plan meeting minutes 07/24/13,08/08/13, and 10/16/13). She had scored 15/15 on the BIMS (Brief Interview for Mental Status) on 10/18/13. She was her own decision-maker during her stay at the facility. A review of the Concern Report files revealed Resident #25 had nine (9) grievances documented during her admission at the facility from 07/23/13 to 11/08/13. Review of the complaints and concerns found that the facility had attempted to resolve all of the issues. None had been dismissed as being unfounded or untrue. A review of her care plan, at 1:37 p.m. on 01/16/13, found she had a focus item for being noted to make false accusations towards staff related to [MEDICAL CONDITIONS]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer medications per physician order. 2. Observe for mental status/behavior changes when new medication started or with changes in dosage. 3. Use consistent approaches when giving care. Medical record review found that although she had a care plan focus item related to being at risk for behaviors due to making false allegations or fabrications, there was no evidence of behaviors documented on the resident ' s comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. The only progress note in the entire record alluding to behaviors was the following on 10/18/13, which was the initiation date of the care plan for this focus, (typed as written) Nurse was standing outside of room passing medications when resident call light came on. Nurse finished passing pills that were already started. Nurse answered call light. Resident states, ' Its about time my call light has been on for an hour. ' Nurse explained to resident that she was standing outside of the room when the call light came on but I would be glad to assist her in repositioning. Resident states, ' You are just like everyone else, liars. ' Will continue to monitor. There was no entry in any of the physician's progress notes suggesting the presence of any behaviors. An interview was conducted with acting social services director, contracted Employee #44 on 1/21/14 at 11:50 a.m. She was identified by the Administrator, Employee #120 as the person responsible for facilitating resident care plan meetings. She was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. There was no evidence of behaviors being discussed in any of her care plan meeting minutes (07/24/13, 08/08/13, and 10/16/13) and her daughter had been in attendance at two (2) of the meetings. 3) Resident #57 This resident had eight (8) complaints/concerns/grievances documented. Resident #57 had experienced a recent significant change of condition and was determined by her physician to lack the capacity to make informed medical decisions on 12/27/13 due to illness/early dementia. Prior to that determination, she had acted as her own responsible party throughout her residency in 2013. Her Brief Interview for Mental Status (BIMS) score, as assessed on 11/27/13 was 15, indicating she was cognitively intact. Review of her care plan on 01/16/13 at 1:42 p.m. found she had a focus item for being at risk for behavior symptoms such as making false accusations towards staff and family related to mental illness and [MEDICAL CONDITION]. The goal associated with this item was (typed as written): Will reduce risk of behavioral symptoms. Interventions implemented toward meeting this goal were (typed as written): 1. Administer meds per physician orders, observe for effectiveness and side effects such as but not limited to dizziness, drowsiness, and falls. 2. If resident exhibits inappropriate behaviors, speak in a soft, calm tone, attempt to redirect, and encourage resident to express herself in a more appropriate manner. 3. Observe for mental status/behavior changes when new medication started or with changes in dosage. 4. Use consistent approaches when giving care. c) Review found each of these residents had care plan focus items related to being at risk for behaviors due to making false allegations or fabrications, although none of them had evidence of behaviors documented on their comprehensive assessments (MDS) or any other systematic behavior monitoring that caused these focus items to be triggered for inclusion in their care plans. d) In an interview with the acting social services director, contracted Employee #44, on 01/21/14 at 11:50 a.m. (she was identified by administrator, Employee #120, as the person responsible for facilitating resident care plan meetings), she was asked about general procedures during care plan conferences when a resident acting as their own decision-maker was in attendance, specifically if each focus item would be discussed with the resident. She said each department would in turn bring up all the items on their section of the care plan for discussion, and confirmed that, if an issue was significant enough to be initiated as a focus area on the care plan, it would be discussed during the conference with the responsible party. It was then discussed that review had found those residents having the most complaints all had care plan focus items bringing their credibility into question. She was asked if the focus item related to making false allegations or fabrications had been discussed with these residents. She said they had not.",2018-05-01
6420,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,154,D,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform one (1) of five (5) sampled residents of the healthcare status and treatment which necessitated medication changes. Resident #54 was receiving two (2) medications used to treat sexual behaviors. These medications had dosage adjustments of which Resident #54 was not informed. Resident Identifier: #54 Facility Census: 68. Findings Include: a) Resident #54 Review of Resident #54's medical record, at 3:17 p.m. on 03/03/15, found the resident had capacity to make medical decisions. The medical record contained one (1) capacity statement completed by the attending physician. The capacity statement indicated Resident #54 had the ability to appreciate the nature and implications of a health care decision, to make an informed choice regarding the alternatives presented, and to communicate the choice in an unambiguous manner. This form was completed on 05/31/14 and was still in effect at the time of this review. Further review of Resident #54's medical record found a physician's orders [REDACTED]. The nurse progress notes were reviewed. A note, dated 02/16/15, indicated Resident #54's spouse was notified of the medication change. There was no evidence in the medical record to suggest Resident #54 was notified of this medication change or was informed of the reason the medications were ordered and provided. Interview with the Director of Nursing (DON), at 12:23 p.m. on 03/06/15, confirmed there was no evidence to suggest Resident #54 was informed of the medication change on 02/16/15. She said staff called the spouse, but there was no evidence the resident was informed. The DON stated the physician was going to review the resident's capacity; however, at the time of the medication changes the resident was determined capable of making medical decisions.",2018-03-01
8217,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,154,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to accurately inform the family and resident of the total health status related to antibiotic use for one (1) of three (3) residents reviewed for the use of antibiotics. The facility notified the resident and family member the resident was receiving the antibiotic [MEDICATION NAME] for a urinary tract infection. The resident was actually receiving the antibiotic for another diagnosis. He did not have a urinary tract infection at the time this antibiotic was ordered. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the medical record, on 07/24/13, identified a physician's orders [REDACTED].#90 (licensed practical nurse - LPN) dated 06/29/13. The physician's orders [REDACTED]. Further review of the medical record found a general note written by Employee #90 (LPN), on 06/29/13 at 19:12, stating the family was notified this resident was ordered [MEDICATION NAME] for a urinary tract infection. During an interview conducted on 07/24/13 at 3:11 p.m., Employee #137 (family nurse practitioner), revealed she did not order [MEDICATION NAME] for a urinary tract infection. She stated, The [MEDICATION NAME] was ordered for results of a chest-x-ray called to me on 06/29/13, by the facility. Employee #137 also stated, I wouldn't have ordered [MEDICATION NAME] for a urinary tract infection. Review of the medical record identified a chest x-ray, dated 06/29/13, with the following impression: Under ventilated lungs, mild cardiomegaly, ill-defined densities left lung base could represent atelectasis or mild consolidation, recommend follow up.",2016-07-01
9546,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,154,D,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to inform one (1) of twenty-one (21) sampled residents of the potential risks and available alternative treatments relating to bladder elimination. An alert and oriented resident, whose indwelling Foley urinary catheter continued to be used at her request (beyond the time-limited physician's orders [REDACTED]. Resident identifier: 25. Facility census: 157. Findings include: a) Resident #25 Resident #25's medical record, when reviewed on 11/19/09 at 1:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was alert and oriented and had been determined by her physician to possess the capacity to understand and make informed healthcare decisions. The resident was on bedrest due to a fall at home resulting in fractures to the lumbar spine. The physician ordered an indwelling Foley urinary catheter for seven (7) days on 11/01/09 due to excoriation. Resident #25, when observed in bed at 1:45 p.m. on 11/19/09, had in place an indwelling urinary catheter. The resident, when interviewed, reported she did not want the catheter removed until she was off of bedrest and able to ambulate. The director of nurses (DON - Employee #165), when interviewed on 11/20/09 at 3:15 p.m., reported it was the resident's choice to keep the catheter. However, the DON did acknowledge the facility failed to inform the resident of potential risks of continuing to use an indwelling catheter over an extended period of time or alternative treatments available.",2015-10-01
10569,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,154,D,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to fully inform one (1) of twenty (20) sampled residents, who had been determined by his physician to have the capacity to make his own healthcare decisions, of his rights as a resident, his healthcare status and the treatment interventions planned, and/or his discharge planning arrangements. Resident identifier: #62. Facility census: 114. Findings include: a) Resident #62 A review of the medical record revealed Resident #62 was a [AGE] year old male with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. His attending physician determined he lacked the capacity to make his own informed healthcare decisions on 04/13/09, and assigned his niece as his health care surrogate (HCS). The social services note, written by the social worker (SW - Employee #80) on 09/29/09, recorded the resident's niece came to the facility on this date and stated that, for health reasons, she could no longer serve as the resident's HCS. She was advised the facility would seek a HCS from WV DHHR. There was also evidence that a 30-day notice of discharge had been mailed to the HCS on or about 09/24/09, although she reported to the SW she had not received it. On 10/06/09, the resident's attending physician determined the resident now demonstrated the capacity to make his own informed healthcare decisions. All social services notes, progress notes, and nurses' notes after that date were reviewed, but there was no evidence that the resident had his care plan (especially his discharge plan) or his rights explained to him. During the general tour at 3:30 p.m. on 10/19/09, this resident approached the surveyor and asked if there was any rule about the sharing of the television in his room; he also asked the surveyor to find out why he had not been discharged yet. At 11:20 a.m. on 10/20/09, the resident was interviewed about his healthcare status. He said he was sick a few months ago but was well now and ready to go home. He could not relate to the surveyor any healthcare instructions and said that his niece took care of everything. During an interview with the social worker (Employee #80) at 9:45 a.m. on 10/21/09, she acknowledged the resident had not ""formally"" been included in any care discussions since he had been declared to have capacity and that the niece had formally rescinded her agreement to act as HCS for the resident. There was no evidence in the record that the resident had been informed of his rights, his code status, or that the facility has issued a 30-day notice of discharge. .",2015-01-01
10783,HEARTLAND OF CLARKSBURG,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2011-08-02,154,D,1,0,H4MU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, physician interview, and family interview, the facility failed to ensure the responsible party of one (1) of five (5) sampled residents, who lacked capacity to understand and make informed healthcare decisions, was informed in advance about a change in care that may affect the resident's well-being. The facility did not receive approval from Resident #72's health care surrogate (HCS) before discontinuing the resident's medication, labs and diagnostic tests, and weights. Facility census: 106. Findings include: a) Resident #72 Record review revealed Resident #72 was a [AGE] year old male admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. The resident weighed 88 pounds (#) on admission, and his current weight on 08/02/11 was 98#. -- On 06/23/11, a physician's orders [REDACTED]. Resident refusal."" -- An interview with the social worker, on 08/02/11 at 11:35 a.m., revealed the social worker had no knowledge of the resident not receiving his medication, labs and diagnostic tests, and weights. She was not aware that the resident was refusing to take his medication and was refusing to be weighed. She also stated, ""I was unaware that the HCS was not returning the calls to the nursing staff about his (the resident's) refusal to take his medication and refusing to be weighed."" -- An interview with the director of nursing (DON), on 08/02/11 at 10:00 a.m., revealed the resident was refusing to take his medication and refusing to be weighed. She stated, ""The HCS was notified multiple times and did not return the calls."" She further stated, ""When a resident is refusing to take their medication and refusing to be weighed, it is my practice to have the physician discontinue the medication and weights."" -- An interview with the physician, on 08/02/11 at 2:00 p.m., revealed the physician was unaware that the resident's HCS was not informed of the medications and the weights discontinued. She stated, ""Put me through to the charge nurse, and I will get the ball rolling to change the HCS if necessary."" -- An interview with the resident's HCS, on 08/02/11 at 2:15 p.m., revealed she could not remember if she had returned a call to approve the discontinuation of the medications and weights. She reported she was unaware that she was responsible for making the decisions concerning the resident's medical needs. She stated, ""I now understand my responsibilities concerning (Resident #72's) health needs and want to remain his HCS."" .",2014-12-01
10944,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,154,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy regarding cardiopulmonary resuscitation (CPR), and staff interview, the facility failed to ensure residents were fully informed in advance of care or treatment that might affect their well-being. Resident #94's medical record included a Physician order [REDACTED]. There was no evidence the resident / responsible party had been made aware of the facility's policy. One (1) of eight (8) residents whose closed record was reviewed was affected. Resident identifier: #94. Facility census: 86. Findings include: a) Resident #94 Review of the resident's medical record found a POST form had been completed by the resident's medical power of attorney representative (MPOA) on [DATE]. The MPOA had checked the POST form, indicating the resident was to be resuscitated. Further review of the medical record found an entry, dated [DATE] at 3:00 a.m., recording, ""Called to residents (sic) room by staff at 12:30 AM (sic) No pulse - radial/carotid. No respirations. Skin cold to touch. Pupils fixed / dilated /c (with) pupil indented. Tem (temperature) 87.2 (degree mark) F...."" The note continued, and the MPOA was quoted as saying, ""I spent a long time with her a couple of days ago and I have been expecting this."" No attempts were made to provide CPR. The director of nursing (DON), when interviewed regarding these findings at 7:45 a.m. on [DATE], stated they have night time briefs so staff do not have to disturb residents so often. She said staff does not go in and check to see whether residents are still breathing every two (2) hours, as this would disturb the sleeping residents. The DON said this resident had been stiff when she was found, and the resident's death was ""very unexpected"". The DON was asked whether there was a policy regarding when CPR would be provided. Shortly after, she provided a copy of the facility's policy entitled ""Cardiopulmonary Resuscitation."" The policy included, ""Cardiopulmonary resuscitation (CPR) will be instituted in cases of witnessed cessation of cardiac and/or [MEDICAL CONDITION] function until advanced cardiac life support is available on any resident who does not have a 'Do Not Resuscitate' order."" (The policy did not have a date, so it could not be ascertained whether it had been in place in 2005.) When asked whether residents or their responsible parties were informed of this when they completed the POST form, the DON said the social workers explain this when the POST form is signed. Approximately one (1) hour later, Employee #51 (a facility social worker) was asked about what she told people when they were deciding how to fill out the POST form. She provided a thorough explanation but did not mention the facility's CPR policy. When specifically asked about this policy, she said she was not aware of it. She added that, fortunately, she had not had admitted anyone who had wanted CPR. It was suggested she obtain a copy of the policy. .",2014-11-01
11148,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,154,D,0,1,OCKG11,"Based on medical record review and staff interview, the facility failed to ensure one (1) of thirteen (13) sampled residents was fully informed in advance of medication changes. Resident #8 was determined to possess the capacity to make her own health care decisions, but a note in the resident's medical record indicated her daughter, who was not a legally designated health care surrogate, was to be informed of medication changes before the resident was. Facility census: 50. Findings include: a) Resident #8 Resident #8 was an alert and oriented resident who had been determined by her physician to possess the capacity to understand and make her own health care decisions. Review of Resident #8's medical record found the following statement dated 02/24/09 and signed by the former director of nursing: ""Nurses: Please contact (name) before ordering new medications for (Resident #8). She would like to talk it over with her mother first. The above is not to be discussed with (Resident #8)."" A review of the statement with the current director of nursing, on 08/12/09 at 2:00 p.m., found the director of nursing was unaware of the note in the resident's medical record. .",2014-08-01
11218,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-03-16,154,D,1,0,81RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not inform the legal representatives of three (3) of five (5) sampled residents when changes were made to their care and/or treatment. Resident identifiers: #73, #85, and #8. Facility census: 116. Findings include: a) Residents #73, #85, and #8 A review of MEDICATION ORDERS FOR [REDACTED]. 1. Resident #73 Record review revealed a physician's orders [REDACTED]."" On 12/08/10, another physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; these areas were blank on the above telephone orders. - 2. Resident #85 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. - 3. Resident #8 Record review revealed a physician's orders [REDACTED]. Each physician's telephone order form contained a place for the nurse to record the name of the family member who was notified of the new order; this area was blank on the above telephone order. -- b) An interview with the administrator, on 03/16/11 at 9:30 a.m., revealed the nurses were all educated to notify families of residents when a change was made in medications. .",2014-07-01
2435,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2017-06-30,155,D,1,1,45HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure Resident #133 was afforded the right to request, refuse, and/or discontinue treatment, and to formulate an advance directive. Resident #133 was determined to have capacity to make medical decisions, however; his caregiver had signed all his admission paperwork for admission and treatment at the facility. This was true for one (1) of one (4) residents reviewed for the care area of Choices during Stage 2 of the Quality Indicator Survey. Resident identifier: #133. Facility census: 76. Findings include: a) Resident #133 A review of Resident #133's medical record, at 1:12 p.m. on 06/28/17, found the resident was [AGE] year old resident with an admission date of [DATE]. Consent for treatment and release of information found in medical records was signed by Resident #133's Medical Power of Attorney (MPOA) on 04/07/17. Review of the record found a Physician's Determination of Capacity dated 04/08/17 which indicated Resident #133 was capacitated to make medical decisions. Contained in Resident #133's medical record was a form titled, Resident Representative Designation which allows the representative on behalf of patient to sign the for purposes of nursing facility admission. This form was signed by Resident #133's MPOA on 04/11/17. Resident #133 did not sign this form. Review of Resident #133's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/12/17, found Resident #133's Brief Interview of Mental Status (BIMS) score was 14. This score indicates Resident #133 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #133's MPOA were ever discussed with Resident #133. An interview with the Admission Director, at 10:26 a.m. on 06/29/17, confirmed she completed the admission form with Resident #133's MPOA on 04/07/17 and 04/08/17. She stated, what typically happens we have an admission meeting and the resident is involved in the process if they have capacity. She then reviewed Resident #133's record and stated, It looks like it was not documented the resident was involved in the decisions and wishes of his care. An interview, on 06/29/17 at 11:30 a.m., with Acting Administrator, when the medical records for Resident #133 was reviewed. She confirmed there was no evidence Resident #133 was involved in his medical decisions. No further information was provided.",2020-09-01
2795,WAYNE NURSING AND REHABILITATION CENTER,515168,6999 ROUTE 152,WAYNE,WV,25570,2017-05-05,155,D,1,1,43JR11,"**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 #9 was afforded the right to execute an advanced directive. Resident #9 was determined to have capacity to make medical decisions, however; her son had signed her Physician order [REDACTED]. Resident identifier: #9. Facility census: 55. Findings include: a) Resident #9 A review of Resident #9's medical record, at 1:12 p.m. on [DATE], found this [AGE] year old resident was admitted to the facility on [DATE]. Contained in Resident #9's medical record was a form titled, Authority to act on behalf of patient for purposes of nursing facility admission. This form was signed by Resident #9 on [DATE] and gave her son permission to act as her representative for the purpose of executing the admission agreement. Further review of the record found a POST form signed by Resident #9's son which was also dated [DATE]. This form indicated Resident #9 was designated as Do Not Resuscitate (DNR) with limited additional interventions with Intravenous Fluids for a trial period and no feeding tube. This form was not signed by Resident #9. Further review of the record found a Physician's Determination of Capacity dated [DATE] which indicated Resident #9 was capacitated to make her own medical decisions. Review of Resident #9's admission Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE], found Resident #9's Brief Interview of Mental Status (BIMS) score was 15. This score indicates Resident #9 was cognitively intact. Further review of the record found no evidence to suggest the decisions made by Resident #9's son on her POST form were ever discussed with Resident #9. During an interview with Resident #9 at 10:21 a.m. on [DATE], when asked, Has any one here ever talked to you about your wishes for CPR (Cardiopulmonary Resuscitation) and the use of other life sustaining measures? Resident #9 stated, No they have never talked to me about any of that. She further stated, I am against feeding tubes I don't think I would want one of them to prolong my suffering. An interview with the Social Services Supervisor (SSS), at 10:26 a.m. on [DATE], confirmed she completed the POST form with Resident #9's son on [DATE]. She stated, what typically happens if the resident is capacitated the POST form would be reviewed with the resident to make sure it accurately reflected their decisions in regards to advance directives. She then reviewed Resident #9's record and stated, It looks like I did not follow up with her. She indicated, she must have just missed this and she would follow up with the resident today and clarify the POST form decisions with her.",2020-09-01
3468,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,155,D,0,1,ITHZ11,"**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 choices was afforded the right to refuse a shower without receiving a [MEDICAL CONDITION] medication. Resident identifier: #25. Facility census: 83. Findings include: a) Resident #25 Review of the resident's Medication Administration Record, [REDACTED] [MEDICATION NAME] 0.5 milligrams (mgs) by mouth, as needed (PRN), every 24 hours for aggressive behavior, anxious mood/behavior related to unspecified dementia with behavioral disturbances, give before shower due to frequent refusal of care. Further review of the MAR found the resident had received the PRN [MEDICATION NAME] on 07/25/17, 08/23/17 and 09/03/17. An interview with the director of nursing (DON) at 2:10 p.m. on 9/20/17, found the resident had received the medication on 07/25/17, 08/23/17, and 09/03/17 for aggressive behaviors with non-pharmacological interventions prior to administration. Although the medication had not been administered for refusal of a shower, the DON confirmed the potential still existed for the resident to receive the medication if she refused a shower. The DON said the resident had the right to refuse her showers. She said she was going to call the doctor and get a new order as the current order, should have never been written this way.",2020-09-01
3875,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2016-11-18,155,D,0,1,TJMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews, the facility failed to ensure Resident #52 was afforded the right to have her advance directives incorporated into her treatment regimen, failed to communicate this choice to the Interdisciplinary Team (IDT), and failed to ensure that when the resident experienced a severe weight loss, her treatment reflected this choice. Resident identifier: #52. Facility Census: 52. Findings include: a) Resident #52 Review of Resident #52's medical records on 11/17/16 at 10:00 a.m. found the resident was admitted to the facility on [DATE]. A West Virginia Physician order [REDACTED]. A review of Resident #52's medical record at 9:11 a.m. on 11/17/16, found the following recorded weights (All weight loss/gain Percentages calculated using the following formula % of body weight loss = (usual weight - actual weight)/(usual weight) x 100.): -- Date of admission 01/20/16 - 172.4 pounds (lb) -- 01/31/16 - 169 lbs. -- 02/02/16 - 169 lbs. -- 02/09/16 - 167 lbs. -- 02/15/16 - 168 lbs. -- 02/23/16 - 174 lbs. -- 03/01/16 - 175 lbs. -- 04/01/16 - 176 lbs. -- 05/03/16 - 170 lbs. -- 06/06/16 - 168 lbs. -- 07/05/16 - 165 lbs. -- 07/07/16 - 165 lbs. -- 07/11/16 - 165 lbs. -- 08/02/16 - 161 lbs. -- 09/08/16 - 152 lbs. -- 10/03/16 - 149 lbs. -- 11/01/16 - 148 lbs. From 08/02/16 through 09/08/16, Resident #52 lost 9 lb or 5.6% (percent) in 30 days - a severe weight loss in 30 days. From 06/06/16 through 09/08/16, Resident #52 lost 16 lb or 9.5% in 90 days - a severe weight loss 90 days. From 03/01/16 through 09/08/16 Resident #52 experienced a 23 lb or 13.1% in 180 days - a severe weight loss in 180 days. Guidance to Surveyors related to suggested parameters for evaluating significance and unplanned and undesired weight loss, found in Appendix PP of the CMS (Centers for Medicare and Medicaid Services) State Operations Manual contained the following: Interval Significant Loss Severe Loss 1 month 5% Greater than 5% 3 months 7.5% Greater than 7.5% 6 months 10% Greater than 10 % Review of Resident #52's meal intake percentages found her intakes were poor and inadequate at 1-25% meals consumed and 240 milliliters (ml) to 480 ml of fluids consumed in 24 hours. Review of the Medication Administration Record [REDACTED]. On 11/04/16 at 2:46 p.m., the dietary manager noted, The residents current weight is 148 lbs., in which is a significant weight loss of 13 lbs. or 8.1% in 90 days, 22 lbs. or 12.9% in 180 days. Resident simply refuses to eat, refuses to let staff feed her, refuses care on a daily basis. Dietician recommended changing Health shakes two times a day to Ensure/[MEDICATION NAME] two times daily in hopes resident will consume Ensure. Resident may need a failure to thrive diagnosis. Nurse to discuss this with the physician. To continue to monitor intake, weights and condition changes. No further progress notes were found to indicate the physician was aware of Resident #52's weight loss and Resident #52's desire to have a feeding tube as directed in her POST form. Review of Resident #52's physician's progress notes showed the physician saw the resident on 09/27/16 and 10/25/16 with no mention of weight loss. Interview with the registered dietitian on 11/17/16 at 2:15 p.m., found the resident had had a significant weight loss. She further communicated she did not feel the resident was a candidate for a feeding tube due to [MEDICAL CONDITION] and it was contraindicated. She also stated the resident's weight should be monitored on a weekly weight when a significant weight loss was determined. She confirmed Resident #52 remained on monthly weights. On 11/17/16 at 3:25 p.m., the Director of Nursing was informed of the resident ' s significant weight loss. She was asked to provide information concerning the physician's notification of weight loss and the resident's wish of the resident to have a feeding tube as directed in the POST form. As of the exit of the survey on 11/18/16 at 1:00 p.m. no further information was provided.",2020-04-01
3894,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,155,D,0,1,0MB311,"Based on record review and staff interview, the facility failed to establish and maintain policies about a resident's right to refuse treatment. This had the potential to affect all residents currently residing at the facility. Facility Census: 178. Findings Include: a) Policy In the early afternoon of 09/23/16, the Assistant Nursing Home Administrator (ANHA) was asked to provide the facility's policy and/or procedures which were followed when a resident wished to exercise their right to refuse treatment. At 2:44 p.m. on 09/23/16, the ANHA and Nursing Home Administrator (NHA) both confirmed the facility did not have a policy in regards to the residents' right to refuse treatment. They provided the facility's advance directive policy. This policy did include the following statement, Prior to or upon admission of a resident to the facility, the Social Service Director or designee will provide written information to the resident concerning his/her right to make decisions concerning medical care, including the right to accept or refuse medical or surgical treatment, and the right to formulate and advance directive. The remaining eight (8) statements contained in the policy were solely directed to written advanced directives such as medical power of attorney or a living will, and not the right to accept or refuse medical treatment. At approximately 3:00 p.m. on 09/23/16, the Admissions Coordinator #77 was asked to provide what written information was given to residents upon admission to the facility in regards to advance directives and their right to accept and/or refuse medical treatment other than an advance directive. She referred to the facility's Admission Information Packet pages 14 - 26. The information contained on these pages specifically related to the creation of and the authority of written advance directives such as a Medical Power of Attorney or Living Will. It did not include any information pertaining to the residents' right to accept or refuse medical treatment other than the creation of a written advance directive. At 4:04 p.m. on 09/23/16, while reviewing these findings, the NHA was again asked to provide any written policies or procedures related to the residents' right refuse treatment. As of the time of exit, at approximately 7:15 p.m. on 09/23/16, no further information had been provided.",2020-04-01
4697,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,155,D,0,1,TULX11,"**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 formulate a plan of care with written policies and procedures to provide cardiopulmonary resuscitation (CPR) to residents on the 500 hall/memory care unit; a separate unit isolated from other parts of the building. Staff were unaware of the location of emergency equipment and/or the planned procedure to call for additional staff in the event of a cardiac and/or respiratory emergency. This was found for two (2) of seven (7) residents with advanced directives for CPR residing on the memory care unit. Resident identifiers: #76 and #94. Facility census: 92. Findings include: a) Resident #76 Review of Resident #76's medical record on [DATE] at 11:00 a.m. revealed the West Virginia Physician order [REDACTED]. The resident's care plan with a revised date of [DATE], included, Resident has multiple cardiac issues; CAD ([MEDICAL CONDITION]),[MEDICAL CONDITION](hypertension), [MEDICAL CONDITIONS], stenosis of carotid artery. However, care plan did not reflect the resident's resuscitation status. b) Resident #94 Resident #94's medical record, reviewed on [DATE] at 11:30 a.m., found Resident #94's POST form, signed by her daughter/power of attorney (POA) on [DATE], identified the resident was to receive resuscitation with full interventions. c) Random observations of the unit on [DATE], and on [DATE] at 2:00 p.m., revealed no emergency equipment or written procedures for staff to follow in the event of a cardiopulmonary emergency. d) During an interview on [DATE] at 11:00 a.m. Registered Nurse (RN) #92 reported the 500 hall/memory care unit currently housed seven (7) residents and was staffed every shift by two (2) people - a nurse and a nurse aide (NA). She was unaware of any stairs connecting this unit to the remainder of the building and reported all staff must enter the unit from outside of the building. RN #92 reported Residents #76 and #94 had advanced directives requiring resuscitation with full interventions. When asked about the location of the crash cart and/or emergency supplies, RN #92 acknowledged there was no crash cart and/or emergency supplies for resuscitation on the 500 hall/memory care unit at that time. The future unit director, RN #100, was working on these. In the event of an emergency they would have to call upstairs for assistance. When asked if there was a specific number identified to guarantee someone would answer the phone in the event of an emergency she replied No. The minimum data set (MDS) nurse/director of the memory care unit, RN #100, interviewed on [DATE] at 1:15 p.m., said a crash cart was ordered, but there were currently no resuscitation supplies available on the 500 hall/memory care unit. In addition, she was unaware of any connecting stairs and reported the only way to enter the unit was from the outside of the building. Dietary Aide #101, during an interview on [DATE] at 3:11 p.m., reported there were no stairs and the only access to the 500 hall/memory care unit was from the outside of the building. It was later learned that there was a stairway, but staff working on the unit were not aware of the stairs. Nurse Consultant #136 reported there was no CPR policy for the staff to follow during an interview on [DATE] at 5:30 p.m.",2019-08-01
5101,RALEIGH CENTER,515088,1631 RITTER DRIVE,DANIELS,WV,25832,2015-04-10,155,D,0,1,CRGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, policy review, and resident interview, the facility failed to ensure two (2) of two (2) sample residents, reviewed for the care area of choices during Stage 2 of the survey, were afforded the right to formulate an advanced directive. The facility determined each of the residents had capacity to make health care decisions; however, a family member for each resident signed their Physician order [REDACTED]. Resident Identifies: #32 and #83. Facility Census: 66. Findings Include: a) Resident #32 A review of Resident #32's medical record, at 9:04 a.m. on [DATE], found she was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #32 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #32's attending physician on [DATE]. This form indicated Resident #32 was able to make her own informed medical decisions. The medical record contained a POST form which indicated Resident #32 was not to receive cardiopulmonary resuscitation (CPR). The form also noted she was to receive intravenous fluids and a feeding tube for a defined trail period only. The POST form was signed by Resident #32's daughter on [DATE]. Licensed Practical Nurse (LPN) #36 assisted Resident #32's daughter in completing this form on [DATE], as indicated by the LPN's signature on the back of the POST form. The form went into effect on [DATE], when Resident #32's attending physician signed the form making it a physician's orders [REDACTED].>The medical record contained no evidence indicating Resident #32's wishes for CPR, use of IV fluids, and use of a feeding tube were ever discussed with her. An interview with the Director of Admissions (DOA) #42, at 1:20 p.m. on [DATE], confirmed Resident #32 had capacity to make medical decisions. She stated the POST form should have been completed by Resident #32 and not her daughter. The DOA was unable to provide any information to indicate these decisions were ever discussed with the resident. She stated she would complete a new POST form with Resident #32 as soon as possible. At 3:00 p.m. on [DATE], DOA #42 provided a new POST form completed by Resident #32. This POST form indicated the resident was not to have CPR, was to only have IV fluids for a defined trial period. and was not to have a feeding tube. The resident's wishes in regards to a feeding tube conflicted with the previous POST form completed by her daughter. b) Resident #83 A review of Resident #83's medical record, at 9:14 a.m. on [DATE], found he was admitted to the facility on [DATE]. Review of the resident's admission information found Resident #83 signed all admission paperwork on [DATE]. Further review of the medical record found a Physician Determination of Capacity completed by Resident #83's attending physician on [DATE]. This form indicated Resident #83 was able to make his own informed medical decisions. Resident #83's medical record contained a POST form which indicated he was to receive CPR, and a feeding tube and IV fluids long term if needed. The POST form was signed by Resident #83's daughter on [DATE]. Registered Nurse (RN) #41 assisted Resident #83's daughter in completing this form on [DATE], as indicated by the RN's signature on the back of the form. The form went into effect on [DATE], when Resident #83's attending physician signed the form making it a physician order. The medical record contained no evidence indicating Resident #83's wishes for CPR, use IV fluids, and use of a feeding tube were ever discussed with him. An interview with Resident #83, at 11:30 a.m. on [DATE], revealed facility staff had never spoken with him about his wishes in regards to CPR. He stated, That topic of conversation has never come up with anyone. An interview with DOA #42 and Social Service Director (SSD) #59, at 12:51 p.m. on [DATE], confirmed Resident #83 should have signed his own POST form. SSD #59 stated she had reviewed his code status on his quarterly and admission assessments, but failed to notice Resident #83 had not signed his own POST form. She stated she would have to complete a new POST form with Resident #83. At 4:30 p.m. on [DATE], a POST form dated [DATE] was provided by SSD #59. This form indicated Resident #83 was to receive CPR, and was only to receive IV fluids and a feeding tube for a defined trial period only. His wishes in regards to IV fluids and feeding tube conflicted with the form completed by his daughter. c) Healthcare Decision Making Policy A review of the Facility's Health Care Decision Making policy on [DATE], found the following, .9. Upon admission, quarterly, and with a change in condition, the physician, in collaboration with designated center staff, will meet with the patient or health care decision maker to complete or review advance directives . and define and clarify medical issues .",2019-03-01
5185,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2016-03-03,155,D,1,0,MTOL11,"**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 right to refuse treatment. Resident #5 was given [MEDICATION NAME] ([MEDICATION NAME]) (an atypical antipsychotic medication) although the resident's son did not want the medication given until he read about the drug. This was true for one (1) of three (3) residents reviewed for unnecessary medications during a complaint survey. Resident identifier: #5. Facility census: 125. Findings include: a) Resident #5 Review of Resident's #5's medical records on 03/03/16 beginning at 9:00 a.m., revealed a physician's orders [REDACTED]. A nursing note, dated 07/19/15, revealed the facility called the resident's son, . to see if he wanted [MEDICATION NAME] (same as [MEDICATION NAME]) started. He stated that he would read up on it at home and sign it if he wanted to start the medications when he is in to visit again. I told him I would place the psychotic medication informed consent in her chart for him to sign if he decided to have his mother take it. The Medication Administration Record [REDACTED]. A physician's orders [REDACTED]. An additional physician order [REDACTED]. [MEDICATION NAME] was administered to Resident #5 on three (3) occasions after the resident's son verbally indicated he wanted the antipsychotic medication held until further notice. On 03/03/16 at 2:20 p.m., the director of nursing stated the mediation was given, held, and discontinued according to physician orders.",2019-03-01
5242,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2015-08-06,155,D,0,1,SMTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure the accuracy and clear intent of end of life decisions. The facility physician's orders did not reflect the resident's desire to be a do not resuscitate status in a timely manner. Two different sets of West Virginia Physician Orders for Scope and Treatment (POST) were in the medical record. This practice had the potential to affect one (1) of twenty five (25) stage 2 residents. Resident identifier: #174. Facility census 117. Findings include: a) Resident #174 Resident #174 admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A closed record review performed [DATE] at 3:00 p.m. found she had a physician's order on the date of her admission declaring her a full code status. She filled out a Physician Orders for Scope and Treatment (POST) form twice since her admission requesting to be a do not attempt resuscitate (DNR) status, once on [DATE] and again on [DATE]. There was no physician's order in the medical record designating the resident as a DNR status until the following monthly orders for (MONTH) (YEAR). This matter discussed with the director of nursing (DON), on [DATE] at 9:30 a.m., revelaed the pharmacy received a facsimile of the change in code status, but no evidence of a physician's order in the medical record changing the code status of the resident from [DATE] until [DATE]. During an interview with Social Worker #105 on [DATE] at 9:00 a.m. she said after a POST form is completed, a physician's order is written for DNR if that is what is designated on the POST. She also said a red dot is put on the back (spine) of the hard chart and also a red page stating DNR is placed in the medical record when a resident is of DNR status. Review of HCR Healthcare, LLC procedure for EMERGENCY MANAGEMENT for code status identification, last revised ,[DATE] finds implementation of a color-coded cover sheet may be used to assist with easy access of information. the red sheet signifies no code or no CPR status. Review of the closed record on [DATE] at 9:15 a.m. found no red dot or red sheet in the record. The record review of Resident #174 revealed two (2) POST forms had been completed and signed by both the resident and physician with different wishes expressed in regards to medically administered fluids and nutrition. The first POST completed by the resident was dated on [DATE] and requested intravenous fluids for a trial period of no longer than 1 month. This POST was signed by the physician [DATE]. The second POST completed by the resident and dated [DATE] and it did not designate a length of time for trial of intravenous fluids. It did, however, indicate the resident requested no feeding tube. This form included the signature of the physician on [DATE]. During an interview with social worker #105 on [DATE] at 9:00 a.m. she said because the first POST filled out by the resident [DATE] was actually signed by the physician after the second POST form was completed, the original POST would be the one honored by the facility. She agreed that the resident's wishes last expressed on the POST filled out on [DATE] would not be honored because the physician had signed the first POST on [DATE] after the second POST, [DATE]. She said We usually pull them and put them (the POST forms) in medical records if a new one is completed, but this one must have gotten missed. Instructions for Review of the POS [REDACTED]. If this form is to be voided, write the word VOID in large letters on the front of the form.",2019-02-01
5335,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2015-10-21,155,E,0,1,4PJF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to accurately and consistently incorporate the resident's choices regarding Advance Directives into the clinical record for seven (7) of fourteen (14) residents reviewed. Resident identifiers: #35, #9, #3, #26, #4, #21, and #29. Facility census: 29. Findings include: a) Resident #35 A review of Resident #35's clinical record, at 1:30 p.m. on 10/20/15, revealed the resident was [AGE] years old and was admitted to the facility on [DATE]. Resident #35 was determined by the physician to lack capacity to form her own health care decisions, and the record indicated Resident #35 had appointed a medical power of attorney (MPOA). The resident admission record front sheet indicated, under a section entitled Advanced Directives, that no advanced directives were selected for Resident #35. Further review of the record revealed a Physician Orders for Scope of Treatment (POST) form signed and completed on 03/06/14. In addition, the admission orders [REDACTED]. These findings were reviewed with Social Worker #37 at 2:20 p.m. on 10/20/15. Social Worker #37 acknowledged the statement on the admission record was an error and provided evidence of discussion of the DNR decision with the MPOA at the time of admission to the facility. She agreed the front sheet of the clinical record should reflect that choice and said she would have this corrected. A review of the facility policy entitled: Documentation of Advance Directives, provided by the Social Worker, indicated the existence of the advanced directive was to be entered into the record by the admissions department. If not present at admission, the policy stated, The unit clerk shall follow-up with the patient within 24 hours to secure a copy of the advance directive and will continue to do so during the admission until patient disposition, and This will be scanned to the record by the unit clerk. b) Resident #9, #3, #26, #4, and #21 Further review revealed the same findings for Resident #9, #3, #26, #4, #21, and #29. During an interview with the Social Worker #37, at 3:05 p.m. on 10/20/15, she stated she had reviewed the records of the identified residents, and the same entry had been entered on the front sheets of the clinical record at admission and never updated. During an interview with the director of nurses, at 11:00 a.m. on 10/21/15, she agreed the record should not include conflicting information for communicating the residents' choices to the interdisciplinary team.",2019-01-01
5456,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2015-06-22,155,D,0,1,N2E611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for the care area of choices during the Quality Indicator Survey (QIS), was afforded the right to have her advance directive incorporated into her care and treatment. The resident indicated on her POST form, she did not want a feeding tube; however, a feeding tube was inserted. Resident Identifier: #67. Facility Census: 62. Findings include: a) Resident #67 Feeding Tube Resident #67's POST form, reviewed at 9:46 a.m. on 06/17/15, also revealed the resident indicated No feeding tube. Under section C titled: Medically administered fluids and nutrition: Oral fluid and nutrition must be offered as tolerated, an X was placed in the box beside, No feeding Tube, indicating the resident's wish to not have a feeding tube. According to information on the POST form, LPN #6 assisted the resident in completing the form on 12/20/14. The resident's medical record contained a Physician Determination of Capacity, completed on 12/30/14, by Licensed Psychologist #77. This form indicated Resident #67 lacked capacity to make healthcare decisions due to Multiple Infarct Dementia, cognitive loss, inappropriate answers to questions, and inability to understand or make medical decisions. Licensed Psychologist #77 indicated the incapacity would be short term in nature and would likely improve as the resident's medical condition improved. Also contained in Resident #67's medial record, was a medical power of attorney (MPOA) form, completed by Resident #67 on 08/26/13, appointing her niece as her MPOA. Additional review of the medical record found a physician's progress note dated 04/13/15, which contained the following text (typed as written): Spoke with MPOA and agreed for PEG (Percutaneous endoscopic gastrostomy) placement with (Name of local Physician) ASAP (as soon as possible). Resident #67's medical record contained information which indicated the resident had a gastrostomy tube ([DEVICE]) placed at a local hospital on [DATE]. An interview with the Director of Nursing (DON), at 11:24 a.m. on 06/17/15, confirmed Resident #67 had a [DEVICE] inserted on 04/15/15. When asked why the resident's directive for No feeding tube on the POST form was not honored, the DON stated the resident did not fully understand the form when it was completed with her on 12/20/14. She said she felt Resident #67 did not fully comprehend the form. The DON was unable to answer, when asked if the resident's wishes were honored. An interview with Resident #67's attending physician, at 11:32 a.m. on 06/17/2015, revealed Resident #67 needed the feeding tube because her wounds were getting worse, she was losing weight, and she was refusing to eat. He stated he talked to Resident #67's MPOA, who was in agreement with having the tube inserted. When asked why the MPOA was allowed to make a decision contrary to the resident's wishes, the physician stated, I don't really think she was capacitated when she completed the POST form. He stated he wanted to wait for the psychologist to review her capacity because of her [DIAGNOSES REDACTED]. The physician said later, the information the resident provided was found inaccurate. When asked why the resident was sent for a feeding tube when her POST form indicated she did not want one, he stated, She knew what she was going for she could have refused to go to the appointment if she did not want it.",2019-01-01
5526,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,155,D,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to afford Resident #99 the right to formulate an advanced directive. This was found for one (1) of five (5) sampled residents. Resident #99 was deemed to have capacity to make medical decisions; however, the facility allowed someone other than the resident to make decisions in regards to his advanced directives and/or refusals of treatment. Resident identifier: #99. Facility census: 98. Findings include: a) Resident #99 A review of Resident #99's medical record, at 1:10 p.m. on [DATE], found a Physician's Determination of Capacity completed by Resident #99's attending physician on [DATE]. This form indicated Resident #99 maintained capacity to make his own healthcare decisions. Further review of the record found a West Virginia Physician order [REDACTED].#99's attending physician on [DATE]. This form indicated Resident #99 was to receive cardiopulmonary resuscitation (CPR) in the event he would need it. This form was signed by another person, not the resident. There was no indication the resident was consulted about this decision or had asked for another person to sign on his behalf. The person who signed the POST form also signed a Psychoactive Medication Informed Consent form and an Informed Refusal of Treatment consent form on behalf of Resident #99. These forms were signed on [DATE], again with no evidence of input by the resident. An interview with Social Service Director (SSD) #21 and Social Worker (SW) #55, at 3:13 p.m. on [DATE], confirmed Resident #99 was deemed to have capacity to make healthcare decisions on [DATE] by his attending physician. SSD #21 and SW #55 indicated that until the attending physician saw the resident and made a determination of incapacity, the capacity of a resident who was alert and orientated should be assumed. They stated even though Resident #99 was somewhat confused on admission, his capacity should have been assumed. SSD #21 confirmed another person should not have signed the referenced forms because the resident's capacity was presumed and he had the right to make the decisions in regards to CPR, psychoactive medication use, and any refusals of treatment he chose.",2018-11-01
5645,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2015-07-29,155,D,0,1,DSPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to ensure the responsible party of a resident with a severe decline in health status was given information about the resident's rights regarding cardiopulmonary resuscitation and the facility's policies regarding exercising these rights. Resident identifier: #98. Facility census: 99. Findings include: a) Resident #98 A review of the clinical record revealed that Resident #98 was a [AGE] year old male initially admitted to the facility on [DATE]. He had been determined by his physician to lack the capacity to make health care decisions and his brother was indicated as his MPOA (Medical Power of Attorney). He was designated to be a Full Code. His present [DIAGNOSES REDACTED]. These [DIAGNOSES REDACTED].#217 at 10:15 a.m. on 07/22/15. The resident had multiple hospitalization s in (YEAR). When discharged to the hospital on [DATE], his skin was clear with no pressure ulcers and on readmission on 04/02/15, his admission physical indicated [MEDICAL CONDITION] of his lower extremities, but no evidence of pressure ulcers. A Significant Change comprehensive assessment was completed on 04/09/15. An entry in the clinical record by NP #217 on 05/21/15, indicated the resident had multiple unstageable pressure wounds. His last readmission was 07/08/15 and although there was no terminal [DIAGNOSES REDACTED]. The record on readmission indicated Resident #98 was a Full Code. The record indicated Resident #98 now had 1 unstageable pressure ulcer and 11 DTI's (deep tissue injury) and the treatment goal stated by the NP/Physician stated, Expectation is for non-healing with goal to prevent worsening of wounds. The care plan meeting notes from 07/19/15, indicated he was a Full Code; had recent cognitive changes and scored 0/15 on his BIMS (brief interview for mental status); and was refusing oral intake. There was no evidence of any discussion of the resident's status with the MPOA. During an interview with the resident's brother/MPOA at 9:35 a.m. on 07/21/15, he said he knew the resident had been getting worse for the past few months and when asked what the plan of care was at present; he stated they wanted him to eat more and be able to get out of bed more. The resident, observed during the conversation was very frail and thin, with pale skin. He was lying on one side with his knees drawn up. He was awake but did not respond when spoken to. During an interview with Social Worker (SW) #145 at 2:00 p.m. on 07/23/15, she was asked if there had been a discussion with the MPOA about changing the Code status or about the use of palliative care or Hospice when the resident's health status deteriorated. She stated she had no knowledge of this and referred to SW #154, who was unavailable at that time. At 10:50 a.m. on 07/27/15, SW#154 was interviewed and also asked the same questions. She stated she had spoken to the MPOA and he had refused to change the Code status, but would have to review her notes. At 11:45 a.m. SW #154 returned after reviewing the record and stated she had been unable to find written evidence of discussing the Code status with the MPOA. At 4:30 p.m., on the same day, SW #154 stated she had re-explained Advanced Directives to the resident's brother/MPOA and had entered that into the record.",2018-09-01
5712,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2014-11-19,155,D,0,1,H5V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to involve the resident in formulating an advance directive. A medical power of attorney (MPOA) and physician filled out paperwork designating a resident as Do Not Resuscitate (DNR) without discussing the matter with the resident. This is true for one (1) randomly reviewed resident. Resident identifier: #211. Facility census: 110. Findings include: a) Resident #211 An interview conducted with the social worker occurred on [DATE] at 4:00 p.m. Two (2) surveyors witnessed this interview. The social worker stated Resident #211 was readmitted to the facility in (MONTH) 2014 and he no longer had capacity. The social worker said the medical power of attorney (MPOA) was who she contacted for issues such as care planning. A medical record review was performed, on [DATE] at 10:00 a.m., where a note was found written by the social worker. The note dated [DATE] stated Resident is a do not resucitate DNR and has a DNR order, MPOA, durable power of attorney (DPOA), and living will (LW) posted on his chart. Resident lacks capacity and is oriented to person, place and time. Resident's brief interview of mental status (BIMS) is 13 . According to the Minimum Data Set (MDS) completed with an assessment reference date (ARD) of [DATE], the resident had a BIMS of 13. This score means cognitively intact. The resident also had a capacity statement on the chart stating he had capacity, signed and dated by a physician on [DATE]. The medical record contained a physician prescription stating DNR signed and dated by a physician on [DATE]. There was also a Release of Liability for Withholding of Life Prolonging Interventions filled out by the resident's MPOA requesting to withhold CPR on [DATE]. This form was not signed and dated by the physician until [DATE], the same date the resident was determined to have capacity. On [DATE] at 10:30 a.m. an interview was held with the resident regarding his wishes for life prolonging measures. He stated no one has discussed this with him and also I think CPR (cardiopulmonary resuscitation) would be good! This matter was then discussed with the social worker on, [DATE] at 10:45 a.m., and she could not find evidence that the matter of life prolonging measures was ever discussed with the resident prior to the DNR order being written.",2018-08-01
5827,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2015-01-29,155,D,0,1,3O8G11,"**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 twenty-three (23) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) was afforded the right to refuse treatment. The resident desired a code status of Do Not Resuscitate (DNR); however, cardiopulmonary resuscitation (CPR) was performed on the resident. Resident identifier: #56. Facility Census: 67. Findings Include: a) Resident #56 Review of medical records, on [DATE] at 9:00 a.m., revealed Resident #56 was admitted on [DATE] and died on [DATE]. The medical record contained a Pre-admission Report Sheet which listed the resident as a DNR. Handwritten notes from the hospital discharge report also designated the resident as a DNR. A nursing progress note, dated [DATE] at 08:45 a.m., by Employee #100 included, Unable to get B/P, pulse or resp. at this time. Unable to verify post (POST - physician's orders [REDACTED]. Dr. (physician name) entered facility and called to res. room. Orders received to initiate CPR until post verified. CPR initiated by nursing staff. Review of the resident's interim care plan, dated [DATE], showed the advance directives section was blank and not filled out. The interim care plan is the method nursing staff use to be aware of each resident's immediate needs. On [DATE] at 4:35 p.m., the Social Worker (SW) said, The interim care plan should be completed by the admitting nurse. The SW reviewed the interim care plan for Resident #56 and confirmed the advanced directive section was not completed, but should have been completed by the admitting nurse. On [DATE] at 5:05 p.m., interview with Employee #53, a registered nurse (RN), revealed this was the nurse who admitted Resident #56 to the facility on [DATE] at 10:22 p.m. The nurse confirmed the advance directive section of the interim care plan should have been filled out upon the resident's admission. Employee #53 said he/she must have been missed filling out that section when completing the physician's orders [REDACTED].",2018-07-01
5860,HILLCREST HEALTH CARE CENTER,515117,462 KENMORE DRIVE,DANVILLE,WV,25053,2014-11-17,155,D,0,1,LO0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and policy review, the facility failed to allow one (1) of four (4) Stage 2 residents reviewed for the care area of choices, the right to formulate an advanced directive related to cardiopulmonary resuscitation (CPR). After Resident #89 regained the capacity to make her own healthcare decisions, the facility failed to provide the resident the right to choose whether or not she wanted to receive CPR should it be necessary. Resident identifier: #89. Facility census: 87. Findings Include: a) Resident #89 Review of the resident's medical record at 10:08 a.m. on [DATE], revealed she was admitted to the facility on [DATE], at which time she lacked capacity to make healthcare decisions. Her son was appointed as her health care surrogate (HCS). The medical record contained a physician's orders [REDACTED]. The POST form indicated Resident #89 was to receive CPR in the event she would need it. Additional review of the medical record revealed a physician's determination of capacity completed by Resident #89's attending physician on [DATE]. This form indicated Resident #89 demonstrated capacity to make medical decisions. There was no evidence in the medical record to indicate the facility had ever discussed with Resident #89 her wishes in regards to CPR after she regained her capacity to make health care decisions on [DATE]. In an interview with Resident #89 at 11:27 a.m. on [DATE], she was asked if any one at the facility had ever discussed with her what her choices in regards to CPR would be. Resident #89 replied, No honey, they have never talked to me about that. I would want it because I want to live as long as possible, wouldn't you? An interview with the Social Service Supervisor (SSS), at 1:08 p.m. on [DATE], revealed if a resident was incapacitated upon admission to the facility, but then regained capacity at a later date, a new POST form should be completed with the resident to reflect his/her choice, not the choices of the health care decision maker. The SSS was asked if Resident #89 was afforded the right to complete a new POST form when she regained capacity on [DATE]. The SSS reviewed the medical record and indicted there was never a new POST form completed with Resident #89 and she would have to go speak with the resident and complete a new form. The SSS stated, they discussed CPR in the quarterly care plan meetings, but they never completed a new post form with Resident #89. The facility's advance directive operations policy was reviewed at 12:30 p.m. on [DATE]. The policy contained the following statements in regards to advance directives, .10. At least annually and following any changes or revocations to the documents, the Interdisciplinary Team (IDT) will review his/her advance directives with the patient to ensure that such directives are still the wishes of the patient. Such reviews will be recorded in the patients clinical record. The IDT shall be responsible to ensure that the patient's current plan of care reflects the patient's expressed directives for treatment. Review of the care plan meeting notes for Resident #89 for the previous year revealed no mention of Resident #89's wishes in regards to CPR. The facility was unable to provide any evidence from Resident #89's clinical record to indicate the facility had reviewed the POST form with Resident #89 since she regained capacity on [DATE].",2018-07-01
6079,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,155,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to ensure four (4) of thirty-four (34) sample residents were afforded the right to formulate an advance directive. The facility failed to clarify and periodically review existing advance directives. Advance directives were not accurately documented to effectively communicate the resident's choices to the direct care staff should the need to implement, or not implement, cardiopulmonary resuscitation (CPR) arise. Resident identifiers: #114, #130, #99, and #5. Facility census: 100. Findings include: a) Resident #114 A medical record review was conducted on [DATE]. Resident #114 had a FULL CODE sticker on his condition alert tab in the chart. A green page in the chart stated Full Code. The monthly physician's orders [REDACTED]. (A full code would mean the facility would attempt to resuscitate the resident.) The resident's West Virginia Physician order [REDACTED]. The POST form was signed by the medical power of attorney on [DATE], and was signed by the physician on [DATE]. The information on the POST form was not transferred to the remainder of the medical record. b) Resident #130 Resident #130 was admitted to Hospice services on [DATE]. A copy of a physician's prescription on the medical record stated Please make patient DNR (do not resuscitate) dated [DATE]. This information was not updated in the medical record. His condition alert tab stated FULL CODE. A green page in the medical record stated Full Code. A sticker was placed on this page stating, Do Not Thin From Chart. A physician's orders [REDACTED]. No POST form was in the medical record. c) Resident #99 The condition alert tab in the medically record of Resident #99 did not address the code status of Resident #99. A Medical Power of Attorney, notarized [DATE], stated Do Not Resuscitate. The physician's orders [REDACTED]. No POST form was present. This medical record provided conflicting information in regards to the resident's choice of code status. d) Resident #5 A POST form, signed by the physician on [DATE], was marked Do Not Resuscitate. The physician's orders [REDACTED]. The condition alert tab, which was intended as a reference for staff, had a sticker stating FULL CODE. e) Staff interviews were held on [DATE] at 12:00 p.m. with the licensed nurses on duty. Employee #151, an agency Licensed Practical Nurse (LPN), stated she relied on the sticker on the Condition Alert tab as a reference in an emergent situation regarding the resident's condition Employee #69, LPN, stated she also referred to the sticker on the Condition Alert tab. Another LPN, Employee #110, stated she looked for a red or green paper in the chart to let her know the code status of a resident and compared it to the POST form. Employee #52, LPN, stated she looked on the Condition Alert tab and compared it to the POST form. The conflicting information found in the medical record and among staff members in regards to code status was discussed with the Administrator, Employee #120, and the Director of Care Delivery, Employee #124, Registered Nurse (RN) on [DATE] at 1:00 p.m. They acknowledged there was conflicting information in the residents' medical records. A policy, revised ,[DATE], was provided titled, Emergency Management code status identification. This policy stated, Review and documentation of new physician orders [REDACTED]. Employee #120 stated a new process was going to be put into place effective immediately due to the breakdown of the current system.",2018-05-01
6290,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2014-04-15,155,D,0,1,ZU6S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, interviews with the contracted facility staff, and interview with the resident's medical power of attorney, the facility failed to ensure a resident's rights were honored for one (1) of twenty-nine (29) residents reviewed in Stage 2 of the Quality Indicator Survey. The resident received anticoagulant therapy at the [MEDICAL TREATMENT] center. His medical record indicated he did not want anticoagulant therapy due to religious beliefs. Resident identifier: #169. Facility census: 105. Findings include: a) Resident #169 A medical record review, completed on 04/14/14 at 9:00 a.m., revealed Resident #169 received [MEDICAL TREATMENT] services. The current care plan indicated the facility would coordinate care with the [MEDICAL TREATMENT] center. A hospital discharge summary, dated 03/08/14, noted the resident did not receive anticoagulation therapy related to his religious beliefs. In addition, a physician's progress note included, (name of religion) . no anticoagulant therapy. During an interview with the medical power of attorney, on 04/14/14 at 4:30 p.m., she conveyed Resident #169's religious preferences were very important to him. She confirmed he did not want anticoagulant therapy. Upon inquiry, she related she was unaware of the [MEDICAL TREATMENT] process. She said the [MEDICAL TREATMENT] center had spoken with her, but she did not know how the process worked. An interview with [MEDICAL TREATMENT] staff, on 04/14/14 at 5:30 p.m., revealed they were not aware of the resident's refusal of anticoagulant therapy. Staff member #182, a registered nurse (RN) and Staff member #183 (RN) said information regarding the resident's preference for refusal of anticoagulant therapy was not conveyed to them. Employee #183 said communication with the facility was usually limited to communication forms. In addition, the [MEDICAL TREATMENT] center staff related they were not invited, and had never participated in the facility's care plan process. Employee #182 explained options, other than [MEDICATION NAME], were available for the resident, such as saline flushes. Review of the agreement between the facility and the outpatient [MEDICAL TREATMENT] services revealed the facility would make the necessary individual resident clinical records available as necessary for the [MEDICAL TREATMENT] center to furnish its services. The director of care delivery (DCD), Employee #101, was interviewed on 04/15/14 at 8:30 a.m. regarding what pertinent information was shared with the [MEDICAL TREATMENT] center. She said the information provided to the [MEDICAL TREATMENT] center consisted of a copy of the Medication Administration Record, [REDACTED]. There was no evidence the hospital discharge summary, dated 03/08/14, which noted the resident did not receive anticoagulation therapy related to his religious beliefs, or the physician's progress note which included (name of religion) . no anticoagulant therapy were shared with the [MEDICAL TREATMENT] center. Upon exit, the facility had provided no evidence to indicate an attempt was made to ensure Resident #169's right to refuse treatment in regards to religious preferences was honored.",2018-04-01
6331,DAWN VIEW CENTER,515163,PO BOX 686,FORT ASHBY,WV,26719,2014-07-09,155,D,0,1,2M0C11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a resident who had been determined by her attending physician to have the capacity to make her own healthcare decisions was provided with appropriate information and/or involved in the formulation of her advance directive. She was one (1) of a total of thirty-one (31) residents (both with and without capacity) in the sample reviewed. Resident identifier: #29. Facility census: 66. Findings include: a) Resident #29 A review of Resident #29's medical record revealed she was admitted on [DATE]. At that time, her attending physician deemed she had the capacity to form her own healthcare decisions. There was no evidence in the record stating she wished another individual to make her decisions. She had a Full Code (wanted to be resuscitated and have all life saving measures implemented) decision documented on admission. The resident's Physician order [REDACTED]. The form indicated the decision was explained to only MPOA (medical power of attorney), and was signed by the daughter (MPOA). There was no indication in the record the resident was involved in the decision or that it had been explained to her. During an interview with the director of nurses (DON) and the Social Worker (SW), at 2:00 p.m. on 06/30/14, the DON verified the resident was alert and oriented, and was able to make her needs known. The Social Worker said he remembered the daughter attending a care plan meeting and requesting a change to the DNR status, but he did not remember the resident being present. The SW returned at 2:20 p.m. on 06/30/14, after reviewing the entire record and acknowledged there was no documentation of a request by the resident instructing anyone to sign for her or that she was aware of the change in her code status. The care plan was revised to DNR status on 04/29/14, and included a nursing intervention stating, Inform (Resident #29) and/or healthcare decision maker of any change in status or care needs and Provide (Resident #29)/healthcare decision maker with sufficient information to make an informed decision.",2018-04-01
6889,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,155,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview and policy review, the facility failed to allow two (2) of three (3) Stage 2 residents reviewed for choices, the right to formulate an advanced directive related to Cardiopulmonary Resuscitation (CPR). Both residents were determined to have capacity to make medical decisions upon their admission to the facility. The facility allowed each resident's appointed Medical Power of Attorney to sign their Physician order [REDACTED]. Resident identifiers: #53 and #32. Facility Census: 85. Findings Include: a) Resident #53 Resident #53's medical record was reviewed at 10:24 a.m. on [DATE]. This review revealed the resident was admitted to the facility on [DATE]. The review also revealed a determination of capacity, completed on [DATE], which indicated the resident had capacity to make medical decisions. The resident's medical record contained a POST form dated [DATE]. This form indicated the resident was to receive CPR should she need it. The form was signed by Resident #53's appointed Medical Power of Attorney. The date this form was signed by the MPOA was left blank. The physician signed the POST form, making it an order, on [DATE]. Resident #53 was interviewed at 11:30 a.m. on [DATE]. When asked if she would want CPR should she need it, she replied, I would not want to have CPR. No one here has ever asked me about CPR, but I know I would not want to have it. She further stated, I would want to tell my son before I made any final decisions just to let him know what my plan was. The facility's Notification of Advance Directives policy was reviewed on [DATE] at 11:00 a.m This review revealed the following: The health care center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation, and the right to formulate advanced directives such as living will (declaration to physicians, power of attorney for health care, or health care surrogate The Social Service Director job description was reviewed on [DATE] at 9:15 a.m. This review revealed the following key responsibility related to resident rights under the heading, Key Responsibilities . 9. Acts as resident/family advocate and ensures the resident is knowledgeable in and exercises his/her rights. Employee #88, Social Service Director, was interviewed at 02:24 p.m. on [DATE]. She stated if Resident #53 had capacity, she should have signed her own POST form. The Social Service Director confirmed Resident #53 was not afforded her right to formulate an advanced directive related to CPR. The Social Service Director stated she was aware it was Resident #32's right to formulate an advance directive, but was not aware Resident #32 had not signed her own POST form. The Social Service Director stated, To my recollection I have never talked to this resident about CPR. She confirmed she was unaware Resident #53 had not signed her own POST form. b) Resident #32 Resident #32's medical record was reviewed at 10:00 a.m. on [DATE]. This review revealed the resident was admitted to the facility on [DATE]. The review also revealed a determination of capacity, completed on [DATE], which indicated the resident had capacity to make medical decisions. The Resident's medical record contained a POST form dated [DATE]. This form indicated the resident was not to receive CPR. The form was signed by the resident's appointed Medical Power of Attorney on [DATE]. The MPOA was not in effect because Resident #32 had capacity to make medical decisions at the time the MPOA signed the form. The facility's Notification of Advance Directives policy was reviewed at [DATE] at 11:00 a.m. This review revealed the policy included, The health care center informs and presents written materials to the residents who are admitted pertaining to their legal rights and decisions about medical care. These rights include the right to accept or refuse medical or surgical treatment, the right to choose to receive cardiopulmonary resuscitation, and the right to formulate advanced directives such as living will (declaration to physicians, power of attorney for health care, or health care surrogate. An interview was conducted with Employee #88, Social Service Director, at 12:13 p.m. on [DATE]. She stated if Resident #32 had capacity, she should have signed her own POST form. The Social Service Director confirmed Resident #32 was not afforded the right to formulate an advanced directive, related to choosing whether or not to receive CPR. The Social Service Director stated she was aware it was Resident #32's right to formulate an advance directive, but was not aware Resident #32 had not signed her own POST form. The Social Service Director stated, Since they have a dementia diagnosis, staff is assuming they do not have decision making ability and is just letting the decision maker sign the forms on admission. When asked to describe the typical process for establishing a POST form, the Social Worker stated, The practice is typically if the resident seems with it they will allow the resident to sign the forms otherwise they will wait until the doctor determines the resident's capacity.",2017-11-01
6989,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2013-12-18,155,D,0,1,EUXT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure a resident was afforded the right to formulate an advanced directive. This was found for one (1) of four (4) sample residents reviewed for the care area of choices during Stage 2 of the survey. The resident's code status was determined by a medical decision maker during a time the resident did not have capacity to make medical decisions. The code status was not reevaluated with the resident when she regained capacity to make health care decisions. Resident Identifier: #91. Facility Census: 130. Findings Include: a) Resident #91 Resident #91's medical record was reviewed at 1:00 p.m. on 12/17/13. This review revealed two (2) Physician's Determination of Capacity forms. The first form was dated 12/04/13 and determined the resident had capacity to make medical decisions. The second form was dated 12/07/13, and also determined the resident had capacity to make medical decisions. The record also contained a social service progress note, dated 12/11/13, written by Employee #62, Social Worker. This note revealed Resident #91 was reevaluated for capacity because she had scored a 15 on her latest Brief Interview for Mental Status (BIMS). She indicated Resident #91 was reevaluated by two (2) physicians and had regained her ability to make medical decisions. Further review of Resident #91's medical record revealed a Do Not Resuscitate form. This form contained the following paragraph, I, the undersigned resident or duly authorized legal representative, have made a decision regarding resuscitation in the event that I (the above named resident) am discovered without respiration or pulse. The affected resident or legal representative wishes that medical personnel in attendance would NOT initiate cardiopulmonary resuscitation. I understand I may revoke these directions at any time. This form contained Resident #91's name. It was signed by her Legal Representative on 09/26/12. At the time the form was signed by the legal representative, Resident #91 did not have capacity to make healthcare decisions. A physician's orders [REDACTED]. There was no indication the facility reviewed the Do Not Resuscitate order with Resident #91 when she regained capacity to make medical decisions on 12/07/13. Resident #91 was interviewed at 2:15 p.m. on 12/17/13. She stated no one had ever talked to her about Cardiopulmonary Resuscitation. Employee #62, Social Worker, was interviewed at 2:35 p.m. on 12/17/13. She stated she had not reviewed Resident #91's advance directives with her since she regained capacity to make health care decisions. She confirmed the resident's Do Not Resuscitate status was something she should have reevaluated with the resident when the resident regained capacity to make medical decisions. .",2017-09-01
7172,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2014-07-16,155,D,1,0,1X1U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to determine on admission whether a resident, who had been determined by her attending physician to lack the capacity to form her own health care decisions, had an advance directive formulated by the appropriate legal representative and in compliance with State requirements regarding advance directives. This decision applied to one (1) of nine (9) residents reviewed during the investigation of a complaint. Resident identifier: #61. Facility census: 104. Findings include: a) Resident #61 A review of the medical record revealed Resident #61 was a [AGE] year-old female admitted to the facility on [DATE] from an acute care hospital. Her [DIAGNOSES REDACTED]. She also had deep tissue injury to both feet, right hip, coccyx, both ears, and left hip. The 5 foot, 4 inch tall resident weighed 90.2 pounds on admission. Both the physician who discharged the resident from acute care and the attending physician at the nursing home, who was the resident's prior family physician, determined the resident lacked the capacity to process the information needed to form her healthcare decisions. A review of the hospital records forwarded to the facility revealed the resident had been referred to Adult Protective Services (APS) on admission to the hospital ([DATE]) because of suspected elder abuse neglect. A Forensic Nurse Examiner Consult completed on [DATE], revealed, . patient is confused, does know her name and that she lives in (name of town/city). The Nurse affirmed an APS referral had been made. She also indicated the hospital Social Worker had informed them the resident's Son #1, who was indicated to be the responsible party, had agreed to nursing home placement. The Discharge Instructions from the hospital included, Resuscitation Status: No CPR (cardiopulmonary resuscitation), . A form entitled (Name of other state) Medical Orders for Life - Sustaining Treatment (_OLST) accompanied the resident. It indicated the resident's surrogate was the basis for the orders which included DNR (do not resuscitate), but there was no evidence the resident had a legal surrogate and the form stated, It is valid in all health care facilities and programs throughout (name of other state.) Furthermore, there was no signature of the resident and/or legally responsible party on the form. Resident #61 was admitted to the facility on [DATE]. The nurses' notes indicated she arrived via ambulance and indicated notification of Son #2 and his wife. There was no evidence of attempt to contact Son #1. The nurses' notes revealed Son #1 was in to visit the resident on the evening of her admission ([DATE]). During a review of the clinical record for Resident #61 at 9:00 a.m. on [DATE]. a full-sized red paper was observed on opening the chart stating she was Do Not Resuscitate (DNR) status. Further review failed to reveal documented evidence of a physician's orders [REDACTED].#61. The resident had been deemed to lack the capacity to form her own health care decisions by the attending physician, who had also written an order for [REDACTED]. During an interview with Employees #119 and #131 (both Licensed Social Workers) at 10:00 a.m. on [DATE], they were asked to provide evidence that Resident #61 had a legally appointed health care surrogate. Employee #131 stated the daughter-in-law was making decisions, but she acknowledged the absence of a HCS document, and stated Son #2 and his wife had gone on vacation and said they would take care of that on their return. When asked about the status of Son #1, they stated they had been unable to reach him and he had not contacted them, but there was no supporting evidence of the attempts. A review of the entire record revealed only one (1) entry of an attempt to reach Son #1 since admission, and it was by the DON (director of nurses) on [DATE]. At 11:35 a.m. on [DATE], Resident #61 was observed meeting her son (Son #1) in the hall next to the South Nurses' Station. Both were happy to see the other and greeted each other warmly. Both were being pushed in wheelchairs. They continued to the dining room and were observed sitting next to each other during the meal where he stayed to visit her while she ate. During an interview with Employee #131 at 2:00 p.m. on [DATE], she stated she had contacted APS and confirmed an investigation was pending. She had also contacted the attending physician who informed her he was the family doctor for both the resident and Son #1, who was also sick. When asked why there was still no evidence of a legally designated responsible party, no POST form, or no signed admission forms/consents of any kind on the chart; she stated she had been waiting for Son #2 to return from vacation and had been unable to reach Son #1. She also pointed out the front sheet on the record had been changed and Son #2 and his wife were no longer entered as HCS designees. Employee #131 was asked for evidence the DNR decision had been made by a legally designated responsible party since her chart was flagged to indicate she was not to be resuscitated. She stated the physician had written a DNR order and produced the _OLST document. She admitted she had not discussed the resident's DNR status with any family member. A note written by Employee #131 at 1:34 p.m. on [DATE], stated, SS (social services) spoke with resident's physician who stated that he has MPOA (Medical Power of Attorney) paperwork on resident. At 2:20 p.m. on [DATE], Employee #131, accompanied by the DON produced a HCS form dated [DATE] and signed by Son #2 on [DATE] (today) appointing him HCS. She also had a copy of the MPOA form dated [DATE] naming Son #1, which, per the time stamp, had been received via fax at 12:29 p.m. on [DATE]. Employee #131 stated she had called a local attorney and he said if they couldn't reach the MPOA, the physician could revoke the MPOA d/t the neglect allegation made to APS and re-assign the HCS to Son #2 because he was the successor representative on the MPOA document. They had no comment when informed Son #1, accompanied by his son, was in earlier and visited with the resident throughout lunch. Employee #131 did agree there had been no information from APS confirming the allegation investigation had been completed and/or substantiated; and there was no evidence of documentation by the physician of revocation of the MPOA, although he had signed the HCS form on [DATE]. The resident's chart continued to indicate she was DNR status at 3:00 p.m. on [DATE]. During an interview with Employee #131, the Administrator, and the DON at 2:15 p.m. on [DATE], the Administrator reported they had contacted Son #1 and he had immediately given them a verbal authorization for the DNR status which was witnessed by two staff members. He then came directly to the facility and informed them he intended to remain the MPOA.",2017-07-01
9033,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2013-03-14,155,D,0,1,RKHC12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and policy review, the facility failed to assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a Full Code. This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, The resident desires to be a DNR. The goal contained on the care plan was, DNR will be honored upon absence of pulse, respirations, and/or blood pressure. The care plan contained the following interventions. 1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family. Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: It was questioned whether or not the son would request comfort care. He did make her a do not resuscitate, do not intubate. The medical record contained a Physician's Determination of Capacity, dated [DATE], which identified the resident demonstrated the capacity to make healthcare decisions. Finally, the medical record did not contain any evidence to suggest Resident #193 ever told facility staff she had a desire to have a DNR order. At 9:45 a.m. on [DATE], a resident interview was conducted with Resident #193. The resident was alert and orientated to time, place, and person. She was able to answer questions appropriately. She was asked if she had told the facility what her wishes were in regards to CPR. She stated, I have never really thought about whether or not I would want CPR. She further stated, I have never told anyone here that I did not want CPR. She stated, No one has ever asked me that before. At 9:52 a.m. on [DATE], Employee #108, Licensed Practical Nurse (LPN) and Employee #90, Registered Nurse (RN) were interviewed. They were asked how they determined whether or not to initiate CPR on a resident. They both confirmed they looked at the resident's Condition Alert sheet in the front of the chart for a DNR sticker. They stated if there was no sticker, they then looked at the resident's POST form. If there was no POST form, they reported they would look at the physician's orders [REDACTED].>At 10:00 a.m. on [DATE], Employee #51, the social worker, was interviewed. She stated the resident was a Full Code. She referred to the care plan conference summary sheet dated [DATE]. She confirmed she had not discussed this with the resident since her return from the hospital. She confirmed the resident had a physician's orders [REDACTED]. Employee #51 confirmed the resident had not signed any paperwork at the facility to indicate she would want to be a DNR. Employee #51 also confirmed the resident had a DNR care plan. At 10:22 a.m. on [DATE], Employee #108, an LPN, was asked to review the medical record of Resident #193 and to indicate if he would perform CPR on the resident should she have an absence of pulse, respirations and/or blood pressure. The LPN reviewed the medical record and indicated he would not perform CPR on this resident because she had a physician's orders [REDACTED]. At 10:25 a.m. on [DATE], Employee #46, an RN, was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident should she have an absence of pulse, respirations and/or blood pressure. The RN reviewed the medical record and stated she would not perform CPR on this resident because she had a physician's orders [REDACTED]. Employee #72, RN, Director of Nursing (DON), was interviewed at 10:30 a.m. on [DATE]. She was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident if there was an absence of pulse, respirations, and/or blood pressure. She stated she would perform CPR on this resident because she did not have a DNR sticker on her condition alert page in the front of her chart. The DON then reviewed the chart with the surveyor and confirmed the resident had a physician's orders [REDACTED]. She also confirmed the absence of a POST form and of a DNR sticker on the condition alert form at the front of the resident's medical record. At 10:35 a.m. on [DATE], Employee #37, the social worker, reported the facility contacted the acute care hospital and now had a form which the resident had signed while in the hospital. Employee #37 also reported, Employee #51 had spoken with Resident #193 and completed a POST form. The resident indicated to Employee #51 she wanted CPR should it be needed. The POST form was completed to reflect the resident's wishes regarding end of life care. Later in the afternoon of [DATE], Employee #37 provided a copy of a Do not Resuscitate and Limited Resuscitation orders (DNR) form. This form was completed at the acute care hospital on [DATE]. The form was faxed to the facility at 12:31 p.m. on [DATE]. This form was not signed by Resident #193. It was instead signed by her MPOA. The form was also not signed by a physician which meant it was not a valid physician's orders [REDACTED].>The facility's Advance Directives policy was reviewed at 8:00 a.m. on [DATE]. The policy states, The Social Services Director/Designee assists the resident or legal representative with any questions regarding Advanced Directives at the time of admission by providing them the Advance Directive booklet as applicable. The policy further stated, The Social Services Director/designee periodically provides education related to Advance Directives. At any time the resident who wishes to initiate or change an advance directive, the Social Service Director/designee directs the resident or legal representative to the appropriate resource(s). Upon further review of the Advance Directives policy the following procedure was identified if the resident or legal representative chooses to request a DNR. Documented discussion between the resident or legal representative regarding the request for DNR, which may include signed Request for Do Not Initiate CPR or state specific DNR Consent completed by the resident or legal representative This information was not contained on Resident #193's medical record. The policy also stated, An advanced directive label is placed on the Condition alert tab within the medical record reflecting the resident's choice. This information was not contained on the resident's medical record. b) Resident #217 A review of Resident #217's medical record was completed at 8:30 a.m. on [DATE]. This review revealed the resident had a Physician's Determination of Capacity dated [DATE]. This form indicated Resident #217 demonstrated the capacity to make health care decisions. Further review revealed a POST form which indicated the resident desired to be a DNR. This form indicated this was discussed with the resident's medical power of attorney (MPOA). The form was also signed by the resident's MPOA and not the resident. This form was signed by the MPOA on [DATE] and by the physician [DATE]. The form indicated Employee #51 assisted the MPOA in completing this form. An interview with Employee #51, the social worker, was completed at 9:20 a.m. on [DATE]. Employee #51 stated the resident could not see at all and this was why the resident did not sign the POST form. The social worker reported she did talk to the resident about the POST form, but that the MPOA had signed the form. She reported the resident understood what the POST form was and the resident wanted to be a DNR. The social worker wrote a note, on [DATE], which contained the following information in regards to Resident #217: Resident is alert and orientated, but she has her niece (nieces name) as her MPOA to make all decisions for her. The note further states, . She does not have many hobbies as she can not see and/or hear. Completed post form with MPOA, she is a DNR nurse notified . At 9:36 a.m. on [DATE], Resident #217 was interviewed. Resident #217 confirmed she wanted to be a DNR. She stated she did not want to have CPR. She stated she did not recall anyone ever discussing this with her. The resident confirmed she did not see well, but she stated she could see well enough to sign a paper if someone will show her where to sign. She reported she signed some paperwork when she first came to the facility and they just showed her where to sign and read her the information. An additional medical record review was completed at 10:00 a.m. on [DATE]. This review revealed an Admission Agreement which was signed by Resident #217 on [DATE]. This form was also signed by Employee #60, an admissions employee. There was also a Representative Designation form contained on the medical record which indicated, Resident/Patient completing admission paperwork. No Representative Designated. .",2016-02-01
9141,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2012-04-26,155,D,0,1,JRXZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to ensure one (1) of thirty-three (33) residents was provided the opportunity to exercise his right to refuse treatment. The resident was given a thirty (30) day notice for refusing care and treatment without evidence the facility assessed the reason's for the refusals and without evidence alternative treatments and/or times for treatments were offered. Resident identifier: #78. Facility census: 61. Findings include: a) Resident #78. Review of the medical record found several occasions when Resident #78 refused care and treatment. No evidence could be found the facility investigated why the resident refused care and treatment. Resident #78 was admitted to the facility on [DATE]. The admission [DIAGNOSES REDACTED]. During an interview with the resident, on 04/23/12 at 3:00 p.m., it was learned the resident did not like the type of solution used to treat his wounds. The resident stated, It's a bleach solution and [MEDICAL CONDITION] nose. The treatment was ordered twice a day. The resident stated he was not going to let the facility use Dakins solution twice a day. According to Employee #97 (treatment nurse), during an interview on 04/25/12 at 9:14 a.m., Resident #78 had voiced his opinion of the Dakins solution to her. She stated, He is non-compliant with a twice a day treatment. She further added she contacted the wound care center, but they would not change the treatment. Employee #97 was asked whether she had contacted the attending physician to get the treatment changed. She stated, He will not go against the wound care center. She stated at one time they had used a patch which only had to be changed every three (3) days, and the resident was more compliant with this treatment. No evidence could be found the physician was aware of Resident #78 having difficulty with the current treatment. Additionally, no evidence could be found the facility alerted the physician to why Resident #78 was refusing treatments. During the interview with Resident #78 on 04/23/12 at 3:00 p.m., the resident stated he liked to stay up all night and watch television and slept during the day. This was also a reason he refused treatments, as they were scheduled at times which were inconvenient for him. No evidence could be found the facility made arrangements to work treatments around Resident #78's schedule. On 04/11/12, the facility issued Resident #78 a thirty (30) day notice stating they had no choice, but to give him a thirty (30) day notice related to his refusals of care and treatment. The letter further stated the facility would look for alternative placement that better suited the resident. During an interview with Employee #100 (administrator), on 04/24/12 at 5:57 p.m., he stated the facility had several meetings with Resident #78, but did not have documentation related to these meetings. He further added Resident #78 may have stated he did not want to go to another nursing home. During an interview, on 04/24/12 at 5:57 p.m., Employee #100 was asked for information related to education provided to Resident #78 on the risks and benefits of treatment. He stated, I'm sorry, it's not documented. On 04/24/12 at 3:37 p.m., Employee #78 (social worker/admission coordinator) was asked if he had met with Resident #78 related to his care and treatment. He stated, No, I have not had a lot of contact with him. He further added he was present when the facility gave Resident #78 a thirty (30) day notice for refusal of care. Review of the social worker notes identified only three (3) notes written from 02/14/12 thru 04/23/12. On 02/29/12, Employee #78 wrote a note stating the following, Had been refusing care related to pain, but this has been corrected and he is participating more now. According to the social service note dated 02/29/12 Resident #78 was having no issues at that time.",2016-02-01
9636,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,155,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, Hospice staff interview, and observation, the facility failed, for one (1) of eighteen (18) residents sampled, to allow refusal of treatment. The resident, who was also under the care of Hospice services, had requested through her medical power of attorney representative (MPOA) via the Physician order [REDACTED]. IV fluids had continued for a period of at least twenty-nine (29) days following the resident's hospitalization and return to the facility, with no evidence the facility recognized the right to refuse them and/or worked in conjunction with her physician and the Hospice agency to discontinue the IV fluids. Resident identifier: #13. Facility census: 105. Findings include: a) Resident #13 The medical record of Resident #13, when reviewed on 12/15/09, disclosed this [AGE] year old female had resided at the facility since 12/22/04. Her medical [DIAGNOSES REDACTED]. She had returned to the facility from her most recent hospitalization on [DATE], having been admitted to the hospital with [REDACTED]. On 12/08/09, the resident's attending physician wrote an order for [REDACTED]. The resident's medical record, when further reviewed, revealed she did not have the capacity to make her own medical decisions, as determined by her attending physician on 09/02/08. The most recent minimum data set (MDS), with an assessment reference date of 11/26/09, in the area of Cognitive / Decisionmaking described this resident as 3, severely impaired, rarely / never made decisions. The record disclosed a POST form which stated, This is a physician's orders [REDACTED]. Any section not completed indicates full treatment for [REDACTED]. All areas of the POST form were completed on 12/10/08, with the resident's MPOA signature noted in Section F. The document was reviewed on 11/30/09 with no changes noted. The form requested under Section A - Do Not Attempt Resuscitation; under Section B - Comfort Measures; under Section C - Antibiotics; and under Section D - IV fluids for a defined trial period. In Section E, it was noted these were discussed with MPOA, and under The Basis for These Orders Is was marked Patient's best interests (patient preferences unknown). The resident's medical record did not contain a Living Will document. Observation, during a wound care treatment on the afternoon of 12/15/09, found the resident was receiving an infusion of IV fluids. The infusion was [MEDICATION NAME], and it was infusing at forty (40) cc/per hour. [MEDICATION NAME], according to RxList Inc., the Internet Drug List at www.rxlist.com, is a sterile, nonpyrogenic, moderately hypertonic intravenous injection containing [MEDICATION NAME], a nonprotein energy substrate and maintenance electrolytes. [MEDICATION NAME] is indicated for peripheral administration in adults to preserve body protein and improve nitrogen balance in well-nourished, mildly catabolic patients who require short-term [MEDICATION NAME] nutrition. The source of the implementation of the IV fluids was found to be a physician's orders [REDACTED]. The resident was non-responsive during the wound care, even when turned from side to side by staff. When questioned as to the palliative purpose of the infusing fluids, the nurse completing treatment (Employee #113) stated she wasn't sure. When asked if the fluids had prevented a further decline in the resident's condition, the nurse stated, No. The facility's director of nurses (DON - Employee #99, when interviewed related to this observation on 12/15/09 at approximately 3:00 p.m., stated she did not know if the resident's MPOA had been contacted related to the continuation of the IV fluids at the time of re-admission from the hospital or at the time of the admission to Hospice Services. She did recall there had been discussion about the IV fluids among staff. Return to the medical record divulged a social services note, dated 11/30/09, stating, POST form discussed with Daughter / MPOA on 11/30/09 (sic) with no changes. This note also stated the resident has been exhibiting behaviors of refusing / spitting out meals and medications. The social worker (Employee #140), when interviewed on the morning of 12/16/09, was asked if she was aware the resident's current care was in contradiction with the POST form with respect to the continued administration of IV fluid infusion. The social worker stated that, during the care plan meeting for this resident on 12/08/09, when the resident's MPOA and Hospice nurse were present, Hospice staff had indicated they would address this situation. She made no mention of the issue being addressed at the time of the resident's re-admission to the facility on [DATE], or at the time of the documented Review of the POS [REDACTED] On 12/16/09 at 9:30 a.m., a Hospice nurse (Employee #142) was visiting the resident in her room. This nurse was questioned as to if Hospice staff had attempted to contact the resident's MPOA about the continued infusion of IV fluids, in light of her noted desires on the resident's POST form. It had now been eight (8) days since Hospice had become involved in the resident's care. The Hospice nurse stated he thought someone had tried to contact the MPOA with no success and that he had just met the resident for the first time. He further stated the physician had been contacted by facility staff the previous evening (on 12/15/09), following questioning by this surveyor, and he wanted the IV fluids to continue. The Hospice nurse could give no reason for the continued use of IV fluids and could not describe any palliative purpose the IV fluids may be serving. The Hospice nurse also stated that discontinuing the fluids was the decision of the resident's attending physician. When asked if the Hospice medical director might not intervene in a situation similar to this, the Hospice nurse responded, No. The Hospice nurse then described the resident's attending physician as sometimes being hesitant to act upon recommendations by Hospice staff. Later on this same day at approximately 2:00 p.m., the Hospice nurse informed this surveyor that the resident's MPOA had been contacted and her desire was to discontinue the IV fluid infusion. He stated a request for that order had been communicated to the attending physician. According to Hospice Philosophy, as noted by the Hospice Patient's Alliance and found at www.hospicepatients.org/hospic28.html, When appetite declines and your loved one is refusing food, it's quite difficult to accept. We all know that you have to eat to live, but what many of us don't know is that if your body can't process the food because of a terminal illness, forcing nutrition in will not prolong life. There is a natural process in the dying: decreased appetite, decreased thirst, gradual withdrawal from the concerns of this world and focus on concerns about death and taking care of 'unfinished business' with family. The refusal of food / nutrition, according to Hospice Philosophy, is a normal part of the dying process. At the time of the resident's admission to Hospice, the resident's MPOA, with the resident's best interest in mind, agreed to accept the Hospice philosophy. Review of the documents on the resident's medical record that had been provided to the MPOA at the time of admission disclosed a document entitled Section C: Bill of Rights. This document stated, Consistent with state laws, the patient's family or guardian may exercise the patient's rights when the patient is unable to do so. Hospice organizations have an obligation to protect and promote the rights of their patients. There was no evidence, through record review or staff interview, that the facility had made efforts to coordinate with the resident's MPOA, the Hospice Agency, and the resident's attending physician to effectively honor the desire for IV fluids only for defined trial period. There was no documentation of a plan to discontinue the IV fluids, a defined time period for their use was not designated, and there was no documented purpose for their use in providing palliative / comfort care to the resident. At the time of exit from the facility at 10:00 a.m. on 12/17/09, the IV fluids continued to infuse for this resident.",2015-10-01
9878,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2013-05-17,155,D,0,1,RKHC12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, resident interview, and policy review, the facility failed to assist two (2) of three (3) residents, reviewed for decision making, to formulate an advance directive, stating their desire to receive or not to receive cardiopulmonary resuscitation (CPR). Resident #193's wishes were to receive CPR if she was found to have no pulse, respirations and/or blood pressure. This was not assessed by the facility. She had a physician's orders [REDACTED]. Resident #217 had a Physician order [REDACTED].#217. The form was signed by her medical power of attorney (MPOA); however the resident still maintained capacity to make medical decisions. Resident identifiers: #193 and #217. Facility Census: 113 Findings Include: a) Resident #193 A medical record review was completed at 9:20 a.m. on [DATE]. This review revealed the resident had an order for [REDACTED]. The resident was readmitted to the facility from an acute care hospital on [DATE]. A care plan conference summary sheet was reviewed. It noted the resident wanted to be a ""Full Code."" This indicated the resident wanted to have CPR initiated should it be needed. This summary was signed by Employee #36, a Registered Nurse (RN), minimum data set (MDS) Coordinator, Employee #51, Social Worker, a Licensed Physical Therapy Assistant, a Certified Occupational Therapy Assistant, and Resident #193. The resident's care plan was also reviewed. The care plan contained the following problem, ""The resident desires to be a DNR."" The goal contained on the care plan was, ""DNR will be honored upon absence of pulse, respirations, and/or blood pressure."" The care plan contained the following interventions. ""1. Verify the absence of apical pulse, respirations, and/or blood pressure. 2. Notify Physician. 3. Notify Family."" Additional review of the medical record revealed a hospital discharge summary, dated [DATE], which contained the following statements: ""It was questioned whether or not the son would request comfort care. He did make her a do not resuscitate, do not intubate."" The medical record contained a Physician's Determination of Capacity, dated [DATE], which identified the resident demonstrated the capacity to make healthcare decisions. Finally, the medical record did not contain any evidence to suggest Resident #193 ever told facility staff she had a desire to have a DNR order. At 9:45 a.m. on [DATE], a resident interview was conducted with Resident #193. The resident was alert and orientated to time, place, and person. She was able to answer questions appropriately. She was asked if she had told the facility what her wishes were in regards to CPR. She stated, ""I have never really thought about whether or not I would want CPR."" She further stated, ""I have never told anyone here that I did not want CPR."" She stated, ""No one has ever asked me that before."" At 9:52 a.m. on [DATE], Employee #108, Licensed Practical Nurse (LPN) and Employee #90, Registered Nurse (RN) were interviewed. They were asked how they determined whether or not to initiate CPR on a resident. They both confirmed they looked at the resident's Condition Alert sheet in the front of the chart for a ""DNR sticker"". They stated if there was no sticker, they then looked at the resident's POST form. If there was no POST form, they reported they would look at the physician's orders [REDACTED]. At 10:00 a.m. on [DATE], Employee #51, the social worker, was interviewed. She stated the resident was a ""Full Code"". She referred to the care plan conference summary sheet dated [DATE]. She confirmed she had not discussed this with the resident since her return from the hospital. She confirmed the resident had a physician's orders [REDACTED]. Employee #51 confirmed the resident had not signed any paperwork at the facility to indicate she would want to be a DNR. Employee #51 also confirmed the resident had a DNR care plan. At 10:22 a.m. on [DATE], Employee #108, an LPN, was asked to review the medical record of Resident #193 and to indicate if he would perform CPR on the resident should she have an absence of pulse, respirations and/or blood pressure. The LPN reviewed the medical record and indicated he would not perform CPR on this resident because she had a physician's orders [REDACTED]. At 10:25 a.m. on [DATE], Employee #46, an RN, was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident should she have an absence of pulse, respirations and/or blood pressure. The RN reviewed the medical record and stated she would not perform CPR on this resident because she had a physician's orders [REDACTED]. Employee #72, RN, Director of Nursing (DON), was interviewed at 10:30 a.m. on [DATE]. She was asked to review the medical record of Resident #193 and to indicate if she would perform CPR on this resident if there was an absence of pulse, respirations, and/or blood pressure. She stated she would perform CPR on this resident because she did not have a ""DNR sticker"" on her condition alert page in the front of her chart. The DON then reviewed the chart with the surveyor and confirmed the resident had a physician's orders [REDACTED]. She also confirmed the absence of a POST form and of a DNR sticker on the condition alert form at the front of the resident's medical record. At 10:35 a.m. on [DATE], Employee #37, the social worker, reported the facility contacted the acute care hospital and now had a form which the resident had signed while in the hospital. Employee #37 also reported, Employee #51 had spoken with Resident #193 and completed a POST form. The resident indicated to Employee #51 she wanted CPR should it be needed. The POST form was completed to reflect the resident's wishes regarding end of life care. Later in the afternoon of [DATE], Employee #37 provided a copy of a ""Do not Resuscitate and Limited Resuscitation orders (DNR)"" form. This form was completed at the acute care hospital on [DATE]. The form was faxed to the facility at 12:31 p.m. on [DATE]. This form was not signed by Resident #193. It was instead signed by her MPOA. The form was also not signed by a physician which meant it was not a valid physician's orders [REDACTED]. The facility's ""Advance Directives"" policy was reviewed at 8:00 a.m. on [DATE]. The policy states, ""The Social Services Director/Designee assists the resident or legal representative with any questions regarding Advanced Directives at the time of admission by providing them the Advance Directive booklet as applicable."" The policy further stated, ""The Social Services Director/designee periodically provides education related to Advance Directives. At any time the resident who wishes to initiate or change an advance directive, the Social Service Director/designee directs the resident or legal representative to the appropriate resource(s)."" Upon further review of the ""Advance Directives"" policy the following procedure was identified if the resident or legal representative chooses to request a ""DNR"". ""Documented discussion between the resident or legal representative regarding the request for DNR, which may include signed Request for Do Not Initiate CPR or state specific DNR Consent completed by the resident or legal representative"" This information was not contained on Resident #193's medical record. The policy also stated, ""An advanced directive label is placed on the Condition alert tab within the medical record reflecting the resident's choice."" This information was not contained on the resident's medical record. b) Resident #217 A review of Resident #217's medical record was completed at 8:30 a.m. on [DATE]. This review revealed the resident had a Physician's Determination of Capacity dated [DATE]. This form indicated Resident #217 demonstrated the capacity to make health care decisions. Further review revealed a POST form which indicated the resident desired to be a ""DNR"". This form indicated this was discussed with the resident's medical power of attorney (MPOA). The form was also signed by the resident's MPOA and not the resident. This form was signed by the MPOA on [DATE] and by the physician [DATE]. The form indicated Employee #51 assisted the MPOA in completing this form. An interview with Employee #51, the social worker, was completed at 9:20 a.m. on [DATE]. Employee #51 stated the resident could not see at all and this was why the resident did not sign the POST form. The social worker reported she did talk to the resident about the POST form, but that the MPOA had signed the form. She reported the resident understood what the POST form was and the resident wanted to be a DNR. The social worker wrote a note, on [DATE], which contained the following information in regards to Resident #217: ""Resident is alert and orientated, but she has her niece (nieces name) as her MPOA to make all decisions for her."" The note further states, "". . . She does not have many hobbies as she can not see and/or hear. Completed post form with MPOA, she is a DNR nurse notified....."" At 9:36 a.m. on [DATE], Resident #217 was interviewed. Resident #217 confirmed she wanted to be a DNR. She stated she did not want to have CPR. She stated she did not recall anyone ever discussing this with her. The resident confirmed she did not see well, but she stated she could see well enough to sign a paper if someone will show her where to sign. She reported she signed some paperwork when she first came to the facility and they just showed her where to sign and read her the information. An additional medical record review was completed at 10:00 a.m. on [DATE]. This review revealed an ""Admission Agreement"" which was signed by Resident #217 on [DATE]. This form was also signed by Employee #60, an admissions employee. There was also a ""Representative Designation"" form contained on the medical record which indicated, ""Resident/Patient completing admission paperwork. No Representative Designated."" .",2015-08-01
10745,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-08-31,155,D,1,0,H3XI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the advance directives of one (1) of six (6) sampled residents were honored by the facility. Resident #94's expressed her wishes with respect to advance directives in writing prior to losing the capacity to make her own informed medical decisions. The facility permitted the resident's medical power of attorney representative (MPOA) to change these written instructions for end-of-life care after the resident was no longer able to express her wishes. Facility census: 93. Findings include: a) Resident #94 A review of Resident #94's closed medical record revealed she was admitted to the facility on [DATE]. On 05/08/11, the physician determined she possessed the capacity to make her own informed health care decisions. Further record review disclosed a combined WV Advance Directive / Living Will / Medical Power of Attorney document, which had been completed and signed by Resident #94 on 03/13/07. This form contained the following: ""If I should reach a point when I lack capacity to make medical decisions, am in a terminal state, or become permanently unconscious or remain in a permanent vegetative state I have indicated my wishes by my initials on the lines below."" In the section of the document labeled Living Will, the resident indicated she did not want life prolonging treatment and wished to be permitted to die naturally with only the administration of any medication or the performance of any medical treatment deemed necessary to alleviate pain. Regarding the administration of artificial nourishment, the resident stated, ""I do not want artificially provided water or other artificially provided nourishment or fluids (tube feedings intravenous fluids etc)."" The form had an area labeled ""Special Directions or Limitations"", in which the resident indicated she wanted to be kept comfortable and was to be a DNR (do not resuscitate). In the section designating a medical power of attorney representative, the resident identified her daughter as the person to ""make health care decisions for me, in accordance with this directive, when I no longer have decisional capacity and cannot communicate my healthcare wishes."" The resident was discharged to home on 06/02/11. She was then readmitted to this facility on 06/30/11, after she had a fall at home resulting in a hospitalization . When the resident was readmitted , her previous advance directives remained unchanged. On 06/30/11, the physician subsequently determined she no longer possessed the capacity to understand and make her own health care decisions capacity to make her own decisions. On 07/01/11, the resident's MPOA came to the facility and changed her code status to a ""Resuscitate"", which was contrary to the wishes the resident specifically stated in her advance directives. The administrator and director of nursing were made aware of this finding at 10:30 a.m. on 08/31/11. The administrator contacted by telephone the nurse who changed this resident's code status to a ""Resuscitate"". The administrator then related that the resident's MPOA requested the change, so the nurse completed a new form.",2014-12-01
11022,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,155,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure that residents with capacity were involved in making decisions with respect to the advance directives documented on the Physician order [REDACTED]. Resident identifiers: #92 and #104. Facility census: 121. Findings include: a) Resident #92 A review of the medical record revealed a POST form indicating Resident #92 was to receive cardiopulmonary resuscitation (CPR) and ""Limited additional interventions"". This form was signed by the resident's medical power of attorney representative (MPOA) on [DATE]. The resident's attending physician determined Resident #92 lacked the capacity to understand and make healthcare decisions on [DATE]. This determination was validated by a second determination made by a psychologist on [DATE]. On [DATE], the resident's attending physician reversed this and determined the resident now had the capacity to formulate healthcare own decisions. However, there was no evidence in the record to indicate the advance directives recorded on the [DATE] POST form had been reviewed with the resident. During an interview at 11:45 a.m. on [DATE], the social worker (Employee #119) was asked if the advance directives noted on the POST form had been reviewed with the resident. The social worker could not remember and, at the time of exit, she had not produced any evidence to indicate the resident had been informed of the decisions made by the MPOA. b) Resident #104 A review of Resident #104's medical record revealed the resident was admitted on [DATE]. On [DATE], the social worker recorded in social services notes that the resident had the capacity to make his own healthcare decisions and he had ""Full Code"" status. His attending physician also determined, on [DATE], that Resident #104 had the capacity to make healthcare decisions. However, an attached form stated: ""It is my desire that (Name) , my (wife) , sign all forms on my behalf to admit me to Heartland of Keyser, as I am presently in a weakened condition and do not wish to sign all of the forms necessary for admission."" The resident had several acute hospitalization s, and a social service note on [DATE] indicated his daughter was his health care surrogate and that he was still ""full-code status"". A new POST form, indicating the resident was not to be resuscitated and was to receive limited additional interventions, was signed by his wife on [DATE], while he was in the hospital. There was no evidence to show the wife had any legal authority to make healthcare decisions for him at that time. The resident was readmitted to the facility on [DATE], and all documentation indicated the resident had the capacity to form his own healthcare decisions. However, there was no evidence he had been involved in his healthcare decisions, including formulating the advance directives recorded on the POST form. In an interview with both social workers (Employees #79 and #119) at 2:40 p.m. on [DATE], they were asked if the resident was aware of his code status. Neither answered, nor was any documentation offered. They both verified the resident was alert, oriented, and able to make his needs known with sign language. .",2014-09-01
11105,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2011-04-27,155,D,1,0,MWLC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview, record review, and policy review, the facility failed to ensure that a resident's right to refuse treatment. This was evident for one (1) of six (6) sampled residents, who possessed the capacity to understand and make informed health care decisions. The resident refused an injection when he was attempting to leave the facility, and the nurse gave the injection contrary to his wishes. The syringe contained a psychoactive medication ([MEDICATION NAME]). Resident identifier: #23. Facility census: 61. Findings include: a) Resident #23 1. Interview with a social worker (Employee #312), on 04/26/11 at 3:30 p.m., revealed that, on 03/03/11, she observed staff physically trying to pull Resident #23, who was attempting to leave the facility. Employee #312 said she went outside and informed staff they could not do that, as the resident has capacity. She stated that, at one point during this incident, a licensed practical nurse (Employee #35) allegedly told the resident, ""I have the insulin the doctor wants you to take,"" but it was [MEDICATION NAME], instead. At that point, the nurse left him alone and did not administer the injection. Employee #312 said, at another point, she looked out her window and saw two (2) maintenance men and the administrator talking to the resident, and the workers had their hands on the resident. She said those staff members somehow got him back inside the fence, and Employee #35 allegedly gave the injection of [MEDICATION NAME] through his clothing. - 2. Interview with another social worker (Employee #119), on 04/27/11 at 8:30 a.m., revealed Resident #23 was determined by his attending physician on 12/10/10 to have health care decision-making capacity, but at the time of the incident on 03/03/11, Resident #23 was extremely out of control. She said this resident walks with a crutch or a cane, and that was his weapon that day, although he did not hit anyone. Both she and the director of nursing (DON) agreed that Employee #35 gave Resident #23 an injection of [MEDICATION NAME] during the incident. - 3. Review of the facility's policy titled ""Against Medical Advice Discharge"" (revised 09/2008), produced by Employee #119 on 04/27/11 at 12:40 p.m., revealed the following statement: ""No capacitated resident will be held in the nursing facility against their wishes, unless with a court order. Any incapacitated resident cannot be responsible for their medical decisions. These residents will not be allowed to leave the facility as they wish."" - 4. Interview with Employee #35, on 04/27/11 at 4:30 p.m., revealed when she came to work at 3:00 p.m. on 03/03/11, Resident #23 was already upset and agitated because his wife had come to the facility and brought him some clothing, but he thought he was going home. The family, however, did not want to take him home. Employee #35 asked Resident #23 if she could give him something to calm his nerves, but he refused, so she backed away with the [MEDICATION NAME]. The resident was on the grounds but outside the fence and was in and out of the facility numerous times during this hour-long episode, and police were on the scene at one point. She called the physician, who allegedly told her he had capacity, so let him leave if he wants to, but she spoke her fear that the resident could enter the highway and get killed, and she would be held liable for manslaughter. She said the physician, then, gave her the order to give the resident [MEDICATION NAME] 0.5 mg. According to Employee #35, while staff distracted the resident and tried to take his cane, she gave the injection of [MEDICATION NAME]. Resident #23 was not held down and was not restrained while the injection was given. - 5. Review of the medical record revealed that, on 03/14/11, the facility's medical director (Employee #81) evaluated the resident and determined that he lacked capacity related to dementia with cognitive loss, disorientation to person / place / time, and the inability to understand or make medical decisions, with expected long-term incapacity. - 6. Review of the attending physician's progress notes, dated 03/18/11, found the attending physician ""did not have him declared as lacking mental capacity and with some coercion he got [MEDICATION NAME] intramuscularly and apparently he settled down. I have seen him in the clinic since then to see if I need to change his mental status evaluation ... and I did not change it."" - 7. During an interview with Resident #23 on 04/27/11 at 4:45 p.m., he said he recalled being mad once when they (facility staff) would not let him leave when he wanted to go home. He did not have clear recall about any injections other than insulin, and he said he had never been hurt by anyone at the facility. .",2014-08-01
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
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
395,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,156,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon family interview, staff interview, record review, and facility policy review, the facility failed to ensure that one (1) of eleven (11) (Resident #115) sampled residents family representative was informed of the resident's rights and Medicare charges, and failed to obtain a consent for treatment upon admission. Facility census: 114. Findings include: a) Resident #115 Review of the resident's clinical record revealed he was admitted to the facility on [DATE] and discharge to home on 07/03/17. The resident's admissions [DIAGNOSES REDACTED]. On 06/15/17, the physician determined the resident lacked the capacity to make health care decisions. The admission agreement was signed by the resident's representative and Social Worker (SW) #38 on 07/03/17, but there was no signed consent for treatment in the resident's clinical record. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated one of her responsibilities included obtaining the resident's signature, or the signature of the resident's representative on admission paperwork, which included consent for treatment, resident rights, and Medicare charges. SW #38 stated this information was obtained on admission to the facility within one (1) to two (2) days. SW #38 confirmed she had obtained Resident #115's representative signature on 07/03/17, but was unable to provide why the consent for treatment, resident rights and Medicare charges were not obtained on admission to the facility. During an interview on 08/08/17 at 4:20 p.m., Business Office Manager (BOM) #121 stated the social worker did all the admission paperwork with residents and their families. The BOM #121 stated the corporate expectation was for all admission paperwork to be completed within 72 hours of admission. During a telephone interview on 8/9/17 at 1:21 p.m., Resident #115's representative stated she was in the facility daily from 06/27/17 until the resident's discharge to home on 07/03/17. The representative stated she was in the facility for 20 out of 24 hours each day and confirmed she had signed the admission paperwork on 07/03/17. The family representative was not provided any explanation of facility services, she was just asked to sign the papers. On 08/08/17 at 5:00 p.m., review of the facility's policy entitled Admission Policy, revised 04/19/17, found it included, Center will explain to residents on admission the special characteristics or service limitations of the center, which are also identified in the admission packet.",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
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
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
2536,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-08-08,156,E,0,1,0QX311,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 88 Findings include: a) On 07/31/17 at 10:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview with the Nursing Home Administrator on 07/31/17 at 11:50 a.m., agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.",2020-09-01
3371,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2017-11-08,156,D,0,1,XW9J11,"Based on staff interview, Center for Medicaid and Medicare Services (CMS) Survey and Certification (S&C) letter review, and a review of liablity notices, the facility failed to provide the correct notice when the resident exhausted their Medicare covered skilled nursing facility benefit days. This failed practice affected one (1) of three (3) residents reviewed. Resident identifier: #6. Facility census: 58. Findings include: a) Resident #6 On 11/07/17 at 1:55 p.m., a review of the liability notices revealed Resident #6 received the Notice of Medicare Non-Coverage (NOMNC) Centers for Medicaid and Medicare Services (CMS) form on 07/07/17. The NOMNC form indicated the resident would exhaust Medicare Part A benefits on 07/12/17. On 11/07/17 at 2:02 p.m., Social Worker (SW) #60 said the resident recieved the NOMNC because he had exhausted his skilled service days. The NOMNC form explained the resident had the right to appeal this decision. SW #60 also said she had previously been issuing the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) along with the NOMNC but now realized this did not need issued each time the NOMNC was issued. According to CMS Survey and Certification (S&C ) letter 09-20, dated 01/09/09, the skilled nursing facility (SNF) must issue the NOMNC when there is a termination of all Medicare Part A services for coverage reasons. The SNF should not issue this notice if the beneficiary exhausts the Medicare covered days as the number of SNF benefit days set in law and the QIO cannot extend the benefit period. Thus, a service termination due to the exhaustion of benefits is not considered a termination for coverage reasons.",2020-09-01
3854,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,156,D,0,1,DBHB11,"Based on staff interview and record review, the facility failed to ensure Resident #43 received notice of the decision to terminate Medicare covered services two (2) days prior to the proposed end of Medicare services. This was true for one (1) of three (3) residents reviewed for the mandatory care area of liability notices and beneficiary appeal. Resident identifier: #43. Facility census: 62. Findings include: a) Resident #43 At 1:25 p.m. on 01/18/17, Business Office Manager (BOM) #4, provided a copy of the notice of Medicare non-coverage form, Centers for Medicare and Medicaid Services (CMS) form # , issued to Resident #43. The form noted the resident's Medicare services would end on 11/29/16. The first day of non-skilled services would begin on 11/30/16. The resident's responsible party signed the form on 11/29/16. BOM #43 said she was only the keeper of the form, she did not provide the form to the resident's responsible party. She identified the social worker as the employee responsible for issuing the form. At 1:43 p.m. on 01/18/17, Social Worker #84 was unable to provide documentation the responsible party was notified of the determination to end services two (2) days before the proposed cut of services. The responsible party could have been contacted by telephone if unavailable to sign the form; however, no documentation was available to substantiate contact was made with the responsible party within the required time frame. Providing the notice two (2) days prior the end of services allows the resident/responsible party time to contact the Quality Improvement Organization (QIO) if they wish to appeal the decision. Resident #43 remained in the facility with benefit days remaining when the notice of Medicare non-covered services form was given.",2020-04-01
4193,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,156,D,0,1,XDKG11,"Based on staff interview and review of the facility's notices of Medicare provider non-coverage forms, the facility failed to notify the beneficiary or responsible party of the decision to terminate covered Medicare services no later than 2 days before the proposed end of the services. This was true for three (3) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #3, #35, and #44. Facility census: 113. Findings include: a) Resident #3 A form entitled Medicare Determination of Non coverage on Continued Stay, noted the resident's last day of Medicare services was 01/14/17. The form contained no information to verify when the responsible party was notified of the decision to terminate Medicare services. b) Resident #35 On 03/10/17, the resident's responsible party signed a form entitled Medicare Determination of Non coverage on Continued Stay. The resident's last day of Medicare coverage was 03/04/17. c) Resident #44 On 01/10/17, the resident's responsible party signed a form entitled Medicare Determination of Non coverage on Continued Stay. The resident's last day of Medicare coverage was 01/10/17. d) At 3:27 p.m. on 04/05/17, Business Office Manager (BOM) #13 confirmed she did not have verification the responsible parties of Residents #3, #35, and #44 had at least a 2 day notice before the proposed end of Medicare services. BOM #13 said she did mail the notices to the responsible parties in advance, but she had no verification as to when the responsible parties actually received the notice. BOM #13 said she was unaware if the resident or responsible party was unable to receive the notice, the facility representative could contact the legal representative and inform him/her by telephone. The date of telephone contact was considered the date the notice was given as long as it was not disputed by the beneficiary. The facility must also follow up the telephone contact with written notice.",2020-02-01
4348,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2016-01-20,156,E,0,1,96LU11,"Based on record review and staff interview, the facility failed to provide written information to residents whose Medicare covered services were discontinued. No evidence was presented to determine if liability notices were provided to three (3) of three (3) residents chosen for review by the Quality Indicator Survey (QIS) program during Stage 2 of the QIS survey. Resident identifiers: #72, #168, and #175. Facility census: 115. Findings include: a) Resident #72, #168, and #175 At 2:30 p.m. on 01/19/16, a request was made to the Administrator for the liability notices supplied to Residents #72, #168, and #175. All three (3) residents no longer resided in the facility. At 4:00 p.m., a corporate representative informed the survey team the requested records were not available for review. He said the previous facility owners had taken all paper and electronic records of residents when the facility ownership changed. At 9:30 a.m. on 01/20/16, the Administrator verified the absence of the records for the three (3) residents in question. Due to the absence of any documentation, the facility could not provide any evidence that the required notices were given to the three (3) residents when Medicare services were discontinued.",2019-11-01
4822,EASTBROOK CENTER,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2015-11-05,156,E,0,1,ZW2211,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare benefits. The facility had not prominently displayed the written information regarding these benefits as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 129. Findings include: a) On 11/02/15 at 11:25 a.m., an observation of the facility revealed there was no written information posted to inform a resident about how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview on 11/03/15 at 3:15 p.m., the Assistant Nursing Home Administrator agreed the facility had not prominently posted the information regarding how residents could apply for and use Medicare benefits.",2019-07-01
5071,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-09-14,156,C,0,1,HR8011,"Based on observation, resident council president interview, and staff interview, the facility did not post the required information within the facility regarding names, addresses and telephone numbers of all pertinent State client advocacy groups. The facility failed to post the name, address, and telephone number of the Office of Health Facility Licensure and Certification (OHFLAC), and/or a statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property. This practice had the potential to affect all residents at the facility. Facility census: 88. Findings include: a) Observation on 09/08/15 at 12:45 p.m. found no evidence of contact information for the State survey and certification agency posted within the corridors of the facility. At 1:00 p.m. on 09/08/15, Registered Nurse (RN) #20 and the licensed social worker looked for the required posted information. They could not locate a posting with the name, address, and telephone number of the State survey agency, including a statement that the resident may file a complaint with this agency concerning resident abuse, neglect, and misappropriate of resident property, and non-compliance with the advance directives requirements. They said there was none posted within the facility. The social worker devised and posted a temporary form, which included contact information and purpose, until she could obtain a laminated form. During an interview with Resident Council President (RCP) #4 on 09/14/15 at 11:50 a.m., RCP #4 said they did not know how to notify the State if they or other residents had complaints. RCP #4 knew the name of the Ombudsman and his contact information, but had no knowledge of the telephone number or address of the State survey and certification agency. RCP #4 stated she might find that information in the survey book, but did not recall seeing that information posted in the building.",2019-03-01
5098,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-03-31,156,E,1,0,LC2M11,"> Based on medical record reviews and staff interviews, the facility failed to ensure each resident had access to updated written information regarding how to contact the certification agency. The Transfer or Discharge Notice had the incorrect address for the certification agency for Residents #20, #26, #59, #109 and #165. This had the potential to affect more than an isolated number of residents. Resident identifiers: Resident #20, #26, #59, #109 and #165. Facility census: 162. Findings include: a) On 03/31/16 at 8:35 a.m., during a review of the Transfer or Discharge Notices for Residents #20, #26, #59, #109 and #165, it was discovered the address for the certification agency was incorrect. The written information provided on the notice regarding the appeal information had not been updated to reflect the correct address for the certification agency. This written information is required to fulfill the facility's obligation to adequately inform residents of their appeal process regarding discharge and transfer. An interview with the Medical Records Clerk, on 03/31/16 at 8:58 a.m., verified the Notice of Transfer or Discharge had the incorrect address for the certification agency for Residents #20, #26, #59, #109 and #169.",2019-03-01
5143,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,156,F,0,1,PDA311,"Based on observation and staff interview, the facility failed to prominently display written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. This practice had the potential to affect all residents. Facility census: 55 Findings include: a) Observations throughout the facility, from 06/15/15 through 06/18/15, revealed no evidence the facility displayed information related to Medicare and Medicaid application and benefits. An interview with the nursing home administrator (NHA), on 06/18/15 at 3:10 p.m., confirmed the facility had not posted information about how to apply for and use Medicare or Medicaid benefits, or receive refunds. She related, It would be right here, and gestured at the bulletin board. The NHA asked the maintenance director if he knew where the information was posted in the facility. He related the information was not posted.",2019-03-01
5219,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2015-09-16,156,B,0,1,5JCO11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 81 Findings include: a) Observation of the facility, on 09/14/15 at 11:45 a.m., revealed there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator, on 09/16/15 at 10:20 a.m., verified the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-02-01
5229,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,156,B,0,1,76WG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits, or how to contact the State Ombudsman. The facility did not prominently display the written information regarding these benefits or the Ombudsman contact information. This had the potential to affect more than an isolated number of residents. Facility census: 160 Findings include: a) On 07/22/15 at 1:35 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform residents or responsible parties about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview with the Nursing Home Administrator on 07/22/15 at 3:07 p.m., revealed she was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits. b) Ombudsman Information On 07/20/15 at 1:00 p.m., during an interview with the resident council president, the president did not know if the facility had the Ombudsman contact information posted. At 1:20 p.m. on 07/20/15, Director of Nursing #205 and Assistant Administrator #235 toured the facility and confirmed the facility did not have the Ombudsman contact information posted.",2019-02-01
5327,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2015-06-18,156,D,0,1,6BSN11,"Based on review of the liability notices and staff interview, the facility failed to provide the correct notice of termination of Medicare services, required by the Centers for Medicare and Medicaid Services (CMS), for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. Resident #127 received a notice informing her she could appeal her discharge from a skilled service after she had exhausted her allotted amount of skilled care days. Resident identifier: #127. Facility census: 94. Findings include: a) Resident #94 At 06/18/15 at 9:07 a.m., Clinical Reimbursement Coordinator #78 provided a copy of the notice given to Resident #127 on 01/08/15 regarding the exhaustion of her 100 days benefit period for medically necessary skilled care. The facility had attached to the notice a request for a Medicare Intermediary Review. The resident had indicated on the form that she did not want her bill for the services she continued to need to be submitted to the intermediary for a Medicare decision. According to CMS, the number of skilled care days is set in law and the Medicare Intermediary cannot extend the benefit period. Clinical Reimbursement Coordinator #78 said she did not know the facility could not give residents the right to appeal the exhaustion of the 100-day skilled care period.",2019-01-01
5343,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2015-01-28,156,B,0,1,11X211,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 64 Findings include: a) On 01/20/15 at 11:45 a.m., during an observation of the facility, observation revealed there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. During an interview on 01/27/15 at 9:30 a.m. the Nursing Home Administer was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-01-01
5368,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2015-06-25,156,E,0,1,1EZS11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 57 Findings include: a) On 06/22/15 at 11:15 a.m., during an observation of the facility, no written information to inform a resident about how to apply for and use Medicare and Medicaid benefits was observed in the facility. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 06/23/15 at 10:15 a.m., with the Nursing Home Administrator. He was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-01-01
5397,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2015-06-11,156,D,0,1,3Y2511,"Based on review of liability notices and staff interview, the facility failed to provide the correct notice of termination of Medicare services, required by the Centers for Medicare and Medicaid Services (CMS), for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal. Resident #32 did not receive the appropriate notice when skilled care services were terminated with skilled days remaining, and the resident remained in the facility. Resident identifier: #32. Facility census: 81. Findings include: a) Resident #32 At 2:18 p.m. on 06/10/15, Bookkeeper #44 provided a copy of the Medicare non-coverage form given to Resident #32 when Medicare services were terminated. The facility issued CMS form # to Resident #32, on 01/16/15, to notify him Medicare services were being terminated on 01/18/15. Bookkeeper #44 verified Resident #32 began receiving skilled care services on 01/02/14, and was discharged from skilled care services on 01/18/15. She further verified the resident had skilled days remaining and the resident continued to remain at the facility after the termination of skilled care services. According to a memorandum issued by CMS on 01/09/09, The Notice of Medicare Provider Non-coverage (form CMS- is issued when all covered services end for coverage reasons. If after issuing the Notice of Medicare Provider Non-coverage, the SNF (skilled nursing facility) expects the beneficiary to remain in the facility in a non-covered stay, either the SNFABN (skilled nursing facility advanced beneficiary notice) (form CMS- ) or a denial Letter must be issued to inform the beneficiary of potential liability for the non-covered stay. During this evaluation of liability notices and beneficiary appeal rights, Bookkeeper #44 confirmed the facility did not issue the correct notice of Medicare non-coverage form to Resident #32.",2019-01-01
5448,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,156,D,0,1,7OP711,"Based on staff interview and review of the liability notices, the facility failed to ensure one (1) of three (3) residents, reviewed for the care area of liability notices and beneficiary appeal rights, received the notice of termination of Medicare services forty-eight (48) hours before the proposed end of services as required by the Centers for Medicare and Medicaid Services (CMS). Resident identifier: #13. Facility census: 71. Findings include: a) Resident #13 At 8:18 a.m. on 06/24/15, the care area of liability notices and beneficiary appeal rights were reviewed with Employee #29, the business office manager. Resident #13 was receiving Part A Medicare skilled services at the time of termination of benefits. The facility provided the resident's responsible party a copy of CMS form # . The form notified the responsible party the resident's skilled nursing services would end on 02/13/15. CMS form was signed by the responsible party on 02/12/15. This signature indicated the responsible party was notified that coverage of services would end on 02/13/15, and the responsible party had the right to appeal the decision of termination by the facility. Employee #29 was unable to locate any evidence the responsible party was contacted by any means, including telephone notification of termination of services, forty-eight (48) hours prior to termination of the services as required by CMS. Employee #29 stated, We do so many of them, I guess someone could have missed notifying her daughter. According to CMS reference letter S&C-09-20, issued on 01/09/2009, . The SNF (skilled nursing facility) is required to notify the beneficiary of the decision to terminate covered services (Generic Notice, CMS ) no later than 2 days before the proposed end of services . At 3:54 p.m. on 06/24/15, when the administrator was advised of the findings, he stated his business office manager had already told him about the issue.",2019-01-01
5477,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2015-09-24,156,B,0,1,HNWB11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 65. Findings include: a) On 09/21/15 at 11:45 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident on how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview on 09/24/15 at 10:20 a.m., the Nursing Home Administrator, agreed the information was not posted prominently to inform residents on how to apply for and use Medicare and Medicaid benefits.",2019-01-01
5507,MINNIE HAMILTON HEALTH CARE,51A013,186 HOSPITAL DRIVE,GRANTSVILLE,WV,26147,2015-10-07,156,B,0,1,WP4G11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 22 Findings include: a) On 10/05/15 at 11:45 a.m., an observation of the facility revealed there was no written information posted in the facility to inform a resident how to apply for and use Medicare benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. In an interview, on 10/06/15 at 9:45 a.m., the Director of Social Services agreed the information was not posted prominently to inform residents on how to apply for and use Medicare benefits.",2019-01-01
5573,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2014-12-12,156,D,0,1,VNJW11,"Based on review of the facility's reported allegations to proper state authorities, staff interview, record review, resident interview, and review of the care area of liability notices and beneficiary appeal right review, the facility failed to ensure Residents #9 and #47 were informed of the facility's rules regarding safeguarding of personal property prior to alleged allegations of misappropriation of resident property made by both residents. This was true for two (2) of eight (8) reported allegations to proper state authorities reviewed. The facility also failed to ensure Resident #181 received notice of the decision to terminate Medicare covered services two (2) days before the proposed end of services. This was true for one (1) of three (3) residents reviewed for the care area of liability notices and beneficiary appeal right review. Resident identifiers: #9, #47 and #181. Facility census: 154. Findings include: a) Resident #9 Review of the facility's immediate fax reporting of allegations to the nursing home program, on 12/02/14, found the resident reported $70.00 was missing from her purse. The incident was reported to the Office of Health Facilities Licensure and Certification (OHFLAC) on 11/04/14. The five (5) day follow up report, completed on 11/10/14, found the corrective action by the facility was, Has resident trust available and access to that money at all times. Has a locked drawer she can keep her valuables in. In an interview with the administrator and the social services director, at 8:48 a.m. on 12/04/14, the administrator stated residents could get a lock on their night stand drawer and a key if they wished to lock up valuables. The administrator verified the facility's admission agreement did not contain this information, but residents were informed of a locking drawer by the activity director during competition of a recreational assessment. At 10:45 a.m. on 12/04/14, the administrator provided a copy of the recreation assessment and stated the activity staff ask resident's the question, How important is it to you to have a place to lock your things to keep them safe. He said this was when the activity staff informed the residents about the locking drawer. The most recent recreation assessment for Resident #9 was completed on 04/28/14. Review of the assessment found the resident said it was very important to have a place to lock her belongings to keep them safe. When asked, How important is it to you to take care of your personal belongings or things, the typed response was, Likes to watch over all of her stuff. During an interview with the resident, on 12/04/14 at 2:15 p.m., she said she was never offered a key to lock up her stuff in her room until after she reported the $70.00 was missing. She said she was aware the, Front office staff could keep her money, but I like to get out my cash and keep it with me. The resident's responsible party, her daughter, was interviewed by telephone on 12/05/14 at 11:30 a.m. The daughter said she was unaware of a locking drawer and a key until just about two (2) weeks ago when someone at the nursing home gave her mother a key to lock a drawer in her night stand. She said her mother now wears the key on a band around her arm. She said her mother always liked to keep cash with her and she would keep her purse at the foot of the bed. She replied, After all those years, Mom just got a key. At 8:30 a.m. on 12/08/14, Employee #73, the maintenance director, was asked when he gave the resident a key to the dresser. He replied, Just last week. At 9:23 a.m. on 12/08/14, the activity director, Employee #161, acknowledged she completed the recreation assessment on 04/28/14. When asked if she previously told Resident #9 about a locked drawer and a key, she stated, If I offered a locked drawer it would be on the assessment. I can't say I did or didn't offer it. b) Resident #47 Review of the facility's reported allegations to proper state authorities found the resident reported, on 09/15/14, when she went to therapy she left her tablet (electronic), debit card, and about $80.00 on her bed. When she returned from therapy the items were gone. The facility's five (5) day follow-up report to the nursing home program found the corrective action by the facility was, Will move locking night stand to other side of bed if able. Upon inquiry, at 8:30 a.m. on 12/08/14, Employee #73 said he could not recall if or when he provided a key to Resident #47. Review of the recreation assessment, completed on 09/08/14, found the resident said it was very important for her to take care of her personal belongings and the comments were, Has cell phone and tablets with her. The resident also said, it was very important to have a place to lock her things to keep them safe. At 9:23 a.m. on 12/08/14, the activity director, Employee #161, stated, If I offered a locked drawer it would be on the assessment. I can't say I did or didn't offer it. At approximately 10:19 a.m. on 12/09/14, the social services director stated the resident could not reach her night stand because she had a bariatric bed. She said that was why the five (5) day follow-up report said the night stand needed to be moved. The social service director was unable to provide evidence the night stand was moved. The facility's Welcome Packet, provided to each resident upon admission, was reviewed. The only reference to personal items was the following statement, .We advise against bringing the following items: Jewelry, credit cards or any expensive sentimental or one-of-a-kind items that are irreplaceable. If you would like to have some money for personal spending, please discuss this with our Business Office Manager or designee upon arrival .Notice: (name of the corporation) is not responsible for any items that are lost or stolen during your stay. The Welcome Packet did not contain any information about requesting a locked drawer. c) Resident #181 Review of three (3) computer selected residents for the mandatory facility task, liability notices and beneficiary appeal right review, at 2:23 p.m. on 12/10/14, with Employee #71 (office personnel) found Resident #181 ended Medicare services on 07/16/14 and continued to remain at the facility. On 07/15/14, the facility provided the resident's responsible party a notice of Medicare Provider Non-Coverage stating the effective date coverage of the current skilled nursing services would end on 07/16/14. The directions for completing the Notice of Medicare Non-Coverage from the Centers for Medicare/Medicaid Services (CMS), approved 12/31/2011, require the notice be provided, .not later than two (2) days before the termination of services. Employee #71 verified the notice was not provided two (2) days before the termination of services at 2:23 p.m. on 12/10/14. At 4:30 p.m. on 12/10/14, the administrator was advised of the findings regarding the facility's failure to provide timely non-coverage notification.",2018-09-01
5988,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2014-09-18,156,D,0,1,7HHJ11,"Based on staff interview, review of the facility's liability and appeal notices, and review of the memorandum from the Centers for Medicare and Medicaid Services (CMS) regarding liability notices and beneficiary appeal rights in nursing homes (issued on 01/09/09), the facility failed to issue the correct notice of Medicare non-coverage form for two (2) of three (3) residents when Medicare services were discontinued by the facility. Both residents were receiving therapy and were discharged from Medicare services with Medicare benefit days remaining. Resident identifiers: #60 and #62. Facility census: 98. Findings include: a) Resident #60 Review of the resident's notice of Medicare non-coverage form with Employee #94, the registered nurse (RN) admissions coordinator, at 1:53 p.m. on 09/17/14, found Resident #60 was discharged from Medicare skilled services on 04/23/14. The reason for the discontinuation was, Resident has met goals established with PT. OT (physical and occupational therapy) and has plateaued. RN #94 verified the resident had benefit days remaining. RN #94 issued form CMS to the resident's responsible party on 04/21/14. b) Resident #62 Review of the resident's Notice of Medicare Non-Coverage form, with RN #94 at 1:53 p.m. on 09/17/14 found the resident's last covered day of Medicare skilled services was 04/02/14. The reason for the denial was, Patient has met all goals with therapy and no longer meets criteria for skilled services. RN #94 verified the resident had benefit days remaining when discontinued from Medicare services. RN #94 issued form CMS to the resident's responsible party on 03/31/14. c) According to the CMS, S&C-09-20 memorandum guidance, dated 01/09/09, Use the Notice of Provider Noncoverage (Form CMS ) also known as the Generic Notice to notify resident of the right to an expedited review by a QIO (Quality Improvement Organization): All covered services are ending for coverage reasons and resident has benefit days remaining. The example provided was, SNF (skilled nursing facility) decides to discharge the resident because he/she has reached all therapy goals and no other qualifying medical conditions exist. RN #94 verified the facility had not provided the correct form, CMS , to Resident #60 or Resident #62 when the facility discontinued Medicare coverage / services. She expressed understanding that since both residents had benefit days remaining, form CMS should have been provided instead of form CMS .",2018-05-01
6157,MONTGOMERY GENERAL ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2014-08-26,156,D,0,1,6MJ711,"Based on staff interview, review of the Centers for Medicare and Medicaid Services (CMS) instructions for notices of Medicare noncoverage, and review of the facility's liability and appeal notices, the facility failed to issue the correct notice of Medicare noncoverage form for one (1) of three (3) residents reviewed when a resident was terminated from Part A Medicare services with benefit days remaining. Resident identifier: #16. Facility census: 55. Findings include: a) Resident #16 An interview with Employee #65, the social worker, at 10:40 a.m. on 08/21/14, found Resident #16 was cut from Medicare part A services on 04/08/14. The facility issued a Center for Medicare and Medicaid Services (CMS) Form # , skilled nursing facility advance beneficiary notice (SNFABN), to the resident on 04/04/14 stating the resident was being cut from Medicare part A services because the resident had reached her maximum rehabilitation potential. The resident had remaining days remaining. The facility also provided a second notice of Medicare non-coverage, CMS form # to the resident on 04/04/14. The resident had remaining benefit days and according to the directions on the CMS, SNF (skilled nursing facility) Notice Structure, the resident should have received CMS form # . The instructions stated: . Use the Notice of Provider Noncoverage (Form CMS # ) also know as the 'Generic Notice' to notify resident of the right to an expedited review by a QIO (Quality Improvement Organization): All covered services are ending for coverage reasons and resident has benefit days remaining. The example provided by CMS for use of form # was, SNF decides to discharge the resident because s/he has reached all therapy goals and no other qualifying medical conditions exist, which was the exact condition for ending Medicare coverage for Resident #16. On 08/21/14 at 10:40 a.m., Employee #65 verified Resident #16 should have received CMS form # , instead of CMS form # issued by the facility.",2018-05-01
6185,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2014-09-18,156,B,0,1,O60P11,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility Census: 55 Findings include: a) On 09/17/14 at 10:10 a.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of their benefits. An interview was conducted on 09/17/14 at 1:20 p.m., with the Nursing Home Administrator. She was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2018-05-01
6732,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2013-11-13,156,B,0,1,IQK011,"Based on observation and staff interview, the facility failed to ensure each resident had access to information regarding how to apply for and use Medicare and Medicaid benefits. The facility had not prominently displayed the written information regarding these benefits, as required by this regulation. This had the potential to affect any resident wishing to apply for and use these benefits. Facility census: 107. Findings include: a) On 11/12/13 at 2:15 p.m., during an observation of the facility, it was discovered there was no written information posted in the facility to inform a resident about how to apply for and use Medicare and Medicaid benefits. This posting is required to fulfill the facility's obligation to adequately inform residents of these benefits. An interview was conducted, on 11/12/13 at 2:45 p.m., with the Nursing Home Administrator. He was unable to locate any information posted to inform residents on how to apply for and use Medicare and Medicaid benefits.",2017-11-01
6795,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,156,D,0,1,6TWN11,"Based on review of liability notices and through staff interview, it was determined the facility had not given liability notices in the timeframe established by Centers for Medicare and Medicaid (CMS) and was providing the notices using an outdated form. Resident identifiers: #54 and #53. Facility census: 11. Findings include: a) Resident #54 This resident was given a liability notice stating the services for the Transitional Care Unit were going to end effective 02/19/14, and signed as received the same day. Instructions from the Centers for Medicare and Medicaid indicate these notices are to be given two (2) days prior to the services being cut. b) Resident #53 This resident was presented with a liability notice dated 03/27/14 and signed as received the same day, 03/27/14, indicating coverage for Transitional Care Unit services would end that date. c) Discussion with Registered Nurse (RN) Coordinator #2 on 08/05/14 at 2:25 p.m., revealed the residents were verbally given notification at a meeting on Tuesdays that services will be stopped on Thursday or Friday which were usually discharge days and the residents went home. The written notices were given and signed on the date of discharge and not two (2) days prior as required by instructions on using the form by CMS. Additionally the facility was using the form to give the notices dated 06/30/08. The most current form is dated 12/31/11.",2017-11-01
7027,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2013-08-14,156,B,0,1,66WU11,"Based on record review, policy review, and staff interview the facility failed to ensure the information communicated to the residents when there was a change in their skilled status was complete. The liability notices did not identify the services being discontinued and/or the reason for the action for three (3) of six (6) sampled residents who had medicare covered services discontinued. Resident identifiers: #87, #78, and #112. Facility census 68. Findings include: a) Residents # 87, 78, and 112 A review of the Notice of Medicare Provider Non-Coverage document which was provided to the residents and/or their responsible parties revealed the following verbiage: The Effective Date Coverage of Your Current: SKILLED NURSING Services Will End (date). The document did not, in a language the resident can understand, identify all skilled services that were being received by the residents which were being discontinued. The document also did not explain why the service was being discontinued. A review of the medical records of Residents #87, #56, and #86 revealed that they were also receiving Skilled Therapy services. The residents were being asked to make an appeal decision without this information. During an interview with Employee #97 (Physical Therapy Aid) at 8:30 a.m. on 08/07/13, she confirmed Residents #87, #56, and #86 were receiving Physical Therapy services which were discontinued on the date stated in the Medicare Non-Coverage notice. After reviewing the liability notices with the Administrator at 8:45 a.m. on 08/13/13, he acknowledged the notices did not contain what services were being discontinued or why they were being discontinued. During an interview with the Social Worker (Employee #68) at 1:45 p.m. on 08/13/13, she stated she knew the resident or his responsible party should be informed of all services and the reason for discontinuing them. She stated she was not the person who filled out the notices, although she did sign them indicating she issued the notice to Resident #112.",2017-09-01
7083,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2013-11-21,156,B,0,1,DACE11,"Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicare and Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 36. Findings include: a) During the initial tour of the facility on 11/18/13, at approximately 11:45 a.m., observations found the posting of how to apply for and use Medicare and Medicaid benefits was not present. On 11/21/13 at 11:30 a.m. the director of nursing and the social worker, Employee #35, confirmed the information was not posted in the facility. Employee #35 stated the building had recently been painted and she thought the painters must have removed the information.",2017-08-01
7094,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,156,C,0,1,1ZMG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure residents were informed both orally and in writing, and in a language the resident understands, of his or her rights during the stay in the facility. The facility did not post the address for the State survey agency. This agency serves as the entity to which residents can make formal complaints about the care they are receiving. This practice had the potential to affect all residents and/or their responsible parties. Facility census: 118. Findings include: a) On 09/16/13 at 4:00 p.m., the resident council president (Resident #61) said she did not know where the posting was that had the name, address, and telephone number of the State survey agency. This agency is responsible for receiving complaints from residents regarding their care in nursing homes. At 4:30 p.m. on 09/16/13, an observation of the posting revealed the name and telephone number of the State survey and certification agency was posted; however, the posting did not contain the address for this agency. On 09/17/13 at 10:55 a.m., during an interview, the administrator (Employee #66) said he said he would update the postings so they contained this information.",2017-08-01
7275,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2014-05-15,156,B,0,1,SERN11,"Based on observation and staff interview, the facility failed to ensure it had prominently displayed written information about how to apply for and use Medicaid benefits. This practice had the potential to affect any residents and/or residents' responsible parties who might need access to this information. Facility census: 15. Findings include: a) During the initial tour of the facility on 05/12/14 at 10:50 a.m., observations found the posting of how to apply for and use Medicaid benefits was not present. On 11/14/14 at 11:15 a.m., Employee #1, the registered nurse clinical coordinator supervisor (RN, CCS) and Employee #20, the social worker, confirmed the facility had not posted the information in the facility.",2017-06-01
7317,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,156,D,0,1,KPNE11,"Based on record review and staff interview, the facility failed to ensure one (1) of three (3) residents selected for the liability notice and beneficiary appeal rights review were given information in writing when they were discharged from a skilled service covered by Medicare. Resident identifier: #20. Facility census: 51. Findings include: a) Resident #20 On 04/16/13 at 1:00 p.m., the billing clerk (Employee #74) assisted in a review of the liability notices and beneficiary appeal rights for three (3) residents. Two (2) of the three (3) residents selected for review were discharged to another skilled nursing facility. Resident #20 had refused to participate in the skilled therapy service. Employee #74 said the resident said she was too sick to participate. Employee #74 indicated she did not send the resident a written notice informing her of her discharge from a skilled service covered by Medicare. She said she did not think she had to send a written notice when the resident refused to participate. According to the Centers for Medicare and Medicaid Services (CMS) survey and certification letter 09-20: If a SNF provider believes on admission or during a resident's stay that Medicare will not pay for skilled nursing or specialized rehabilitative services and the provider believes that an otherwise covered item or service may be denied as not reasonable and necessary, the facility must inform the resident or his/her legal representative in writing why these specific services may not be covered and the beneficiary's potential liability for payment for the non-covered services.",2017-06-01
7358,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-07-22,156,B,0,1,MT7G11,"Based on observation and staff interview, the facility failed to post contact information of pertinent State client advocacy groups in a manner which was accessible to wheelchair bound residents. This had the potential to affect more than a limited number of residents. Facility census: 104. Findings include: a) During a random observation on 07/22/13, a copy of residents' rights with a listing of telephone numbers was observed posted in the lobby of the facility. The bottom of the form was about eye level, if standing. Upon inquiry, on 07/22/13 at 8:15 a.m., Employee #131 (social services), confirmed the information was not posted in another area accessible to residents. She also acknowledged the posted information, containing residents rights and contact information for pertinent State client advocacy groups, would be difficult to read from a seated position, such as a wheelchair, and was therefore not accessible to all residents.",2017-05-01
7532,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2013-07-18,156,D,0,1,5IAE11,"Based on review of Medicare beneficiary liability notices and staff interview, the facility failed to provide notice of termination of Medicare services at least two (2) days in advance of the service termination. This was true for one (1) of three (3) residents selected for review during the quality indicator survey. Resident identifier: #84. Facility census: 61. Findings include: a) Resident #84 Review of liability notices (Centers for Medicare Services - form number ) found the notice was provided to Resident #84's responsible party on 05/21/13. An interview was conducted with Employee #25, the register nurse responsible for issuing the liability notice, at 4:22 p.m. on 07/17/13. It was revealed the last day of covered services for Resident #84, was 05/22/13. Employee #25 verified the responsible party should have received the notice at least two (2) days in advance of the service termination.",2017-04-01
7557,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2013-06-13,156,D,0,1,UM2S11,"Based on record review and staff interview, the facility did not inform Resident #68 when her level of care no longer met the qualifications for Medicare payment. Beginning on 04/11/13 Resident #68 had a change in payer source. The resident's Medicare benefit no longer paid for her care and services. There was no evidence the facility had issued the appropriate notices to the resident when her Medicare coverage ended. The facility was unable to provide evidence the resident had been notified of Medicare non-coverage. This was true for one (1) of three (3) sampled residents. Resident Identifier: #68. Facility Census: 88. Findings Include: a) Resident #68 Employee #45, the business office manager (BOM), was interviewed at 12:30 p.m. on 06/11/13. This interview revealed Resident #68's payer source changed on 04/11/13. The BOM confirmed the resident's last covered day for Medicare services was 04/10/13. The BOM also confirmed Resident #68 was not notified when her care no longer met the requirements for Medicare coverage.",2017-04-01
7691,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2013-04-18,156,D,0,1,JBS911,"**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, who the facility determined was no longer eligible for Medicare services, received the proper notice before discontinuing Medicare services. This was true for one (1) of three (3) residents reviewed for liability notices during the Quality Indicator Survey. Resident identifier: #58. Facility census: 51. Findings include: a) Resident #58 Medical record review found Resident #58 was admitted to the facility on [DATE]. Further review found the resident was notified in writing, by a facility generated form, on 12/06/13, that Medicare services would end on 12/12/12. The reason for the discontinuation of services was listed as, discontinuation of skilled therapy. According to the Centers for Medicare and Medicaid Services (CMS), termination (end of covered care) requires the provider to, Use the notice of provider non coverage (form CMS ) also known as the 'Generic Notice' to notify the resident of the right to an expedited review by a QIO (Quality Improvement Organization): All covered services are ending for coverage reasons and resident has benefit days remaining. The director of nursing (DON) was interviewed at 2:00 p.m. on 04/17/13. She verified the facility had not used the CMS form to notify the resident of the discontinuation of Medicare services. She further agreed the facility notice provided to the resident did not include the telephone number of the QIO for appeal. The DON also verified the resident had remaining benefit days when Medicare was discontinued. .",2017-02-01
7736,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,156,B,0,1,H1U811,"Based on review of liability notices and staff interview, the facility failed to provide specific written information to three (3) of three (3) residents whose Medicare covered skilled services were discontinued. The liability notices provided these residents did not indicate the reason the services would no longer be covered. Resident identifiers: #9, #53, and #51. Facility census: 44. Findings include: a) Residents #9, #53, and #51 A review of the Notice of Medicare Provider Non-Coverage document which was provided to residents and/or their responsible parties included the following statement: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END (followed by the date). The document did not identify which service was being discontinued and did not explain why the service was being discontinued. The resident was being asked to make an appeal decision without this information. During an interview with the administrator, at 9:45 a.m. on 04/24/13, he acknowledged the form did not indicate which skilled service was being discontinued or the reason for the discontinuation.",2017-02-01
7803,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2013-03-07,156,D,0,1,22CL11,"Based on record review and staff interview, the facility failed, for one (1) of four (4) residents reviewed for liability notices, to give notice to the resident when therapy services were ending and how to appeal the decision if desired. Resident identifier: #15. Facility census: 33. Findings include: a) Resident #15 Medical record review revealed that Speech Therapy, Occupational Therapy, and Physical Therapy were discontinued in December 2012 for Resident #15. Medical record review found no evidence that a liability notice, or the right to appeal the cessation of coverage, was given to this resident, or to her power of attorney. During an interview with the Director of Nursing (DON), on 03/02/13 at 10:00 a.m., she said she thought this resident should have received a notification letter, but other staff had been adamant that she did not require a notification letter. Findings include: c) Resident #1 Resident #1 was interviewed on 03/05/13 at 11:40 a.m., regarding resident council issues. She said she was unaware of who to notify or how to formally notify a state agency if she had a concern. Upon further inquiry, the resident was adamant she would not know what to do, or to whom to report concerns outside of the facility. The Resident council minutes provided by the facility, reviewed on 03/05/13 at 1:30 p.m., provided no evidence of a discussion related to how to report concerns to a state agency.",2017-01-01
7823,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2012-08-23,156,C,0,1,1T2X11,"Based on review of information posted in the facility, review of medical records, and staff interview, it was determined the facility had not posted the names, addresses and telephone numbers for the agencies that are required to be posted to provide information to the residents and others. This practice had the potential to affect all residents who resided in the facility and should have access to this information. Additionally, the facility had not provided residents with a timely notice of their right to appeal when Medicare coverage of services was to be discontinued. The appeal notice timeliness affected two (2) of three (3) residents who were reviewed for appeal notices. Resident identifiers: #69 and #24. Census: 56. Findings include: a) Observation of informational materials posted in the facility found the name, address, and telephone number for the Medicaid Fraud Unit were not posted on the boards that contained information for the residents, their families, and the public. Additionally, there was no notice of how to file a complaint with the State survey and certification agency, nor how to apply for Medicare and Medicaid services. This was discussed with the administrator, Employee #78 and the social worker, Employee #35, on the afternoon of 08/20/12. b) Resident #69 Review of Resident #69's medical records found no evidence she was provided a forty-eight (48) hour notification of discontinuation of skilled services. Medical record review revealed, on 03/27/12, the facility had determined this resident no longer qualified for skilled services beginning 03/08/12. On 03/27/12, the resident signed section C of the form, the acknowledgement of receipt of the notice of non-coverage of services under Medicare. This was nineteen (19) days after the date services would no longer be covered. Staff interview, on 08/22/12 at 09:00 a.m., with Employee #35 (social worker) confirmed Employee #35 did not give Resident #69 a 48 hour notification as required. c) Resident # 24 Review, on 08/22/12 at 9:15 a.m., of Resident #24's medical record revealed the Notice of Medicare Provider Non-Coverage indicated skilled /rehabilitation services would end on March 13, 2012. There was no evidence the resident received notification these services would be discontinued 48 hours prior to the discontinuation of the services. Further review found a form which was signed by the resident on 04/03/12. This form indicated services would no longer be covered after 04/04/12. Resident #24's record review also revealed the notice of Medicare provider non-coverage form the resident signed had an expiration date of 07/31/11. The social worker was interviewed on 08/22/12 at 09:30 a.m. She confirmed the date (04/04/12) was incorrect on the form which indicated when skilled services for this resident would end. Employee #35 stated, I do not know why I put that date. She also acknowledged she used a notification letter which had an expiration date of 07/21/11.",2017-01-01
7888,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,156,D,0,1,INBY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to two residents (Resident #6 and #41) out of five sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #6 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #6 was notified by the facility that skilled nursing services would end on July 18, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident's Medical Power of Attorney on July 17, 2012. Resident #41 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident #41 was notified by the facility that skilled nursing services would end on July 27, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident's Power of Attorney on August 1, 2012, 5 days after the cessation of the services on July 27, 2012. Both resident #6 and #41 remained in the facility and were not discharged following the end of covered services. However, the residents were not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ) or an appropriate generic denial letter. An interview with employee #176 was conducted on August 17, 2012. Employee #176 stated that she issued the CMS Form and not the CMS Form or another appropriate Denial Letter. A subsequent interview was conducted with licensed social worker on August 17, 2012. Staff stated that she was aware of the requirements for issuing liability notices but could not locate the form in the facility's computer drive and believed that it was not the facility policy to issue any liability notices other than the CMS . A verbal policy that the facility complies with Federal requirements regarding liability notices was provided by the facility.",2016-12-01
7919,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2012-08-24,156,D,0,1,PYCQ11,"Based on staff interview and review of 3 liability notices, the facility failed to provide timely notice for one (resident #29) of the three prior to discharging the resident from Medicare skilled services. This involved Resident #29. Findings include: A review of three randomly selected closed records for residents recently discharged from Medicare skilled services was conducted. Resident #29 was a Medicare beneficiary who was discharged from skilled services on 3/10/2012. A review of the Notice of Medicare Provider Non-Coverage letter (denial letter) was conducted. The denial letter issued by the facility indicated the following statement: The effective date of coverage of your skilled services will end 3/10/2012 The Additional Information section of the denial letter also indicated, Resident will be cut from skilled services on 3/10/2012. Under the section entitled, please sign below to indicate that you have received this notice was the following statement: I have been notified that coverage of my services will end on the effective date indicated on this notice and that I may appeal this decision by contacting my QIO. The resident's power of attorney (POA) signed the letter on 3/12/2012, two days after Medicare skilled services had ended. As a result, the facility did not provide the resident or POA sufficient time to appeal the decision to the QIO, (Quality Improvement Organization) should they have desired to utilize the appeal process. An interview was conducted with both the facility administrator and the director of care delivery on 8/23/2012 at 5:05 PM. The facility personnel were unable to provide any other documentation to indicate that the resident's POA had been notified prior to discharging the resident from skilled services. The administrator commented that the resident began receiving Hospice services on 3/10/2012, but still was unable to validate that the responsible party had been notified of the discharge from skilled services prior to the effective date that all skilled services were terminated. Based on these findings, the facility did not provide timely notice to the resident and or representative before discharging the resident from skilled Medicare services.",2016-12-01
7947,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2012-08-20,156,D,0,1,HTLJ11,"Based on staff interview and record review the facility failed to provide 3 of 3 sampled residents ( #17, #74 and #113), or their responsible party, a specific reason for their discharge from skilled medical services. Findings include: A review of three randomly selected closed records was conducted for Medicare beneficiaries who were discharged from skilled services within the past six months. Resident # 17 was a Medicare beneficiary who was discharged from skilled services on 3/30/2012. The denial letter was issued by the facility and signed by the business office representative on 3/23/2012. The business office representative' s signature represented that the notice was delivered telephonically. The letter was also signed by the resident's responsible party on 3/26/2012. There was no reason for discharge listed on the denial letter. Resident # 74 was also a Medicare beneficiary who was discharged from skilled services on 6/22/2012. The denial letter was issued by the facility and signed by a business office representative on 6/15/2012. The business office representative's signature represented that the notice was delivered telephonically. The letter was also signed by the resident's responsible party on 6/26/2012. No reason for discharge was listed on the denial letter. Resident # 113 was a Medicare beneficiary who was discharged from skilled services on 3/20/2012. The denial letter was issued by the facility and signed by the business office representative. The business office representative's signature represented that the notice had been issued telephonically. There was no date indicating the date that the form was signed by the business office representative. The letter was also signed by the resident's responsible party on 3/17/2012. There was no reason for discharge listed on the denial letter. An interview was conducted with the business office representative (facility employee # 4) on 8/15/2012, at 10:00 AM. The business office manager voiced that she is unsure why the Notice of Medicare Non-Coverage (denial letter) form failed to indicate the reason why skilled services would end for resident # 113. Although the business office representative signed the form herself she stated that she is not clinical, and if the resident or a family member were to ask, she would just transfer them over to the therapy department to explain the reason for discharge. She voiced that for as long as she has been completing the denial letters, she has never included a reason for the discharge from the skilled service. The business office representative stated, You could pull 15 more (denial letters) and you won't find a reason listed on any of them. An interview was conducted with the facility administrator on 8/16/2012 at approximately 5:15 PM to discuss the denial letters. The administrator voiced that she believed the denial letter (template) that was pulled from the CMS website should have been sufficient to cover all required documentation.",2016-12-01
8037,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,156,B,0,1,8KXK11,"Based on record review and staff interview, the facility failed to identify the services being discontinued and/or the reason for the action on the liability notices. This affected three (3) of three (3) sampled residents who had Medicare covered services discontinued. Resident identifiers: #228, #21, and #215. Facility census: 127. Findings include: Residents #228, #21, and #215 A review of the Notice of Medicare Provider Non-Coverage document, which was provided to the residents and/or their responsible parties, found the following verbiage: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: (followed by the date) The document did not, in a language the resident could understand, identify the service that was being discontinued, nor did it explain why the service was being discontinued. The resident was being asked to decide whether to make an appeal of the decision without this information. During an interview with the Social Worker on the skilled unit, at 11:00 a.m. on 08/22/12, it was revealed that Residents #228 and #21 had met their goals and were either discharged to home or another health care facility. During an interview with the Administrator and the Director of Nurses, at 11:30 a.m. on 08/22/12, the Administrator acknowledged that the name of the service and reason for discontinuing it were not being added to the form, although it was a CMS approved form.",2016-10-01
8049,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2012-06-06,156,C,0,1,RKJW11,"Based on observation and staff interview, the facility failed to prominently display the required written information on how to apply for Medicare and Medicaid. This had the potential to affect all facility residents. Facility census: 87. Findings include: a) On 05/29/12 at 2:20 p.m., a tour of the facility revealed no prominently displayed written information on how to apply for Medicare and Medicaid. In an interview with the administrator and social worker (Employee #24) at that time, they agreed there was no posting of the information on how to apply for Medicare and Medicaid in the building. Employee #24 stated she was not aware this was a requirement.",2016-10-01
8094,LEWISBURG CENTER,515144,979 ROCKY HL,RONCEVERTE,WV,24970,2012-06-21,156,E,0,1,URTG11,"Based on a review of liability notices and beneficiary appeal rights, and staff interview, the facility failed to ensure four (4) of four (4) residents who were cut from Medicare Part A skilled services, received the appropriate information regarding their discharge. Resident identifiers: #119, #117, #36, and #126. Facility census: 87. Findings include: a) Residents #119, #126, and #36 On 06/21/12, at approximately 8:30 a.m., the admission director (Employee #40) provided a list of resident's who were discharged from a Medicare Part A skilled service within the past seven (7) months. Resident #119 discharged from a skilled nursing service on 05/17/12. Resident #126 was discharged from a skilled nursing service on 01/11/12. Resident #36 was discharged from a skilled service on 05/04/12. The facility provided the residents with the Notice of Medicare Non-Coverage (CMS - ). The form did not explain to the residents the reason for the discontinuation of the skilled service. Employee #40 indicated the skilled services ended because all three (3) residents were discharged from the facility to a private residence. According to the Center for Medicare Services (CMS), the facility has no obligation to provide the resident with a notice if they discharge home. The resident, and not the facility made the decision to terminate services. The facility should not issue the Notice of Medicare Non-Coverage when the resident discharges to home. b) Resident #117 Resident #117 was discharged from Medicare Part A services on 11/25/11. Employee #40 indicated the resident had exhausted her Medicare Part A benefit days. The facility provided the resident with the Notice of Medicare Non-Coverage (CMS ). According to CMS, the facility should not issue the Notice of Medicare Non-Coverage also known as the generic notice if the resident exhausted the Medicare covered days. The Medicare covered days are set in law and the Quality Improvement Organization (QIO) cannot extend the benefit period. c) On 06/21/12 at approximately 9:00 a.m., Employee #40 acknowledged the facility had sent incorrect notices to the four (4) residents and/or their responsible parties.",2016-10-01
8102,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,156,C,0,1,QR3O11,"Based on observation and staff interview, it was determined the facility had not posted the correct addresses for the State survey agency and the Medicaid Fraud Unit. These addresses are to be posted for all residents and the public should an individual wish to contact one of the agencies. Census: 97. Findings include: a) Review of information posted in the hallways on first floor for residents and the public noted the wrong address was listed for the Office of Health Facility Licensure and Certification. This was verified with the administrator, Employee #107, and the social worker, Employee #61, on 10/24/12 at 9:30 a.m. b) Posting of advocacy groups - Medicaid Fraud Control Unit At 10:15 a.m. on 10/25/12, a poster containing the address and telephone number of the State Medicaid Fraud Control Unit was observed on the first floor beside the elevator. An interview with the administrator, on 10/25/12 at 10:30 a.m., confirmed the address of the State Medicaid Fraud Control Unit was incorrect.",2016-10-01
8107,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,198 JOHN COOK NURSING HOME ROAD,HINTON,WV,25951,2012-10-11,156,D,0,1,YXKJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability and appeal notices to two residents (#'s 1 and 66) out of three residents discharged from skilled services. Findings include: -Resident #1 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #1 was discharged from skilled services on [DATE], and remained in the facility with benefit days remaining until the resident expired on [DATE]. The facility was unable to provide evidence that the resident or responsible party had been provided the appropriate liability and appeal notices. Resident #66 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Resident #66 was discharged from skilled services on [DATE] and remained in the facility with benefit days remaining. The facility was unable to provide evidence that the resident or the responsible party had been provided the appropriate liability and appeal notices. An interview was conducted with licensed nursing staff #118 on [DATE]. Staff stated that she had not kept copies of the notice of medicare non-coverage letters that were provided to both residents and/or responsible parties prior to the cessation of their skilled services. Furthermore, staff was unaware that an additional denial letter or CMS- should have been provided once the residents remained in the facility with benefit days remaining after their last covered day.",2016-10-01
8186,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,156,B,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide appropriate liability notices to one (resident #277) out of four sampled residents reviewed for liability notices and beneficiary appeal rights. Findings Include: Resident #277 was admitted on [DATE], with [DIAGNOSES REDACTED]. Resident was notified by the facility that skilled nursing services would end on May 12, 2012. Notice of Medicare Non-Coverage (CMS Form ) was signed by the resident on May 10, 2012. Resident remained in the facility and was not discharged following the end of covered services. However, the resident was not issued the Skilled Nursing Facility Advance Beneficiary Notice (CMS Form ). An interview with employee #76 was conducted on May 16, 2012. Employee #76 stated that she issued the CMS Form and not the CMS Form . A subsequent interview was conducted with employee #76 on May 17, 2012. Employee #76 stated that she misunderstood the training she received regarding the requirements for issuing liability notices.",2016-07-01
8198,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2012-05-22,156,E,0,1,JXHC11,"Based on medical record review, staff interview, resident interview, and observation, the facility did not ensure written information was prominently displayed about how to apply for and use Medicaid benefits. The facility also failed to ensure one (1) of forty- six (46) residents had received information regarding how to contact the physician responsible for her care. In addition, the facility failed to ensure two (2) of five (5) residents received the appropriate liability notice after they were discharged from a Medicare Part A service. Resident identifiers: #45, #58, and #114. Facility census: 115. Findings include: a) On 05/15/12, at approximately 9:00 a.m., an observation of the facility revealed they had not posted the necessary information regarding how to apply for and use Medicaid benefits. On 05/16/12, at approximately 9:00 a.m., the administrator (Employee #43) agreed the facility had not posted this information. She indicated the facility had previously posted the information, but people kept taking it down. b) Resident #114 On 05/15/12, at approximately 4:00 p.m., the director of admissions (Employee #68) indicated she gave the residents the consent for treatment and release of information form at the time of admission. Review of Resident #114's medical record, conducted on 05/15/12, at approximately 4:30 p.m., found the consent for treatment and release of information form. The form did list the resident's physician; however, the form did not have contact information listed for the physician. The form had a place to list the physician's telephone number and physician's address, but this information had not been provided on the form. In an interview on 05/22/12, at approximately 8:45 a.m., Resident #114 indicated she did not know how to contact her physician. On 05/22/12, at approximately 5:00 p.m., the director of nursing (Employee #2) asked what type of contact information the facility needed to give the residents regarding how to contact their physician. The director of nursing agreed that the resident's consent for treatment and release of information form required the telephone number and/or address of the resident's physician. c) Liability notices On 05/17/12, at approximately 9:00 a.m., the social workers, Employee #17 and Employee #24, were interviewed regarding the notices given to residents who were discharged from a Medicare Part A service. Resident #45 and Resident #58 were both discharged from Medicare Part A services in April 2012. 1) Resident #58's skilled services ended on 04/30/12 due to the resident reaching his functional ability potential and no longer needing the supervision or skills of a therapist. The facility provided the responsible party with the Notice of Medicare Provider Non-Coverage (CMS form ). They did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form ). The resident remained in the facility and services were terminated prior to the 100-day benefit period per the facility's decision. The facility needed to provide the responsible party with the SNFABN because benefit days remained and there was a potential for financial liability. 2) Resident #45's skilled services ended on 04/02/12 due to the resident having learned to perform the tasks ordered by her physician. The facility provided the responsible party with the Notice of Medicare Provider Non-Coverage (CMS- ). They did not provide the Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) (CMS form ). The resident remained in the facility with benefit days. The facility needed to issue the SNFABN because benefit days remained and there was a potential for financial liability. On 05/17/12, at approximately 9:30 a.m., the social workers confirmed they had not sent the SNFABN to Resident #45's and Resident #58's responsible parties.",2016-07-01
8286,COLUMBIA ST. FRANCIS HOSPITAL,515110,333 LAIDLEY STREET,CHARLESTON,WV,25322,2013-02-01,156,E,0,1,BSMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews and staff interviews, the facility failed to post information for residents on how to apply for Medicaid and Medicare, and failed to post the correct address for the Office of Health Facility Licensure and Certification (OHFLAC). Findings a) On 01/29/13 at 2:30 p.m., an interview was completed with Employee #7, the Activities Coordinator, who stated that she was responsible for the required postings on the bulletin board. Employee #7 was shown there were no postings providing written information about how to apply for and use Medicaid or Medicare benefits. It was also brought to her attention that the address for OHFLAC was incorrect and the correct address was under state health department.' OHFLAC is not the state health department. b) A review was completed on 01/30/13 at 8:30 a.m. of the facility's Skilled Nursing Unit Determination of Continued Stay/Notice of Discharge. There was a sample of three (3) residents who had received these notices. Review of their discharge plans were completed on 01/30/13 at 9:00 a.m 1) Resident #127 The notice for Resident #127 was signed and dated on 11/19/12. Resident #127 was also discharged and the services ended on 11/19/12. The resident was not given the required two (2) days notice of discharge. 2) Resident #86 The resident signed her notice on 09/17/12. Which was on the same day her services ended and she was discharged . This resident was not given the required two (2) days notice of discharge. 3) Resident #84 Resident #84, signed his notice on 08/30/12. His services were also ended and he was discharged on [DATE]. This resident was not given the required two (2) days notice of discharge. c) Employee #14 (the admissions nurse) was interviewed on 01/30/13 at 1:30 p.m. The liability notices for the three (3) residents were shown to her. She stated to her knowledge, these notices were given to the residents on the day of their discharge. She was asked how the facility ensured proper notice of termination of services was received and understood by residents, so they had time to decide whether or not they wanted to appeal. She said she thought it was, All part of discharge planning and the discussion staff would have with residents leading up to and preparing for their discharge. Further, she said she was not aware residents were to be given a certain amount of notice by a formal document before services were terminated. A copy of the form instructions for the 'Notice of Medicare Provider Non-Coverage, The Generic Notice CMS- ,' was printed directly from the Internet in the facility on 01/30/13 at 1:15 p.m. A copy was given to Employee #14 during this interview. It was explained to Employee #14 that these regulations were readily available on the Internet under the Center for Medicare and Medicaid Services' website. The form instruction stated in the first paragraph, A medicare provider must give a completed copy of this notice to beneficiaries receiving services from skilled nursing facilities (SNFs) .not later than 2 days before the termination of services. Paragraph three (3) explained, 'Providers will note that the notices must be validly delivered. Valid delivery means that the beneficiary must be able to understand the purpose and contents of the notice in order to sign for receipt of it. The beneficiary must be able to understand that he or she may appeal the termination decision.",2016-07-01
8370,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,156,C,0,1,X70T11,"Based on observation of posted information and staff interview, it was discovered the facility did not have the current address for the (state agency) Office of Health Facility Licensure and Certification (OHFLAC) posted as required. This practice had the potential to affect all residents and the public, who are to have access to this information. Facility census: 48. Findings include: a) While observing posted information on 11/28/12, at mid morning, it was discovered the address posted for OHFLAC was incorrect. The address listed was not the address for this agency, and had not been for more than a year. This was discussed and confirmed with the director of nursing, Employee #127, and the social worker, Employee #292, at the time of the review.",2016-07-01
8522,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2013-05-30,156,D,1,0,6GZU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide information upon admission to a resident to ensure the resident had knowledge of his/her rights, and information related to the responsibilities of the facility. During a random review of the medical record for Resident #67, it was discovered the resident was admitted to the facility on [DATE], but did not receive or sign information in the admission packet until ten (10) days after her admission to the facility. Resident identifiers: #67. Facility census: 137. Findings include: a) Resident #67 During a review of the medical record for Resident #67, on 05/29/13 at 12:45 p.m., it was discovered the resident was admitted to the facility on [DATE]. Further review identified the resident did not receive information provided in the facility's admission packet until 05/24/13 - two (2) weeks after admission. The facility's admission packet included the following information provided to each resident upon admission to the facility. I. Rights and Responsibilities of the patient. 1.01 Room and Board Rate 1.02 Ancillary Charges 1.02 a. Transportation 1.03 Collection/Late payments 1.04 Independent Providers 1.05 Governmental Programs 1.06 Third party payors and managed care organizations 1.07 Private pay patient 1.08 Admission information 1.09 Application for Benefits 1.10 Primary Reasonability for Payment 1.11 Personal Physician 1.12 Pharmacy II. Rights and Responsibility of the Responsible party. 2.01 Legal Authority 2.02 Agreement to make payments on behalf of patient 2.03 Exhaustion of Patient's Funds 2.04 Cooperation for Financial Assistance 2.05 Actions Upon Discharge 2.06 Additional Responsibilities III. Rights and Responsibility of the Center 3.01 Room and Standard Services 3.02 Other services 3.30 Deposit 3.04 Refunds IV. General Provisions 4.01 Consent to Release Information 4.02 Consent to Treat (signed on 05/10/13) 4.03 Consent to Photographs 4.04 Notice of Services, Polices and Additional Information 4.05 Assignment of Benefits 4.06 Termination, Discharge and Transfer 4.07 Indemnification 4.08 Venue Notice 4.09 Changes in the Law On 05/29/13, at 12:01 p.m., Employee #166 (Admissions director) stated, The admission paper work was not completed until May 24th. Employee #166 was then asked if this was standard procedure. She stated, No, we have had meetings to get admission paper work completed in a timely manner, I was not here and no one completed the paper work.",2016-05-01
8527,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2012-04-26,156,E,0,1,JZJM11,"Based on observation and interview, the facility failed to post the names, addresses and telephone numbers of all pertinent client advocacy groups in a manner in which Residents can view them. The facility also failed to post contact numbers for the State Survey and Certification agency with a statement that a Resident may file a complaint in a manner that Residents can read them. This had the potential to affect any resident dependent on a wheel chair for ambulation. Findings include: a) Observations of the facility on 04/26/12, revealed a bulletin board located across from the social service office on the south side of the building. There was small poster board located on the top left hand side of the bulletin board. The poster board contained information concerning the State Survey and Certification agency and Medicaid and Medicare. The contact information for the agencies was small and difficult to read from a seated wheelchair position. Observations of the facility on 04/26/12, revealed a bulletin board located across from the south nurses' station. At the top right hand corner of the bulletin board was a small poster board which contained information about the Ombudsman including a contact number. The information was not easily accessible for residents. A nurse's treatment cart was located in front of the bulletin board preventing residents, staff and visitors from easily viewing the information. Observations of the facility on 04/26/12, revealed a bulletin board located across from the north nurses' station. There were no posted names, addresses and telephone numbers for pertinent client advocacy groups or contact numbers for the State Survey and Certification agency. During an interview with the facility Administrator, on 04/26/12 at 12:35 p.m., it was verified the required information of all State client advocacy groups was not easily accessible to all residents, staff, and visitors.",2016-05-01
8641,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,156,C,0,1,5VE911,"Based on observation and staff interview, the facility failed to post the current address of the State survey agency. This practice has the potential to affect all residents and members of the general, public since all are to have access to this information. Facility census: 89. Findings include: a) On 08/09/11 at mid morning, observation of postings containing the contact information (addresses and telephone numbers) for various State client advocacy groups found the address for the State survey agency was not current. The agency had moved its office to a new location in July 2010, and the address in the posting had not been updated to reflect this change. This was brought to the attention of the facility's administrator (Employee #15) at the time. She verified the information was incorrect and had staff change the information to reflect the new address.",2016-04-01
8660,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,156,C,0,1,46GB11,"Based on interview and review of documentation, the facility was not using the correct Centers for Medicare and Medicaid Services (CMS) form when notifying residents of changes in the services being provided them under the plan. Residents are to be notified when they no longer are going to receive Medicare skilled services using form CMS . The facility was using a a form entitled C-4. This was evident for three (3) of three (3) residents whose records for denial of payment for services were reviewed. This practice had the potential to affect any resident who was discharged from Medicare services. Resident identifiers: #40, #26 and #70. Facility census: 76. Findings include: a) Residents #40, #26, and #70 Review of documentation given these residents, when they no longer qualified for Medicare services, revealed the facility was using a form entitled C-4. This was not the required form as specified by CMS. The form specified by CMS is form CMS . This is the form to be given at the time residents are no longer eligible for skilled services. Such reasons include: when a resident has used all their days, has reached his/her potential, and/or for any reasons, as set forth by CMS, in which Medicare services are discontinued. This was discussed, on 01/09/12 at mid-morning, with the business office manager(Employee #63) who was responsible for providing these notices. Employee #63 stated he was not aware of form CMS , and would begin using it immediately.",2016-04-01
8691,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2012-03-22,156,E,0,1,GA6A11,"Based on the liability notice and beneficiary appeal review and staff interview, the facility failed to ensure three (3) of three (3) residents who were discharged from a Medicare Part A skilled service received the appropriate notice. In addition, the facility did not ensure the residents were informed of the reason they were discharged from a skilled service. Resident identifiers: #5, #15, and #9. Facility census: 13. Findings include: a) Residents #5, #15, and #9 On 03/21/12, at approximately 3:00 p.m., the social worker (Employee #30) provided a copy of the notices that were given to three (3) residents who were discharged from a skilled service. Resident #5 received the notice of Medicare Provider Non-Coverage (CMS ) on 10/18/11. The form did not state why the facility had discharged the resident from the skilled service. According to the social worker the resident had reached her maximum potential in therapy. She was discharged from the facility on 10/19/11. Resident #15 received the notice of Medicare Provider Non-Coverage (CMS ) on 11/29/11. He was discharged from the facility on 12/02/11. The notice did not contain the reason the resident was discharged from the skilled service. According to the social worker this resident had reached his maximum potential in therapy. Resident #9 received the notice of Medicare Provider Non-Coverage (CMS ) on 10/28/11. She was discharged from the facility on 10/29/11. The notice did not contain the reason why the resident was discharged from the skilled service. According to the social worker this resident had reached her maximum potential in therapy. According to the Center for Medicare and Medicaid Services Survey and Certification letter (S&C-09-20) the facility has the obligation to not only issue the CMS- , but also the SNFABN (skilled nursing facility advanced beneficiary notice) or a denial letter to address liability for payment. The SNFABN is given because benefit days remain to inform the patient of potential financial liability. The generic notice (CMS ) is given to notify the resident of their right to an expedited review by the QIO (quality improvement organization.) The social worker stated Resident #15, #9, and #5 were all discharged from Part A services. She said the unit normally did not keep residents more than twenty (20) days, if that long. She did comment that these residents did have skilled nursing days left and also could have chosen to pay privately for a continued stay on the unit.",2016-04-01
8698,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,156,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to prominently display in the facility, written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The information could not be located in the area of the facility to which residents and visitors members were directed on the facility's information board. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8755,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2012-01-11,156,D,0,1,K0ZK11,"Based on record review and staff interview, the facility failed to identify the services being discontinued, and / or the reason for the action, on the liability notices provided to three (3) of three (3) sampled residents who had Medicare covered services discontinued. Resident identifiers: # 22, #26, and #42. Facility census 141. Findings include: a) Residents #22, #26, and #42 A review of the Notice of Medicare Provider Non-Coverage document which was provided to the residents and / or their responsible parties included the following verbiage: THE EFFECTIVE DATE COVERAGE OF YOUR CURRENT SKILLED SERVICES WILL END: SEPTEMBER 27, 2011 The document did not, in a language the resident could understand, identify which service was being discontinued and explain why the service was being discontinued. The resident was being asked to make an appeal decision without this information. During an interview with the administrator and the corporate clinical consultant, at 9:00 a.m. on 01/10/12, the administrator stated that she was sure this was a CMS approved form. When the form being used was reviewed, they nodded in agreement that the name of the service and reason for discontinuing it could be written in under Additional information.",2016-03-01
8767,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2012-05-03,156,C,0,1,2ZMR11,"Based on observation and staff interview, the facility failed to ensure written information regarding how residents could apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits, was prominently displayed. This had the potential to affect more than an isolated number of residents. Facility census: 101. Findings include: a) On 05/03/12, at approximately 9:00 a.m., a tour of the facility revealed no information was displayed regarding how residents could apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. The administrator (Employee #23), who accompanied the tour of the facility, agreed there were no postings regarding how to apply for and use these benefits, or to receive refunds.",2016-03-01
8827,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,156,C,0,1,5Y7411,"Based on observation and staff interview, the facility failed to prominently display, for residents and applicants, written information about how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. This deficient practice had the potential to affect all residents and families desiring to view this information. Facility census: 100. Findings include: a) Observations of the facility, on 08/30/11, failed to find any prominent postings of information about how to apply for and use Medicare and Medicaid benefits and how to receive refunds for previous payments covered by such benefits. The activity director (Employee #23) and the interim administrator (Employee #119) were unable to locate the posting when asked at 11:35 a.m. on 08/30/11. Employee #23 stated the information had been posted at one time but someone must have taken it down.",2016-03-01
8896,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2012-03-29,156,D,0,1,EEP611,"Based on the liability notice and beneficiary appeal rights review and staff interview, the facility failed to issue the correct notice to one (1) of five (5) residents discharged from a skilled service due to exhausting all Medicare Part A benefits. Resident identifier: #65. Facility census: 60. Findings include: a) Resident #65 On 03/28/12, at approximately 11:00 a.m., Employee #69, the registered nurse assessment coordinator (RNAC), provided copies of the liability notice letters given to five (5) residents who were discharged from a skilled service within the last six (6) months. Resident #65 was discharged from a skilled service (therapy) on 12/25/11. The facility failed to send the appropriate liability notice to the resident's representative. The facility issued the CMS - (Notice of Medicare Provider Non-Coverage). The facility did not issue the NEMB (Notice of Exclusion from Medicare Benefits) (CMS ). In cases where a resident terminates Medicare Part A due to exhausting the 100 day benefits and remains in the facility under another payer source, the NEMB-SNF is issued for technical details. Resident #65 remained in the facility with Medicaid as primary payer source. On 03/28/12 at 2:20 p.m., Employee #69 indicated she had not sent the NEMB-SNF notice to Resident #65's representative.",2016-03-01
8914,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,156,C,0,1,NP7N11,"Based on observation and staff interview, the facility failed to ensure they had prominently displayed written information about how to apply for and use Medicare and Medicaid benefits. The facility did not display information regarding how to apply for and use Medicare and Medicaid benefits on one (1) of three (3) units. This practice had the potential to affect all residents of that unit. Facility census: 90. Findings include: a) During a tour of the facility, on 12/07/11, at approximately 4:30 p.m., the postings of written information regarding how to apply for and use Medicare and Medicaid benefits were located on the second and third floor units. However, the first floor unit did not have this information posted. On 12/07/11, at approximately 4:45 p.m., the administrator (Employee #10) and the director of social services (Employee #100) both verified the first floor unit did not contain this information.",2016-03-01
8938,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,156,C,0,1,R8A111,"Based on observation and staff interview, the facility failed to prominently display how to apply for Medicare and Medicaid. Furthermore, the facility failed to post current contact information for the regional Ombudsman and State survey and certification agency. This practice had the potential to affect all residents residing in the facility. Facility census: 50. Findings include: a) On 09/19/12 at 4:47 p.m., a tour of the facility was conducted with the administrator. During the tour, no information was found posted regarding how residents could apply for Medicare and Medicaid. The administrator agreed this information was not posted. Also, the poster containing resident rights did not have the current address and phone number for the survey and certification agency or the name, address and phone number for the regional ombudsman. The administrator stated she would contact the social worker about this posting to see why this was an old posting. At 5:15 p.m., the social worker stated the correct posting had fallen off the wall and broke the glass. The social worker further stated the old posting had been put in its place until the frame was repaired.",2016-03-01
9034,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2013-03-14,156,C,0,1,RKHC11,"Based on observation and staff interview, the facility failed to display instructions about how to apply for Medicare and Medicaid. Additionally, the address for reporting Medicaid fraud was incorrect. This had the potential to affect all residents residing in the facility. Facility census: 113. Findings include: a) On 03/11/13 at 2:00 p.m., a random tour of the building, with the nursing home administrator (NHA), revealed no evidence of prominently displayed information about how to apply for and use Medicare and Medicaid benefits. The NHA agreed this information was not displayed, and stated she was unaware of this. b) On 03/07/13 at 10:23 a.m., another observation of posted information revealed the address for reporting Medicaid fraud was incorrect. The posting contained an outdated address. On 03/11/13 at 2:00 p.m., this was brought to the attention of the NHA. She agreed the address was not correct, and stated she would immediately correct the address.",2016-02-01
9116,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,156,E,0,1,REFP12,Deficiency Text Not Available,2016-02-01
9187,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-09-21,156,B,0,1,2WLP11,"Based on review of beneficiary liability notices and staff interview, the facility failed to complete the liability notices in accordance with CMS instructions. The facility was not documenting the reasons why Medicare-covered services were being discontinued and/or specific information regarding the delivery of the notices themselves. This was evident for three (3) of three (3) discharged residents whose beneficiary liability notices were reviewed. Resident identifiers: #147, #48, and #104. Facility census: 94. Findings include: a) Resident #147 Review of Resident #147's Notice of Medicare Provider Non-Coverage form found it did not contain any information regarding the reason the Medicare-covered services were being discontinued. The notice recorded the date the service was ending (05/08/11), and there was a note stating: Wife was notified by phone on 5-8-11. -- b) Resident #48 Review of Resident #48's Notice of Medicare Provider Non-Coverage form indicated the Medicare-covered services would end on 07/17/11. The notice also stated staff notified son (POA) (power of attorney) by phone on 7-17-11. -- c) Resident #104 Review of Resident #104's Notice of Medicare Provider Non-Coverage form found the Medicare-covered services were to be discontinued on 05/10/11. The only other notation was: Wife notified by phone 5-10-11. -- d) According to instructions from the Centers for Medicare & Medicaid Services (CMS), when completing the Generic Notice CMS- form, the facility is to insert the kind of services being terminated, such as skilled nursing, home health, hospice or comprehensive outpatient rehab. This information was not recorded on any of the forms reviewed. The instructions further stated that, if the provider is unable to personally deliver a notice of non-coverage to a person legally acting on behalf of a beneficiary, then the provider should telephone the representative to advise him or her when the beneficiary's services are no longer covered as follows: - The beneficiary's appeal rights must be explained to the representative, and the name and telephone number of the appropriate quality improvement organization (QIO) should be provided. - 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. - Place a dated copy of the notice in the beneficiary's medical file and document the telephone contact to include: name of person initiating the contact, name of the representative contacted, date and time of the contact and the telephone number called. - When direct phone contact cannot be made, send the notice to the representative by certified mail, return receipt requested. - The date that someone at the representative's address signs (or refuses to sign) the receipt is the date of receipt. - When notices are returned by the post office, with no indication of a refusal date, then the beneficiary's liability starts on the second working day after the provider's mailing date. These procedures also may be used where a beneficiary has authorized or appointed an individual to act on his or her behalf, and the provider cannot obtain the signature of the beneficiary's representative through direct personal contact. The specifics regarding the notification delivery to representatives was not included on any of the forms reviewed, and this information was not found recorded anywhere in the residents' medical records. -- e) Interview with the administrator (Employee #2) and the billing supervisor (Employee #9), at 2:30 p.m. on 09/15/11, revealed the beneficiary liability notices were usually given three (3) days in advance of the actually non-coverage, so wrong dates had been put on these documents. The dates showed that the notices were given the same day the services were discontinued. Employee #9 stated physical therapy staff will give them a notice of what is being cut, and they verbally notify the resident or responsible party of the reason, but this verbal notification was not documented on the form.",2016-01-01
9196,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-06-08,156,C,0,1,MZQB11,"Based on observation and staff interview, the facility failed to prominently display required information and post the names, addresses and phone numbers of all pertinent State client advocacy groups and information concerning how to file a complaint with the appropriate State agency(ies) concerning abuse, neglect or misappropriation of resident property in the facility. This practice has the potential to affect all residents and families desiring to view this information. Facility census: 149 at the onset of the complaint investigation on 05/18/11 and 144 at the onset of the annual survey on 05/24/11. Finding include: a) During the initial tour of the facility at the onset of the complaint investigation on 05/18/11, this surveyor attempted to view the posting of the required information. The entire first floor was toured, and there was no evidence of any posting containing contact information for the required State agencies. The director of nursing (DON), when questioned about the posting at 3:20 p.m. on 05/18/11, stated the facility had been remodeling and the posting must have been temporarily taken down while this was being done. During the initial tour of the facility at the onset of the annual Medicare / Medicaid certification resurvey at 11:00 a.m. on 05/24/11, observation found the State agency contact information had been posted on the front office door. Access to the front lobby through double doors from the nursing unit was also restricted for any resident wearing a Wanderguard bracelet, so this information would not have been readily available to all residents even if it were posted.",2016-01-01
9230,"ROANE GENERAL HOSPITAL, D/P",515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2011-06-08,156,C,0,1,O68G11,"Based on observation and staff interview, the facility failed to prominently displayed in the facility written information on how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. Additionally, information posted regarding various agencies' names and addresses contained the wrong address for the State survey agency and the wrong name of the State long-term care ombudsman. This had the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations of information posted throughout the unit during the survey revealed a typed notice which contained the names, addresses and telephone numbers of various agencies which the residents may need to contact. On this list, the State survey agency's street address and the name of the State long-term care ombudsman were incorrect. b) Observations also found no notices of any kind which provided information regarding how to apply for Medicaid / Medicare benefits, nor was there information about how to receive refunds for previous payments covered by those benefits. c) These issues were discussed with the social worker (Employee #77) at 1:50 p.m. on 06/ 7/11. She accompanied the surveyor to observe the notices, and she verified the above findings.",2016-01-01
9274,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2011-11-04,156,C,0,1,PGFX11,"Based on observation and staff interview, the facility failed to publicly post the contact information for the State survey and certification agency. This has the potential to affect all residents and visitors who may wish to have access to this information. Facility census: 55. Findings include: a) During the initial tour of the facility beginning at 8:30 a.m. on 11/01/11 and subsequent observations over the course of this survey event until 11/04/11, no posting of the telephone number and address of the State survey and certification agency could be found. On 11/04/11 at 12:30 p.m., this issue was brought to the attention of the administrator. At that time, this surveyor and administrator reviewed all publicly posted addressed and telephone numbers for pertinent State client advocacy groups, and the administrator verified that no contact information was posted for the survey agency.",2016-01-01
9287,"WEBSTER NURSING AND REHABILITATION CENTER, LLC",515165,"ERBACON ROAD, PO BOX 989",COWEN,WV,26206,2012-03-09,156,C,0,1,LL6H11,"I. Based on the liability notice and beneficiary appeal review and staff interview, the facility failed to ensure three (3) of three (3) residents selected for review had received the appropriate notice when there was a termination of Medicare Part A services. Resident identifiers: #27, #28, and #64. Facility census: 55. Findings include: a) On 03/08/12, at approximately 10:00 a.m., the liability notice and beneficiary appeal review revealed three (3) of three (3) residents discharged from a Medicare Part A skilled service in the past six (6) months did not receive the appropriate notice when there was a termination of Medicare Part A services. Resident #27 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice Fee For Service Beneficiary) on 01/17/12. At that point the facility felt Medicare probably would not continue to pay for her therapy due to her plateau in therapy progress. The facility did not provide the resident / responsible party with the SNFABN (Skilled Nursing Facility Advanced Beneficiary Notice - CMS - ). This resident / responsible party should have received this notice to inform the resident of potential financial liability since the resident still had benefit days. Resident #28 received the notice of Medicare provider non-coverage (CMS - - Generic Expedited Determination Notice) on 01/05/11. At that time the facility determined the resident no longer met the criteria for skilled nursing services. The resident / responsible party should have also received the SNFABN (CMS - ). Resident #64 received the notice of Medicare provide non-coverage (CMS - ) on 01/04/12. At that time the resident had used all of her available Medicare Part A days. The facility did not send the Notice of Exclusions from Medicare Benefits Skilled Nursing Facility (CMS - - NEMB - SNF). This notice should have been provided for technical details. The facility did not need to send the generic notice (CMS - ) because the resident had exhausted Medicare Part A benefits. On 03/08/12, at approximately 10:30 a.m., Employee #78 (registered nurse) indicated she sent out the notices to the above three (3) residents. She indicated she normally sent the generic notice (CMS 0 - ). She said the chart she utilized may not be current. She felt that was the reason she did not send the appropriate notices. II. Based on observation of the facility's required postings and staff interview, the facility had not correctly listed the address of the state licensure and certification agency. This agency serves as the entity where residents / families and others can make complaints regarding unsatisfactory care rendered in long term care facilities. This had the potential to affect all residents residing in the facility. Facility cenus: 55. Findings include: a) Observations on 03/07/12, at approximately 2:00 p.m., of the postings on one (1) information board in the hallway toward the dining room, and on one (1) information board in the hallway as one first entered the building, found inaccuracies in the address of the Office of Health Facility Licensure and Certification (OHFLAC), the agency to which residents or families may contact to voice complaints. One information board, contained the incorrect OHFLAC address of Capitol Street in Charleston, WV. The other information board contained the incorrect OHFLAC address of Davis Street in Charleston, WV. In both cases, there was a potential for visitors, residents, or family members to communicate written grievances to the incorrect address of OHFLAC. Also, one (1) of the two (2) information boards contained conflicting information regarding the identity of the regional ombudsman for residents, family members, or other concerned entities who wished to make contact to report any concerns. In one place on the information board, both the identity and telephone number of the regional ombudsman were listed incorrectly, and on the same board the correct name, address, and telephone number of the current long-term care ombudsman was listed. During an interview with the licensed social worker (SW), on 03/07/12, at approximately 3:00 p.m., the SW acknowledged the information board contained incorrect information as written above, and made the necessary corrections.",2016-01-01
9302,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-10-20,156,C,0,1,EWP711,"Based on observation and staff interview, the facility failed to prominently display required information related to how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits. This practice has the potential to affect all residents and visitors desiring to view this information. Facility census: 59. Findings include: a) During the initial tour of the facility at the onset of the survey on 10/17/11, this surveyor attempted to view the posting of the required information. The entire facility was toured, and there was no evidence of any posting containing information on how to apply for Medicare and Medicaid benefits. This observation was immediately reported to the administrator (Employee #1) on 10/17/11, who confirmed the information was not posted prominently.",2016-01-01
9349,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2011-10-04,156,C,0,1,4F0I11,"Based on observation and staff interview, the facility failed to prominently display in the facility written information about how to apply for and use Medicare benefits and how to receive refunds for previous payments covered by Medicare benefits. This deficient practice had the potential to affect any resident or family member wishing to view the information. Facility census: 51. Findings include: a) On the morning of 09/29/11, observation revealed a bulletin board in the main corridor leading to the kitchen area. The bulletin board contained information on how to apply and use Medicaid benefits and how to receive refunds for previous payments covered by Medicaid, but it failed to contain the same information pertaining to Medicare benefits. On 09/29/11 at 9:20 a.m., the above deficient practice was discussed with the director of nursing, who stated the situation would be corrected.",2015-11-01
9363,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,156,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible parties of two (2) of thirty-two (32) Stage II sampled residents when Medicare-covered skilled treatments were discontinued and/or the reason(s) for the services being discontinued. Resident identifiers: #102 and #63. Facility census: 87. Findings include: a) Resident #102 A review of the medical record revealed that resident #102, who was admitted on [DATE], had received therapy services from 10/19/09 through 11/28/09. Althought the responsible party was notified by letter that the resident's Medicare Part A benefit days had exhausted on 11/28/09, there was no evidence in the medical record to show that the responsible party had been notified which services had been discontinued and no medical reason was given for the stoppage. The physical therapy (PT) notes written on 11/18/09, state: d/c (discontinue) PT - all goals met, and the occupational therapy (OT) notes written on 11/26/09, stated that the goals were partially met; but, neither indicated that this had been discussed with the family. The nurses notes from 11/24/09 - 12/03/09 were reviewed without any evidence of discussion with resident and/or family regarding the changes in the resident's care. During an interview with the director of nursing and the assistant director of nursing at 2:00 p.m. on 02/24/10, they stated that they could find no documentation that an explanation of which services were being discontinued and the reason for this had been given to the family, although they stated that they were sure it had been done. b) Resident #63 A review of the medical record revealed that resident #63, who was admitted on [DATE], received physical therapy (PT) and occupational therapy (OT) services from 09/15/09 - 12/21/09. A review of the nurses notes from 12/15/09 - 01/06/10 and of the PT and OT discharge notes failed to reveal any evidence that the resident and/or family had been notified of which services had been discontinued and/or of the reason for this discontinuance. The Notice of Exclusions from Medicare Benefits letter was reviewed, but it did not explain which services or the reason either. During an interview with the director of nursing and the assistant director of nursing at 2:00 p.m. on 02/24/10, they stated that they could find no documentation that an explanation of which services were being discontinued and the reason for this had been given to the family, although they stated that they were sure it had been done.",2015-11-01
9400,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2010-04-08,156,B,0,1,85AT11,"Based on record review and staff interview, the facility failed to assure one (1) of one (1) applicable resident / responsible party was informed of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. This practice had the potential to affect any resident who was discontinued from Medicare-covered skilled services. Resident identifier: #60. Facility census: 97. Findings include: a) Resident #60 On 04/07/10 at 3:30 p.m., a review was conducted, with the facility's business office manager, of residents whose Medicare-covered skilled services had been discontinued by the facility. Three (3) of four (4) residents reviewed had met their rehabilitation potential and were discharged home. One (1) resident (Resident #60) was discontinued from Medicare-covered services but remained in the facility. He had not exhausted his allowable one hundred (100) Medicare days, but facility staff believed he had met his rehabilitation potential. Because of this, he should have been offered the opportunity to request a demand bill. Review of the notice provided to the resident revealed the form did not contain an option for the resident / responsible party to request a demand bill. There was a space to indicate no regarding submission of a demand bill, but no space to indicate yes requesting the facility to submit a demand bill. In an interview conducted with the social worker (Employee #103) at 4:00 p.m. on 04/07/10, Employee #103 stated she had no idea how this situation had happened but confirmed the form did not contain the required information to allow a resident / responsible party to request the facility submit a demand bill in the resident's behalf.",2015-11-01
9478,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,156,D,0,1,SJCY11,"Based on medical record review, review of information provided to residents upon admission, and staff interview, the facility failed to inform one (1) of thirty-two (32) Stage II sample residents, both orally and in writing, of all the rules and regulations governing resident conduct and responsibilities during the stay in the facility. There was no evidence and/or acknowledgement in writing the resident was notified of the facility's smoking policy prior to or upon admission to the facility. Resident identifier: #109. Facility census: 84. Findings include: a) Resident #109 Closed record review, on 01/26/11, revealed this resident was admitted from the hospital to the facility for rehabilitation services on 12/16/10. The resident had been determined to possess the capacity to understand and make informed making health care decisions. Further review revealed the resident left the facility against medical advice (AMA) on 01/24/11. Interview with the director of nursing (DON - Employee #1), at 10:00 a.m. on 02/01/11, revealed the resident left AMA because he wanted to smoke and the facility was a non-smoking facility. Additional medical record review revealed no evidence the resident was informed, prior or at the time admission, that he would not be able to smoke at the facility. There was no discussion in the record that the resident had been informed of this rule, and there was nothing within the record which the resident had signed acknowledging his understanding of this facility rule. Review of the facility's admission contract revealed it did not contain information relative to the facility's smoke-free status. Additionally, the facility had no formal means of assuring residents were made aware of this facility policy prior to or upon admission. On 02/02/11 at 12:00 p.m., an interview was conducted with one (1) of the facility's social workers (Employee #51). Employee #51 confirmed the facility had not provided Resident #109 with written information regarding the facility's smoking policy. At that time, Employee #51 also confirmed the facility's smoking policy had not been a part of the facility's admission information at the time this resident was admitted .",2015-11-01
9547,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,156,C,0,1,5V2011,"Based on observation and staff interview, the facility failed to include the name, address, and telephone number of the State long-term care ombudsman together in its posting of information. This practice had the potential to affect all residents and visitors. Facility census: 157. Findings include: a) On 11/17/09, an observation of the facility's posting in the front lobby, which included names and addresses of individuals who could be contacted for questions related to long term care, revealed the facility had not listed the name of the State long term care (LTC) ombudsman. On 11/20/09 at 4:00 p.m., the administrator agreed the State ombudsman's name needed listed and agreed to change the posting to correct the issue. (NOTE: On 12/02/09, the administrator faxed to the State survey agency a copy of a posting titled Information Services located elsewhere in the facility. While it did contain the State LTC ombudsman's name and telephone number, it did not contain an address. Consequently, an individual who wanted the name, telephone number, and mailing address of the State LTC ombudsman would have had to locate and access both postings to obtain complete contact information.)",2015-10-01
9568,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2011-07-14,156,C,0,1,L3JB11,". Based on observation and staff interview, the facility failed to provide a posting of names, addresses and telephone numbers of all pertinent state client advocacy groups; failed to display a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non-compliance with advance directives; and failed to prominently display written information about how to apply for and use Medicare and Medicaid benefits. These practices had the potential to all residents and visitors. Facility census: 114. Findings include: a) On 07/14/11 at approximately 11:42 a.m., observations of the facility's hallways and lobby failed to find postings of necessary information, such as the names, addresses, and telephone numbers of all pertinent state client advocacy groups, a written statement informing residents of their right to file a complaint with the State survey and certification agency concerning abuse, neglect and misappropriation of property and non compliance with advance directives, and written information on how to apply for and use Medicare and Medicaid benefits. At approximately 12:00 p.m., the maintenance supervisor (Employee #89) accompanied the tour of the building and could not locate the signs and postings. He reported these signs were taken down due to the facility's remodeling project. At approximately 2:45 p.m., these signs were located, and the maintenance director said he would ensure they were displayed in the facility.",2015-10-01
9652,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,156,C,0,1,860Y11,"Based on observation and staff interview, the facility failed to ensure the names, addresses and phone numbers of advocacy groups remained posted and accessible at all times to residents and members of the general public. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Surveyors were unable to find the posted information related to advocacy groups as is required by regulation. Observations, made on 02/01/11, found a bulletin board where other information was located; however, there was no information regarding the names, addresses and phone numbers for all advocacy groups. The surveyor, on 02/01/11 at 10:36 a.m., then questioned the director of nursing (DON - Employee #15) and the administrator (Employee #25) as to where this information might be. After searching for the missing data, the administrator informed the surveyor that it had been found in a notebook that a confused resident (#61) had been given to put paperwork in. This resident had been known to remove posted items from bulletin boards, and staff would be unable to locate them. The facility provided her with a notebook, which would give staff some idea where to begin looking when things were missing. According to the administrator, this happened frequently, and staff would look once a week to see things were posted as necessary. If not, they would search the notebook.",2015-10-01
9724,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,156,B,0,1,U9W011,"Based on observations and staff interviews, the facility failed to ensure the name of the State long-term care ombudsman was posted, and failed to ensure residents had ready access to information regarding Medicare and Medicaid. This had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) State long-term care ombudsman On 10/05/10 at approximately 10:00 a.m., the posting of required information was reviewed as a part of the CMS- Environment observations, triggered by findings in Stage 1. The name of the State long term care ombudsman did not appear on any of the postings, just the address and telephone number. The posting requirement is: A posting of names, addresses, and telephone numbers of all pertinent State client advocacy groups such as the State survey and certification agency, the State licensure office, the State ombudsman program, . -- b) Medicare & Medicaid information On 10/05/10 at approximately 10:00 a.m., the Medicare information (a publication entitled Medicare at a Glance - from CMS) and Medicaid information (Your Guide to Medicaid - from WVDHHR) were observed posted in the entrance hall in a locked glass-covered display case. These contents of these multi-page documents would not be readily accessible to residents wishing to review them. This was discussed with the administrator and social worker during the mid-afternoon on 10/06/10. The administrator stated the social worker had copies and would provide / discuss them with residents / responsible parties and that the nurses had keys to the enclosed display case should a copy be needed. However, it was pointed out that the requirement was for the information to be posted.",2015-10-01
9782,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,156,C,0,1,2XEX11,". Based upon review of the notices of non-coverage for Medicare skilled services (denial notices) and staff interview, the facility failed to specify the service being denied and/or the reason for the denial in the letter provided by the facility to the resident and/or responsible party, when informing them of services that would no longer be covered under Medicare, for six (6) of (6) sampled notices. Resident identifiers: #97, #34, #16, #66, #161, and #96. Facility census: 57. Findings include: a) Residents #97, #34, #16, #66, #161, and #96 A review of the Notice of Medicare Non-Coverage letters, on 05/31/10, revealed that the only description of services paid for by Medicare that were no longer being covered, for Residents #97, #34, #16, #66, #161, and #96, was skilled nursing services, and none of the six (6) residents' denial notices provided any reason for the denial of Medicare coverage as required. During a discussion with the facility's administrator (Employee #63) on 05/31/10 at 2:00 p.m., she acknowledged the required information was not included. .",2015-09-01
9880,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-05-09,156,C,1,0,SZNR11,". Based on record review and staff interview, the facility failed to ensure three (3) of three (3) resident's received the appropriate discharge notice, as required by the Centers for Medicare and Medicaid Services (CMS), after they were discharged from a Medicare skilled service. Resident #22, Resident #72, and Resident #39 were all discharged from Medicare Part A skilled services in April 2012. The facility did not issue one (1) of two (2) notices at the time Medicare Part A services ended. Facility census: 77. Findings include: a) Resident #22 This resident was discharged from Medicare Part A, on 04/21/12, due to no further skilled services being available for her. b) Resident #72 This resident was discharged from Medicare Part A, on 04/15/12, due to no further skilled services being available for her. c) Resident #39 This resident was discharged from Medicare Part A, on 04/26/12, due to a completion of antibiotic therapy. d) An interview with Employee #10 (business office manager), on 05/09/12 at 1:00 p.m., revealed these three (3) residents had received the Notice of Non Coverage, CMS form ( ). The generic notice (form ) simply informs the resident of their right to an expedited review of the service termination for coverage reasons. The facility must issue the skilled nursing advanced beneficiary notice to address the resident's potential liability for payment if they remain in the facility. The residents had not received the Skilled Nursing Advanced Beneficiary Notice (SNFABN). According to the business office manager, all three (3) residents remained in the facility under another payer source. The facility needed to give the three (3) residents both notices because all Medicare covered services were ending and the center intended to deliver non-covered care. The SNFABN is given because benefit days remain to inform the resident of potential financial liability. .",2015-08-01
10024,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,156,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to provide to written notification to one (1) of five (5) randomly reviewed residents, who had been discharged from Medicare-covered skilled services, when the skilled services were discontinued and the resident's payer status changed. Resident identifier: #7. Facility census: 50. Findings include: a) Resident #7 A review of facility records reveals Resident #7 was discharged from Medicare-covered skilled services on 10/11/09, but there was no evidence she received a liability notice to inform her of the reason for the discontinuation of skilled services. This was verified by the nurse case manager (Employee #9) at 3:10 p.m. on 02/09/10, who stated that, because the resident had exhausted her one hundred (100) skilled days, she did not receive an notice. A request was made to the nurse to supply evidence the resident or her responsible party had been notified of this change in payer status. During an interview with the director of nurses, Employee #9, and the administrator at 11:10 a.m. on 02/11/10, Employee #9 acknowledged, after reviewing the record, that she could not state the responsible party had been clearly notified of the change in Resident #9's payer status. .",2015-07-01
10058,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2012-01-19,156,D,0,1,ZNLH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . I. Based on record review and staff interview the facility failed to show evidence that one (1) of the two (2) persons who had been appointed ""dual"" medical power of attorney (MPOA) by one (1) of forty-nine (49) Stage II sampled residents had been included in the admission process and / or had been involved in treatment decisions since admission to the facility. Resident identifier: #102. Facility census: 118. Findings include: a) Resident #102 Review of the medical record revealed Resident #102 was an [AGE] year-old female admitted on [DATE], with [DIAGNOSES REDACTED]. She was determined by her attending physician to lack the capacity to make informed healthcare decisions. On 06/14/05, prior to the decision of incapacity, she had appointed her son and daughter to act jointly as her medical power of attorney (MPOA). Review of the admission process revealed the resident's son had signed all admission documents, including the ""Advance Directive Acknowledgement Form"" which indicated the resident was to be DNR (Do Not Resuscitate) status. On 12/27/11, he was also the sole MPOA signing the permission for admission of the resident into the Alzheimer's unit of the facility. Review of social service notes failed to reveal any evidence the daughter, who was a dual MPOA, had been consulted about placement or care decisions. In addition, a review of the nurse's notes revealed on 01/10/12, when the resident's health status declined, only the son was notified about her transfer to an acute care hospital. In an interview, at 1:00 p.m. on 01/17/12, the Memory Care director / social worker, Employee #114, stated she ""was sure that the daughter was agreeable to the resident being here."" She acknowledged, after reviewing the record, there was no evidence of her (the MPOA) involvement in the admission process nor of her permission to have the son complete the admission process. At 2:00 p.m. on 01/18/12, Employee #114 presented documentation indicating contact had been made on that date with the daughter (MPOA). Employee #114 expressed the daughter would now also be contacted relative to all healthcare decisions. . . II. Based on the liability notice and beneficiary appeal review, and staff interview, the facility failed to ensure one (1) of three (3) resident's selected for review had received the appropriate notice when there was a termination of Medicare Part A services. Resident identifier: Resident #106. Facility census: 118. Findings include: a) Resident #106 On 01/18/12, at approximately 10:00 a.m., the liability notice and beneficiary appeal review revealed one (1) of three (3) residents, who had been discharged from the skilled nursing facility in the past six (6) months, had not received the appropriate notice when there was a termination of Medicare Part A services for a coverage reason. On 01/18/12, at approximately 10:10 a.m., Employee #40 (office staff person) provided a copy of the letters the facility had sent to each of these residents. Resident #106 had received a letter, dated 08/03/11, which stated ""(Resident #106) has been receiving skilled nursing services under Medicare Part A services. As of 8/3/11 (Resident #106) will not meet the requirements for skilled level of nursing care at this time."" Resident #106 received the skilled nursing facility advanced beneficiary notice (SNFABN) (Centers for Medicare and Medicaid Services (CMS) form ). The SNFABN informed the beneficiary of his right to have a claim submitted to Medicare and advised him of the standard claim appeal rights that applied if the claim was denied by Medicare. The facility did not issue the ""Notice of Medicare Provider Non-Coverage"" (CMS form ) when there was a termination in the resident's Medicare Part A for coverage reasons. The ""Notice of Medicare Provider Non-Coverage"" informs the beneficiary of his / her right to an expedited review of a service termination by the Quality Improvement Organization (QIO). On 01/18/12, at approximately 10:30 a.m., a telephone call to the office manager (Employee #130) revealed she had not sent the ""Notice of Medicare Provider Non-Coverage"" to Resident #106. She explained that she only sent CMS form when residents were discharged from Medicare Part B services. .",2015-07-01
10090,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,156,E,0,1,FFCS11,". Based on observation and staff interview, the facility failed to post the correct names, addresses, and telephone numbers of all pertinent State agencies. Incorrect contact information was posted for the State survey and certification agency and the local Medicaid office. This had the potential to affect any resident who might need to contact these agencies. Facility census: 112. Findings include: a) Observation of the posted contact information for pertinent State agencies, in the company of the administrator at 10:30 a.m. on 03/04/10, found the following: 1. The address of the State survey and certification agency was incorrect. 2. The address and telephone number of the local Medicaid office address were incorrect. The administrator confirmed these errors at the time of the observation. .",2015-07-01
10137,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2010-01-14,156,E,0,1,CSOG11,"Based on observation and staff interview, the facility failed to ensure the required posting regarding how to apply for Medicaid and Medicare benefits was prominently displayed for public viewing. This practice had the potential to affect more than an isolated number of residents. Facility census: 106. Findings include: a) On 01/14/10 at approximately 12:00 p.m., a tour of the facility revealed the postings for how to apply for Medicaid and Medicare benefits were not present anywhere in the facility. On 01/14/10 at approximately 2:00 p.m., the admissions director (Employee #80) agreed the postings were not where she had originally thought they were. She said visitors were removing them. Employee #80 stated she would arrange to have this information put back on the bulletin board for resident and public viewing. .",2015-06-01
10192,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,156,D,0,1,MFK411,"Based on record review, review of the denial notice letters, and staff interview, the facility failed to include the identification of the service being denied and/or the reason for the denial in the letter provided by the facility to the resident and/or responsible party, informing them of services not covered under Medicare for one (1) or eighteen (18) sampled and two (2) of three (3) random residents whose Medicare notification letters were reviewed; and/or failed to inform the responsibility party of rights related to the formulation of advance directives for one (1) of eighteen (18) sampled residents. Resident identifiers: #29, #41, #34, and #53. Facility census: 100. Findings include: a) Resident #29 A review of the medical record revealed that, upon admission to the nursing home on 06/02/08, Resident #29 had been determined by a physician to have the capacity to make healthcare decisions, and Resident #29 expressed a desire for a ""Do Not Resuscitate"" (DNR) order. Since this admission, he lost the capacity to make his own healthcare decision. As of 12/30/08, his physician appointed a health care surrogate (HCS) to make these decisions on his behalf, in accordance with his known wishes as required by State law. Further review, however, found no evidence to reflect the facility fully informed the HCS of the resident's DNR decision. During an interview with the social worker at 1:45 p.m. on 01/27/10, she acknowledged she had not discussed the resident's code status with the HCS, but she stated she would do this as soon as possible. b) Residents #41, #34, and #53 A review of the Medicare denial letters for the aforementioned residents revealed the facility failed to indicate which skilled service was being discontinued and the reason(s) for this non-coverage. When this was discussed with the administrator at 9:30 a.m. on 01/27/10, he agreed this information was not present. A follow-up interview with a nurse (Employee #27) confirmed this information was not being included in the denial notices at present, as she was not aware it was required. .",2015-06-01
10409,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2009-08-27,156,B,0,1,Y5MX11,"Based on observation and staff interview, the facility failed to prominently display written information on how to apply for and use Medicare and Medicaid benefits. The facility also failed to include information on how residents / families could receive refunds for previous payments covered by Medicare and Medicaid benefits. This practice has the potential to affect more than an isolated number of residents at the facility. Facility census: 76. Findings include: a) On 08/27/09 at approximately 11:00 a.m., a tour of the facility revealed no posting describing how residents and their families could make application for and use Medicaid or Medicare benefits. The facility had information posted regarding how to file complaints and also advocacy information such as the name / address of the ombudsman; however, Medicare / Medicaid information was not on display. At approximately 11:30 a.m., the administrator agreed this information was not posted. He then made arrangements to have it posted for public display in the facility's main hallway. .",2015-04-01
10452,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,156,B,0,1,924C11,"Based on observation and staff interview, the facility failed to post contact information for all pertinent State client advocacy groups in a location accessible to all residents. This practice has the potential to affect more than an isolated number of residents who could benefit from this information. Facility census: 153. Findings include: a) Observation, on the morning of 08/13/09, found the names, addresses, and telephone numbers for State advocacy groups were posted on a bulletin board located between two (2) sets of double doors as one enters the facility. Many residents do not go near this location and would not easily access the information on these postings. When brought to the attention of the administrator on the early afternoon of 08/13/09, he verified the information would be more easily accessible at another location and stated he would move them to a new area which was frequented more often by residents. .",2015-03-01
10570,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,156,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to fully inform residents both orally and in writing when changes will occur in their bills and/or of their appeal right to request that a bill be submitted to Medicare for three (3) random reviewed residents, and failed to clearly denote in the resident's clinical record the advance directive formulated by the resident for one (1) of twenty-three (23) sampled residents. Resident identifiers: #100, #118, #49, and #116. Facility census: 114. Findings include: a) Residents #100, #118, and #49 A review of the ""Skilled Nursing Facility Determination"" letters on file at the facility for Residents #100 (two (2) letters on file) and #118 failed to provide evidence that the resident or the resident's legal representative was informed of the discontinuance of a skilled service prior to the service being stopped, as the signatures of the resident and/or the legal representative were not dated, and on the letter dated 08/27/09 for Resident #100, there was no date for the non-coverage of services. None of the letters reviewed show evidence of the resident's or legal representative's decision to request a bill to be submitted to the intermediary for a Medicare decision, as that area of the letter was blank. During an interview with the administrator at 10:20 a.m. on 10/22/09, she acknowledged the letters were not completed per facility policy and the intent of the form. b) Resident #116 Review of the closed record for Resident #116 revealed a Physician order [REDACTED]. In an interview with the social worker (Employee #80) at 4:00 p.m. on 10/21/09, she agreed there was a potential for error made by the inconsistencies. .",2015-01-01
10621,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,156,D,0,1,GCMN11,". Based on record review and staff interview, the facility failed, for one (1) of two (2) applicable residents / responsible parties, to provide notice of the right to request a demand bill when the resident's Medicare-covered services were discontinued by the facility. Resident identifier: #3. Facility census: 83. Findings include: a) Resident #3 During the morning of 12/08/10, records were reviewed for three (3) residents whose Medicare-covered services had been discontinued by the facility. At the same time, interviews were conducted with facility corporate office personnel who were assisting with bookkeeping responsibilities in the absence of the facility's bookkeeper. Record review revealed Resident #3's Medicare-covered services were discontinued on 09/16/10, because he had reached his maximum potential in occupational therapy services. The corporate persons were unable to locate evidence Resident #3 received a notice his Medicare services were discontinued, and no evidence the resident / responsibility party had been given the opportunity to request a demand bill. On 12/09/10, the facility's bookkeeper (Employee #18) searched her records for evidence that the appropriate notices had been given to Resident #3. During the morning of 12/09/10, Employee #18 reported the ""cut letter"" and opportunity to request a demand had not been provided this resident / responsible party. .",2015-01-01
10688,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2009-07-02,156,C,0,1,DBCB11,"Based on observation and staff interview, the facility failed to post all complete contact information for all applicable State advocacy agencies as required by the regulation. Only the regional ombudsman's name and contact information were posted for public view. This has the potential to affect all residents as all residents and families are to have access to this information. Facility census: 81. Findings include: a) On 07/01/09 at 2:30 p.m., review of posted contact information of all pertinent State client advocacy groups, observed on the third floor of the facility, revealed only the name, address and telephone number of the regional ombudsman. Phone numbers were listed for other agencies, but not addresses. Discussions with the administrator, on the afternoon of 07/01/09 and again on the morning of 070/2/09, revealed the addresses and phone numbers of the other advocacy groups were not posted in any other locations of the facility as well. The following information was omitted from the public postings: - The contact information for the State survey and certification agency (which is also the State licensure office); - The contact information for the State long-term care ombudsman; - The contact information for the protection and advocacy network; - The contact information for the Medicaid fraud control unit; and - A statement that the resident may file a complaint with the State survey and certification agency concerning resident abuse, neglect, and misappropriation of resident property in the facility, and non-compliance with the advance directives requirements. .",2015-01-01
10726,SUMMERSVILLE REGIONAL MEDICAL CENTER D/P,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2010-10-20,156,B,0,1,H9I611,". Based on a review of the facility's Medicare demand bill records and staff interview, the facility failed to provide the appropriate beneficiary liability and appeal notices for three (3) of three (3) residents who had recently had their Medicare-covered services terminated. There was no evidence that the facility notified the beneficiary of his/her potential liability for payment and standard appeal rights. This practice affected Resident #40 and had the potential to effect more than an isolated number of residents who received Medicare-covered services. Facility census: 49. Findings include: a) Resident #40 Record review of residents who had received Medicare-covered services in the last three (3) months revealed one (1) demand bill had been requested. This was for Resident #40. The letter used to notify the resident / responsible party that services would no longer be covered by Medicare was a letter designed by the facility which did not contained all required elements found in Form CMS- or one (1) of the five (5) uniform denial letters found in the CMS Skilled Nursing Manual. The letter sent by the facility did not notify the legal representative of the beneficiary's potential liability for payment of the non-covered services. An interview with the staff member responsible for patient accounts (Employee #130) confirmed the facility was not utilizing the CMS forms to notify residents / responsible parties of Medicare non-coverage and of their right to request demand bills, which contained all of the required information for notification to the beneficiary. .",2014-12-01
10833,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2009-08-14,156,C,0,1,L59911,"Based on observation and staff interview, the facility failed to post accurate information regarding the State licensure office. This practice had the potential to affect all facility residents. Facility census: 48. Findings include: a) Observation of facility postings, at 4:00 p.m. on 08/13/09, revealed the address for the Office of Health Facility Licensure and Certification (OHFLAC) was incorrect. Additionally the posting did not state that residents could file a complaint with OHFLAC, but stated that this was the agency to whom the residents should address ""appeal rights"". This was brought to the attention of the social worker (SW) at 4:05 p.m. on 0/13/09. The SW stated the posted information had just been revised and the wrong form must have been posted. .",2014-12-01
10884,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,156,E,0,1,4I6911,"Based on record review and staff interview, the facility failed to provide a written notice to residents who were no longer eligible for Medicare skilled services that stated the reason they no longer qualified, as required in the Medicare Skilled Nursing Manual at ""Notifying Patient of Noncoverage SNF-356.1"". This practice was observed when reviewing a sample of three (3) such letters that had been provided to residents or their responsible parties in the previous three (3) months. The practice had the potential to affect all residents of the facility who had been, or would be in the future, determined to be ineligible for Medicare-covered skilled services. Resident identifiers: #35, #54, and #37. Facility census: 111. Findings include: a) Residents #35, #54, and #37 The Notice of Medicare Provider Non-Coverage, as provided by the facility for Residents #35, #54, and #37, was requested for review on 12/09/09. Review of these notices disclosed, on the third page of the document associated with Item #4, the document stated: ""Because: Not requiring a skilled service."" Each of the notices had the same statement and made no explanation specific to the individual resident's discontinuation of Medicare-covered services. The facility employee responsible for the distribution of these notices (Employee #53), when interviewed on 12/09/09 at 2:45 p.m., confirmed this was the notice provided to all residents of the facility at the time they were determined by the facility to no longer qualify for Medicare-covered skilled services. This employee further confirmed the information was not individualized for each resident and situation. .",2014-11-01
10945,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,156,C,0,1,T34S11,"Based on observation and staff interview, the facility failed to post accurate information regarding the regional ombudsman. This practice had the potential to affect all residents. Facility census: 86. Findings include: a) During the initial tour of the facility on 05/18/09 at approximately 3:45 p.m., observation revealed the signs posted in the front lobby area of the building contained the incorrect telephone number and no name listed for the regional ombudsman. Other signs containing this same type of information were posted in various locations throughout the building and did have to correct information related to the regional ombudsman. At approximately 5:00 p.m. on 05/18/09, the administrator agreed the sign in the front area of the building needed to be corrected. .",2014-11-01
11118,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2009-04-30,156,E,0,1,6TSD11,"Based on record review and staff interview, this Medicare-participating facility failed, for four (4) of four (4) residents reviewed, for whom a determination was made by the facility that Medicare will not pay for skilled nursing or specialized rehabilitative services and that an otherwise covered item or service may be denied as not reasonable and necessary, to notify the resident or his/her legal representative in writing why these specific services may not be covered; the beneficiary ' s potential liability for payment for the non-covered services; the beneficiary right to have a claim submitted to Medicare; and the beneficiary ' s standard claim appeal rights that apply if the claim is denied by Medicare. This practice had the potential to affect all residents for whom a determination of non-coverage by Medicare had been made by the facility. Resident identifiers: #52, #99, #66, and #4. Facility census: 101. Findings include: a) Residents #52, #99, and #66 A review of the forms entitled ""SNF Determination on Continued Stay"" for these residents revealed only the date that Medicare-covered services would be discontinued; there was no mention in writing of what specific service may no longer be covered or why. The only verbiage included in the form was ""no longer requires skilled services"" or ""exhausted benefits"". During an interview with the administrator and the office person responsible for providing this notification at 3:20 p.m. on 04/27/09, they acknowledged that this was form given to the resident and/or the responsible party as the notification of discontinuance of Medicare-covered skilled services and of their right to appeal this decision. They also agreed, after reviewing the forms, that the documentation did not on these residents' forms did not specify the service that was no longer being covered. When asked, neither person was able to state, during the interview, exactly what service had been discontinued for each of these three (3) residents. b) Resident #4 A review of the Notice of Medicare Provider Non-coverage notice provided to Resident #4 and/or her responsible party revealed: ""Resident will no longer receive speech therapy effective 4/26/09."" However, this notice did not include any reason for why the service was being discontinued. During an interview with the administrator and the office person responsible for notification at 3:20 p.m. on 04/27/09, they acknowledged that this was the only documentation given to the resident. c) In the interview of 04/27/09, the person responsible for obtaining signatures on the non-coverage notification forms stated she assumed that someone else had explained the service involved and why it was being stopped prior to the notification being signed, but both she and the administrator acknowledged, after reviewing the above residents' forms, that the Medicare-covered skilled services being discontinued and/or the reasons for discontinuation were not there. .",2014-08-01
11199,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,156,C,1,0,7YYR11,". Based on observation, review of the facility's procedure for filing complaints, and staff interview, the facility failed to post the correct mailing address for contacting the State survey and certification agency and failed to provide clear and concise information to residents and the public on how to file a complaint with that agency. This practice had any residents, legal representative, or member of the general public wishing to file a complaint with the State. Facility census: 61. Findings include: a) The bulletin board posting in the front lobby of the facility gave an incorrect mailing address listed for the Office of Health Facility Licensure and Certification (OHFLAC - the State survey and certification agency). b) The same bulletin board also contained a posting of how to file complaints. This was a facility-originated form informing residents / legal representatives of the steps to follow if they wanted to report complaints. The information was unclear as to how to make a formal complaint to OHFLAC when an individual believed this action was necessary. c) In an interview with the administrator (Employee #59) and the director of nursing (DON - Employee #54) at 12:30 p.m. on 05/19/10, both agreed the posted address for OHFLAC was incorrect. Both employees also agreed the posted form for making in-house complaints did not clearly address who to contact at the State level to file a complaint. .",2014-07-01
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
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
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
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
401,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,157,D,1,1,FUQO11,"> Based on resident interview, staff interview, and record review, the facility failed to notify a resident of a room change for one (1) resident reviewed. The failed practice had the potential to affect an isolated number of residents. Resident identifier: #47. Facility census: 98. Findings include: a) Resident #47 An interview with Resident #47 on 08/03/17 at 10:00 a.m. revealed she had been moved to a new room without any notice. The resident stated she could not remember the exact date but the move recently took place. The resident stated she had left her room to visit another resident and upon returning the staff was moving her belongings to a room across the hall. The resident stated she became very upset because nobody told her she was switching rooms. An interview with Licensed Social Worker (LSW) #15 on 08/03/17 at 10:45 a.m. revealed a resident is supposed to be contacted before a room change occurs in order to provide options and to ease the transition for the resident. The LSW stated she did not contact Resident #47 before the room change on 07/03/17 because she was unaware the resident was switching rooms until the change was completed. An interview with the Administrator on 08/08/17 at 12:00 p.m. revealed she is the one who ordered the room change to occur on 07/03/17. The Administrator stated she let the resident's daughter know about the change and instructed the nursing staff to inform the resident. The Administrator stated she cannot be certain if the nursing staff informed the resident prior to the room change. A review of Resident #47's medical record on 08/08/17 at 12:30 p.m. revealed no indication the resident was informed of the room change prior to it occurring. A review of the resident's quarterly Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 07/18/17, was conducted on 08/08/17 at 12:45 p.m. Section C-Cognitive Patterns of the assessment revealed the resident scored a 14 on the Brief Interview for Mental Status (BIMS) assessment. A score of 14 indicated the resident had little to no impairment at the time of the assessment.",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
695,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2017-06-15,157,D,1,0,DQI311,"> Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of three (3) residents reviewed experienced a fall on 06/06/17. Resident identifier: #80. Facility census: 157. Findings include: a) Resident #80 A review of the Incident and Accident records, reported Resident #80 was found on the floor next to her bedresulting in a skin tear to the left upper arm and a bruise on the top of her right foot. No other injuries were noted, and the report stated she was assisted back to her bed by three (3) staff. Neurological checks were implemented and she placed non-skid socks on her feet. The physician was notified and the responsible party was notified. An interview with Resident # 80's legal representative on 06/15/17 at 9:00 a.m., reported she received no call from the facility letting her know about the fall her mother had on 06/06/17. During an interview with the director of nursing (DON) on 06/15/17 at 10:05 a.m., Unit Manager #138, had contacted the wrong person regarding the fall sustained by Resident #80 on 06/06/17. She verified she did not contact the legal representative regarding this fall.",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
1000,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2017-01-31,157,E,0,1,1Y9Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the attending physician when Residents #33 and #87 had no bowel movements for greater than three (3) days. The facility staff also failed to administer the standing orders for bowel protocol. This was evident for two (2) of two (2) residents reviewed for notification of changes. Resident identifiers: #33 and # 87. Facility census: 82. Findings include: a) Resident #33 Review of the medical record on 01/26/17, revealed physician's orders signed and dated on 12/02/16, which included orders for a bolus of one (1) can (240 milliliters) of [MEDICATION NAME] 1.5 every four (4) hours via his gastrostomy tube. His only other intake was medication and water through the gastrostomy tube. [DIAGNOSES REDACTED]. Other pertinent [DIAGNOSES REDACTED]. Further medical record review found standing orders/protocols if the resident went three (3) days with no bowel movement as follows: On the third day of no bowel movement, administer Milk of Magnesia 30 milliliters (ml). On the fourth day of no bowel movement, administer [MEDICATION NAME] 10 milligrams (mg) suppository rectally. On the fifth day of no bowel movement, administer a Fleets enema rectally. If no results from the Fleet's enema, notify the physician for further orders. These orders were signed by the medical director. Review of the activities of daily living records (ADL) for (MONTH) (YEAR), found evidence of three (3) instances this resident went greater than three (3) days with no bowel movement. According to the ADL record, this resident had a bowel movement on 12/05/16, and none again until five (5) days later on 12/10/16. Also according to the ADL record, this resident had a bowel movement on 12/15/16, and none again until seven (7) days later on 12/22/16. Again according to the ADL record, this resident had a bowel movement on 12/23/16, and none again until five (5) days later on 12/28/16. Review of the medication administration record (MAR) for December, (YEAR), found no evidence the standing orders for bowel protocol as the physician ordered to treat constipation was initiated on any of those three (3) instances where the resident went greater than three (3) days with no bowel movement. Also, review of the (MONTH) nurse progress notes provided no evidence of treatment for [REDACTED]. An interview was conducted with the director of nursing (DON) on 01/26/17 at 4:00 p.m. She reviewed the (MONTH) ADL bowel movement record, and agreed on three (3) different stretches of time in (MONTH) that the resident had no bowel movements recorded for three (3) or more consecutive days. The DON then reviewed the MAR for December, and the (MONTH) nursing progress notes. She agreed there were no notations about bowel medications or treatments administered. She agreed there was no evidence that the physician was notified of the absence of bowel movements, or of the absence of the bowel protocol treatment. b) Resident # 87 Review of Resident #87's medical record, on 01/30/17 at 1:00 p.m., found a quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 12/27/16. The bowel continence was not rated, (this indicates the resident did not have a bowel movement for the entire seven (7) day look back period (12/21/16 through 12/27/16). Resident #87's Activities of Daily Living (ADL) sheet reviewed for the seven (7) day look back period, revealed Resident #87 had a soft formed bowel movement on 12/18/16 and no further bowel movement was recorded for the rest of (MONTH) (YEAR) (12/19/16 through 12/31/16). Medication Administration Record (MAR) for the month of (MONTH) (YEAR) for Resident #87, revealed on 12/27/16 at 10:00 p.m., Milk of Magnesia (MOM) 30 milliliters (ML) was given, on 12/29/16 at 8:00 a.m. MOM 30 ml was given and on 12/31/16 (no time documented on the MAR) [MEDICATION NAME] rectal suppository given. Review of the Nurses' progress notes for 12/19/16 through 12/31/16 for Resident #87 found no notes regarding bowel movement and/or the administration of bowel protocol. Additionally, no evidence the physician was notified of no bowel movements. Review of the facility's bowel protocol (standing orders) found it included, (typed as written): If a resident goes three (3) days with no bowel movement, contact physician to initiate the bowel protocol. Bowel protocol: 1. On the third (3rd) day of no bowel movement, administer Milk of Magnesium (MOM) 30 ml by mouth (PO) for (X) one (1) dose. 2. On the fourth (4th) day of no bowel movement, administer [MEDICATION NAME] ([MEDICATION NAME]) 10 milligrams (MG) suppository rectally x one (1) dose. 3. On the fifth (5th) day of no bowel movement, administer fleets enema rectally x one (1) dose. 4. If no results from fleet enema, notify physician for further orders. In an interview on 01/30/17 at 1:20 p.m., the Director of Nursing (DON) confirmed Resident #87 had no bowel movement documented from 12/19/16 through 12/31/16 (11 days). She stated, The bowel protocol should have been initiated after three (3) consecutive days without a bowel movement. She also confirmed the physician should have been notified.",2020-09-01
1203,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2017-05-17,157,E,0,1,VMTW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of the facility's weight loss policy, the facility failed to notify the attending physician and/or the responsible party when Residents #50, #10, #12, #48, and #11 experienced significant weight losses. This deficient practice was true for five (5) of six (6) residents reviewed for the care area of nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #50, #10, #12, #48, and #11. Facility census: 39. Findings include: a) Resident #50 Medical record review for Resident #50 began on 05/11/17 at 2:30 p.m. The care area of nutritional status was selected for review because the resident had lost weight, did not have a condition or chronic disease that might result in a life expectancy of less than 6 months, was not receiving a nutritional supplement (defined as a prescribed high protein, high calorie, nutritional supplement between or with meals), and the resident was not on a planned weight loss program. Review of Resident #50s electronic medical records found the following weights recorded in last six (6) months: -- 11/29/16 - 130.2 pounds (#) (note weight obtained 7 days after admission) -- 12/12/16 - 130.4# -- 01/30/17 - 121.8# -- 02/20/17 - 130.8# -- 03/20/17 - 132.8# -- 04/06/17 - 142.0# -- 05/09/17 - 107.0# Resident #50 was admitted to the facility on [DATE]. The first weight recorded in the electronic medical record was on 11/29/17, which was 130.2 #. The resident's Body Mass Index (BMI) was 16.8. (A BMI of less than 18.5000 is considered too low.) The resident's admission comprehensive minimum data set (MDS), with an assessment reference date (ARD) of 11/30/16, identified the resident's weight was 160#. The 14-day MDS, with an ARD of 12/05/16, noted the resident's weight was 160#. The 30-day MDS, with an ARD of 12/19/16, noted the resident weighed 130#. The quarterly MDS, with an ARD 02/28/17, identified the resident's weight was 131#. Review of the current physician's orders found no evidence the resident was on a physician prescribed weight loss regimen. The resident's most recent weight, 107#, was obtained on 05/09/17. The resident had lost another twenty-four (24) pounds since the quarterly MDS with an ARD of 02/28/17 was completed. Review of the physician's progress notes found the resident was seen by the physician with no indication the physician was aware of, and had addressed the resident's weight loss. During an interview at 9:30 a.m. on 05/16/17, the administrator and DON reviewed the physician's progress notes. They both confirmed the physician's notes did not address a weight loss. Neither employee could provide any information to confirm the physician was aware of the resident's weight loss. At the close of the survey on 05/17/17 at 1:30 p.m., no further information was provided to confirm the physician was aware of the resident's weight loss. b) Resident #10 Review of this [AGE] year-old male' medical record, readmitted to the facility on [DATE], found this resident had experienced a weight loss, prompting a review of the care area of nutritional status during Stage 2 of the Quality Indicator Survey (QIS). Review of the resident's electronic medical record found the following weights: -- 11/15/16 - 224.0# - (Note: weighed 19 days after readmission) -- 12/20/16 - 223.4# -- 01/30/17 - 213.4# -- 02/20/17 - 205.2# -- 03/21/17 - 194.4# -- 03/29/17 - 199.6# -- 04/06/17 - 201.4# -- 05/09/17 - 184.2 The resident's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 01/16/17, identified the resident's weight as 223 #. According to the quarterly MDS with an ARD of 04/07/17, the resident's weight was 200#. The resident lost 23# between 01/16/17 and 04/07/17; a 10.31% weight loss in three (3) months. Since readmission on 10/27/16 until 04/07/17, the resident lost 23#, or 10.27% in six (6) months. Review of the physician's progress notes found the resident was seen by the physician with no indication the physician was aware of, and addressed, the resident's weight loss. When interviewed at 9:30 a.m. on 05/16/17, the administrator and DON reviewed the physician's progress notes. They both confirmed the physician's notes did not address a weight loss. Neither employee could provide any information to confirm the physician was aware of the resident's weight loss. At the close of the survey on 05/17/17 at 1:30 p.m. no further information was provided to confirm the physician was aware of the resident's weight loss. c) Resident #12 Review of Resident #12's medical records on 05/15/17 at 9:30 a.m., found this [AGE] year-old female was admitted to the facility on [DATE]. Review of the resident's electronic medical record found the following weights: -- 01/23/17 - 105.6 # (Note: weighed five (5) days after admission) -- 01/25/17 - 103.6# -- 01/30/17 - 99.8# -- 02/20/17 - 90.0# The resident's admission comprehensive minimum data set (MDS), with an assessment reference date (ARD) of 01/25/17, identified the resident's weight as 104#. On 05/15/17 at 10:30 a.m., the DON verified the resident's weight should have been 106# on the admission MDS with an ARD of 01/25/17. The 30-day MDS with an ARD of 02/13/17, noted the resident's weight was 100#. The resident had lost 6# between 01/25/17 and 02/13/17; which was a 5.66% weight loss in three (3) months. On 02/20/17, the resident weighed 90#; which was 15.9# or a 15.01% weight loss since admission on 01/25/17. The resident was discharged on [DATE]. Review of the physician's progress notes found the resident was seen by the physician with no indication the physician was aware of, and addressed, the resident's weight loss. During an interview at 9:30 a.m. on 05/16/17, the administrator and DON reviewed the physician's progress notes. They both confirmed the physician's notes did not address a weight loss. Neither employee could provide any information to confirm the physician was aware of the resident's weight loss. At the close of the survey on 05/17/17 at 1:30 p.m. no further information was provided to confirm the physician was aware of the resident's weight loss. d) Resident #48 Review of the resident's medical record for the care area of nutritional status began at 11:35 a.m. on 05/15/17. The care area of nutritional status was selected for review because the resident had lost weight, did not have a condition or chronic disease that may result in a life expectancy of less than 6 months, the resident was not receiving a nutritional supplement, defined as a prescribed high protein, high calorie, nutritional supplement between or with meals, and the resident was not on a planned weight loss program. Review of the resident's electronic medical record found the following weights recorded for the past six (6) months: -- 11/15/16 - 135.90 pounds (#) -- 12/20/16 - 129.60# -- 01/24/17 - 126.40# -- 02/20/17 - 121.60# -- 03/21/17 - 123.20# -- 04/06/17 - 120.80# -- 05/11/17 - 118.40# The resident's last comprehensive minimum data set (MDS), an annual with an assessment reference date (ARD) of 12/07/16, identified the resident's weight was 136#. The quarterly MDS with an ARD of 03/09/17, noted the resident weighed 122#. Review of the current physician's orders found no evidence the resident was on a physician prescribed weight loss regimen. The resident's most recent weight, 118.40# was obtained on 05/11/17. The resident continued to lose another four (4) pounds since the quarterly MDS with an ARD of 03/09/17 was completed. Review of the physician's monthly progress note, dated 01/26/17, found the resident's chief complaint was, Patient has had no new complaint or problems this month. Dexa scan (measures bone density) did show [MEDICAL CONDITION]. The physician's next visit was 03/07/17. The resident's chief complaint was listed as, Patient has had no new complaints or problems this month. The physician saw the resident again on 04/19/17. The resident's chief complaint was listed as, Patient did have a fall over the weekend but all xrays are negative for any new fractures. Otherwise no new incidents or complaints noted. There was no evidence the resident's physician was aware of any weight loss according to the progress notes. At 9:15 a.m. on 05/16/17, when asked if they had any evidence the physician was notified of the resident's weight loss, the DON and administrator were unable to provide any supporting information. At the close of the survey at 1:30 p.m. on 05/17/17, the facility had not provided any further information regarding notifying the physician the resident had lost weight. d) Resident #11 This [AGE] year-old female, admitted to the facility on [DATE], was reviewed during Stage 2 of the Quality Indicator Survey (QIS) for the care area of nutritional status. Review of the resident's electronic medical record found the following weights: -- 02/28/17 - 92.6#, -- 03/07/17 - 90.2#, -- 03/25/17 - 88.8#, -- 04/06/17 - 84.4#, -- 05/12/17 - 78.4#. The resident had lost 14.2# since her admission, representing a 20% weight loss in less than three (3) months. Review of the physician's progress notes found the resident was seen by the physician on 03/28/17 and 05/04/17 with no indication the physician was aware of, or addressed, the resident's weight loss. The administrator and the DON were interviewed at 9:30 a.m. on 05/16/17. The administrator reviewed the physician's documentation for the 03/28/17 and 05/04/17 visits. On both occasions the administrator confirmed the physician's handwritten notes included the word, negative, on both visits under the heading of weight. Neither employee could provide any information to confirm the physician was aware of the resident's weight loss. At the close of the survey on 05/17/17 at 1:30 p.m. no further information was provided to confirm the physician was aware of the resident's weight loss. f) Facility policy The facility's policy for weight monitoring was, The facility will document and an action plan will be made for residents who have had a weight loss of 5% in 30 days or 10% in 180 days. The procedure included: -- Charge Nurse shall be responsible for ensuring weights are obtained as ordered by physician. Charge Nurse shall report weight losses/gains to the resident's physician as directed by physician. -- If the resident has an unplanned weight loss or gain of 5% or more in 30 days or 10% in 180 days, the nursing staff will contact the Director of Nursing, Dietary manager, MDS (minimum data set) Coordinator and the physician. g) The DON and the administrator confirmed the facility's policy requiring notification of the physician of weight losses was not followed for Resident's #48 and #11.",2020-09-01
1508,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2017-10-13,157,D,0,1,UMXO11,"**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 when Resident #16's blood sugar was below 50 milligrams per deciliter (mg/dl) as ordered by the physician. This was true for one (1) of five residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #16. Facility Census: 32. Findings include: a) Resident #16 A review of Resident #16 medical record as 10:56 a.m. on 10/11/17 found a sliding scale insulin order dated 10/05/17 which contained the following instructions from the physician, Blood Glucose (mg/dl) less than 50 Give 1 amp of [MEDICATION NAME] 50% (50 ml) and Notify physician. For patient without IV (intravenous) access, give high carbohydrate snack or juice if alert, [MEDICATION NAME] 1 mg IM now if not alert and notify the physician. Review of Resident #16's Patient Finger Stick Glucose Testing Record found the following dates and times which her blood sugar was less than 50 mg/dl: --10/07/17 at 7:20 a.m. blood sugar was 44. --10/10/17 at 7:25 a.m. blood sugar was 43. --10/11/17 at 7:20 a.m. blood sugar was 40. Further review of the medical record found no evidence to suggest Resident #16's attending physician was notified on these occasions when her blood sugar was less than 50 mg/dl. An interview with the Director of Nursing (DON) at 12:39 p.m. on 10/11/17 confirmed there was no information contained in the record to indicate the nurse had notified the physician of the residents low blood sugar. She stated, We do not typically notify the physician if the resident is symptomatic.",2020-09-01
1665,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2017-10-10,157,D,1,1,UKRP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, clinical record review and policy review, the facility failed to notify the physician of change in condition related to an episode of unresponsiveness (Resident #74), and failed to notify the family of change in pain management (Resident #39). This failed practice had the potential to 2 out of 17 resident. Resident identifiers: #74 and #39. Facility census 48. Findings include: a.) Resident #74 Clinical record review revealed Resident #74 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. A nurses noted dated 06/19/17 at 10:30 p.m., (written by Licensed Practical Nurse #14) stated had an episode form her A-fib this evening. I was across the hall in another residents room giving meds, and was called in to check on (name of resident) by a residents spouse who was in the room with her. Resident was found lying flat on her bed, supine position, eyes dilated and was unresponsive for approximately 30 seconds, I was unable to get a pulse for about 10 seconds, then pulse became weak and thready and slowed to 20 for approximately 2 minutes. Resident then started to respond to my voice, her pulse wen back up to 60 and resident said she was ok, but very tired. Checked vitals BP (blood pressure) was 118/52, pulse was 63, R (respiratory rate) 16, oxygen was 92% via nasal cannula at 2 liters/minute. Resident is now responsive and alert at this time. Will continue to monitor. A nurses noted dated 06/20/17 at 8:35 a.m., revealed, Spoke with (name of physician) this AM to alert him to episode with patient. Instructions to continue to monitor. During a phone interview, on 09/28/17 at 10:40 a.m., LPN #14 stated on 06/19/17 she worked the evening shift with Resident #74. LPN #14 stated she did not remember notifying the physician of the resident's unresponsiveness. LPN #14 stated if she had notified the physician she would have documented it in her note. During an interview, on 09/28/17 at 3:05 p.m., the DON #35 after reviewing the 06/19/17 (10:30 p.m.) nurses note stated the nurse should have notified the physician immediately of the episode of unresponsiveness. DON #35 stated staff should not have waited until the following morning to notify the physician at 8:35 a.m. DON #35 provided a copy of the change in condition policy on 09/28/17 at 4:00 p.m Review of facility policy entitled: Change in Condition: Notification of dated 11/28/16 stated a Center must immediately consult with the patient physician when there is a significant change in the patient's physical mental, or psychosocial status (that is, a deterioration in health, mental or psychosocial status in either life-threatening conditions or clinical complications). b) Resident #39 On 10/03/17 at 11:35 a.m., review of records revealed an order dated 08/01/17 for [MEDICATION NAME] 20 mg/1 ml(milligrams/milliliter) solution 0.5 ml (10 mg) by mouth every one (1) hour as needed for pain. The Medication Administration Record [REDACTED]. Nurses were to give 10 mg by mouth every 1 hour as needed for Pain. Review of records did not show anywhere were the family representative or medical power of attorney(MPOA)had been notified of the change in pain management medication regimen. Interview with Licensed Practical Nurse(LPN# 19), on 10/03/17 at 3:35 p.m., revealed LPN#19 after reviewing the records could not see where the family representative or MPOA had ever been notified of the change in pain management medication regimen, when 10 mg of [MEDICATION NAME] had been added. On 10/04/17 at 9:15 a.m., review of the facility's Change in condition: Notification of policy, revealed the resident's health care decision maker must be immediately informed if there is a need to alter treatment significantly or commence a new form of treatment.",2020-09-01
1966,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2016-09-28,157,D,0,1,4Y1511,"**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 nursing staff was unable to start a physician ordered intravenous line, and administer intravenous fluids. This affected one (1) of fifteen (15) Stage II sampled residents. Resident identifier: #134. Facility census: 109. Findings include: a) Resident #134 Medical record review for Resident #134 on 09/28/16 at 1:30 p.m. revealed the following admission principal [DIAGNOSES REDACTED]. The resident also had a surgical wound in the lower midline and a wound vac. The surgical wound occurred from another recent hospitalization for a diverting [MEDICAL CONDITION] and repair of a colvaginal fistula. Other pertinent [DIAGNOSES REDACTED]. physician's orders [REDACTED]. The physician also ordered a complete blood count and a comprehensive metabolic profile the following morning. Review of nurse progress notes found the nurse obtained only twenty (20) cubic centimeters (cc) of urine with the catheterization. physician's orders [REDACTED].) per hour for forty-eight (48) hours. Review of nurse progress notes dated 05/08/16 at 3:23 a.m. found the nurse attempted unsuccessfully four (4) times to insert the intravenous line. The nurse stated (typed as written), Will pass on to daylight nurse to attempt to start. Pushing fluids all night with care. Thus far resident has drank 60 cc with a lot of encouragement. There was no evidence the nurse notified the physician of her inability to start the physician ordered intravenous fluids. It was not until twelve (12) hours later, on 05/08/16 at 11:42 a.m., any evidence that nursing staff spoke with the physician. The nurse stated (typed as written) Lab results received. DR (doctor) made aware, new orders received. POA (power of attorney) made aware The record was silent for notification of the inability to administer the IV fluids. A nurse progress note dated 05/08/16 at 12:31 p.m., stated (typed as written) Resident having increased confusion, not taking PO (oral) fluids or foods. Resident void x 1 (times one) this shift with small amount of dark yellow urine approximately 30 (thirty) ml (milliliters) BUN (blood urea nitrogen) 73, Creat (creatinine) 2.78, WBC (white blood cell count) 22.3. A nurse progress note dated 05/08/16 at 1:07 p.m., found the facility sent the resident to emergency room , where she was later admitted . An interview conducted with the director of nursing (DON) on 09/28/16 at 3:15 p.m., verified there was no evidence the physician was notified of the inability to insert the intravenous line and administer the intravenous fluids.",2020-09-01
2350,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2017-02-28,157,E,0,1,MNKY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to notify the physician and/or the resident's legal representative of a change in medical condition for two (2) of two (2) residents reviewed for notification of change during the Quality Indicator Survey (QIS). For Resident #39, the facility failed to notify the physician of the resident's high glucose results (over 400) on multiple occasions. If the physician is not notified of resident's high glucose results, they cannot evaluate if further medical intervention is needed or make decisions regarding treatment. For Resident #116, the facility failed to promptly notify the resident's legal representative on two (2) occasions when medication changes were made in his drug regimen. Resident identifiers: #39 and #116. Facility census: 89. Findings include: a) Resident #39 A review of Resident #39's medical record found a physician's orders [REDACTED]. --0 to 250 glucometer blood glucose give 0 (zero) units of insulin --251 to 300 glucometer blood glucose give 4 units of insulin --301 to 350 glucometer blood glucose give 7 units of insulin --351 to 400 glucometer blood glucose give 11 units of insulin --401 to 450 glucometer blood glucose give 14 units of insulin --If glucometer blood glucose is below 70 or above 400 notify physician Review of the Medication Administration Record [REDACTED] --11/25/16 at 7:00 a.m. glucometer blood glucose of 414 and at 8:00 p.m. glucometer blood glucose of 401 --11/26/16 at 8:00 p.m. glucometer blood glucose of 425 --11/27/16 at 7:00 a.m. glucometer blood glucose of 420 and at 8:00 p.m. glucometer blood glucose of 430 --11/28/16 at 8:00 p.m. glucometer blood glucose of 463 --11/29/16 at 8:00 p.m. glucometer blood glucose of 430 --11/30/16 at 7:00 a.m. glucometer blood glucose of 425 and at 8:00 p.m. glucometer blood glucose of 420 --12/01/16 at 8:00 p.m. glucometer blood glucose of 411 --12/02/16 at 7:00 a.m. glucometer blood glucose of 405 and at 8:00 p.m. glucometer blood glucose of 458 --12/03/16 at 7:00 a.m. glucometer blood glucose of 465 and at 8:00 p.m. glucometer blood glucose of 445 --12/04/16 at 7:00 a.m. glucometer blood glucose of 591 and at 8:00 p.m. glucometer blood glucose of 491 --12/05/16 at 8:00 p.m. glucometer blood glucose of 448 --12/06/16 at 7:00 a.m. glucometer blood glucose of 432 and at 8:00 p.m. glucometer blood glucose of 450 --12/07/16 at 7:00 a.m. glucometer blood glucose of 448 and at 8:00 p.m. glucometer blood glucose of 450 --12/08/16 at 7:00 a.m. glucometer blood glucose of 417 and at 8:00 p.m. glucometer blood glucose of 481 --12/09/16 at 8:00 p.m. glucometer blood glucose of 485 --12/10/16 at 8:00 p.m. glucometer blood glucose of 450 --12/11/16 at 8:00 p.m. glucometer blood glucose of 450 --12/12/16 at 8:00 p.m. glucometer blood glucose of 454 --12/13/16 at 7:00 a.m. glucometer blood glucose of 444 and at 8:00 p.m. glucometer blood glucose of 573 --12/14/16 at 8:00 p.m. glucometer blood glucose of 450 --12/15/16 at 8:00 p.m. glucometer blood glucose of 457 --12/16/16 at 8:00 p.m. glucometer blood glucose of 527 --12/17/16 at 8:00 p.m. glucometer blood glucose of 488 --12/18/16 at 8:00 p.m. glucometer blood glucose of 433 --12/19/16 at 8:00 p.m. glucometer blood glucose of 410 --12/20/16 at 8:00 p.m. glucometer blood glucose of 401 --12/22/16 at 7:00 a.m. glucometer blood glucose of 436 --12/24/16 at 8:00 p.m. glucometer blood glucose of 454 --12/25/16 at 8:00 p.m. glucometer blood glucose of 511 --12/26/16 at 8:00 p.m. glucometer blood glucose of 512 --12/27/16 at 7:00 a.m. glucometer blood glucose of 420 --12/28/16 at 8:00 p.m. glucometer blood glucose of 511 --12/31/16 at 7:00 a.m. glucometer blood glucose of 512 --01/01/17 at 7:00 a.m. glucometer blood glucose of 550 and at 8:00 p.m. glucometer blood glucose of 546 --01/02/17 at 8:00 p.m. glucometer blood glucose of 525 On 01/03/17, the physician order [REDACTED]. Review of the medical record found the following glucometer blood glucose readings greater than 401 after the physician order [REDACTED]. --01/07/17 at 11:00 a.m. glucometer blood glucose of 483 --01/10/17 at 9:00 p.m. glucometer blood glucose of 585 --01/12/17 at 7:00 a.m. glucometer blood glucose of 402 --01/14/17 at 9:00 p.m. glucometer blood glucose of 410 --01/22/17 at 11:00 a.m. glucometer blood glucose of 403 Further review of Resident #39's medical record found no evidence the physician was notified of the glucometer blood glucose results greater than 400 according to the 11/22/16 physician order, or for glucometer blood glucose results greater than 401 according to the 01/03/17 physician order. During an interview with the Director of Nursing (DON) and the Unit Manager (UM), at 8:16 a.m. on 02/27/17, a list of the dates the physician was not notified according to physician ordered parameters was provided for their review. The DON confirmed the nurses should have notified the physician each occasion the glucometer blood glucose readings were outside of the physician ordered parameters. On 02/28/17 at 1:15 p.m., the DON confirmed after review of Resident #39's medical records did not contain any evidence of physician notification of the glucometer blood glucose results outside the ordered parameters. b) Resident #116 During an interview in Stage 1 of the Quality Indicator Survey (QIS), on 02/21/17 10:45 a.m., the Resident's responsible party indicated the facility did not always provide prompt notification when changes in care occurred. Review of the medical record found two (2) handwritten physician's orders [REDACTED]. --[MEDICATION NAME], daily for allergies [REDACTED].>--Decrease Klonopin to 0.5 milligrams (mg), one (1) tablet every a.m. and two (2) tablets at bedtime, dated 11/11/15 The physician orders [REDACTED]. Both orders failed to indicate the resident and/or the family was notified of the changes in treatment. At 4:13 p.m. on 02/21/17, the DON reviewed the nursing notes and the orders. The DON confirmed he was unable to provide evidence the responsible party was notified of the changes in treatment. The DON further confirmed the Resident's responsible party should have been notified of the changes as the resident lacked capacity to make medical decisions.",2020-09-01
2436,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2017-06-30,157,D,1,1,45HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to inform the responsible party of one (1) of three (3) residents reviewed for the care area of Nutritional status when a significant weight loss occurred. Resident #75 experienced a 5.5% weight loss fifteen (15) days after admission to the facility. Resident identifier: #75. Facility census 76. Findings include: a) Resident #75 Record review, at 10:56 a.m. on 06/27/17, found the resident triggered the care area of nutritional status due to a 5.5% weight loss fifteen (15) days after his original admission to the facility. The resident was admitted to the facility on [DATE] and was discharged from the facility to his home on 03/10/17. The following weights were available in the resident's electronic medical record: --02/16/17 - 181.6 pounds (lbs) --02/21/17 - 176.6 lbs. --02/28/17 - 173.6 lbs. --03/07/17 - 171.8 lbs. The resident did not have a terminal diagnosis. He was admitted to the facility after a hospital stay where he was treated for [REDACTED]. The resident planned to receive rehabilitation and return to his home. On 02/26/17, the resident was deemed to lack capacity to make medical decisions. The incapacity was expected to be long term due to cognitive loss. Further review of the medical record found no evidence the resident's responsible party had been informed of the weight loss. The Director of Nursing (DON) was interviewed, on 06/28/17 at 2:45 p.m., regarding the resident's weight loss and notification of his responsible party. The DON concluded the electronic medical record only alerts the facility of weight loss after 30 days. The DON said since the resident was here less than 30 days, and his weight loss did not show up on the computer. The DON was unable to provide evidence the resident's responsible party was aware of the weight loss when the facility should have known about the weight loss on 03/07/17.",2020-09-01
2724,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2017-06-13,157,E,0,1,QOJB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to notify the physician and/or the resident's legal representative of a change in medical condition for two (2) of two (2) residents reviewed for notification of change during the Quality Indicator Survey (QIS). For Resident #79, the facility failed to promptly notify the physician of the resident's high glucose results (over 400) on multiple occasions. For Resident #5, the facility failed to promptly notify the resident's physician when her medication ([MEDICATION NAME]) was unavailable for administration. Resident identifiers: #79 and #5. Facility census: 55. Findings include: a) Resident #79 A review of Resident #79's medical record beginning at 10:00 a.m. on 06/12/17 found the following physician's orders [REDACTED]. -- Order with start date of 12/19/16 (date of admission to the facility) - Obtain blood sugar (BS) twice a day. (Standing order was to notify the physician if the blood sugar was less than 60 or greater than 400). Review of Resident #79's Medication Administration Record [REDACTED] -- Resident #79's blood sugar (BS) at 5:00 p.m. on 12/30/16 was 537. The Family Nurse Practitioner (FNP) was notified at 5:47 p.m. and new order received to recheck the blood sugar at bedtime (9:00 p.m.). No blood sugars were recorded for Resident #79 for 9:00 p.m. on 12/30/16. -- 01/01/17 at 5:00 p.m. - BS was 503. -- 01/02/17 at 5:00 p.m. - BS was 517 and at 9:00 p.m. BS - was 490. Physician not notified until 01/03/17 at 12:17 a.m. -- 01/04/17 at 7:00 a.m. - BS was 406. -- 01/04/17 at 9:00 p.m. - BS was 417. -- 01/05/17 at 5:00 p.m. - BS was 420. -- 01/06/17 at 11:30 a.m. - BS was 411 and at 5:00 p.m. - BS was 432. Physician was notified but not until 01/06/17 at 11:51 p.m. -- 01/07/17 at 5:00 p.m. - BS was 456. -- 01/08/17 at 5:00 p.m. - BS was 597. -- 01/09/17 at 9:00 p.m. - BS was 501. -- 01/11/17 - BS was 444 at 7:00 a.m. -- 01/12/17 - BS was 585 at 7:00 a.m. -- 01/13/17 - BS was 567 at 5:00 p.m. -- 01/14/17 - BS was 50 at 7:00 p.m. During an interview at 12:30 p.m. on 06/13/17, when asked to review the resident's orders, the Director of Nursing (DON) agreed the orders for Resident #79's diabetes management had not been followed. She confirmed the nursing staff did not notify the physician when the resident's blood sugar was less than 60 and/or greater than 400 b) Resident #5 A review of Resident #5's medical record beginning at 11:13 a.m. on 06/08/17 found a physician's orders [REDACTED]. This order also specified to hold the [MEDICATION NAME] if the resident's Hemoglobin (HGB) was greater than 10.0. Review of the Medication Administration Record [REDACTED]. Review of the nursing progress notes found the medication was held on both days because it had not arrived at the facility from the pharmacy. Further review of the nursing progress notes found a note dated 10/08/16 which indicated the nurse had telephoned the Nurse Practitioner and informed her the medication was not available. At which time the NP gave orders to give the medication when available. This dose of [MEDICATION NAME] was administered on 10/09/16. The medical record contained no evidence to suggest the NP or the Physician was ever notified that the dose of [MEDICATION NAME] scheduled to be administered on 10/22/16 was unavailable for administration. However, despite failing to notify the physician and/or NP the facility administered Resident #5's [MEDICATION NAME] on 10/23/16 when it was delivered to the facility. An excerpt from the facility's Pharmacy policy and procedures stated the following, .If an ordered medication is not available for dispensing, . B. Nursing Staff Shall: 1) Notify the attending physician of the situation and explain circumstances, expected availability and optimal therapy(ies) that are available. 2. Document and implement any orders obtained from the physician. 3. Communicate order changes to the provider pharmacy. Further review of the medical record found a physician's orders [REDACTED]. A review of the (MONTH) (YEAR) MAR found that Resident #5's [MEDICATION NAME] was held on 05/16/17 and 05/30/17. Review of the nursing progress notes found two (2) progress notes dated 05/16/17 and 05/30/17 which indicated that Resident #5's [MEDICATION NAME] was held on these days because the Hemoglobin results were unavailable for review. The progress notes also contained notes dated 05/17/16 and 05/31/17 which indicated the [MEDICATION NAME] was administered to Resident #5 on these days. Both of which were the day after it was ordered. The medical record contained no evidence to suggest the NP and/or physician were notified Resident #5's did not receive her [MEDICATION NAME] until the day after it was scheduled. During interviews with the Director of Nursing (DON) on 06/08/17 at 2:07 p.m. and on 06/12/17 at 10:33 a.m., she confirmed the medical record contained no evidence to suggest the NP and/or attending physician was notified when Resident #5's [MEDICATION NAME] had to be administered the day after it was scheduled.",2020-09-01
2960,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2017-09-28,157,D,0,1,BKPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, The facility failed to notify the responsible party/family when Resident #103 experienced a fall with head injury and when Resident #103 required hospitalization due to unresponsiveness due to the head injury. This deficient practice was affected one (1) of two (2) reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). This was determined to be a past non-compliance due to the facility having implemented action that corrected the non-compliance prior to the beginning of the survey. Resident identifier: #103. Facility census: 61. Findings include: a) Resident #103 Review of Resident #103's medical records, on 09/27/17 at 2:10 p.m., revealed Resident #103 was admitted to the facility on [DATE] at 8:51 p.m. Resident #103 experienced a fall with head injury at 9:30 p.m. on 05/02/17. He became unresponsive at 10:30 p.m. on 10/02/17 and was transported to acute care facility. No evidence was found to indicate the facility had notify Resident #103's responsible party/family when he experienced a fall with a head injury and no evidence the facility notified the responsible party/family when Resident #103 became unresponsive and required care at an acute care facility. Interventions to correct the problem was provided by the Director of Nursing (DON) as follows: Education of all licensed nurses related to notification of responsible party of any/all incidents/accidents, change in condition, falls, new physician orders, and/or acute medical transfers. Phone numbers of family/responsible party telephone numbers can be located on new admissions in the discharging facilities paperwork. Interventions to monitor the effectiveness of corrective measures: Upon admission of a resident an Admission Checkoff List will be completed. This form requires the licensed nurse to accompany resident to the room with ambulance personnel and remain with resident during transfer from gurney to bed. Obtain vital signs (blood pressure, pulse, temperature, respirations and oxygen saturation). Ensure call light is within reach, bed at normal height for resident. Ask resident if he/she needs anything and ensure the resident has all that is needed. Explain to resident that someone will be back to do admission paper work and will complete a full body assessment. Responsible Party will be notified of admission/readmission upon the resident's arrival to the center. Point Click Care computer documentation will be completed. The DON was interviewed on 09/28/17 at 9:00 a.m. She confirmed the nurse had failed to notify the responsible party of Resident #103's fall and when he was sent to an acute care facility for treatment.",2020-09-01
3063,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,157,E,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and family interview, the facility failed to notify the responsible party or physician of a significant change in physical behaviors and the need to alter treatment to address elevated blood sugars. This affected two (2) of 119 residents reviewed. Resident identifiers: #119 and #108. Facility census: 59. Findings include: a) Resident #119 On 06/06/17 at 3:55 p.m., the clinical record for Resident #119 was reviewed. Resident #119 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. On 06/05/17 at 5:18 p.m., an interview was completed with the responsible party for Resident #119. She stated, There were about 3 incidents of Resident #119 hitting or threatening the staff and they didn't tell me before last Thursday (06/01/17). Review of the Nurses' Notes for Resident #119 began on 06/06/17 at 3:55 p.m. revealed the first incident occurred on 05/31/17. On 05/31/17 at 6:30 a.m., Nurse #38 documented in the nurses' notes, Resident bed alarm was going off and this nurse went into his room to redirect him and help him with his needs. Resident stated he was getting up this nurse said okay and asked him to allow me to help him so he doesn't fall. At that time resident started to lose his balance and started to lean on the chair in the room. This nurse had her hand placed on his elbow as a guide. Resident then attempted to punch this nurse in the face. I quickly moved my head so resident did not make contact with my face. At that time, the Certified Nursing Assistant (CNA) came in to the room to take over. Continued review of the clinical record revealed a second incident occurred on 06/01/17 at 6:41 a.m. The Nurses' Notes documented by Nurse #5 revealed on 06/01/17 at 6:41 a.m., Resident #119 was combative during care, attempting to kick staff and yelling out 'I will hurt you' Resident attempted to get up unassisted, found walking to bathroom. Further review of the clinical record revealed a third incident occurred on 06/03/17. The Nurses' Notes note dated 06/03/17 at 5:45 a.m. written by Nurse #1 revealed, 5 am Nurse saw resident in the hall he was unsteady on his feet staggering he was urinating in the hall, a large amount of urine, staff asked to get him to sit down in a W/C so he would not fall and he started to roll his fist up said, 'I am going to hit you all' he started to swing his fist. Staff moved from him and he still wanted to hit someone after he returned to bed he grab the CNA's hand and hurt her thumb, he continue to be combative with another CNA grabbing her hand and bending them. 5:48a (a.m.) after resident was calm Nurse attempted to give him his 6 am meds (medications) and he refused them said he was not going to take them right now he would take them when he got up. During an in interview conducted with the Administrator on 06/06/17 at 3:30 p.m., she said, I talked to (Resident #119's family member) yesterday about her concerns. I talked to (Nurse #1) yesterday. (Nurse #1) said that on 06/03/17 at around 5:00 a.m., (Resident #119) was awake and combative. She said that she called the (Responsible Party) on 06/04/17 at around 3:00 a.m. (Nurse #1) said that on shift report on 06/04(2017) that (Responsible Party) wanted to be called with any issues. She saw that (Responsible Party) was not called about 06/03 (2017) incident so she called her at 3 a.m. on 6/4 (2017). I'm not sure why she called at 3 in the morning. There was a care plan meeting last Thursday and they talked about his behavior. I will have to check to make sure that (Responsible Party) hadn't been called before the meeting. On 06/07/17 at 6:10 a.m., during an interview with Nurse #38, she stated, The first night I took care of (Resident #119) I went in to give him his 6:00 a.m. meds (medications) and do a finger stick (for blood glucose). I went in and told him I need to do his finger stick and give him his medication. He said okay. After I left the room, his bed alarm went off. I went in and he was standing up and he wasn't steady. I grabbed his arm to steady him and he drew back and then swung at me. I moved out of the way. It's the only bad interaction I've had with him. I yelled and the CNA (nursing assistant) came in. She had a good rapport with him and said she was OK so I got out of the room and she took care of him. I finished my med pass and reported to the nurse coming on and told all of the aides to document his behaviors. I didn't call (Family Member) at that time, but looking back I should have called her even if it was 6 in the morning. On 06/07/17 at 2:18 p.m., an interview was conducted with Nurse #5. Nurse #5 stated that she was familiar with Resident #119, and I was the nurse on night shift on 6/01 (2017) and it was just before 6:40 (a.m.). When he was trying to go to the bathroom by himself. His alarm went off so I went in to see what was going on. Another nurse came in and we helped him into the bathroom. He was combative as we tried to get him in and out of the bathroom. We got him back to bed and he was OK. I didn't notify the responsible party; the family has now asked to be notified about any of his behaviors. I wouldn't always notify about this, it depends on the situation. The change in condition assessment was started on 5/31 (2017) for his behavior. (Nurse #38) started it and she would have notified the family. Nurse #5 reviewed the record for Resident #119 and noted that she could not find documentation that Resident #119's family was notified of the change in behaviors on 05/31/17. b) Resident #108 Review of Resident #108's clinical record began on 06/07/17 at 2:45 p.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] --04/07/17 at 8:00 PM, the blood sugar was 413 mg/dl --04/08/17 at 8:00 PM, the blood sugar was 440 mg/dl --04/15/17 at 8:00 PM, the blood sugar was 377 mg/dl --04/16/17 at 8:00 PM, the blood sugar was 384 mg/dl --04/29/17 at 8:00 PM, the blood sugar was 400 mg/dl Review of the nursing documentation for the above mentioned dates did not include physician notification for a blood glucose level greater than 350 mg/dl. Review of the (MONTH) (YEAR) MAR indicated [REDACTED] --05/03/17 at 8:00 PM, the blood sugar was 382 mg/dl --05/07/17 at 8:00 PM, the blood sugar was 360 mg/dl --05/13/17 at 8:00 PM, the blood sugar 356 mg/dl --05/18/17 at 8:00 PM, the blood sugar was 354 mg/dl --05/19/17 at 8:00 PM, the blood sugar was 423 mg/dl --05/20/17 at 8:00 PM, the blood sugar was 387 mg/dl --05/21/17 at 8:00 PM, the blood sugar was 396 mg/dl --05/22/17 at 8:00 PM, the blood sugar was 379 mg/dl Review of nursing documentation for the above mentioned dates did not include physician notification for blood glucose level greater than 350. During an interview conducted on 06/07/17 at 2:56 p.m., the Assistant Director of Nursing #37 verified the lack of physician notification for the elevated blood glucose levels greater than 350 on the referenced dates.",2020-09-01
3254,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,157,E,0,1,467L11,"**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 when a change of condition occurred for two (2) of three (3) residents reviewed for the care area of notification of changes during Stage 2 of the Quality Indicator Survey (QIS). Resident #88's international normalized ratio (INR) results on six (6) of nine (9) occasions from 09/16/16 through 09/24/16. Newly developed pressure ulcers for Resident #20 ' s were not reported to the attending physician on two (2) separate occasions. Resident identifiers: #88 and #20. Facility Census: 75. Findings include: a) Resident #88 A review of Resident #88's medical record, at 2:03 p.m. on 12/12/16, found a physician ' s order dated 09/15/16 which read as follows, Daily INR, then call physician for dosing. A review of Resident #88's medication administration record (MAR) found the nurses initials daily, beginning on 09/16/16 through 09/24/16, to indicate they checked the residents INR. However, the INR results for 09/16/16 through 09/23/16 were not documented on the MAR. A review of the nursing progress notes found a note on 09/16/16 which indicated the residents attending physician was notified of the INR result and gave an order to start [MEDICATION NAME] 10 milligrams (mg). On 09/18/16 the attending physician changed Resident #88's [MEDICATION NAME] dose to 9 mg daily. The INR result was not noted in the medical record. Finally, on 09/24/16, a nursing note indicated Resident #88's INR was 1.9 and the attending physician was notified and gave new orders to continue the 9 mg daily and to check INR on Monday and Thursday. There was no other indication in the medical record to show Resident #88's physician was notified of his INR results on 09/17/16, 09/19/16, 09/20/16, 09/21/16, 09/22/16, and 09/23/16. Which is six (6) of the nine (9) occasions in which the attending physician should have been notified. An interview with the director of nursing (DON) at 1:16 p.m. on 12/13/16, confirmed the medical record contained no evidence the attending physician was notified of Resident #88's INR results on 09/17/16, 09/19/16, 09/20/16, 09/21/16, 09/22/16, and 09/23/16. She stated if they notified the attending physician this should be indicated in a nursing note. She indicated, there was no way to know if they notified the attending physician or not because it is not documented. b) Resident #20 A review of Resident #20's medical record, at 12:35 p.m. on 12/11/16, found she was originally admitted to the facility on [DATE], returned from an acute care hospital on [DATE] after receiving treatment for [REDACTED]. Review of Resident #20's progress notes revealed, on 02/24/16 at 12:40 p.m., a Stage II pressure ulcer noted to right upper inner buttocks. The medical record contained no indication the physician was notified of this new pressure ulcer until 02/29/16 during the physician's visit. Further review of Resident #20's progress notes indicated on 05/17/16 a deep tissue injury (DTI) was noted on the right buttocks measuring 4 cm in length and 2.5 cm in width with a deep purple center with redness surrounding the area. No indication the physician was notified until 05/23/16. An interview with the DON, at 12:16 p.m. on 12/12/16, confirmed the medical record contained no evidence the attending physician was notified of Resident #20's new pressure ulcers on 02/24/16 and 05/17/16. She stated if they notified the attending physician this should be indicated in a nursing note. She indicated, there was no way to know if they notified the attending physician or not because it is not documented.",2020-09-01
3271,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,157,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party when one (1) of seventeen (17) residents reviewed, experienced changes in medical conditions. The responsible party was not notified when Resident #86 experienced a fall at the facility, and when changes to medication were made due to an irregular laboratory value. Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. .",2020-09-01
3807,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-21,157,D,1,0,0AC711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and clinical record review, the facility failed to notify the physician when Resident #98 refused oral medications for eleven (11) days. This was found for one (1) of six (6) sampled residents reviewed. Resident Identifier: #98. Facility census: 97. The findings include: a) Resident #98 Clinical record review revealed Resident #98 resided in the facility from [DATE] until her death on [DATE]. Her [DIAGNOSES REDACTED]. Her oral medications at the time of her [DATE] admission included: - [MEDICATION NAME] 8 milligrams (mg) daily (a steroid), - [MEDICATION NAME] 100 mg twice daily (a stool softener), - [MEDICATION NAME] 4 mg every 8 hours (to prevent nausea and vomiting), - senna 176 mg/5 milliliters (ml) 15 ml twice daily (a laxative), - [MEDICATION NAME] 40 mg daily (a diuretic), - [MEDICATION NAME] 10 mg daily (for allergies [REDACTED].>- [MEDICATION NAME] 10 mg daily (allergies [REDACTED].>- Movantik 12.5 mg daily (for opiod induced constipation), - [MEDICATION NAME] 17 grams (g) daily (a laxative), - K-Dur 20 milliquivalents (meq) twice daily (a potassium supplement), and - [MEDICATION NAME] 100 mg/ 5 ml 20 mg every hour as needed (a highly concentrated [MEDICATION NAME]). Review of the (MONTH) (YEAR) Medication Administration Record (MAR) revealed all oral medications except the [MEDICATION NAME] were circled as not given from [DATE] until her death on [DATE]. The reasons stated on the MAR for refusing her medications were she was, too sick or complaint nausea/vomiting. The clinical record contained no evidence of notification of the physician until [DATE], at which time the physician discontinued the [MEDICATION NAME], [MEDICATION NAME], and K-Dur. During an interview on [DATE] at 11:58 a.m., Licensed Practical Nurse (LPN) #69 stated Resident #98 was always nauseated, and would not take her oral medications except for her [MEDICATION NAME] for pain. LPN #69 stated the medications made her feel more nauseated. LPN #69 confirmed a circle around initials on the MAR meant the medication had not been administered. LPN #69 stated facility policy was to notify the physician if a resident refused their medications after 3 doses. LPN #69 stated facility policy was to make a note in the clinical record when a physician was notified and the physician's response. After review of the clinical record, LPN #69 stated she did not notify the physician of Resident #98's refusal of her oral medications. During a telephone interview on [DATE] at 2:18 p.m., Registered Nurse (RN) #102 stated if Resident #98 refused her medications, I would circle the medication on the MAR and document the reason. The nurse said Resident #98 would only take her oral [MEDICATION NAME]. RN #102 said facility policy was to notify the MD when a resident refused a medication after 3 doses. She also said if she had notified the physician, she would have made a note in the clinical record. RN #102 stated if there was no note by her in the clinical record, she must not have notified the physician of the resident's refusal of oral medications. During an interview on [DATE] at 5:25 p.m., Director of Nursing (DON) #18 confirmed the facility policy was to notify the physician of a resident's refusal of medications after 3 doses. Staff were expected to complete documentation in the clinical record that the physician was notified and any change in physician orders. DON #18 confirmed the clinical record contained no evidence the physician was notified of Resident #98's refusal of medications from [DATE] until [DATE].",2020-08-01
3840,HOLBROOK HEALTHCARE CENTER,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2016-11-10,157,D,0,1,6GKK11,"Based on record review, policy reviews, and staff interview, the facility failed to immediately notify the nurse supervisor and the attending physician when Resident #69 had a fall resulting in injury. This was true for one (1) of seven (7) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #69. Facility census: 92. Findings include: a) Resident #69 Review of the resident ' s medical record on 11/02/16 found a progress note dated 07/12/16 at 4:35 a.m. The note identified the resident was found on the floor beside her bed on her right side and that during the assessment, the resident had complained of pain in her right shoulder. There was no indication the supervising nurse or attending physician were notified of the fall or the pain in her right shoulder. Another progress note written on 07/12/16 at 12:50 p.m., reported the resident had complained of pain in her right shoulder and arm and had bruising and swelling to her right shoulder and clavicle (collarbone) area. The Nurse Practitioner was called and ordered the resident sent to the emergency room (ER). A review of the ER notes dated 07/12/16 at 1:53 p.m., reported the x-rays for Resident #69 revealed she had a right-sided mid clavicular fracture. The facility failed to follow its own Fall Intervention Policy and Procedure revised on (MONTH) 16, 2010. Section 3, c. NOTIFICATION TO THE PHYSICIAN AND LEGAL REPRESENTATIVE REGARDING ANY ACCIDENT, INCIDENT OR CHANGE OF CONDITION IS MANDATORY! The Incident, Accident and Unusual Occurrences Policy and Procedure revised on 03/16/11, included under Notifications: The physician is to be immediately notified of all incidents or circumstances that pertain to the resident's care or that have the potential for harm, or creating an unsafe condition. An interview with the Director of Nursing (DON) on 11/03/16 at 3:10 p.m., verified the nursing supervisor or the physician were not notified immediately of the fall for Resident #69 or the complaint of pain to her right shoulder.",2020-07-01
3895,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,157,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to notify Resident #170's attending physician when she experienced unrelieved pain and she refused six (6) out of eight (8) [MEDICAL TREATMENT] treatments in the month of (MONTH) (YEAR) due to pain from her [DEVICE]. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings include: a) Resident #170 A review of Resident #170's medical record at 10:00 a.m. on 09/21/16 found the resident was originally admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Further review of the record on 09/21/16 at 3:00 p.m., found an admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 08/29/16, identified the resident scored 15 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. Review of Resident #170's medical records found on multiple occasions Resident #170 refused [MEDICAL TREATMENT] treatments from 09/06/16 through 09/22/16. An interview with Resident #170 at 9:35 a.m. on 09/22/16, revealed she was not going to [MEDICAL TREATMENT] because of pain caused from the [DEVICE] which was placed on 09/05/16. The record contained no information to indicate Resident #170's attending physician and/or nurse practitioner were notified of her refusals of [MEDICAL TREATMENT] and/or pain. The [MEDICAL TREATMENT] center, on two (2) occasions, 08/25/16 and 09/08/16, sent recommendations to discontinue Resident #170's [MEDICATION NAME]. The facility did not address this. She continued to receive the medication and the physician had not been notified of the recommendations as of 09/22/16. In an interview on 09/22/16 at approximately 10:05 a.m., the Director of Nursing (DON) was informed of Resident #170's multiple documented occasions when the resident refused [MEDICAL TREATMENT] treatments from 09/04/16 through 09/22/16, and the resident interview in which she stated she was refusing [MEDICAL TREATMENT] due to pain caused by the wound vac. The lack of notification of the attending physician and/or nurse practitioner was also brought to her attention at that time. Additionally, the DON was informed the [MEDICAL TREATMENT] center had sent recommendations to discontinue Resident #170's [MEDICATION NAME] on two (2) occasions, 08/25/16 and 09/08/16, which had not yet been addressed by the facility. The resident continued to receive this medication and the physician had not been notified of the recommendations as of 09/22/16. No further information provided prior to exit. Attempts to interview Resident #170's attending physician on 09/22/16 and again on 09/23/16 were unsuccessful. The NHA reported the physician said he was too busy and did not have time to speak with surveyors.",2020-04-01
3946,WILLOW TREE HEALTHCARE CENTER,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2016-05-26,157,D,0,1,ULQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews, the facility failed to notify the responsible party of one (1) of 24 residents reviewed in Stage 2 for a change of status. Resident identifier: #68. Facility census: 99. Findings include: a) Resident #68 Review of the quarterly Minimum Data Set (MDS) review dated 07/03/15 for Resident #68 on 05/24/16, revealed the resident was always continent. The next MDS dated [DATE] noted Resident #68 was frequently incontinent. Interview On 05/24/2016 at 10:09 a.m. with Nurse Aide (NA) #106 stated Resident #68 is incontinent. NA #106 stated, He gradually became incontinent. That happened months ago. On 05/24/16, a review of Resident #68's progress notes for 07/01/15 through 10/07/15 had no mention of Resident #68 being incontinent. A review of Activities of Daily Living (ADL) sheets for (MONTH) (YEAR) noted Resident #68 was continent each shift. The ADL sheets for (MONTH) showed Resident #68 was frequently incontinent. The ADL sheets for (MONTH) (YEAR), showed nearly every shift Resident #68 was incontinent. An interview completed with Social Worker #45 on 05/24/2016 at 3:17 p.m., revealed she had not talked with the responsible party about Resident #68's incontinence. During an interview with the Director of Nurse (DON) #84 on 05/24/2016 at 3:28 p.m., she said, We would notify the responsible party about any changes in the plan of care. Medication changes, falls and any change in condition. DON #84 said she had not discussed any changes concerning Resident #68 with the responsible party. DON #84 stated notification made to the responsible party the resident was using a wheelchair more, but could find no documentation she informed the legal party Resident #68 had become incontinent.",2020-04-01
4037,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,157,E,0,1,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to notify the resident's responsible party and/or physician of incidents of sexual abuse. This was evident for seven (7) of eight (8) residents reviewed for abuse. Resident identifiers: #51, #49, #24, #37, #1, #39, #26, #10, #62, #52, and #11. Facility census: 61. Findings include: a) Resident #51 Confidential Interviewees (CI) #3 and CI #4, in separate interviews, both said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to whomever was the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. An incident report dated 12/08/16, described that Resident #51 was sitting in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt, and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. Review of the nurse progress report found no documentation on 12/08/16 about this incident between the two (2) residents. There was no evidence the facility informed the responsible party or the physician of these occurrences. b) Resident #49 During separate confidential interviews with CI #1, CI #2, CI #6, CI #10, and CI #11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both separated from Resident #49 on 02/20/17 by other staff, but did not witness it herself. CI #1 said the nurses' reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff was aware that those two (2) male residents touched female residents inappropriately over their clothing. She said the incidents of the morning of 02/20/17 were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and went real slow when he saw a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked the resident if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI#11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. The DON reviewed the computer and her records, and said she found no other incident reports for this resident, and subsequently no evidence of notification of the resident's responsible party or the physician. c) Resident #24 During an interview, CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility, which she estimated as about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate him touching her. CI#11 said that once over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the covers were off the resident, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he scared the crap out of her. She said she heard Resident #24 tell him to leave. CI#11 said she reported this to the nurse in charge at the time. During an interview on 02/28/17 at 1:00 p.m., the DON said staff had not made her aware that a male resident(s) had inappropriately touched this female resident. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of responsible party or physician notification. d) Resident #37 CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said the resident told him, No, and he jerked back his hand. During an interview on 02/28/17 at 1:00 p.m., the DON said she was not aware a male resident had inappropriately touched Resident #37. The DON reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of notification of the responsible party MPOA or physician. The DON said staff should have filed an incident report any time this type of behavior occurred. She said had that been done, an investigation would have ensued, and as part of the investigation, the family members and the physician notified. e) Resident #1 CI #11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #1's legs and inner thighs. She said she reported this to the nurse in charge at the time. During an interview with the DON on 02/28/17 at 1:00 p.m., she reviewed the computer and her records, and said she found no incident reports for this resident of that nature, and subsequently no evidence of MPOA or physician notification. The DON said staff should have filed an incident report any time this type of behavior was observed. She said had that been done, then an investigation would have ensued. As part of the investigation, the family members and the physician would have been notified of the incidents. f) Resident #39 Medical record review found on10/09/16 at 6:46 a.m., Resident #11's behavior monitoring nurses' notes stated, Alert and oriented . Resident was up adlib (as desired) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from Resident 29B. Review of Resident #39's medical record, incident/accident reports, and reports made to State agencies, found no evidence the resident's responsible party was notified of the incident. g) Resident #26 On 10/06/16 at 18:40 (6:40 p.m.), an incident report noted Resident #62 (a male) was observed forcefully grabbing Resident #26 left arm. According to the report, Resident #62 attempted to reach Resident #26's crotch. At 18:47 (6:47 p.m.), Resident #62 was again found reaching for the crotch of Resident #26. Staff separated the residents and Resident #26 was transferred to the Second Floor. Review of Resident #26's medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. h) Resident #62 An incident report identified the alleged perpetrator as Resident #62. Additional evidence was found when the SW noted On (MONTH) 16, (YEAR) (Resident #26's name - a female) was found in the hallway with another male resident. The male resident had his hand down Resident #26s pants. Resident #26 was attempting to get away from the male. Staff moved Resident #26 away from the male. - 10/05/16 at 13:16 (1:16 p.m.) An Activities note stated Resident #62 was redirected at two (2) different times when he had his hand between an unidentified female resident's legs. - 10/06/16 at 10:06 a.m., a nurse noted Resident #62 was found reaching for the crotch of Resident #26. Again, at 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated and continued to follow. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes stated, Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurse's Note stated, Caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m., Hands in female's private parts. -02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated, Housekeeper reported separated touching female resident inappropriately. During the medical record review, incident/accident review, and review of reports made to State agencies, found no evidence the facility notified the resident's responsible party of these incidents. i) Resident #10 This quarterly MDS also identified Resident #10 as having exhibited physical behaviors directed toward others, which included abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of his medical record found the following: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note stated, Sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended entry noted, Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurses' notes stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident's room sitting on the bed with her. Staff told him he might want to come out for the gospel music, which he did. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses' notes stated Resident (#10) found by CNAs (certified nurse aides) in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses' Notes stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurse's note stated, Resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence 'where he was feeling up women today.' The resident was asked why he did this and said 'because they wanted it.' Resident #10 was told, 'No they didn't' and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurses' notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated Found (resident name #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up Resident #10's pants. They would not stay up. Resident #10 began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurse's note stated, Resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurses notes stated, 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. - 02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurse's note written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. - 02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Note stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #10's responsible party was informed of any of these occurrences. j) Resident #11 Medical record review on 02/22/17 at 9:00 p.m. revealed the following about this male resident: - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated, Alert and oriented . Resident was up adlib (as desired) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurse's note for Resident #11 stated, Resident self-propelled wheelchair to up beside an unidentified female resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' Review of the resident's medical record, incident/accident reports, and review of reports made to State agencies found no evidence Resident #11's responsible party was informed of any of these occurrences. k) In an interview with the Director of Nursing (DON) on 02/22/17 at 2:10 p.m., when asked to clarify if there was any information she could provide regarding notification of responsible parties when an incident of sexual abuse occurred, she stated No. When asked if an incident report had been completed would the incident report indicate the responsible party had been notified and she stated Yes, if an incident report had been completed.",2020-02-01
4055,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2016-06-16,157,E,0,1,X1PF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to notify Resident #139's attending physician when she experienced numerous episodes of [MEDICAL CONDITION] (low blood pressure) while receiving two (2) medications for hypertension (high blood pressure). This was true for one (1) of seventeen (17) sampled residents. Resident Identifier: #139. Facility Census: 100. Findings include: a) Resident #139 Review of Resident #139's medical record at 12:28 p.m. on [DATE], found she was admitted to the facility on [DATE] shortly after midnight. She was admitted from the hospital where she had the right upper lobe of her lung removed. She remained at the facility until she expired on [DATE]. Resident #139's admitting [DIAGNOSES REDACTED]. Resident #139's discharge medications from the hospital included the following medications used to treat hypertension: - [MEDICATION NAME] 25 milligrams (mg) every 12 hours, and - Amidarone 200 mg 2 tablets daily for seven (7) days then decrease to 200 mg daily thereafter. Review of the facility's admission orders [REDACTED]. Review of Resident #139's nursing admission assessment dated [DATE] at 12:45 a.m., found the resident's blood pressure on admission was ,[DATE] and she was orientated to person, place, and time. Further review of the record found that on [DATE] at 11:46 a.m., Resident #139's blood pressure was ,[DATE]. Further review of the record found a change in condition nursing note written at 9:40 p.m. on [DATE]. This change in condition note indicated Resident #139 had an unwitnessed fall in her room. At the time of her fall, the nurse obtained her vital signs. At 9:00 p.m., her blood pressure was recorded as ,[DATE]. The nurse also indicated the resident was confused. The resident's attending physician was notified of the fall, but there was no evidence to suggest that he was notified of Resident #139's [MEDICAL CONDITION]. ([MEDICAL CONDITION] can cause dizziness, which can contribute to falling.) The nurse indicated that neurological checks were initiated as a result of this fall. Review of the neurological checks found the following blood pressures recorded: - [DATE] at 9:30 p.m. ,[DATE] - [DATE] at 10:00 p.m. ,[DATE] - [DATE] at 10:30 p.m. ,[DATE] - [DATE] at 11:30 p.m. ,[DATE] - [DATE] at 12:30 a.m. ,[DATE] - [DATE] at 1:30 a.m. ,[DATE] - [DATE] at 2:30 a.m. ,[DATE] - [DATE] at 6:30 a.m. ,[DATE] (Note: Some physicians consider blood pressure too low only if it causes noticeable symptoms, such as dizziness. Some define low blood pressure as readings lower than 90 mm Hg (millimeters of mercury) systolic or 60 mm Hg diastolic and only one number needs to be in the low range for the individual's blood pressure to be considered lower than normal.) Further review of the record found another change in condition nursing note dated 9:14 a.m. on [DATE]. This change in condition note indicated that Resident #139 had another fall in her room, which was unwitnessed. Her blood pressure at 8:00 a.m., which was the approximate time of the fall, was recorded as ,[DATE]. The note also indicated the resident continued to be confused. The physician was again notified of this fall, but the record contained no evidence that he was made aware of the resident's multiple low blood pressure readings. The facility continued neurological checks on the resident and obtained the following blood pressure reading following this fall: - [DATE] at 8:30 a.m. ,[DATE] - [DATE] at 9:30 a.m. ,[DATE] - [DATE] at 10:00 a.m. ,[DATE] - [DATE] at 11:00 a.m. ,[DATE] - [DATE] at 12:00 p.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE] - [DATE] at 5:00 p.m. ,[DATE] - [DATE] at 9:00 p.m. ,[DATE] - [DATE] at 1:00 a.m. ,[DATE] - [DATE] at 5:00 a.m. ,[DATE] - [DATE] at 9:00 a.m. ,[DATE] - [DATE] at 1:00 p.m. ,[DATE] - [DATE] at 4:00 p.m. ,[DATE] - [DATE] on the 7:00 a.m. to 3:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 3:00 p.m. to 11:00 p.m. shift (actual time not documented in the record) the resident's blood pressure was ,[DATE]. - [DATE] on the 11:00 p.m. to 7:00 a.m. shift (actual time not documented in the record the resident's blood pressure was ,[DATE]. There was no evidence to indicate Resident #139's attending physician was notified of any of her episodes of [MEDICAL CONDITION], which began on [DATE] and continued until [DATE] with the exception of 9:30 a.m. on [DATE] until 9:00 p.m. on [DATE], when the resident's blood pressures were not hypotensive. The facility continued to administer her prescribed medications, which lower blood pressure, until [DATE] at 11:00 a.m. It was at that time a change in condition note was completed and indicated the resident had episodes of dizziness and loss of balance and [MEDICAL CONDITION]. Her blood pressure at that time was recorded as ,[DATE]. When notified of this, the physician gave the following order (typed as written): Orthostatic (blood pressures) q (every shift) (laying, sitting, and standing) for three (3) days. (Orthostatic [MEDICAL CONDITION] is defined as a decrease in systolic blood pressure of 20 mm Hg or a decrease in diastolic blood pressure of 10 mm Hg within three minutes of standing when compared with blood pressure from the sitting or supine position.) An interview with Resident #139's family member at 3:10 p.m. on [DATE] revealed that Resident #139 never had any trouble with her blood pressure and she was not sure why she was receiving two (2) blood pressure medications. She indicated she had discussed this with staff, but she did not think the facility had addressed this. During an interview with the Director of Nursing (DON) at 9:31 a.m. on [DATE], evidence the facility had notified the physician about Resident #139's [MEDICAL CONDITION] prior to [DATE] was requested. She indicated that the physician had seen her on three (3) occasions during her stay here. She stated that on [DATE] he saw her related to her falls. Review of the physician progress notes [REDACTED]. When he saw her on [DATE], he completed her history and physical, but did not note what her vital signs were upon his visit, nor was there mention of anything related to [MEDICAL CONDITION]. However, her episodes of [MEDICAL CONDITION] had not started by that date. The physician again saw the resident on [DATE] and noted that she had two (2) unwitnessed falls, which was the reason for his visit. The vital signs section of his progress note was blank. The physician indicated they would encourage the resident to use her call button and for her to have no unsupervised transfers. The physician's final visit with the resident on [DATE], was after he was contacted by staff and made changes to the resident's drug regimen regarding the management of her hyper/[MEDICAL CONDITION]. After review of the physician's progress notes with the DON, she stated she would see if she could find any other information that would indicate the physician was notified of the resident's [MEDICAL CONDITION] prior to [DATE]. At 11:43 a.m. on [DATE], the DON confirmed that she could find no evidence the physician was notified of Resident #139's [MEDICAL CONDITION] prior to [DATE].",2020-02-01
4133,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,157,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician when the medication [MEDICATION NAME] was held for one (1) of five (5) residents due to lethargy. R. This had the potential to affect a limited number of people. Resident Identifier: #32. Facility Census: 29. Findings Include: a) Resident #32 A review of Resident #32's medical record found a physicians order for [MEDICATION NAME] .5 milligrams (MG) twice daily beginning on 06/30/16. This order was in effect until 07/13/16 when it was discontinued. There were no parameters to hold the medication if the resident was sedated. On 07/13/16 the physician changed Resident #32's [MEDICATION NAME] order to .25 mg twice daily and gave the parameter to hold if sedated. A review of the Medication Administration Record [REDACTED] -- 07/03/16 - 8:00 p.m. dose and the reason for holding the medication noted as Lethargy -- 07/04/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/05/16 - 8:00 a.m. dose and the reason for holding the medication Lethargy -- 07/05/16 - 8:00 p.m. dose and reason for holding the medication was listed as Doctors order -- 07/06/15 - 8:00 a.m. dose and the reason for holding the medication was again Lethargy -- 07/06/16 - 8:00 p.m. dose and the reason for holding the medication was listed as Doctors order -- 07/07/16 - 8:00 a.m. and 8:00 p.m. doses and the reason for holding the medication on both occasions was Lethargy -- 07/08/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy -- 07/09/15 - 8:00 a.m. dose and the reason for holding the medication was Lethargy Further review of Resident #32's medical record found no evidence the physician was notified when this medication was held. The record contained no order to hold Resident #32's [MEDICATION NAME] until 07/13/16 when the doctor was in the facility and saw the resident and decreased his dose of [MEDICATION NAME] and added the parameter to hold the medication if Resident #32 was sedated. An interview with the DON at 4:36 p.m. on 11/03/16 confirmed his medication was held on the above mentioned dates. She indicated she was certain that the physician knew they were holding the medicine, but agreed it was not documented in his record until 07/13/16. She stated, (Name of Attending Physician) was out of town and (Name of another physician) was covering for him in his absence and he came up to the floor frequently and she knows they had to have told him they were holding the medication. She indicated that once he was started on that medication he just went to sleep for days and that is why they were not giving it to him.",2020-02-01
4218,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,157,E,0,1,1GMW11,"**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 notified when two (2) of five (5) residents, reviewed for the care area of unnecessary medications, experienced episodes of [MEDICAL CONDITION]. Resident identifiers: #8 and #85. Facility census: 84. Findings include: a) Resident #8 Medical record review, at 2:00 p.m. on 08/09/16 found Resident #8 found current physician's orders for treatment of [REDACTED]. --Blood sugar check, two (2) times a day; --[MEDICATION NAME] Solution 100 unit/ (milliliter) ML, inject 40 units subcutaneously in the evening; and --[MEDICATION NAME] solution 100 unit/ML, inject 53 units subcutaneously in the morning. On 03/18/16, the physician signed standing orders for this resident directing the implementation of the facility's hyper/[DIAGNOSES REDACTED] protocols unless parameters otherwise ordered by the physician. The current physician's orders did not contain any parameters. Review of the [DIAGNOSES REDACTED]/[MEDICAL CONDITION] management policy found the following: --Notify the physician, if blood sugars are greater than 300 mg/dl during all or part of 2 consecutive days (unless this represents an improvement from a recently measured value or existing orders specify how the patient's [MEDICAL CONDITION] should be managed). --Notify the physician if the patient with diabetes has not eaten well or not consumed sufficient fluids for 2 or more days and has one or more of the following additional symptoms: abdominal pain, fever, [MEDICAL CONDITION], lethargy or confusion, or respiratory distress. --Document action, resident condition and response and the physician response in the Nurse's notes. The resident's medication administration records (MAR's), were reviewed with the Director of Nursing (DON) at 3:00 p.m. on 08/09/16. Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugars were over 300 on 2 consecutive days: --04/06/16: blood sugar was 360 --04/07/16: blood sugar was 332 --04/09/16: blood sugar was 324 --04/10/16: blood sugar was 301 --04/11/16: blood sugar was 361 --04/13/16: blood sugar was 332 --04/14/16: blood sugar was 327 --04/16/16: blood sugar was 342 --04/17/16: blood sugar was 325 --04/22/16: blood sugar was 301 --04/23/16: blood sugar was 346 Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two consecutive days: --05/04/16: blood sugar was 318 --05/05/16: blood sugar was 314 --05/07/16: blood sugar was 326 --05/08/16: blood sugar was 326 --05/09/16: blood sugar was 388 --05/25/16: blood sugar was 312 --05/26/16: blood sugar was 377 Review of (MONTH) the (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two (2) consecutive days: --06/06/16: blood sugar was 349 --06/07/16: blood sugar was 320 --06/18/16: blood sugar was 329 --06/19/16: blood sugar was 334 --06/20/16: blood sugar was 338 --06/21/16: blood sugar was 313 --06/22/16: blood sugar was 341 Review of the (MONTH) (YEAR) MAR found the following occasions when the resident's blood sugar was over 300 on two (2) consecutive days: --07/04/16: blood sugar was 306 --07/05/16: blood sugar was 368 --07/07/16: blood sugar was 302 --07/08/16: blood sugar was 305 --07/10/16: blood sugar was 323 --07/11/16: blood sugar was 362 --07/12/16: blood sugar was 325 --07/13/16: blood sugar was 305 --07/19/16: blood sugar was 321 --07/20/16: blood sugar was 315 --07/27/16: blood sugar was 361 --07/28/16: blood sugar was 315 At 4:00 p.m. on 08/09/16, the DON confirmed the physician was not contacted each time the resident's blood sugars were over 300 on two consecutive days. b) Resident #85 Medical record review, at 9:11 a.m. on 08/10/16, found Resident #85 received the following medications for the treatment of [REDACTED].>--[MEDICATION NAME] Solution 100 units three times a day (TID) --[MEDICATION NAME] Solution, inject per sliding scale: if blood sugar is 200-299 give 6 units, if blood sugar is 300-399 give 8 units, and if blood sugar is 400-499 give 10 units. On 07/09/16 at 11:30 a.m. the resident's blood sugar was 548. The nurse did not administer any sliding scale insulin. The physician was not notified. The order contained no parameters as to what the nurse should do if the blood sugar was over 499. On 08/10/16 at 11:00 a.m. the DON said she would have expected the nurse to call the physician when the blood sugar was 548. The DON confirmed she could find no evidence the physician was contacted for direction. The resident's physician was interviewed by telephone at 1:50 p.m. on 08/11/16. She stated she would have expected the nurse to call her when the resident's blood sugar was 548.",2020-02-01
4349,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2016-01-20,157,D,0,1,96LU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to inform one (1) of twenty-four (24) Stage 2 sampled residents and/or her legal representative of a change in room assignment. Resident identifier: #204. Facility census: 115. Findings include: a) Resident #204 During a Stage 1 family interview on 01/18/16 at 3:58 p.m., Resident #204's granddaughter/Durable Power of Attorney (DPOA) reported she was not notified of a recent room change. Review of the medical record on 01/20/16 at 8:20 a.m., revealed Resident #204 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her granddaughter was listed as her Durable Power of Attorney (DPOA)/Health Care Surrogate. A nurse's progress note written at 11:16 a.m. on 11/04/15 stated, Patient transferred to room [ROOM NUMBER]a /c (with) all personal belongings. Report given to receiving nurse /c (with) all MAR's (medication administration records), TAR's (treatment administration records), medications and treatments. A second progress note written at 3:43 p.m. on 11/04/15 stated, Patient transferred to room [ROOM NUMBER]b /c (with) all personal belongings. Report given to receiving nurse /c (with) all MAR's (medication administration records), TAR's (treatment administration records), medications and treatments. The medical record revealed no evidence the DPOA/granddaughter was notified of any room changes. On 01/20/16 at 10:30 a.m., Social Worker #103 denied Resident #204 had ever been moved. After reading the nurses' notes dated 11/04/15, she reported she was not always aware of when residents were transferred to a new room. Medical Records Director #128 reviewed the electronic and paper chart during an interview on 01/20/16 at 10:45 a.m. and verified there was no evidence the granddaughter/DPOA was notified of any room changes.",2019-11-01
4355,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2016-06-21,157,D,0,1,2UNV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the facility failed to notify the physician in a timely manner of a significant change in the resident's mental status when a resident verbalized [MEDICAL CONDITION]. This was true for one (1) of two (2) residents reviewed for change in condition. Resident identifier: #78. Facility census: 98. Findings include: a) Resident #78 A nursing note dated 06/13/16 at 1:20 a.m., revealed Resident #78 was upset, sitting at the nurses' desk and stated, I might as well kill myself. Registered Nurse (RN) #160, who was on duty when Resident #78 verbalized [MEDICAL CONDITION], stated during an interviewed on 06/16/16 at 4:08 p.m., she did not initiate the facility's suicidal ideation policy immediately because she did not want to call the director of nursing in the middle of the night. RN #160 said Resident #78 verbalized that, All the time, referring to the [MEDICAL CONDITION]. She went on to state she passed the information concerning Resident #78's verbalization of [MEDICAL CONDITION] on to the next shift. Registered Nurse #7, who worked day shift following Resident #78's verbalization of [MEDICAL CONDITION], stated during an interview on 06/16/16 at 12:31 p.m., she had faxed the physician. The physician had responded with, to continue monitoring the resident. A physician's orders [REDACTED]. Review of the facility's suicide precautions policy found it included, The staff is to take any suicide ideation or attempt seriously. Procedures included to notify the charge nurse when a resident expresses [MEDICAL CONDITION] to determine what measures needed to be taken, remove the call bell system and replace it with a tap bell . notify the physician, administrator, DON, social service director, and the resident's responsible designee and to visibly monitor the Resident every fifteen minutes. Resident #78 verbalized [MEDICAL CONDITION] at 1:20 a.m. on 06/13/16, the physician's orders [REDACTED].",2019-11-01
4397,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-12-23,157,E,1,0,G78111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interviews and record review, the facility failed to consult with the residents physician for the need to alter treatment for two (2) of eight (8) residents receiving skilled nursing care. Resident identifiers: #65 and #64. Facility census: 63. Findings include: a) Resident #65 On 12/28/16 at 09:00 a.m. review of the medical record revealed Resident #65 was admitted on [DATE] with a primary [DIAGNOSES REDACTED]. Resident #65 was ordered to receive intraveous (IV) medication related to the [DIAGNOSES REDACTED]. The medical record dated 11/11/16 and 11/12/16 failed to show evidence of physician notification of Resident #65's lack of IV access. During an interview on 12/28/16 at 10:36 a.m., the Director of Nursing (DON) stated she was present during the time of Resident #65's admission. DON stated that the admitting nurse reported that Resident #65 did not have a central IV in place at the time of admission. DON stated she instructed nurse to to notify Physician that a central IV was not in place. DON acknowledged that the nursing documentation dated 11/11/16 and 11/12/16 failed to reflect physician notification of the resident's lack of IV access. The DON stated, I know if it's not documented then it was not done. b) Resident #64 The grievance and concern forms reviewed on 12/21/16 at 9:00 a.m. reveal Resident #64 was identified as not receiving her medication prior to being sent to the hospital on [DATE]. The administrator, director of social services and the director of nursing investigated this grievance/concern. They revealed the medications had been given prior to the resident being sent to the hospital. They revealed the resident received her [MEDICATION NAME] solution, [MEDICATION NAME] hcl. The forms said to see medication admistration record (MAR). A review of the MAR indicated [REDACTED]. The [MEDICATION NAME] revealed to hold if the blood sugar is less than 100. The resident's blood sugar was never checked and/or the above insulin administered at 6:30 a.m. The resident did not receive her [MEDICATION NAME] 60 milligrams ( mg) at 08:00 a.m., and [MEDICATION NAME] 40 mg at 8:00 a.m., [MEDICATION NAME] 25 mg at 8:00 a.m. on 09/15/16 prior to the resident being sent out to a acute care facility. The MAR indicated [REDACTED]. The resident did not receive her [MEDICATION NAME] 40 mg (to be administered twice a day) from 09/11/16 at 8:00 p.m. through the 8:00 a.m. doses on 09/15/16. A review of Resident #64's transfer form on 09/15/16 revealed the resident's vital signs were obtained from 8:27 a.m. to 8:29 a.m. on 09/15/16. The resident's blood sugar was obtained at 8:29 a.m. on 09/15/16. The resident's reason for being sent to the acute care hospital is shortness of breath. The nurse writes on the transfer form the resident is in respiratory distress and her saturated oxygen is 90% at four (4) liters via nasal cannula. When inquired on 12/22/16 at 8:30 a.m., about what Resident #64's blood sugar was on 09/15/16 at 6:30 a.m., the DON provide the transfer form that indicated this resident's blood sugar was checked on 09/15/16 at 8:29 a.m. The resident's blood sugar was 171 milligram per deciliter (mg/dl) . The DON was asked why the resident's blood sugar was not check at 6:30 a.m. and/or the above medications administered to the the resident prior to being sent to the hospital on [DATE]. The DON stated, She probably was not able to swallow pills. The DON made no comment on why the blood sugar was not obtained at 6:30 a.m. on 09/15/16, nor why the the resident did not receive her [MEDICATION NAME] 60 mg at 8:00 a.m., on 09/13/16, [MEDICATION NAME] 40 mg BID from 09/11/16 at 8:00 p.m. through the 8:00 a.m. doses on 09/15/16. In an confidential interview on 12/22/16 at 2:15 p.m., it was identified that Resident #64 was not given her medications prior to being sent out to an acute care facility. A review of the MAR indicated [REDACTED]. The DON was interviewed on 12/27/16 at 11:00 a.m., and she was asked, why did Resident #64 receive some medication, but not all of her medications prior to being sent out to an acute care hospital on the morning of 09/15/16. The DON made no comment on why the medication was not administed as ordered to Resident #64. Resident's #64's physician was interviewed on 12/29/16 at 1:45 p.m. She was asked whether the staff notified her that Resident #64 did not receive her medication as ordered on [DATE]. The physician was asked if the staff informed her that the resident did not receive 25 units of [MEDICATION NAME] and [MEDICATION NAME] 12 units subcutaneous. The resident's blood sugar was not checked at 6:30 a.m., and/or the above insulin administered at 6:30 a.m. The resident did not receive her [MEDICATION NAME] 60 milligrams (mg) at 08:00 a.m., and [MEDICATION NAME] 40 mg at 8:00 a.m. , [MEDICATION NAME] 25 mg at 8:00 a.m. on 09/15/16 prior to the resident being sent out to the acute care facility. In addition the resident did not receive her [MEDICATION NAME] 60 mg at 8:00 a.m., on 09/13/16, [MEDICATION NAME] 40 mg BID from 09/11/16 at 8:00 p.m. through 09/15/16 at 8:00 a.m. when she transported to the acute care facility. The physician confirmed that she was never notified and it was protocol for the staff to notify her anytime medication were being held. She revealed that if they did not want to administer the medication as ordered they should of notified her and she could have had the opportunity to adjust the medication. The physician stated, I wanted the [MEDICATION NAME] given as ordered because the resident was a chronic [MEDICAL CONDITION] resident.",2019-11-01
4452,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2016-10-19,157,D,1,0,43HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interviews, and the facility's procedure related to nursing management of [MEDICAL CONDITION] activity, the facility failed to notify the physician and/or a resident's representative for one (1) of seven (7) resident's reviewed for a significant change in [MEDICAL CONDITION] condition. Resident Identifiers: #27. Facility census 83. Findings include: a) Resident #27 A review of the medical record for Resident #27 found the resident, on 08/26/16 at 3:45 a.m., as having a [MEDICAL CONDITION] at this time with facial grimaces and tremors resolved approximately one (1) minute. No injuries resulted from this episode, oxygen saturation remained above 95% during this episode and the postitcal phases. Vital signs are within normal limits. See flow record. Written by licensed practical nurse (LPN) #115. This progress note did not reveal the physician and /or the resident's representative was notified. A review of Resident #27's physican order reveals the resident dad a [DIAGNOSES REDACTED]. Review of the (MONTH) (YEAR) Medication Administration Record [REDACTED] --[MEDICATION NAME] 50 milligram (mg) by mouth once a day --[MEDICATION NAME] sprinkles 1000 mg by mouth three (3) times a day; and --[MEDICATION NAME] Acudial gel 10 mg insert ten (10) mg rectally as needed for [MEDICAL CONDITION] greater than five (5) minutes. A review of Resident #27's physician progress notes [REDACTED].#27 had a [MEDICAL CONDITION] on 08/26/16 at 3:45 a.m. During an interview, on 10/18/16 at 9:13 a.m., charge nurse/Registered Nurse (RN) #17 stated, Yes, the physician and the resident's representative should have been notified. During an interview, on 10/18/16 9:35 a.m., the assistant director of nursing (ADON) stated, No, the physician and the resident's representative were not notified of this change in condition. The ADON stated, I would expect the nurse to notify the resident's representative and the physician. The ADON said the nurse who wrote this progress notes is no longer a nurse at this facility. During an interview, on 10/18/16 at 11:00 a.m., the director of nursing (DON) confirmed the nurse did not notify the physician of the [MEDICAL CONDITION] that occurred on 08/2616 at 3:49 a.m. for Resident #27. The DON said her staff should have also notified his representative. A review of the facility's procedure for nursing management of [MEDICAL CONDITION] activity confirmed the requirement to, Notify physician of resident's condition. During an interview, on 10/18/16 at 2:18 p.m., physician #114 stated he could not confirm whether he was informed or not. He said he could not remember back that far. .",2019-10-01
4456,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2016-10-07,157,E,1,0,HVK611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the physician and/or responsible party for two (2) of eight (8) residents reviewed had a significant change in health condition or had an accident/incident resulting in an injury. There was no evidence Resident #98's medical power of attorney (MPOA) was notified when the physician ordered laboratory testing and x- rays for a change in condition, and when the resident had re-occurring elevated blood glucose readings which required changes in treatment. In addition, the physician was not notified when the resident's blood glucose readings were not within physician specified parameters. For Resident #100 there was no evidence the physician and or the responsible party were notified of accidents/incidents resulting in injuries. Resident identifiers: #98 and #100. Facility census: 96. Findings include: a) Resident #98 Record review at 8:00 a.m. on 10/06/16, found a sixty-seven (67) year old female resident whose [DIAGNOSES REDACTED]. The resident's last capacity determination, completed on 06/02/16, noted the resident demonstrated incapacity to make medical decisions. The resident had a West Virginia Medical Power of Attorney (MPOA) and living will completed on 10/16/08. Review of the physician's orders [REDACTED]. --On 07/29/16, 10 units of regular insulin, now subcutaneous for a blood glucose reading of 551. --On 07/31/16, 10 units of [MEDICATION NAME] now and increase [MEDICATION NAME] to 55 units every night at bedtime for a blood glucose reading of 585. --On 07/31/16, an urinalysis with a culture and sensitivity. --On 08/02/16, increased [MEDICATION NAME] to 60 units every night at bedtime and give 10 units of regular insulin now for a blood glucose reading of 554. --On 08/03/16, give 10 units of regular insulin now, and a one-time dose for a blood glucose reading over 500. --On 08/04/16, a chest x-ray and a complete blood count test in the morning for increased confusion, increased blood sugars and congestion. --On 08/04/16, the physician ordered, 11 units of [MEDICATION NAME] R insulin now for a fasting blood sugar of greater than 500 and sliding scale [MEDICATION NAME] to be given at 6:00 a.m., 11:00 a.m., 5:00 p.m. and 8:00 p.m. The sliding scale order was the following: --0 - 180 = no units --181 - 240 = 3 units of [MEDICATION NAME] --241 - 360 = 5 units of [MEDICATION NAME] --361 and above = 7 units of [MEDICATION NAME] --Above 400 or below 40 call physician for 5 days then resume previous order, and continue [MEDICATION NAME] 10 units as scheduled. At 10:48 a.m., the director of nursing (DON) reviewed the Medication Administration Record [REDACTED] --On 08/04/16 at 8:00 p.m. blood sugar was 453. --On 08/05/16 at 11:00 a.m. blood sugar was 414. --On 08/06/16 at 11:00 a.m. blood sugar was 414. --On 08/07/16 at 6:00 a.m. blood sugar was 518. --On 08/07/16 at 11:00 a.m. blood sugar was 519. --On 08/07/16 at 5:00 p.m. blood sugar was 487. --On 08/07/16 at 8:00 p.m. blood sugar was 476. --On 08/09/16 at 11:00 a.m. blood sugar was 519 Review of the medical record found no evidence to verify the MPOA was notified of the above changes in treatment. In addition, there was no evidence the physician was notified, as directed by the 08/04/16 sliding scale insulin order, on each occasion when the resident's blood glucose levels were above 400. At 11:00 a.m., on 10/06/16, the director of nursing (DON) said the physician orders [REDACTED]. The DON reviewed the orders and nursing notes and confirmed there was no evidence to support the MPOA was notified of changes in condition. At 11:30 a.m. on 10/06/16, the DON provided a copy of a nurses' fax sent to the physician on 08/08/16 asking the physician to please review the diabetic monitoring flow sheet. This fax copy was not a part of the resident's medical record as verified by the DON and the fax notification was not timely. The fax copy would not have included the blood glucose reading over 400 on 08/09/16. b) Resident #100 Review of Resident #100's medical records, on 10/05/16 at 10:05 a.m., found a quarterly Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 07/19/16. This assessment revealed Resident #100 was a ninety-six (96) year old female readmitted to the facility on [DATE]. Resident #100's vision was highly impaired and she did wear glasses. Her cognitive status was severely impaired. No wandering behavior noted for the seven (7) day look back period. Resident #100 required total/dependent care with all activities of daily living (ADL). Always incontinent of bowel and bladder. [DIAGNOSES REDACTED]. Resident is a high risk for pressure ulcers. There was an incident report turned in over the weekend of 07/23/16 and 07/24/16 with the date of incident being 05/06/16 for Resident #100. This report indicated a scratch was found on the left hip that measured 1.5 centimeter (cm) in length and 1.0 cm in width. Etiology unknown. There was no indication the family/responsible party was notified until 07/25/16. At 4:00 p.m. on 10/05/16, the director of nursing (DON), was asked to review the incident report dated 05/06/16. She said there is no indication the family was notified until two (2) and one half (1/2) months later on 07/25/16. No additional evidence was provided as of the time of exit.",2019-10-01
4460,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2016-05-12,157,D,0,1,UTVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to notify the responsible party when there was a significant change in a resident's physical status and the need to transfer the resident to the hospital for an admission. This was evident for one (1) of twenty-three (23) Stage 2 sampled residents. Resident identifier: #36. Facility census: 108. Findings include: a) Resident #36 On 05/03/16 at 11:07 a.m., during a family interview, Resident #36's responsible party said this resident was recently admitted to the hospital and he did not find out about the hospitalization until two (2) days after she was in the hospital. Medical record review on 05/10/16 at 10:25 a.m., revealed [DIAGNOSES REDACTED]. Further review of the medical record at that time found that on 03/17/16, she was admitted to the hospital immediately following a [MEDICAL TREATMENT] treatment. A nurse progress note dated 03/17/16. said the [MEDICAL TREATMENT] center notified the facility that the resident was sent to (name of hospital) for evaluation due to [MEDICAL CONDITION]. The (name of hospital) called the facility later in the afternoon, to request a copy of the resident's current medication orders. There was no evidence in the medical record that the responsible party was notified when the resident was hospitalized . The resident did not return to the facility until 03/24/16. Admission [DIAGNOSES REDACTED]. Review of the discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/17/16, found staff assessment for mental status functionality indicated the resident demonstrated moderately impaired cognitive skills for daily decision-making. During an interview with the director of nursing (DON) on 05/10/16 at 11:02 p.m., when asked to show evidence of responsible party notification of the resident's transfer and admission to the hospital, she agreed she saw no evidence of family notification of the hospitalization . She said she and the administrator would further review the medical record to see if they could find evidence of family notification of the resident's hospitalization . On 05/10/2016 at 11:49 a.m., the DON said she could find no evidence the facility notified the family of the resident's transfer to the hospital on [DATE]. She said the facility would not have notified the responsible party in this instance, although sometimes they had done so in the past. She said it was good customer service to notify the family that a resident went from [MEDICAL TREATMENT] to the hospital for an admission. However, it was the responsibility of the [MEDICAL TREATMENT] center, not the facility, to notify the responsible party of the transfer to the hospital.",2019-10-01
4551,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2016-11-22,157,D,0,1,EZR311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and policy review, the facility failed to notify the physician and/or legal representative timely when a change in the resident's condition occurred and/or a new form of treatment was commenced. The facility failed to notify the physician when a resident's blood pressure fell below specified parameters. The facility failed to notify the physician when the as needed (prn), or standing order, for oxygen therapy was initiated. The facility failed to notify the physician and/or family when a resident developed a change in condition as evidenced by severe abdominal pain and a decrease in oxygen saturation levels on room air. This affected one (1) of seventeen (17) Stage II sampled residents. Resident identifier: #3. Facility census: 55. Findings include: a) Resident #3 Medical record review on [DATE] found this [AGE] year old former resident came to the facility in (MONTH) of (YEAR), following a two (2) week hospital admission. Discharge [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Another physician order [REDACTED]. The order directed to notify the physician. Review of the medical record found on [DATE], a systolic blood pressure reading below 90 mm/Hg was obtained. As recorded on [DATE] at 8:42 a.m., her blood pressure was only ,[DATE]. There was no evidence within the medical record the blood pressure was rechecked, or the physician was notified of the low reading. Review of the medical record also found a nurse progress note, dated [DATE] at 1:34 a.m., when the resident sustained [REDACTED]. As written in the nurse progress note, Resident complained of sharp, severe pain in her mid/lower stomach and shortness of breath tonight and could (not) get comfortable while in bed. She also stated that she felt nervous. I gave her prn Tylenol and [MEDICATION NAME] Her pulse ox (oximetry) reading was fluctuating between ,[DATE]%. I put her on O2@2L/min via nc (oxygen at two liters per minute via nasal cannula) and she went up to 97%. There was no evidence in the medical record the physician and/or legal representative was notified of this first time use of oxygen since she came to the facility, or of this first time she complained of sharp, severe abdominal pain and shortness of breath. The record was silent for evidence of assessment of the abdomen and bowel sounds, or assessment of the lungs and breath sounds. The record was silent for the assessment of vital signs. According to a nurse progress note dated [DATE] at 10:54 a.m., licensed practical nurse (LPN) #39 assessed the prn medication she gave the resident for an upset stomach was ineffective. The most recent, and only, blood pressure recording that date occurred at 9:03 a.m. at ,[DATE] mm/Hg. The next entry at 11:45 a.m. noted the resident complained of nausea and abdominal pain that is unrelieved with medication. The physician was notified, and gave orders for an oral medication for nausea three (3) times daily, and for an abdominal x-ray. On [DATE] at 2:31 p.m., LPN #39 noted the resident had diarrhea with moderate amounts of bright red stool, and had stomach pain. She notified the charge nurse. The physician and family were then notified, and orders received to send her to the hospital. Review of hospital records found she was admitted to the hospital on [DATE], where a computed tomography (CT) scan indicated she had an acute diverticulitis with perforation. She expired at the hospital eight (8) days later. An interview conducted with the director of nursing (DON), on [DATE] at 3:45 p.m., confirmed the physician's orders [REDACTED]. She said they have a standing order for prn oxygen. She said since her oxygen saturation went up to 97% after the oxygen was applied, she was not certain the physician needed to be notified of the fluctuation of ,[DATE]% on room air prior to the oxygen administration on [DATE]. The DON provided the facility's policy on notification of changes. It stated, in part, the facility will immediately inform the resident, consult with the resident's physician, and notify the resident's legal representative when any one (1) of a list of six (6) criteria occurs, including a significant change in the physical, mental, or psychosocial status of the resident, and/or a need to significantly alter the resident's treatment. During an interview with the DON, on [DATE] at 8:30 a.m., she stated she could find nowhere in the medical record where the resident complained of severe abdominal pain, complained of shortness of breath, or had oxygen saturation levels at or below 90%, until the change in condition that occurred on [DATE] at 1:34 a.m. She said this was the first time the resident required supplemental oxygen therapy since coming to the facility. She acknowledged this would constitute a change in her status, and that the resident's treatment was altered to include supplemental oxygen. She acknowledged that there was no evidence the physician or the family were notified of these changes at that time. A telephone interview with the resident's physician, on [DATE] at 2:15 p.m., verified he would have expected the nurse to call him, at 1:30 a.m. on [DATE], when the resident complained of severe abdominal pain and had the drop in her oxygen level. He said he was not notified at that time. An interview conducted with LPN #46, on [DATE] at 3:15 p.m., revealed he worked with this resident on [DATE]. He said he gave her Tylenol and [MEDICATION NAME] for her abdominal pain which relieved the pain. He said he gave her oxygen for the drop in oxygen saturation, and it was effective. He said since the symptoms improved with treatment, he did not think he needed to call the physician or family that night.",2019-09-01
4585,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2016-01-14,157,D,0,1,325Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and staff interview, the facility failed to notify the physician timely when a resident, who had a history significant for reoccurring urinary tract infections, experienced a change of condition. This was evident for one (1) of four (4) residents reviewed for abuse/neglect, out of twenty-six (26) Stage 2 sampled residents. Resident identifier: #200. Facility census: 117. Findings include: a) Resident #200 Review of the resident's medical record on 01/11/16 at 1:30 p.m., found this [AGE] year-old resident came to the facility from an acute care hospital on [DATE]. Hospital records, dated 10/03/14, assessed chronic urinary tract infections, noting the patient had had a complicated course in the past. Review of the most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/05/15, revealed a Brief Interview for Mental Status (BIMS) score of one (1), on a scale of one (1) to fifteen (15), which indicated severe cognitive impairment. The facility assessed her as sometimes able to understand, and sometimes could be understood. During her stay at the facility, she received treatment for [REDACTED]. The fifth urinary tract infection was diagnosed on [DATE]. During a family interview on 01/11/15 at 5:00 p.m., the medical power of attorney (MPOA) for Resident #200 said she arrived at the facility around 5:30 p.m. on 06/27/15. She found her mother sitting in the hallway in her wheelchair. She found the resident with a change in her level of alertness, unable to open her eyes, and not responding as she usually did. The MPOA said she feared another urinary tract infection. She asked to have the resident put back to bed, and reported she then spoke to the nurses about her concerns. She said Licensed Practical Nurse (LPN) #131 checked her mother's blood sugar, said it was not high enough to be an acute problem as it was only around 350, and there was nothing wrong with her mother. The MPOA said her mother showed no signs of improvement throughout the evening, yet the nursing staff did not notify the physician of her change in alertness. She said that toward the end of the evening shift, she insisted they send her mother to the emergency room , where she was then diagnosed and treated for [REDACTED]. In a confidential interview, an individual said Resident #200 returned to bed on 06/27/15 around 6:30 p.m. The individual recalled it was about that time when the MPOA first asked LPN #131 about sending the resident out to the hospital. This individual corroborated the MPOA's concern that the resident was not acting right. The interviewee said typically the resident was alert, generally laughed, [MEDICATION NAME], made noises, and nonsensical talk, but that evening, the resident did none of those things. The interviewee said LPN #131 obtained a blood sugar reading in the 300's, and allegedly told the MPOA the resident was all right. The interviewee also recalled the MPOA approached Registered Nurse (RN) #81, about her concerns, and that RN #81 allegedly told the MPOA she would get insulin later that night at bedtime. On 01/13/16 at 8:45 a.m., during an interview, the administrator said the MPOA wanted the resident sent out to the hospital (on 06/27/15), and the MPOA felt the lag time between her telling the nurse she wanted the resident to go to the emergency room was too much of an extended period of time. He said from the nurses' assessments the resident's vital signs were good, and there was no reason to send her out, although he recalled they did send her out to the hospital that evening. He said he needed to check his notes, and see about the acceptable lag time. However, no further information was provided by the administrator about the lag time prior to exit. There were no witness statements provided that were taken at the time of the occurrence in (MONTH) (YEAR). On 01/13/16, the director of nursing provided the following statements: 1. A telephone witness statement, dated 01/13/16 at 1:53 p.m., provided by the director of nursing, was reviewed on 01/13/16 at 5:00 p.m. Nurse Aide (NA) #14 said she was asked by another staff person to help transfer Resident #200 from the wheelchair to her bed. She said the other staff member then obtained the resident's vital signs, because the resident did not look right. The time of the transfer to bed and vital sign check was around 6:00 p.m. Less than ten (10) minutes later, LPN #181 checked the resident's blood sugar, and NA #14 left. The daughter and granddaughter were at the bedside. She recalled that around 10:30 p.m. (on 06/27/15), the family came to the desk and asked to send the resident out to the hospital. 2. Review of a witness statement by Registered Nurse (RN) #81, dated 01/13/16 at 2:20 p.m., found she worked 7:00 p.m. on 06/27/15 to 7:00 a.m. on 06/28/15. RN #81 stated she recalled the family was asking a lot from LPN #131. RN #81 said that while LPN #131 was at lunch, she spoke to them (the family) about a urinalysis and culture and sensitivity, after the family questioned her on it. Then, when LPN #131 returned from lunch, she (RN #81) returned to my assignment. 3. Another witness statement, dated 01/13/16 at 2:30 p.m. by LPN #131, noted she worked 3-11 on 06/2715. She admitted the daughter came to her and reported the resident was not right. LPN #131 said she checked the resident's blood sugar, which was up, but not high enough to call the physician. She stated she listened to the resident's lungs. While on lunch break, the aides came and got her. She said she overheard RN #81 talking to the family about urinary tract infections. She stated, We told her we could send her out. She (the daughter) agreed. We sent her to the ER (emergency room ). Review of the medical record found no evidence of a nursing assessment or blood sugar assessment on 06/27/15. The first nursing note on 06/27/15 occurred at 10:27 p.m., stating the MPOA wants the resident sent to ER (emergency room ) because she thinks she may have a UTI (urinary tract infection). Review of hospital records revealed the resident came to the emergency room at 10:56 p.m. on 06/27/15. The reasons for the visit stated blood sugar high, confusion, lethargic. The blood sugar result on 06/27/15 at 11:23 p.m. was high at 262. The normal blood sugar range is 70-108 milligrams/deciliter (mg/dl). The catheterized urine culture grew a positive culture of Escherichia coli (E. coli), with a colony count greater than 100,000 cfu/ml (colony forming unit/milliliter). The colony count of [DIAGNOSES REDACTED] pneumonia was 50,000 - 100,000 cfu/ml. The emergency room physician diagnosed her with an acute urinary tract infection. She received an intravenous injection of [MEDICATION NAME] (an antibiotic), and a prescription for Keflex (an oral antibiotic). The next nurse progress note from the facility occurred a few hours later at 2:25 a.m. on 06/28/15. The resident returned from the emergency room with a [DIAGNOSES REDACTED]. A nursing progress note, dated 06/28/15 at 2:30 a.m., by RN #70, contained an assessment that revealed the resident was confused, lethargic, and oriented to person. The medical record was silent for temperature assessment from the time she left the faciity on the evening shift, and throughout the remainder of the night shift. Review of the medical record found the first evidence of a temperature assessment following the resident's return to the facility, occurred on the day shift. Nursing staff medicated the resident with Tylenol at 9:00 a.m. for a temperature of 100.1 degrees Fahrenheit (F.).",2019-09-01
4643,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2015-12-18,157,E,0,1,5DCP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, physician interview, and review of facility policy, the facility failed to immediately consult with residents' physicians when resident's blood pressures and/or pulses were repeatedly outside of ordered parameters for which antihypertensives were ordered, and also failed to notify the physician when medications were given when they should have been held. This was found for Residents #1, #3, #12 and #10. Additionally, Resident #107's physician was not notified when the resident's blood sugars (finger sticks) were above 200 on multiple occasions. These issues were found for four (4) of four (4) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) who had parameters ordered for medications and one (1) resident who had repeated elevated blood sugars. Resident identifiers: #1, #3, #12, #10, and #107. Facility census: 91. Findings include: a) Resident #1 Medical record review for Resident #1, on [DATE] at 10:00 a.m., found a physician's orders [REDACTED]. The order included instructions to hold for systolic blood pressure (SBP) less than 160 mmHg (millimeters of mercury - the unit used to measure blood pressures) and less than 90 mmHg for the diastolic blood pressure (DBP). Review of the Resident #1's Medication Administration Record [REDACTED] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]: 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] -- [DATE]: 9:00 a.m. - ,[DATE]; 9:30 p.m. - ,[DATE] This review of Resident #1's blood pressures revealed they were out of the physician ordered parameters on sixty (60) occasions, yet the medication was given, not held as directed by the physician's orders [REDACTED]. Additionally, there was no evidence the physician was notified of the medication being given when it should have been held. On [DATE] at 2:00 p.m., during a discussion with Assistant Director of Nursing (ADON) #33, she confirmed the blood pressures for Resident #1, and the administration of the medication outside of the physician ordered parameters. She agreed there was no evidence of physician notification. Resident #1 received [MEDICATION NAME] twice daily (on sixty (60) occasions) outside of the physician established medication administration parameters for the period of [DATE] through [DATE]. b) Resident #3 Medical record review for Resident #3, on [DATE] at 10:30 a.m., found a physician's orders [REDACTED]. Review of Resident #3's MAR, found blood pressures for the period of [DATE] through [DATE] as follows: -- [DATE]: ,[DATE] -- [DATE]: ,[DATE] -- [DATE]: ,[DATE] Resident #3 also had an order for [REDACTED].) Review of the Resident #3's MAR, found the HR for the period of [DATE] through [DATE], was outside of the physician prescribed parameters as follows: -- [DATE]: 56 -- [DATE]: 56 The medications were given although they should have been held. There was no evidence the physician was made aware. c) Resident #12 Medical record review for Resident #12, on [DATE] at 11:00 a.m., found a physician's orders [REDACTED]. Review of the MAR for Resident #12, found the following blood pressures outside of the physician prescribed parameters for the period of [DATE] through [DATE]: -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] -- [DATE] - ,[DATE] On each of these occasions, the medication was given. There was no evidence the physician was made aware of the medication being given when it should have been held. d) Resident #10 Medical record review for Resident #10, on [DATE] at 11:30 a.m., found an order for [REDACTED]. Review of the MAR for Resident #10, found blood pressures for the period of [DATE] through [DATE] outside of the physician prescribed parameters on: -- [DATE] - 52 -- [DATE] - 52 -- [DATE] - 52 There was no evidence the physician was notified of the medication being given outside of the ordered parameters. e) Further review found the parameters for three (3) of fifteen (15) residents with parameters, were discontinued on [DATE]. In an interview on [DATE] at 12:30 p.m., the attending physician was unaware the residents had readings outside the specified parameters, that the facility had administered medication outside of the physician established parameter in (MONTH) (YEAR) to Residents #3, #12, and #10, or that the parameters had been discontinued. In his opinion, the residents remained unstable relative to the conditions for which the medications with parameters were ordered. During this interview on [DATE] at 12:30 p.m., the attending physician for Residents #1, #3, #12, and #10, said at the last Quality Assurance Committee meeting, they discussed the need to review all residents in the facility who received antihypertensive/heart medication with parameters. The parameters were not to be discontinued if unstable. The attending physician also stated parameters were intended to be followed. He was not aware of any of the medications administered outside of the parameters. Even moderate forms of low blood pressure and/or pulse can cause not only dizziness and weakness, but also [MEDICAL CONDITION] and a risk of injury from falls. A severely low blood pressure from any cause can deprive the body of enough oxygen to carry out its normal functions, leading to damage to the heart and brain. f) Resident #107 Medical record review on [DATE] at 9:00 a.m., found Resident #107 was admitted to the facility on [DATE] at 11:50 a.m. The resident expired at the facility on [DATE] at 4:00 p.m. The resident resided at the facility for 22 days before his death. The resident's admitting [DIAGNOSES REDACTED]. On [DATE], the date of admission, an order was written for Accu-chek (blood glucose or sugar monitoring system) two (2) times a day, and as needed for signs and symptoms of high or low blood sugar related to diabetes, type II. According to the Medication Administration Record [REDACTED]. The order contained no parameters as to when to notify the physician when blood sugars were outside of the normal range. At 3:44 p.m. on [DATE], the resident's physician was interviewed by telephone. The physician stated he would have expected to have been notified when the resident's blood sugars were over 200 as a blood sugar of over 200 is, .typically when sliding scale insulin starts. Review of Resident #107's MAR for (MONTH) (YEAR), found seven (7) days of fifteen (15) days when the resident's blood sugar was over 200. On these seven (7) days, Resident #107 had ten (10) blood sugar checks over 200. -- [DATE] at 4:30 p.m. - blood sugar was 318 -- [DATE] at 6:30 a.m. - blood sugar was 354, at 4:30 p.m. - blood sugar was 354 -- [DATE] at 6:30 a.m. - blood sugar was 307, at 4:30 p.m. - blood sugar was 337 -- [DATE] at 6:30 a.m. - blood sugar was 375, at 6:30 p.m. - blood sugar was 212 -- [DATE] at 6:30 a.m. - blood sugar was 222 -- [DATE] at 6:30 a.m. - the blood sugar was 214 -- [DATE] at 6:30 a.m. - blood sugar was 245 In (MONTH) (YEAR) the resident blood sugar was over 200 on five (5) days of seven (7) days obtained. -- [DATE] at 4:30 p.m. - blood sugar was 359 -- [DATE] at 4:30 p.m. - blood sugar was 486 -- [DATE] at 6:30 a.m. - blood sugar was 396 -- [DATE] at 6:30 a.m. - blood sugar was 289 -- [DATE] at 6:30 a.m. - blood sugar was 241 Review of the nursing notes found no evidence of physician notification when the resident's blood sugars were over 200. Interview with the charge nurse, Registered Nurse (RN) #12, at 8:45 a.m. on [DATE], revealed she thought she should only call the physician when the resident's blood sugars were over 400. She said the physician came weekly and he should have been looking at the blood sugars during his visits. It should be noted the physician is required to see a resident every 30 days for the first 90 days of admission, then at least once every 60 days thereafter. Unless there was a concern brought to the attention of the physician by the resident, or nursing staff on behalf of the resident, the physician would not have had occasion to examine the resident or the resident's record. By virtue of the physician ordering blood sugars to be checked on this resident, the expectation would be for nursing staff to monitor the blood sugars and alert the physician of abnormal findings. When Resident #107's blood sugars were high repeatedly, especially as he was not receiving any medications to control his blood sugars, nursing staff should have alerted the physician, just as would be expected if a resident's had a fever or high blood pressure readings. Review of the facility's policy, entitled, Diabetes Management Guideline, Version #4, found the following: All residents will have appropriate treatment and services to manage their Diabetes. The American Diabetes Association states that the ideal goal for adults with diabetes is to achieve glucose levels between ,[DATE] mg/dl before meals and less than 180 two hours after the start of the meals. [MEDICAL CONDITION] is a common cause of illness and is the cause of secondary complications of the disease. Common Signs and Symptoms: More frequent urination, incontinence Increased fatigue Unexplained weight loss New vision problems Decreased mental function, confusion At 10:38 a.m. on [DATE], the Director of Nursing (DON) verified she would call the doctor if the resident's blood sugars were 200 or over. She stated, because, That is the typical scale of when someone would start sliding scale insulin. She was unable to provide any evidence the resident's physician was notified when the resident's blood sugars exceeded 200.",2019-08-01
4673,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2016-02-15,157,G,0,1,F0WT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of a deterioration in a resident's health status with a need to alter treatment, in a timely manner. The physician was not notified of two (2) consecutive elevated blood sugars as ordered, resulting in avoidable harm to this resident. The resident subsequently had a decline in her level of consciousness and was sent to the hospital for treatment. This was found for one (1) of seventeen (17) residents in the Stage 2 sample. Resident identifier: #83. Facility census: 61. Findings include: a) Resident #83 A review of the clinical record revealed Resident #83 was admitted to the facility on [DATE], following an acute hospitalization for diabetic ketoacidosis, a fall with left rib fractures, and a urinary tract infection. Her record indicated her blood sugar fluctuated daily from the 50's at 7:00 a.m. through the 300's later in the day. The physician's orders [REDACTED]. if 151-200 = 2u (units); 201-250 = 3u; 250-300 = 4u; 301-350 = 5u; 351-400 = 6u; 401-500 = 7u, subcutaneously two times a day related to Type 1 Diabetes mellitus with ketoacidosis without coma ., and . Fingerstick with Humalog Insulin. If (greater than) 400 or 2 consecutive readings >300 notify MD. The resident was described in the nurse's notes at 9:50 a.m. on 01/12/16, as, Alert, oriented to self & (and) time, pleasant. Skin warm & dry, color pink, resp (respirations) @ (at) ease with O2 (oxygen) in place @ 2L/min (2 liters per minute) via nasal cannula . Ate 100% of breakfast this morning along with 100% of house supplement. Took medications whole with H2O (water). No s/s (signs/symptoms) of diabetic ketoacidosis, denies abdominal pain, diarrhea, vomiting and dyspnea. At 11:05 a.m. on 01/12/16, an entry in the nurses' notes read, Notified (Dr's name) of blood sugar result 456 @ 11:00 today. Administered scheduled 6 units of Humalog . Awaiting any new orders. There was no evidence in the record of a recheck of the blood sugar after the coverage, or of a response from the physician. At 12:40 p.m. on the same day, the resident was interviewed by Social Worker (SW) #16 who stated in her notes, Pt (resident) is alert and seemed oriented during our conversation. She was tired and weak. The record revealed the resident's blood sugar at 4:00 p.m. on 01/12/16, was 355 and 5 units of coverage was given. This was the second consecutive blood sugar that was over 300, but the physician was not notified, nor was the blood sugar rechecked. At 7:50 p.m. on 01/12/16, the record stated, Resident in bed and very hard to arouse . Resident was not able to stay awake long enough to feed herself. I sat with the resident verbally arousing her between bites while totally attempting to feed her. Resident ate approximately 25% with constant cuing to open mouth. I went back in to check on resident at 7PM (7:00 p.m.) and was unable to arouse her at all. After a few minutes of attempting to stimulate her awake, resident responded. I was unable to get a blood pressure and asked the other nurse to attempt a blood pressure. VS (vital signs) T. (Temperature) 98.1 P. (Pulse) 108. R. (Respirations) 16. B/P (blood pressure) 60/40. O2 sats (saturation) 97% on O2. BS (blood sugar) 221. Order obtained from on call (physician) to send to (hospital) for evaluation at 7:20PM. At 11:40 p.m. on 01/12/16, an entry in the record stated, Return from hospital at this time via (ambulance). Alert and talkative. There was a delay in notifying the physician the resident's blood sugars were out of his ordered range for reporting and other symptoms in a resident newly admitted to the facility following an acute hospitalization for ketoacidosis. There was 3 hours and 20 minutes from the 4:00 p.m. blood sugar until 7:20 p.m. when the physician was reached and ordered the resident transferred to the hospital. This constituted actual harm to the resident. During an interview with Registered Nurse (RN) #74 at 12:45 p.m. on 02/15/16, she acknowledged after reviewing the record the nurse should have contacted the physician at 4:00 p.m. on 01/12/16, when the resident's blood sugar was over 300 for the 2nd time and definitely when she recognized the changes in the resident's demeanor at supper-time (approximately 5:30 p.m.). A further review of the nurses' notes for (MONTH) (YEAR) found no evidence the physician had been notified of the following: -- 59 blood sugar at 7:00 a.m. on 02/03/16 with no indication of treatment or recheck; -- 56 blood sugar at 7:00 a.m. on 02/13/16 with the following entry: Resident alert/oriented - blood sugar this AM was 56 - Resident ate graham crackers with peanut butter and drank milk - re-check BS was 58 - Resident also drank OJ (orange juice) - recheck BS was 86.; -- consecutive blood sugars of 312 at 5:00 p.m. and 346 at 9:00 p.m. with appropriate coverage on 02/06/16. These were all outside of the physician ordered parameters for notification and the physician should have been called. In an interview with RN #11 (director of nurses) at 9:30 a.m. on 02/15/16, she said there was coverage in the absence of physicians by two (2) Nurse Practitioners (NP) and one of them was available at all times. She agreed there should have been contact with one of them sooner. During an interview with NP #84 on the morning of 02/15/16, she explained she or the other NP were available on an on-call basis at all times, but added when she was on call, it was for all the corporate facilities no matter where they were or where she was and acknowledged sometimes there was a delay in response. She said when this happened the facility should proceed with sendnig the resident to the hospital.",2019-08-01
4681,GLASGOW HEALTH AND REHABILITATION CENTER,515118,"120 MELROSE DRIVE, BOX 350",GLASGOW,WV,25086,2016-08-24,157,D,1,0,2HCJ11,"> Based on staff interview and medical record review, the facility failed to notify the responsible party when the physician wrote an order to discontinue the use of a leg brace due to a wound on the resident's toe. This failed practice affected one (1) of eight (8) resident's whose medical records were reviewed. Resident identifier: #52. Facility census: 88. Findings include: a) Resident #52 Review of the medical record for Resident #52 found the following problem, goal, and interventions for the care area of activities of daily living (ADL). --The problem stated, I have a physical functioning deficit related to: Self-care impairment, mobility impairment. --The goal associated with this problem stated, I will maintain my current level of physical functioning. --The interventions associated with the goal included, a right long leg brace and a left short leg brace to be used when out of bed. Leg braces may be removed for skin care and at bedtime. Observation of the resident, attending a morning activity in the dining room at 11:10 a.m. on 08/22/16, found the resident wore a leg brace on his left leg but not the right leg. During an interview with the Director of Nursing (DON), at 11:15 a.m. on 08/22/16, she said she did not know where the right leg brace was, but would ask the resident's nurse. During an interview with Wound Nurse/Registered Nurse (RN) #39, at 11:17 a.m. on 08/22/16, said the resident, Has a place on his toe and he has an order to have the brace off. According to the wound flow sheet, a wound to the right 5th toe was discovered on 08/09/16. The wound was 0.4 cementers (cm) in length and 0.5 cm in width. The wound was noted as a, Small scabbed area to right 5th toe base, no redness, drainage or tenderness noted. Area r/t (related to) rubbing from shoes. On 08/09/16, the physician wrote an order to, leave right leg brace off until further notice. Record review at 11:30 a.m. on 08/22/16, found the resident's physician determined the resident lacked capacity to make medical decisions on 08/26/15. The resident had a court appointed guardian/conservator. At 11:50 a.m. on 08/22/16, the DON confirmed she could find no evidence the resident's responsible party was notified on 08/09/16, when the physician wrote an order to remove the brace to the right leg due to an area on the right 5th toe.",2019-08-01
4687,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2016-03-24,157,D,0,1,4ZOC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's bowel protocol/standing orders, and staff interview, the facility failed to promptly notify the physician when Resident #4 experienced a severe weight loss of 8.5% (percent) in one (1) month. This was evident for one (1) of four (4) residents reviewed for nutrition. Also, the facility failed to notify the physician timely when Resident #28 went more than three (3) days without a bowel movement and did not respond to the bowel protocol. This was evident for one (1) of five (5) residents reviewed for unnecessary medications, Resident #28. Resident identifiers: #4 and #28. Facility census: 51. Findings include: a) Resident #4 A review of Resident #4's weights, on 03/22/16 at 2:00 p.m., found the resident weighed 163 pounds (lbs) on 02/05/16. The resident weighed 149 lbs. on 03/05/16 and the same on 03/06/16. This was a severe weight loss of 8.5% (percent) in one (1) month. A review of Resident #4's medical record on 03/22/16 at 2:05 p.m., found no evidence in the record the physician was informed by the staff of the resident's 8.5% weight loss. In an interview with the Director of Nursing (DON) on 03/22/16 at 2:34 p.m., when asked whether Resident #4's physician was notified of the resident's severe weight loss of 8.5% from (MONTH) (YEAR) to (MONTH) (YEAR), the DON stated, I am not aware the resident had lost any weight. The DON confirmed the physician was not promptly notified. The DON said, we will notify the physician today. After the resident's 8.5% weight loss was brought to the attention of the facility's staff on 03/22/16 at 2:34 p.m., LPN #10 spoke to the resident's physician on 03/22/16 at 3:08 p.m., informing the physician about the resident's thirteen (13) pound weight loss in the past month. b) Resident #28 Medical record review on 03/24/16 at 11:00 a.m., revealed the resident had [DIAGNOSES REDACTED]. Review of the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 03/04/16, found her assessed her as moderately cognitively impaired. She required extensive assistance of one (1) person to eat. She required extensive assistance of two (2) staff persons to turn and reposition in bed. She was unable to walk, and unable to transfer from surface to surface. She was always incontinent of urine and stool. Review of daily scheduled medications to treat her constipation included [MEDICATION NAME] (an osmotic laxative) 17 grams (g) daily on the day shift, sennosides-[MEDICATION NAME] (a stool softener and laxative) 8.6-50 milligrams (mg) two (2) tablets each morning and each night, and [MEDICATION NAME] (laxative) 10 g/15 milliliters (ml) daily each morning. Another physician's orders [REDACTED]. Standing orders included if a resident had no bowel movement for three (3) consecutive days, to implement the bowel protocol. The bowel protocol consisted of milk of magnesia thirty (30) ml with eight (8) ounces (oz) of water by mouth prn (as needed) if a resident had no bowel movement in three (3) days. If no relief from the milk of magnesia by the next shift, give [MEDICATION NAME] ten (10) mg. If there is still not results by the next shift, standing orders direct to give either a fleets or soapsuds enema to the resident. If still no results, standing orders direct to contact the physician. Review of the activities of daily living bowel movement reports, found this resident had a medium sized bowel movement on 03/10/16, with no further bowel movement until 03/19/16. This equated to nine (9) days between bowel movements. However, the physician was not notified of the absence of bowel movements until day eight (8), on 03/18/16. A nurse progress note by Licensed Practical Nurse (LPN) #36, dated 03/18/16 at 1:34 p.m., stated Fax and message left for (name of doctor) r/t (related to) resident on BM (bowel movement) list x (for) six (6) days. no answer at this time. The original fax, dated 03/18/16 at 8:43 a.m., stated this resident was on the BM list on day six (6), and had only taken one (1) dose of milk of magnesia and no [MEDICATION NAME]. During an interview with LPN #36, on 03/24/16 at 12:30 p.m., she said she faxed the physician and left a message for him regarding the lack of bowel movements for this resident on 03/18/16, but received no answer. She said at the end of her shift that day, she passed that information along in report to the oncoming shift. On 03/24/16 at 12:30 p.m., the DON acknowledged there was no evidence of bowel movement for this resident for a period of nine (9) days, the bowel protocol was not begun until day six (6), and the physician was not notified until day eight (8) of the resident having no bowel movement. She said per their policy, the physician should have been notified sooner.",2019-08-01
4698,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,157,D,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify a resident's legal representative when there was a significant change in a resident's condition requiring medical interventions and treatment. This was found for one (1) of twenty-seven (27) Stage 2 sample residents during the Quality Indicator Survey (QIS). Resident identifier: #105. Facility census: 92. Findings include: a) Resident #105 Medical record review on [DATE] at 4:40 p.m., revealed this [AGE] year-old female was admitted on [DATE] and discharged on [DATE] when she was sent to the acute care hospital where she expired on [DATE]. Her [DIAGNOSES REDACTED]. According to a nursing progress note dated [DATE] at 0329 (3:29 a.m.), (typed as written): @ (at) 2335 (11:35 p.m.) was called to residents room by CNA (certified nurses aide) d/t (due to) audible wheezing. Resident assessed wheezing noted to bilateral lung fields. O2 (oxygen) sats (saturation) 83%. HOB (head of bed) elevated. Dr. (physician name) called with request to send resident 911. Dr. (physician name) inquired as to whether resident was a DNR (do not resuscitate) to which I answered yes. Physician then stated he would rather keep her here. Orders obtained for [MEDICATION NAME] 60 mg (milligrams) stat (immediately) with decrease of 5 mg until seen and [MEDICATION NAME] 250 mg qd (every day) x 10 days. Order faxed and phoned to (pharmacy) for stat delivery. [MEDICATION NAME] administered from backup supply. Neb tx (nebulizer treatment) administered with stated relief. Will cont (continue) to monitor. The progress note did not contain documentation of notification of Power of Attorney (POA)/family member during this change in condition. After reviewing the progress note on [DATE] at 11:40 a.m., Registered Nurse (RN)/infection control nurse (previous Director of Nursing) stated, I would hope my nurses notified the brother, but it is not there. Of course if it is not written, it was not done.",2019-08-01
4740,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2016-07-07,157,D,1,0,R67611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to notify the responsible party, of an incapacitated resident, when the resident experienced a significant weight loss within thirty (30) days. This was true for one (1) of eleven (11) resident's reviewed during a complaint survey ending on 07/07/16. Resident identifier: #5. Facility census: 113. Findings include: a) Resident #5 Record review of the resident's weights at 7:30 a.m. on 07/07/16, found the following documented weights in the electronic medical record: --04/04/16 - 107 pounds --05/03/16 - 88.9 pounds --05/10/16 - 91.8 pounds --05/19/16 - 90.2 pounds --05/26/16 - 85 pounds --06/01/16 - 88.5 pounds --06/07/16 - 86.2 pounds --06/16/16 - 86.2 pounds --06/21/16 - 88.5 pounds --07/01/16 - 88.6 pounds The most recent nutritional assessment, completed on 04/27/16, by a registered dietician, revealed the following for Resident #5: --The resident's height was 63 inches and her weight was 107.0 pounds --The resident received a pureed diet with limitation of potassium rich foods. --A supplement previously initiated, but discontinued due to the resident's improved intake and weight gain. --The resident received a snack at 2:00 p.m. --The resident's previous weight loss and underweight body mass index was noted. --However, the resident's current weight at 107 pounds triggered as a significant gain. --The resident's body mass index noted as now within healthy limits, weight gain desirable --The resident noted as currently eating/drinking well with desirable weight gain. Review of the nursing notes found a, weight warning, note dated 05/06/16. The note indicated the resident had a continual and gradual weight loss despite the snacks and regular meals orders, and the assistance with eating. The noted indicated physician notification. Further record review found the physician had determined the resident lacked capacity to make medical decisions. The date the incapacity statement was signed by the physician was illegible. The incapacity statement noted the incapacity was long term. The resident had the inability to process information due to Dementia and a [MEDICAL CONDITIONS]. The resident had appointed her son as her MPOA on 05/13/03. Review of the most recent minimum data set (MDS), a significant change MDS, with an assessment reference date (ARD) of 04/25/16, found the resident's score on her brief interview for mental status (BIMS) was a four (4). A score of 0-7 indicates severe cognitive impairment. At 8:54 a.m. 07/07/16, the director of nursing (DON) was asked to provide verification the resident's medical power of attorney was notified of the weight loss. At 10:22 a.m. on 07/07/16, the administrator was asked if she could provide verification the resident's MPOA was notified of the resident's weight loss. At 10:50 a.m. on 07/07/16, the registered dietician (RD), #122, was interviewed. RD #122 confirmed the resident had a 16.9% weight loss between 04/04/16 and 05/03/16. She had no information to present verifying the resident's MPOA was notified of the significant weight loss. At the close of the survey at 2:30 p.m. on 07/07/16, no further information had been provided.",2019-07-01
4748,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2016-02-12,157,D,0,1,PDOU11,"Based on record review and staff interview, the facility failed to promptly notify the attending physician and responsible party when it was identified Resident #33 had experienced a severe weight loss in one (1) month. This was true for one (1) of three (3) residents reviewed for the Care Area of Nutrition during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #33. Facility census: 40. Findings include: a) Resident #33 A review of Resident #33's medical record at 1:51 p.m. on 02/11/16 found the following recorded weights: 02/03/15 115 pounds (lb.) 03/02/15 115.4 lb. 04/02/15 116.0 lb. 05/13/15 112.2 lb. 06/02/15 112.4 lb. 07/04/15 109.0 lb. 08/04/15 110.4 lb. 09/01/15 107.4 lb. 10/01/16 108.2 lb. 11/03/16 107.8 lb. 12/02/15 104.0 lb. 01/03/16 107.8 lb. 02/04/16 101.2 lb. Resident #33 had experienced a gradual weight loss over the last 12 months, culminating in a severe weight loss in one (1) month. The resident lost 6.1% of her body weight from 01/03/16 to 02/04/16, which was a severe weight loss. There was no indication in Resident #33's medical record to suggest her attending physician, responsible party, and/or Licensed Dietitian were ever notified of the resident's severe weight loss. The weight loss should have been identified on 02/04/16, when the weight of 101.2 lb. was entered into the resident's electronic medical record. During an interview with the Nursing Home Administrator/Licensed Dietitian (NHA/LD), at 5:47 p.m. on 02/11/16, when asked if nursing had notified her of the resident's weight loss, she stated that they had not. She was asked to review the resident's meal percentages from (MONTH) (YEAR) through present. Upon completion of her review, she was asked if she would agree that the resident had had a gradual decline in meal consumption since (MONTH) (YEAR). She stated, Unfortunately I would have to agree with that. When asked what her expectation was as far as being notified of weight changes, she stated that a significant or severe weight loss should be brought to her attention and the attention of the physician within 24 hours of discovery. She was asked if this was done in this situation she stated, No it was not. She further stated she ran a weight report on the 10th of the month and that was not done this month because of the survey - that was why the weight loss was not identified prior to surveyor intervention. The NHA/LD stated, We just missed her weight loss.",2019-07-01
4859,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,157,D,1,0,G6NZ11,"**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 on two (2) incidents of improper medication administration for one (1) of six (6) residents reviewed. Resident identifier #52. Facility census 58. Findings include: a) Resident #52 A review of Resident #52's physician order [REDACTED]. A review of the Medication Administration Record [REDACTED] -- On 07/08/16, Resident #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 2:57 p.m., due to waiting on tubing from the pharmacy. -- On 07/09/16, Residetn #52 received her 9:00 a.m. dose of [MEDICATION NAME] at 3:44 p.m., due to waiting for trough (laboratory results). Review of Resident #52's medical record, on 07/27/16 at 2:37 p.m., revealed Licensed Practical Nurse (LPN) #18 and LPN #80 did not notify the Resident's physician of the 9:00 a.m. dose of [MEDICATION NAME] 1,000 mg IV was not administered on 07/08/16 and 07/09/16 as ordered. In an interview with the Director of Nursing (DON), on 07/27/16 at 4:05 p.m., she stated, they ran out of of tubing on 07/08/16, and had to wait for the tubing to arrive from the pharmacy. The DON further stated the nursed had to do a trough (laboratory) level on 07/09/16, and had to wait on the results. The nurses. The DON revealed the nurses did not notifiy the physician the medication was administered late, nor did they receive a new physician order. The facility's policy for changing IV tubing revealed the intermittent administration set is change every twenty-four (24) hours.",2019-07-01
4908,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2016-01-19,157,D,0,1,CP9N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify Resident #91's attending physician when she experienced a 3.4 pound weight gain in two (2) days. Resident #91 is a [MEDICAL TREATMENT] and [MEDICAL CONDITIONS] patient who had a physician's orders [REDACTED]. This was true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during Stage 2 of the Quality Indicator Survey. Resident Identifier: #91. Facility Census: 57. Findings include: a) Resident #91 A review of Resident #91's medical record at 11:31 a.m. on 01/18/16, found a physician's orders [REDACTED]. (pound) increase in 2 (two) days or 5 lb. increase in 1 (one) week. A review of Resident #91's electronic medical record, in conjunction with her (MONTH) (YEAR) Medication Administration Record [REDACTED] -- 01/03/16 228.4 lb. -- 01/04/16 229.2 lb. -- 01/06/16 222.2 lb. -- 01/07/16 223.8 lb. -- 01/08/16 222.0 lb. -- 01/0916 224.8 lb. -- 01/10/16 228.2 lb. -- 01/11/16 228.2 lb. -- 01/12/16 229.2 lb. Resident #91 gained 3.4 pounds between 01/09/16 and 01/11/16, which required physician notification. During an interview with the Director of Nursing (DON) at 10:43 a.m. on 01/19/16, after reviewing these findings, she stated she would have to see if the attending physician was notified of the weight gain on 01/11/16. An additional interview with the DON at 1:36 p.m. on 01/19/15, confirmed she could not find anything to support the physician was notified of Resident #91's weight gain on 01/11/16.",2019-05-01
4923,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2016-01-28,157,E,0,1,D6QF11,"**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 notify the physician and responsible party for one (1) of twenty-four (24) Stage 2 residents when there was an injury to Resident #55's leg that could potentially require physician intervention. The facility also did not notify Resident #55's responsible party when the resident began to receive new medication and treatments, and/or changes due to the resident's refusal of treatment. Resident identifier: #55. Facility census: 108. Findings include: a) Resident #55 A Stage 1 observation, on 01/25/16 at 4:10 p.m., revealed a two by two (2 x 2) brown colored dressing on Resident #55's left anterior shin, dated 01/23 and initialed. Upon inquiry as to whether the wound beneath the dressing may be a skin tear or laceration, Licensed Practical Nurse #46 (LPN) reviewed the medical record and related she did not see an order for [REDACTED]. Review of physician's orders [REDACTED]. (This was two (2) days after the date on the dressing.) No evidence was present to indicate the facility notified the responsible party. An interview, on 01/27/16 at 8:24 a.m., with LPN #154, revealed when an incident/accident occurred, the resident was evaluated; the physician was notified, and new orders received and put in the medical record. The responsible party was notified of the incident and new orders. LPN #49, LPN #56, and the director of nursing (DON), reviewed the medical record during an interview on 01/27/16 at 10:25 a.m., and confirmed no information was present to indicate the physician had been notified at the time of the injury, or the responsible party had been notified of the wound. Review of the incident and accident policy, on 01/27/16 at 11:32 a.m., noted medical attention included examining the resident, notifying the physician, notify the victim's responsible party/family and document the notification of the physician/responsible party/family in the medical record. Additionally, further review of the medical record, on 01/28/16 at 2:00 p.m., revealed no evidence the responsible party had been notified of the following physician's orders [REDACTED].>-- 01/28/16: [MEDICATION NAME] tablets -- 01/26/16: [MEDICATION NAME] tablet 40 milligrams (mg) orally three times a day for [MEDICAL CONDITIONS] -- 01/26/16: late entry for 01/23/16 treatment order to cleanse open area to left shin with normal saline solution (NSS), apply [MEDICATION NAME] every other day (qod) and as needed (prn) -- 01/26/16: treatment to clean open area to left shin with NSS, apply [MEDICATION NAME] with zinc, cover with [MEDICATION NAME] and wrap with cling every day (QD) and prn -- 12/20/16: a progress note indicated a resident to resident altercation in which Resident #55 acquired a pink area on her chin -- 11/06/15: the physician discontinued the resident's TED hose related to refusal -- 10/28/15: Fluid restrictions were discontinued due to the resident was nonadherent. The assistant director of nursing (ADON #39) reviewed the medical record on 01/28/16 at 2:45 p.m., and confirmed no evidence was present to indicate the responsible party had been notified of the physician's orders [REDACTED].",2019-05-01
4937,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,157,D,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to promptly notify the physician of a resident's change of condition and/or when the physicians' orders directed facility staff to notify the physician for three (3) of twelve (12) sampled residents. Resident #75's scheduled dose of insulin was held without notification and/or the approval of the attending physician. Nurses held Resident #37's scheduled dose of insulin on multiple occasions, but failed to notify the physician the medication was held and/or to gain approval for holding the medication. For Resident #10 the facility failed to notify the physician on several occasions when her blood sugar was greater than 300 as directed by the resident's physician order. Resident Identifiers: #10, #37, and #75. Facility Census: 72. Findings include: a) Resident #75 A review of Resident #75's medical record at 9:30 a.m. on 05/12/16 found the following physician orders for insulin used to treat her [DIAGNOSES REDACTED]. Humalog Solution Inject as per sliding scale if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units - notify physician if less than 60 or greater than 400. This medication was scheduled at 6:00 a.m., 11:00 a.m., 4:00 p.m., and 10:00 p.m. This order had a start date of 09/28/15. [MEDICATION NAME] N Suspension Inject 15 units subcutaneously one time a day related to DM II. The scheduled time for administration was 6:00 a.m. This order had a start date of 09/26/15. When readmitted from the hospital on [DATE], the time of this administration changed to 10:00 a.m. On 04/01/16, the medication administration time was changed back to 6:00 a.m. [MEDICATION NAME] N Suspension Inject 10 units subcutaneously at bed time related to DM II. This medication scheduled at 10:00 p.m., had an order start date of 09/26/15. Review of the medication administration records (MAR) from 09/26/15 through present found Resident #75's [MEDICATION NAME] N scheduled at 6:00 a.m., was held on: - 02/13/16, - 02/15/16, and - 02/17/16. Further review of the Resident #75's medical record found no reason why her scheduled dose of insulin was held on these occasions. The order had no physician ordered low parameter to indicate the physician wanted the medication held. There was also no evidence the nurse had called the physician and notified him that she held Resident #75's scheduled insulin and/or to obtain approval for holding the insulin. b) Resident #37 A review of Resident #37 medical record at 1:00 p.m. on 05/12/16 found this [AGE] year-old female, admitted to the facility in 2012, was in the hospital from 08/07/15 through 08/10/15. Review of Resident #37's MARs from 08/10/15 through 05/12/16 found the resident had a physician's order for, Fingerstick blood sugar in the morning for [DIAGNOSES REDACTED] notify physician if greater than 300 or less than 70. This order had a start date of 08/28/12. Upon Resident #37's readmission to the facility on [DATE], the physician ordered the following insulin regimen to control her DM II: - [MEDICATION NAME] R 5 units SQ three times a day at 6:00 a.m., 11:00 a.m., and 4:00 p.m. This medication began on 08/11/15. - Accucheck four times a day with scale insulin coverage with [MEDICATION NAME] R if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units notify physician if less than 60 or greater than 400. Review of Resident #37's MAR for 09/2015 found LPN #5 held Resident #37 scheduled dose of [MEDICATION NAME] R insulin at 6:00 a.m. on: - 09/15/15 - Blood sugar (BS) 78, - 09/16/15 - BS 78, and - 09/17/15 - BS 109 The only indication in the medical record as to why LPN #5 held the insulin was on 11/15/15 by LPN #5. LPN #5 wrote on the back of the MAR indicated [REDACTED]. Although the resident's blood sugar was above the physician specified parameter to hold the insulin, there was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin. Review of Resident #37's 10/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. Again, there was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin on: - 10/09/15 - BS 95, - 10/10/15 - BS 78, - 10/15/15 - BS 87, and - 10/27/15 (BS 86) Review of Resident #37's 11/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There again was no evidence LPN #5 contacted the physician to obtain an order to hold the insulin, nor did she notify the physician that she held the insulin on: - 11/01/15 - BS 84, - 11/02/15 - BS 90, - 11/11/15 - BS 91, - 11/12/15 - BS 92, - 11/13/15 - BS 106, and - 11/24/15 - BS 94. Review of Resident #37's 12/2015 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication to hold the resident's insulin for a blood sugar of 93 on 12/08/15. Review of Resident #37's 01/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record indicating why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 01/23/16 - BS 86, and - 01/24/16 - BS 74 Review of Resident #37's 02/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record of the reason why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 02/08/16 - BS 84, - 02/11/16 - BS 72, - 02/12/16 - BS 82, - 02/16/16 - BS 78, - 02/18/16 - BS 87, - 02/21/16 - BS 74, - 02/22/16 - BS 94, and - 02/25/16 - BS 98 Review of Resident #37's 03/2016 MAR found LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication on: - 03/19/16 - BS 97, and - 03/20/16 - BS 100 Review of Resident #37's 04/2016 MAR found LPN #21 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/11/16 - BS 92, - 04/13/16 - BS 89, and - 04/16/16 - BS 99 LPN #5 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/17/16 - BS 86 Registered Nurse (RN) #53 held Resident #37's scheduled dose of [MEDICATION NAME] R at 6:00 a.m. on: - 04/19/16 - BS - 102 There was no evidence contained in the medical record which indicated why this medication was held or that the physician was notified and/or gave approval to hold the medication. c) Resident #10 Review of Resident #10's medical record at 9:45 a.m. on 10/16/15 found this resident most recently readmitted to the facility on [DATE] after a hospital stay. Prior to this hospitalization Resident #10 had remained in the facility since 12/30/14 as a long-term care resident. Review of Resident #10's [DIAGNOSES REDACTED]. Both [DIAGNOSES REDACTED]. Review of Resident #10's physician orders for 08/01/15 through 05/16/16 found the following physician orders pertaining to the management of her DM II, -- [MEDICATION NAME] Solution inject as per sliding scale if: - 111-140 = 1 unit, - 141-170 = 2 units, - 171-200 = 3 units, - 201-230 = 4 units, - 231-260 = 5 units, - 261 - 290 = 6 units, - 291 - 320 = 7 units, - 321 - 350 = 8 units, - 351 - 380 = 9 units, and - 381 - 400 = 10 units - notify physician if less than 60 or greater than 400 four times a day before meals and at bedtime. This had an order date of 04/28/16. -- Fingerstick blood glucose two times a day notify physician if less than 70 and greater than 300. This had a start date of 04/30/15 and remained in effect until her readmission to the facility on [DATE]. Review of Resident #10's MARs for 08/01/15 through 05/16/16 found the following occasions when Resident #10's blood sugars were greater than 300 and required notification of the physician as directed by the physician's order dated 04/30/15. -- 04/19/16 at 6:00 a.m. her blood sugar was 382. -- 03/03/16 at 4:00 p.m. her blood sugar was 341. -- 03/10/16 at 4:00 p.m. her blood sugar was 364. -- 03/31/16 at 6:00 a.m. her blood sugar was 401. -- 02/21/16 at 6:00 a.m. her blood sugar was 305. -- 12/27/15 at 4:00 p.m. her blood sugar was 384. -- 11/02/15 at 4:00 p.m. her blood sugar was 319. -- 10/26/15 at 4:00 p.m. her blood sugar was 430. -- 09/04/15 at 4:00 p.m. her blood sugar was 344. -- 09/25/15 at 4:00 p.m. her blood sugar was 425. There was no evidence in the medical record to indicate the physician was notified of Resident #10's elevated blood sugars. Also, on 02/26/16 at 6:00 a.m. Resident #10's blood sugar was 318. There was no evidence the nurse notified the physician of the resident's elevated blood sugar at that time. At 4:00 p.m. when checked again per physician order, her blood sugar was even higher at 545. It was only after obtaining this blood sugar that the facility contacted the physician and obtained an ordered for a onetime dose of 14 units of Humalog. d) Staff Interviews Relating to Diabetic Management During an interview with RN #51 at 11:30 a.m. on 05/12/16, when asked how the nurses determined whether or not to hold a resident's scheduled insulin if there was not a physician established parameter for the order. She said it was a nursing judgement. She stated it was very discretionary depending on a lot of things like the resident's blood sugar, if the resident ate, and what the resident ate. She stated the nurses knew the residents, and how their blood sugars behaved, so it was at the nurse's discretion whether to hold the insulin. She indicated if a resident was not to have anything by mouth because of a scheduled procedure they would not give any of diabetic medications including insulin. She indicated that they learned about this in nursing school and it was really just up to the nurse. When asked if the nurse should contact the physician, she stated, No it is a nursing judgement. An interview with RN #53 at 1:58 p.m. on 05/12/16 found that if she made the decision to hold the resident's insulin, she would call the doctor. She stated that it would depend on the resident's blood sugar and if the resident had eaten and what the resident had eaten, but if she did not feel comfortable administering the insulin she would call and notify the physician so the physician could make the final decision. During an interview at 2:05 p.m. on 05/12/16, when asked about holding a resident's scheduled insulin when there was no physician ordered low parameter, the Director of Nursing (DON) said that to hold or not to hold a resident's insulin was a nursing judgement. He did state however, the expectation would be that the nurse would call the provider and notify them that they felt the insulin should be held and why and let the provider give the final answer on whether or not to hold the resident's insulin. He stated the nurse should document the conversation with the provider in the medical record. e) At 2:45 p.m. on 05/16/16, during a discussion of these findings we with the DON, Administrator, and a Registered Nurse (RN) #102, a facility consultant, they were asked to provide any additional information available. At the time of exit at 4:30 p.m. on 05/18/16, with the Director of Nursing (DON) the facility provided no further information. .",2019-05-01
5072,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-09-14,157,D,0,1,HR8011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to notify the responsible party when a change in condition occurred, or new physician orders [REDACTED]. Resident identifier: #67. Facility census: 88. Findings include: a) Resident #67 a) During an interview with the responsible party for Resident #67, completed on 09/09/15 at 9:18 a.m., she said she is not always notified when the resident sustained [REDACTED]. Review of the medical record on 09/14/15 at 8:30 a.m., found this sixty-five (65) year old resident had diagnoses, which included [DIAGNOSES REDACTED], (a type of dementia), and [MEDICAL CONDITION] (inability to speak). Per the annual minimum data set (MDS) with assessment reference date (ARD) of 01/03/15, this resident had severe cognitive impairment, and was completely dependent on staff for all activities of daily living and for tube feeding. He was unable to understand others or to be understood by others, or to make his needs known. On 09/14/15 at 1:45 p.m., an interview with the director of nursing revealed the resident or responsible party was notified of incidents, accidents, fever of 101 degrees Fahrenheit or greater, changes in condition, and new physician's orders [REDACTED]. Review of the medical record for entries from 06/01/15 to 09/14/15, found the following three (3) instances where responsible party notification was indicated, but there was no evidence of responsible party notification. 1) On 06/04/15 at 1:27 p.m., Resident #67's temperature was 102.2 degrees Fahrenheit (F). During an interview with Registered Nurse (RN) #48 on 09/14/15 at 2:15 p.m., she agreed the responsible party should have been notified of the fever, but there was no evidence of responsible party notification. 2) A nurse progress note SBAR (situation background assessment), dated 07/30/15 at 10:07 p.m., addressed a thick coating on Resident #67's tongue. A physician's assistant assessed the resident, and then ordered [MEDICATION NAME] (a medication used to treat yeast). During an interview with RN #48 on 09/14/15 at 2:15 p.m., she agreed the responsible party should have been notified of the change in condition and of the new medication order, but there was no evidence of responsible party notification. 3) A nurse progress note dated 09/02/15 at 10:58 p.m. stated Tylenol was administered to Resident #67 for a temperature of 101.8 degrees (F). During an interview with RN #48 on 09/14/15 at 2:15 p.m., she agreed the responsible party should have been notified of the fever, but there was no evidence of responsible party notification.",2019-03-01
5091,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2015-08-13,157,D,0,1,ZTVP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a random opportunity for discovery during medication administration observation, record review and staff interview, the facility failed to notify the physician of a change of condition in a timely manner. Resident #14 was noted to have a blood sugar of 466 at 11:06 a.m. on 08/12/15. There was no evidence the physician was informed of the resident's blood sugar level in a timely manner. Resident identifier: #14. Facility census: 90. Findings include: a) Resident #14 Observation, on 08/12/15 at 11:06 a.m., revealed Licensed Practical Nurse #32, (LPN) obtaining a finger stick blood sugar for Resident #14. The finger stick blood sugar test registered at 466. LPN#32 administered twenty (20) units of [MEDICATION NAME] regular insulin at that time. Review of Resident #32's physician orders, on 08/12/15 at 3:45p.m., revealed an order for [REDACTED]. An interview with the director of nursing (DON) on 08/12/15 at 3:55 p.m. confirmed LPN #32, had not notified the physician of the elevated finger stick as directed by the physician's orders [REDACTED].>",2019-03-01
5135,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-03-09,157,D,1,0,K6OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon record review, staff interview, confidential interview, and family interview, the facility failed to promptly consult with a resident's physician and notify the resident's legal representative during a significant deterioration in Resident #94's condition overnight. The resident became lethargic and had an elevated temperature. She subsequently had a decreased level of consciousness, full body tremors, and further elevated temperature for which she was sent to the hospital. This was found for one (1) of six (6) residents reviewed. Resident identifier: #94. Facility census: 95. Findings include: a) Resident #95 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her daughter acted as her decision-maiker as the resident's physician determined the resident lacked the capacity to make informed medical decisions. The review of her record began on 03/02/16 at 11:32 a.m. The record stated as of 12/12/15, she was being treated with an antibiotic for an upper respiratory infection. She was alert and verbal. Pertinent progress notes were found for the afternoon and evening of 12/12/15, and the morning of 12/13/15 as follows (typed as written): -- 12/12/15 (10:46 a.m.) Nurse's Note: Resident is alert and verbal resting in bed at this time. CNA (certified nurse aide) alerted this nurse that resident was not acting like herself. Resident vs (vital signs) take BP (blood pressure) 127/55 p (pulse) 88 Temp (temperature) 100.2 RR (respiratory rate) 32 SP02 (oxygen saturation) 88% on 2L (two liters) of 02 (oxygen). Resident is having jerking involuntary movements. Lung sound diminished in bases and upper crackles noted. Resident states she is not feeling well. MD (doctor) contacted and new orders received for UA (urinalysis) C&S (culture and sensitivity) CBC (complete blood count) and to dc (discontinue) zpack (Zythromax - an antibiotic) and start [MEDICATION NAME] (antibiotic) x (times) 10 days. Residents MPOA (Medical Power of Attorney) (Daughter) contacted and notified of current condition and new orders. Resident denies any pain at this time. -- 12/12/15 (11:07 a.m.) Nurse's Note: Resident straight cathed (catheterized) using sterile tech (technique) to obtain ua/(urinalysis) C&S. Resident tolerated procedure well. Cloudy amber urine with strong odor noted. -- 12/12/15 (2:26 p.m.) Nurse's Note: Residents MPOA and MD notified of recent chest xray results which were negative. UA and labs are still pending. c) The facility's Minimum Data Set (MDS) assessment coordinator, Registered Nurse (RN) #106, covered the first portion of the shift as the evening of 12/12/15 began. Her entries were: -- 12/12/15 (6:30 p.m.) Nurse's Note: Resident weak and had difficulty feeding herself supper. CNA feed her supper to her and she ate a bowl of tomato soup and a grilled cheese sandwich. She denied any pain just stated she felt really weak. Will continue to be observed for any further problems. Spoke with her daughter (name) and notified her of the lab results with CBC and UA. Still waiting on the urine culture. -- 12/12/15 (6:40 p.m.) Nurse's Note: Paged Dr. (name) in regards to lab results of CBC and UA. Awaiting return call. -- 12/12/15 (6:51 p.m.) Nurse's Note: Resident noted with weakness in upper extremities. When trying to hold the phone up to her ear or feed herself her arms would begin jerking and she was unable to hold them up. It appeared that when she tensed her muscles they were too weak to hold up. -- 12/12/15 (7:33 p.m.) Nurse's Note: Dr. (name) returned phone call. Results of UA and CBC given to him. He stated that the [MEDICATION NAME] she is on will cover the possible UTI. She had cloudy urine with protein 30, positive [MEDICATION NAME] and large leudocytes, WBC's > (greater than) 182 and many bacteria. Culture still pending. Order obtained for Chemistry panel Mon. (Monday) 12/14/2015. Daughter (name) notified of results of labs and orders obtained. She also had ask earlier about the calcium being discontinued and Dr. (name) said that because of her [DIAGNOSES REDACTED]. Will continue to observe. d) In an interview on 03/08/16 at 10:42 a.m., RN #106 said when she spoke with the physician and the daughter of Resident #94 at 7:33 p.m., there was understanding of her condition and agreement to continue current treatment and observations. She was relieved by another nurse following that note of 12/12/15 at 7:33 p.m. e) There were only two (2) nurses' notes documented following 7:33 until Resident #94 was apparently sent to the hospital on [DATE] at sometime around 4:30 a.m. (typed as written): -- 12/12/15 (10:07 p.m.) Nurse's Note: Resident cont (continued) to be lethargic, does respond at times to verbal stimuli. Turned and repositioned q (every) 2 hrs (hours) for skin integrity. O2 @2L via n/c in place per order. SPO2 93%. Tylenol 650mg (milligrams) given for elevated temp 100.1 PO (by mouth). Will cont to observe. call bell within reach. -- 02/13/15 (4:48 a.m.) SBAR (Situation Background Assessment Recommendation) Nurse's Note: Elevated temp of 101.0 PO. Increased full body tremors. The resident has orders for the following advance directives: DNR (Do Not Resuscitate). resident had increased temp, decreased L[NAME] (level of consciousness), body tremors noted. The RN on day shift made the next note which showed Resident #94's daughter called the facility to inform them her mother had been admitted to the hospital: -- 12/13/15 (10:50 a.m.) Nurse's Note: Daughter spoke with LPN (Licensed Practical Nurse) on phone and reported that resident was admitted to hospital with IV ABT (intravenous antibiotics)/cath (catheter)-UTI (urinary tract infection) & (and) increased troponin levels. f) Review found an SBAR communication form and an electronic einteract transfer form. The SBAR form documented the elevated temperature, decreased level of consciousness, and body tremors, that the daughter/medical power of attorbey (MPOA) was notified on 12/13/15 at 4:30 a.m., the physician on call for Resident #94's attending physician was called at 4:30 a.m., and the nurse was awaiting a call back. The transfer form documented Resident #94 was sent to a local hospital on [DATE] at 4:30 a.m., the vital signs sent with the resident were documented as taken on 12/12/15 at 11:53 p.m. g) The nurse on duty who authored the notes of 10:07 p.m. and 4:48 a.m. and the SBAR assessment and transfer form, Licensed Practical Nurse (LPN) #122 was interviewed by telephone on 03/08/16 at 12:10 p.m. She said she thought Resident #94 should go to the hospital, but she could not send her without speaking to the physician or the MPOA. h) In an interview on 03/-8/16 at 4:45 p.m., Director of Nursing, RN #17, said the optimal situation for transfer was that a physician's orders [REDACTED]. If that could not be obtained, the Director of Nursing or Nurse on Call should be contacted. If that could not be accomplished, then a nursing judgment should be made and the resident sent out for assessment. i) Resident #94's MPOA, when interviewed on 03/08/16 at 4:20 p.m., said she had received no calls from the facility during the night of 12/12/15 until the early morning of 12/13/15, when she demanded her mother be sent to the hospital. j) There was no evidence of any attempts by the facility to contact the physician, the MPOA, the Director of Nursing, or the nurse on call after 7:33 p.m. on 12/12/15 until 4:30 a.m. on 12/13/15.",2019-03-01
5199,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2014-09-24,157,D,0,1,PSV811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to notify the physician when one (1) of thirty (30) Stage 2 sample residents had a change in condition. The facility did not notify the attending physician when the resident had an oral temperature of 102.3 degrees Fahrenheit (F.). Resident identifier: #71. Facility census: 60 Findings include: a) Resident #71 On 09/22/14 at 11:45 a.m., record review for Resident #71 found she was admitted on [DATE]. Her admission [DIAGNOSES REDACTED]. At 12:05 p.m. on 09/22/14, a review of the resident's vital signs in the electronic health record, found Resident #71 had an oral temperature of 102.3 F on 07/31/14 at 6:12 a.m. A review of the nurses' progress notes revealed the resident's son was notified of the temperature; however, there was no documentation the attending physician was notified of the elevated temperature. On 09/22/14 at 1:40 p.m. an interview was conducted with Employee #64, the Director of Nursing (DON). She stated according to the facility's policy/standing order template, the physician should have been notified of an elevated temperature. She further stated, due to Resident #71's health history and diagnoses, the high temperature could have produced adverse effects to the resident. The DON stated according to policy and based on the resident's health history, the nurse should have notified the physician. She said she would look for evidence of this notification. No further documentation was provided by the DON. A copy of the facility standing orders template was provided on 09/22/14 at 2:10 p.m. The standing orders included (typed as written): For fever: -- [MEDICATION NAME] 650 mg (milligrams) or [MEDICATION NAME] PO (by mouth) . every four hours prn (as needed) for temperature above 100.4 degrees F. The order also included to notify the physician. At 2:30 p.m. on 09/22/14 in an interview with Employee #12, the Assistant Director of Nursing (ADON), she stated there was no nursing note or evidence to show the physician was notified the resident had a temperature of 102.3 degrees F. She further stated the physician should have been notified.",2019-03-01
5290,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2015-10-08,157,D,0,1,NC4111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to promptly notify the attending physician and/or the healthcare decision maker of changes in condition for two (2) of two (2) residents reviewed for the care area of notification of change. Resident #7 experienced a significant weight loss and the attending physician and healthcare decision maker was not promptly notified. For Resident #58, the facility failed to immediately inform the resident's physician of blood sugars less than 40 as directed by the physician. Resident Identifiers: #7 and #58. Facility Census: 53. Findings Include: a) Resident #7 A review of Resident #7's medical record at 1:41 p.m. on 10/06/15, found the following weights recorded: -- 08/31/15 - 177.5 pounds, -- 09/01/15 - 177.5 pounds, -- 09/08/15 - 169.0 pounds, -- 09/15/15 - 159.0 pounds, -- 09/21/15 - 158.0 pounds, -- 10/01/15 - 150.0 pounds. From 08/31/15 to 09/01/15, Resident #7 lost 8.5 pounds. She then lost another 10 pounds from 09/08/15 to 09/15/15, and an additional nine (9) pounds from 09/15/15 to 10/01/15. Review of Resident #7's progress notes found a note written by the dietitian, dated 09/22/15, which addressed Resident #7's significant weight loss of 19.5 pounds since her admission to the facility on [DATE]. The dietitian's progress note indicated the weight loss was likely contributed to the [MEDICAL CONDITION] which was present upon admission to the facility. Review of the residents' urine output record since admission found the resident had larger than normal amounts of urine output on an almost daily basis and her [MEDICAL CONDITION], which was present on admission, had subsided. The resident's record indicated she had a [DIAGNOSES REDACTED]. Review of the nursing progress notes and the physician progress notes [REDACTED].#7's attending physician was notified of the resident's significant weight loss. An interview with the Director of Nursing (DON) and the Certified Dietary Manager (CDM), at 3:16 p.m. on 10/06/15, confirmed neither the attending physician nor the healthcare decision maker for Resident #7 were notified of the resident's significant weight loss prior to intervention during the survey on 10/06/15. They both agreed they did not notify the doctor because the dietitian did not make any recommendations on 09/22/15 which needed to be acted on by the physician. They indicated they did not notify the physician and the healthcare decision maker because the weight loss was expected due to the [MEDICAL CONDITION]. When asked why the physician and the healthcare decision maker were notified on 10/06/15 after the resident's weight record was requested, the CDM indicated it was because she spoke with the dietitian, who recommended a supplement which needed to be cleared through the physician and the healthcare decision maker. The physician, when notified of the weight loss on 10/06/15, ordered the resident have lab work completed on 10/07/15. The healthcare decision maker, when notified of the weight loss, indicated she was pleased her mother had lost weight, She instructed the nursing staff that she did not want her mother to have the recommended supplement, because the weight loss was beneficial to her mother. b) Resident #58 Review of Resident #58's medical record, on 10/07/15 at 10:00 a.m., revealed a physician's orders [REDACTED]. On 10/07/15 at 11:00 a.m., a review of Resident #58's Medication Administration Record [REDACTED]. Further record review found no evidence the physician was notified the resident's blood sugars were less than 40 on 09/23/15 and 09/26/15 as directed by the physician's orders [REDACTED]. In an interview with the director of nursing (DON), on 10/07/15 at 12:30 p.m., she verified there was no evidence the physician was notified Resident #58's blood sugars were less than 40 on 09/23/15 and 09/26/15.",2019-01-01
5408,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-07-23,157,D,0,1,5V2S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the physician of a change of condition in a timely manner for one (1) of five (5) residents reviewed for the care area of nutrition. The resident had a significant weight loss. There was no evidence the physician was informed of this in a timely manner. Resident identifier: #133. Facility census: 99.Findings include: a) Resident #133On 07/22/15 at 11:00 a.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was determined unable to make informed medical decisions by the attending physician on 01/29/15. Resident #133's weights, which were documented in the electronic weight and vital sign summary, were reviewed. The records indicated each weight was obtained using a full body lift. Weight records revealed the following weights and weight losses: -- 01/30/15 at 1:13 a.m. - 123.2 pounds (lbs.) -- 01/30/15 at 2:11 a.m. - 123.2 lbs. -- 02/01/15 at 1:56 p.m. - 123.5 lbs. -- 02/01/15 at 1:57 p.m. - 123.5 lbs. -- 02/08/15 at 1:43 p.m. - 119.9 lbs. -- 02/15/15 at 1:59 p.m. - 120.1 lbs. -- 02/15/15 at 2:00 p.m. - 120.1 lbs. -- 02/22/15 at 2:39 p.m. - 94.6 lbs. - (Loss of 23.2% between [DATE] and [DATE] -- 02/22/15 at 2:40 p.m. - 94.6 lbs. -- 02/23/14 at 2:27 p.m. - 90.7 lbs. - (An additional loss of 4.1%) -- 02/26/15 at 3:09 p.m. - 87.8 lbs. - (An additional loss of 3.19%) -- 02/26/15 at 3:10 p.m. - 87.8 lbs. Further review of Resident #133 medical records found no evidence the physician and/or nurse practitioner were notified of the severe weight loss of 23.2%, which occurred between 01/30/15 and 02/22/15, until 02/26/15. By the time the physician was notified of the weight losses, the resident had lost another 7.2% of her total body weight. On 0723/15 at 1:40 p.m., during an interview with the director of nursing (DON) and the administrator, they reviewed Resident #133's electronic medical records and confirmed there was no evidence the physician and/or nurse practitioner were notified of the resident's weight losses in a timely manner.",2019-01-01
5439,SUMMERS NURSING AND REHABILITATION CENTER,515170,198 JOHN COOK NURSING HOME ROAD,HINTON,WV,25951,2015-07-09,157,D,0,1,R3IE11,"**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 when one (1) of three (3) residents reviewed for the care area of nutrition experienced a significant weight loss. Resident identifier: #96. Facility census: 109. Findings include: a) Resident #96 Medical record review on 07/07/15 at 2:30 p.m., found a fifty-two (52) year old male originally admitted to the facility on [DATE]. The resident's primary [DIAGNOSES REDACTED]. The resident also had a gastrostomy tube. Review of the resident's record found the resident had experienced a significant weight loss since 02/04/15. Weights had been obtained on the following dates: 02/04/15 - 104.80 # 03/01/15 - 103.80 # 04/04/15 - 99.00 # 05/04/15 - 97.80 # 06/03/15 - 93.00 # 06/07/15 - 90.20 # 06/14/15 - 90.80 # 06/26/15 - 88.40 # 06/28/15 - 84.20 # 07/05/15 - 82.20 # At 7:50 a.m. on 07/08/15, Speech Therapist #119 was interviewed regarding the resident's weight loss. She stated the resident had not been on her case load for at least a year. She stated she felt it was not safe for the resident to eat by mouth, but she realized the resident's sister had signed a refusal of treatment. At 8:05 a.m. on 07/08/15, the director of nursing provided a copy of an informed refusal of treatment signed by the resident's responsible party on 07/30/13. The resident's physician had advised, Feedings via enteral nutrition due to a high risk of aspiration. The responsible party had elected the resident receive oral feedings. At 10:46 a.m. on 07/08/15, during an interview regarding the resident's weight loss, the facility's Corporate Registered Dietitian (CRD) #108, was asked what percentage of weight the resident had lost since 02/04/15. CRD #108 calculated the resident's weight loss using the resident's recorded weight of 99 pounds on 04/04/15. She stated the resident had a 10.3% weight loss on 04/04/15. She verified the 10.3% was a significant weight loss and the resident's physician should have been notified of the weight loss. CRD #108 contended the physician would have known about the weight loss because he had signed orders for double portions of food and other interventions implemented by the facility to address the weight loss. CRD #108 was unable to provide evidence the resident's attending physician was aware of the actual weight loss. On 07/05/15, the resident's weight was recorded as 82.2 pounds which was a 21% weight loss. On 07/08/15 at 3:29 p.m., the resident's attending physician was interviewed regarding the resident's weight loss. The physician was asked if the facility had notified him of the resident's weight loss. The resident's physician stated it was his job to know about the weight loss and the facility should not have to tell him. He stated he saw the resident every two (2) months and his goal was for the resident to weigh around 100 pounds. He stated the resident would probably never weigh much more. Further review of the physician's progress notes on 07/08/15 at 4:00 p.m., found two (2) physician's progress notes written between 03/04/15 and 07/05/15. A physician's progress note, dated 04/27/15, stated, .weight stable. A visit on 03/04/15 found, Patient doing well. He is eating 2 full trays at every meal. The staff reports no other issues There was no indication the physician had documented any information concerning weight loss or that he was aware the resident had lost over 16 pounds since he wrote his 04/27/15 progress note.",2019-01-01
5449,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2015-06-26,157,D,0,1,7OP711,"Based on record review and staff interview, the facility failed to notify the attending physician for one (1) of six (6) residents reviewed for the care area of unnecessary medications, of a need to alter her treatment. The resident refused to have her blood drawn for an ordered laboratory (lab) test. The facility failed to notify the attending physician of the resident's refusal to determine how the physician wanted to proceed with her treatment. Resident identifier: #23. Facility census: 71. Findings include: a) Resident #23 A review of Resident #23's medical record, at 12:23 p.m. on 06/24/15, found a physician's order dated 06/11/15 for a Basic Metabolic Panel (BMP) on the morning of 06/12/15. Upon further review of the record, the results of the BMP, which was to be obtained on 06/12/15, could not be located. At 10:11 a.m. on 06/25/15, an Interview with the Assistant Director of Nursing (ADON) Registered Nurse (RN) #91, revealed the BMP ordered for Resident #23 on 06/12/15 was not obtained. When asked why the BMP was not obtained, the ADON stated, Because she refused to let them draw it. The ADON referred to a Lab log for 06/12/15. Resident #23's name was listed on this log. Under the draw site, the word Refused was written. The ADON was asked if Resident #23's attending physician was notified of her refusal. She reviewed the medical record and indicated the attending physician was not notified of the resident's refusal for the lab draw. An additional review of Resident #23's medical record, at 9:00 a.m. on 06/26/15, found the following physician's order dated 06/25/15, . Obtain BMP on 06/25/15 d/t (due to) missed lab on 06/12.",2019-01-01
5467,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2015-03-27,157,D,0,1,HEH611,"Based on resident interview, record review, and staff interview, the facility failed to inform one (1) of 33 Stage 2 sample residents of a change in roommate assignment. Resident identifier: #23. Facility census: 64 Findings include: a) Resident #23 During Stage 1 of the survey, on 03/23/14 at 2:39 p.m., Resident #23 commented she had a roommate change two (2) weeks ago. She said the facility did not notify her of the change in roommate assignment. Resident #23 stated, They just came in one day and moved my bed sideways, then took my roommate out and moved a new roommate into my room. A medical record review, on 03/26/15 at 10:30 a.m., revealed no evidence the resident was notified of a change in her roommate assignment. Licensed Practical Nurse (LPN) #24, commented in an interview on 03/26/15 at 1:20 p.m., that the social worker notified residents regarding a room change or a change in roommates. In an interview, on 03/26/15 at 1:30 p.m., the the director of nursing (DON) stated, Notifications of room and roommate changes are done by the Social Worker. She further commented that there were many roommate and room changes a few weeks ago to cohort residents. During an interview with Social Worker (SW) #27, on 03/26/15 at 1:40 p.m., she stated, if I am here, I notify the residents of a room change or getting a new roommate. If I am not here, nursing notifies them. SW #27 stated she would check on evidence regarding the notification of Resident #23 regarding a new roommate. On 03/2615 at 2:40 p.m., SW #27 stated, There is nothing in her chart about being notified of getting a new roommate. She further stated, I remember talking to her (Resident #23) about a new roommate, but realize if it is not documented then it wasn't done.",2019-01-01
5527,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2015-11-19,157,E,1,0,TPT811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, review of on-line resources, and staff interview, the facility failed to promptly notify the attending physician/nurse practitioner of changes in condition of three (3) of five (5) sampled residents. Resident #99 experienced multiple days with low blood pressure ([MEDICAL CONDITION]) while being administered medication for high blood pressure (hypertension), had a decline in meal consumption, and experienced a weight loss. There was no evidence staff notified his physician and/or nurse practitioner about these issues. The physician and/or nurse practitioner were not notified when Resident #100, who had an indwelling Foley catheter, experienced signs and/or symptoms of a urinary tract infection. Resident #47's physician and/or nurse practitioner were not notified when he experienced a weight loss. Resident Identifiers: #99, #100, and #47. Facility Census: 98. a) Resident #99 1. [MEDICAL CONDITION] A review of Resident #99's medical record, at 1:10 p.m. on 11/17/15, found this [AGE] year-old male was hospitalized from [DATE] through 08/05/15. He entered the facility on 08/05/14 and returned home on 08/25/15 at 2:37 p.m. A review of Resident #99's physician orders, beginning on the day of admission, found Resident #99 was receiving 12.5 milligrams (mg) of [MEDICATION NAME] HCT 160 (an antihypertensive/diuretic combination drug) one time a day,12, and 12.5 mg of [MEDICATION NAME] (an antihypertensive medication) two (2) times a day. Resident #99 received both medications as ordered daily beginning on 08/06/15 through 08/24/15. (Antihypertensive medications are given to treat high blood pressure.) According to definitions provided by the Mayo Clinic, WebMd, the National Institutes of Health, and others, [MEDICAL CONDITION] is a blood pressure below 90 systolic or below 60 diastolic. A review of the resident's records found the following blood pressures which were considered in the [MEDICAL CONDITION] range, recorded for Resident #99: -- 08/14/15 at 12:18 a.m. - 89/87 -- 08/16/15 at 10:59 a.m. - 105/49 -- 08/17/15 at 12:24 a.m. - 82/58 -- 08/18/15 at 12:33 a.m. - 76/59 -- 08/21/15 at 2:12 p.m. - 88/50 -- 08/22/15 at 2:58 a.m. - 110/56 -- 08/22/15 at 12:13 p.m. - 98/56 -- 08/23/15 at 11:07 a.m. - 90/50 There was no evidence the physician or nurse practitioner (NP) were notified of Resident #99's low blood pressure readings which occurred between 08/14/15 and 08/23/15. An interview with the Director of Nursing (DON), at 9:30 a.m. on 11/19/15, confirmed the facility had not notified the physician and/or nurse practitioner about Resident #99's low blood pressure. The DON stated this was because, He only wants notified if something is going on with the resident. She indicated, Resident #99's baseline blood pressure was in the [MEDICAL CONDITION] range so they did not notify the physician or nurse practitioner. In an interview with the attending physician, at 3:00 p.m. on 11/19/15, when asked if he wanted to be notified if the resident was experiencing [MEDICAL CONDITION], he stated he would expect to be notified if the resident's systolic number was consistently (more than 2 or 3 days) below 90 or 95. He stated he would definitely want to be notified if the systolic number went below 80 just one time. The attending physician reviewed Resident #99's medical record during the telephone interview and stated, On the 18th is was below 80, so I should have been notified. The medical record contained no evidence the physician or nurse practitioner were notified of Resident #99's blood pressure on 08/18/15 when it was recorded as 76/59. 2) Weight Loss/Decreased Meal Intake A review of Resident #99's medical record, at 1:10 p.m. on 11/17/15, found the following recorded weights: -- 08/06/15 - 153.8 lb (pounds) -- 08/07/15 - 153.8 lb -- 08/09/15 - 154.8 lb -- 08/16/15 - 143.8 lb -- 08/17/15 - 146.2 lb -- 08/23/15 - 139 lb -- 08/25/15 - 141.1 lb and 141 lb From 08/06/15 to 08/16/15, the resident lost 10 pounds or 4.94 percent (%) of his body weight. From 08/06/15 to 08/23/15 the resident lost 14.8 pounds or 9.62% of his body weight. From 08/06/15 to 08/25/15, the resident lost 12.7 pounds or 8.3% of his body weight. (All percentages calculated using the formula: % of body weight loss = (usual weight - actual weight) / (usual weight) x 100) A review of Resident #99's meal intakes found that from 08/06/15 through 08/12/15, the resident's average meal consumption was 82.14%. His meal consumption percentage drastically declined from 08/13/15 through 08/24/15 to an average percentage of 25.44%. Review of Resident #99's progress notes found the following notations related to Resident #99's nutritional status: -- 08/12/15 at 11:31 a.m. - for a weight and nutrition meeting held on 08/11/15: Current status: 154.8 Weight history. status: 153.8 His IBW (ideal body weight) is 149 - 180 and BMI (body mass index) is 25 Average weekly intake of foods/fluids: He is currently receiving a NCS (no concentrated sweets) with ground meats no salt packets. His fluids intake is 1492 and meal intakes are 82%. Residents weight has been stable since admission. Will continue with the current interventions as the resident's weight is stable and he is within his ideal body weight -- 08/14/15 at 12:06 p.m. - Consumed less than 50% of meals will enc (encourage) intake at meal time. -- 08/15/15 at 2:37 p.m. - Consumed less than 50% of meals will enc intake at meal time. -- 08/16/15 at 12:04 p.m. - Consumed less than 50% of meal will enc intake at meal time. -- 08/17/15 at 11:43 a.m. - Consumed less than 50% of meals will encourage intake at meals. -- 08/19/15 at 4:04 p.m. - an Appointment/Outing Return note, following his return from a Modified [MEDICATION NAME] Study - . Recommendations: . Diet level Liquids Regular Dietary Supplement if pts (patients) oral intake continues to be poor recommend he be given a dietary supplement at least once a day,) -- 08/21/15 at 9:59 a.m. - a Multidisciplinary Care Conference note - .Response to treatment including dietary interventions: Patients weights are stable. He receives regular, ground meat diet, no added salt packet on tray, super cereal every day and pudding bid (twice a day) By this time, the resident had lost over 7 pounds in 11 days. There was no indication the physician and/or nurse practitioner were made aware of the resident's decreased intake and weight loss. There was no evidence of any discussion about whether he consumed the meals, super cereal and pudding at this conference. -- 08/25/15 at 2:18 p.m. - Late entry (name of nurse practitioner (NP) in facility yesterday 08/24/15 informed of weight loss, no new orders regarding weight status. The staff noted on 08/14/15 through 08/17/15 the resident consumed less than 50% of his meal, but failed to notify the physician and/or nurse practitioner and failed to put into place any interventions in an attempt to increase Resident #99's intake and prevent weight loss. On 08/16/15, the facility obtained Resident #99's weight, which represented a 10 pound weight loss or a loss 4.94% since admission and failed to notify the physician, the nurse practitioner, or the Registered Dietitian of the resident's declined intake status and weight loss at that time. It was not until 08/24/15, the day before Resident #99's scheduled discharged , that the facility notified the nurse practitioner, who provided no new orders in regards to the resident's weight loss. At 2:30 p.m. on 11/18/15, the Director of Nursing was asked to provide any information pertaining to the notification of Resident #99's attending physician and/or nurse practitioner in regards to the resident's weight loss or decreased meal intake. At the time of exit on 11/19/15 at 6:15 p.m., she had provided no further information. b) Resident #100 Review of Resident #100's medical record found this [AGE] year-old female, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Further review of Resident #100's medical record found she was admitted to the facility with an indwelling Foley catheter. A review of her care plan found the following goal related to Resident #100's indwelling catheter: Patient will show no s/sx (signs/symptoms) of urinary tract infection [MEDICAL CONDITION] through review date. This goal had a target date of 01/04/16. Interventions pertaining to this goal included, Document/report to physician s/sx UTI: burning, blood tinged urine, cloudiness, no output, deepening of urine color, increased temp. (temperature), urinary frequency, foul smelling urine, fever, chills, altered mental status, change in behavior, change in eating patterns. The nursing progress notes from 08/28/15 (the day of resident's readmission) through 09/09/15 (the day of resident's next discharge to an acute care hospital) found the following progress notes: -- 08/31/15 at 10:35 p.m. - Reason: odor to urine . action taken: patient continues with catheter, patent and draining amber colored urine. -- 09/06/15 at 11:11 p.m. - Reason: uncharacteristic odor of urine . Actions taken: patient urine with strong odor, yellow urine draining into bedside drainage bag There was no indication the facility notified the attending physician or the nurse practitioner when Resident #100's urine had an odor change and color change on 08/31/15, or when the urine had a change in odor on 09/06/15, as directed by her care plan as signs and symptoms of a UTI. Interviews with Clinical Care Supervisor (CCS) Registered Nurse (RN) #89 at 3:22 p.m., 4:05 p.m., and 5:30 p.m. on 11/19/15, confirmed the physician and/or nurse practitioner were not notified of the changes in the color and odor of the resident's urine on 08/31/15 and 09/06/15, as possible indicators of a urinary tract infection and as directed by the resident's care plan. . c) Resident #47 Review of the resident's medical records on 11/17/15 at 1:00 p.m., revealed this [AGE] year-old male, admitted to the facility on [DATE], had admission [DIAGNOSES REDACTED]. The review of medical records found a Physician's Determination of Capacity completed on 11/02/15. This form indicated Resident #47 demonstrated the capacity to make decisions. A review of Resident #47's weights in the electronic medical record found the following weights recorded: -- 10/23/15 at 6:18 p.m. - 254.1 lb (pounds) -- 10/25/15 at 11:03 a.m. - 254.2 lb -- 11/01/15 at 10:50 a.m. - 250.0 lb -- 11/01/15 at 10:51 a.m. - 254.0 lb -- 11/08/15 at 2:18 p.m. - 221.6 lb -- 11/10/15 at 1:18 p.m. - 215.9 lb -- 11/10/15 at 2:18 p.m. - 216.0 lb -- 11/15/15 at 1:25 p.m. - 213.6 lb From 11/01/15 to 11/08/15, the resident lost 32.4 pounds or 12.76 percent (%) of his body weight in 7 days. From 11/08/15 to 11/10/15 the resident lost 5.6 pounds or 2.5% of his body weight in 2 days. From 11/10/15 to 11/15/15 the resident lost 2.4 pounds or 1.11% of his body weight in 5 days. From 10/23/15 to 11/15/15 the resident lost 40.5 pounds or 15.94% in 23 days. Further review of Resident #47's medical records found no evidence the physician and/or nurse practitioner were notified of the severe weight loss of 12.76%, which occurred between 10/23/15 and 11/08/15, until 11/15/15. By the time the physician or nurse practitioner was notified of the resident's weight loss, the resident had lost another 3.61% of his total body weight.",2018-11-01
5574,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2014-12-12,157,D,0,1,VNJW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure the physician was notified of changes which required physician directives for two (2) residents identified through random opportunities for discovery. The physician was not notified when Resident #222 had [MEDICAL CONDITION] (a resting heart rate under 60 beats per minute). In addition, the physician was not notified when there was a need to alter Resident #1's order for enteral feedings. Resident identifiers: #222 and #1. Facility census: 154. Findings include: a) Resident #222 Review of the medical record revealed no evidence the physician or nurse practitioner was notified of Resident #222's [MEDICAL CONDITION] (a resting heart rate under 60 beats per minute). According to the MAR indicated [REDACTED]. The electronic medical record (EMR) contained documentation of a pulse of 56 bpm at 12:37 p.m. on 11/11/14 and 42 bpm at 6:00 p.m. In addition, the EMR indicated the resident's pulse was 43 bpm on 11/12/14 at 1:20 a.m. There was no evidence the physician or nurse practitioner was notified the resident was experiencing [MEDICAL CONDITION] until 11/13/14, when the resident's pulse was 48 bpm at 9:50 a.m. On 11/13/14 new orders were received from the nurse practitioner to (typed as written), D/C [MEDICATION NAME], (due to) decrease (indicated by a downward pointing arrow) HR (heart rate) and BP (blood pressure). Decrease (indicated by a downward pointing arrow) [MEDICATION NAME] to 50 mg po daily hold SBP (systolic blood pressure) Interview with DON, at 8:25 a.m. on 12/08/14, confirmed the physician/nurse practitioner was not notified of the Resident #222's [MEDICAL CONDITION] until 11/13/14 when new orders were given by the nurse practitioner. b) Resident #1 Observation of the resident, at 10:16 a.m. on 12/02/14, with licensed practical nurse (LPN), Employee #154 found a bag of [MEDICATION NAME] 1.5 infusing. The [MEDICATION NAME] 1.5 was dated 11/30/14 at 8:00 p.m. It contained approximately 300 milliliters (ml) of the tube feeding formula. Upon inquiry, Employee #154 stated the date on the feeding must be incorrect. Review of the physician's orders [REDACTED]. The total nutrient was 1170 ml every 24 hours. Each ready to hang bag of [MEDICATION NAME] 1.5 contained 1500 ml. If the bag of [MEDICATION NAME] 1.5 was infused according to the physician's orders [REDACTED]. The next bag of [MEDICATION NAME] 1.5 should have already been in use. During the review of the physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED]. There was no indication the resident's tube feeding was resumed after he returned from the physician's visit at 3:33 p.m. on 12/01/14. During an interview with the director of nursing (DON), at 11:07 a.m. on 12/4/14, she stated, We should have called the doctor or had some kind of an order, we will get one.",2018-09-01
5679,NELLA'S NURSING HOME,5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2015-09-03,157,D,1,0,XCLN11,"Based on review of incident reports, medical record review, and staff interview, the facility failed to promptly notify one (1) of three (3) residents' legal representatives when there was an accident involving injury, a need to significantly alter treatment, and/or a need for physician intervention. The resident suffered an injury during an elopement from the facility. Because of aggressive behaviors during the elopement, the facility also decided to discharge the resident. The responsible party was not informed of any of these issues in a timely manner. Resident identifier: #76. Facility census: 74 Findings include: a) Resident #76 Accident/incident reports from June, July, and (MONTH) (YEAR) were reviewed on 08/31/15 at 1:37 p.m. The review found Resident #76 suffered a scrape to a knuckle on his left hand during an elopement from the facility on 07/20/15 at 3:20 a.m. Due to his aggressive behaviors during the elopement, the facility made the decision to send the resident to a regional hospital emergency room to be evaluated for possible readmission, assessment, and treatment at the hospital's behavioral health unit. The report did not indicate the date or time the responsible party was notified. Review of the resident's medical record found the responsible party was not notified until 9:45 a.m., over six (6) hours later. Since the notification of the incident itself was delayed, the responsible party found out about the elopement, the injury, the aggressive behavior, and the soon to be initiated transfer to the regional hospital all at the same time, and after the decision was already made to discharge Resident #76. On 09/03/15, at approximately 10:00 a.m., the director of nursing was interviewed. He acknowledged the incident was at 3:20 a.m., yet the resident's responsible party was not notified until 9:45 a.m.",2018-09-01
5838,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2015-01-09,157,D,0,1,RXZ911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and observation, the facility failed to notify the resident/responsible party of the presence of wounds upon admission to the facility. This affected one (1) resident during a random opportunity of discovery (wound dressing). Resident identifier: #52. Facility census: 15. Findings include: a) Resident #52 This resident was admitted to the facility on [DATE]. According to the nursing admission skin assessment, he was admitted with an area on the top of the left foot (at the base of the leg) which measured 2 centimeters (cm) in length and 0.25 cm in width with a scab described as an abrasion. Additionally, Resident #52 had an area on the left heel described as tissue is purple/maroon in color and measures 1 cm in length and 1 cm in width. The wound treatments for Resident #52 were observed on 01/07/15 at 2:17 p.m. The treatments were performed by Employee #39, licensed practical nurse (LPN). During observation of the treatment, it was noted the resident asked the nurse, What are you looking at? Employee #39 responded, You have wounds on the top of your left foot and heel. The resident indicated he was unaware of having any wounds on his left foot at all. Interview with Employee #31, registered nurse (RN), the admission nurse, on 01/07/15 at 2:40 p.m., revealed she had not informed the resident and/or the responsible party of the wounds which were present on admission to the facility. On 01/07/15 at 3:15 p.m., an interview with the clinical director confirmed the resident/responsible party should have been informed of the wounds which were present on admission.",2018-07-01
5897,GRANT COUNTY NURSING HOME,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2015-07-01,157,D,1,0,LIFD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to ensure a resident's responsible party/family and/or physician were notified in a timely manner when a resident had an accident resulting in injury. Resident #107 had a witnessed fall resulting in a hematoma on the back of her head, Resident #11 had an unwitnessed fall with a possible head injury, and Resident #45 had a fall at which time small lumps were noted on both sides of his head. This was true for three (3) of eight (8) residents reviewed for timely notification to physician/family of residents' changes in condition. Resident identifiers: #107, #11, and #45. Facility census: 104. Findings include: a) Resident #107 Review of medical records on 06/29/15 at 2:00 p.m., revealed Resident #107 fell on [DATE] at 10:35 p.m. The fall was observed and described as the resident losing her balance and falling to the floor. The nursing assessment revealed a hematoma to the back of the resident's head, an abrasion to her back (along her spine), and the resident's coccyx area appearing red. Licensed Practical Nurses (LPN) #141 and #146 assessed the resident. The assessment was reported to Registered Nurse (RN) #148 who decided it was not necessary to call the physician at the time of the fall incident. Following the incident, neurological checks were completed according to facility policy/procedures. At 6:25 a.m. on 06/11/15, the resident assessment revealed a temperature of 101.4 Fahrenheit (F). She had a small amount of emesis, and had decreased breath sounds in the right lung. According to a nursing note dated 06/11/15 at 6:45 a.m., a message concerning the resident's condition was left with both the resident's physician and her power of attorney (POA). At 07:58 a.m. on 06/11/15, a nursing entry noted the on-call doctor was contacted and informed of the resident's fall at 10:35 p.m. on 06/10/15, and of the resident's condition failing to improve. At 8:00 a.m. on 06/11/15, the physician ordered the resident sent to the emergency room for evaluation. The facility protocol for notifying the attending physician of changes in a resident's medical/mental condition, received from the director of nursing (DON) on 06/30/15 at 3:25 p.m., revealed, Our facility shall promptly notify the resident, his or her Attending Physician, and representative (sponsor) of changes in the resident's medical/mental condition and/or status. The facility did not attempt to call the physician or inform the power of attorney (sponsor) of Resident #107's fall with head injury for eight (8) hours after the fall and did not actually verbally interact with a physician until at least nine (9) hours after the fall. b) Resident #11 A review of the medical record revealed Resident #11 was an [AGE] year-old female admitted to the facility on [DATE], with diagnoses, including dementia, alcoholism, [MEDICAL CONDITION], anxiety, and depression. The resident had been determined by her physician to lack the capacity to form health care decisions, but was verbal and able to make her needs known. She was ambulatory with a walker for short distances and able to feed herself. An incident report completed by Licensed Practical Nurse (LPN) #74 indicated at 09:35 p.m. on 04/09/15, Resident #11 was found sitting crossed legged on the floor beside her bed. States she slipped and fell hitting the back of her head. An untimed Late Entry was entered the into the record on 04/10/15, but there was no evidence, the physician or the responsible party had been notified of the incident until 3:50 p.m. on 04/10/15, when the physician was contacted after the resident complained of pain in her wrist. During an interview with the director of nurses at 4:00 p.m. on 06/30/15, she acknowledged after reviewing the record, the family nor the physician had been notified at the time of the fall, even though the resident had stated she hit her head. The nurses started neurological checks on the resident. She reviewed the Change of Condition Policy also and agreed it instructed the nursing staff to report all falls to both the physician and the responsible party. c) Resident #45 A review of the medical record for Resident #45 revealed he was a [AGE] year-old male admitted to the facility on [DATE]. He was identified as a high risk for falls as he frequently attempted to self-ambulate. An incident report submitted by Employee #11 (LPN) indicated he had been found lying on the floor in the bathroom at 12:35 p.m. on 04/18/15. He was assessed by the nurse and has small lumps to both sides of head. An entry in the nurses' notes at that same time also stated the resident had a lump on both sides of his head. An entry in the nurses' notes at 3:20 p.m. on 04/18/15 indicated the resident's Power of Attorney had been notified, but neither the notes nor the incident report had any evidence the physician had been notified of the fall. During an interview with the director of nurses at 4:00 p.m. on 06/30/15, she acknowledged after reviewing the record, the physician had not been notified at the time of the fall, even though the resident had lumps on his head. The nurses had started neurological checks on the resident. She reviewed the Change of Condition Policy also, and agreed it instructed the nursing staff to report all falls to both the physician and the responsible party.",2018-07-01
6138,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2014-10-07,157,D,0,1,BVWT11,"**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 two (2) sampled residents reviewed for the care area of notification of change during Stage 2 of the Quality Indicator Survey (QIS) was notified of a change in treatment. An outside physician ordered antibiotic therapy after performing a procedure at a hospital. There was no evidence the resident's attending physician was made aware of this order. Resident Identifier: #43. Facility Census: 90. Findings Include: a) Resident #43 A review of Resident #43's Medication Administration Record [REDACTED]. She received this medication for five (5) days. Further review of Resident #43's medical record, revealed she had a [MEDICAL CONDITION] removed from her lip on 08/04/14 at an area hospital. Upon her return to the facility on [DATE], the physician who removed the [MEDICAL CONDITION] sent a prescription for the Keflex 500 mg every six (6) hours for five (5) days. The facility administered this medication as ordered by the outside physician. There was no evidence to suggest Resident #43's attending physician at the facility was notified of Resident #43 receiving Keflex as ordered by the outside physician. At 9:25 a.m. on 10/07/14, Licensed Practical Nurse (LPN) #31, was asked what the process was when a resident returned from a procedure with new medication orders from an outside physician. She stated the nurses were to call the attending physician and write a telephone order for the medication if the attending physician agreed with the order. She reviewed Resident #43's medical record and confirmed there was not a telephone order for the Keflex. She then confirmed there was no evidence in the medical record to suggest Resident #43's attending physician was notified of her antibiotic therapy. At 10:30 a.m. on 10/07/14, the Director of Nursing (DON) was asked what the process was when a resident returned from a procedure with new medication orders from an outside physician. The DON stated, The process is we will get the information from the consultation and phone the attending physician and document in the resident's chart where the physician was notified of the changes to the resident's medication regimen. He reviewed Resident #43's medical record and confirmed there was no evidence to support her attending physician was notified of her antibiotic therapy.",2018-05-01
6158,MONTGOMERY GENERAL ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2014-08-26,157,D,0,1,6MJ711,"Based on medical review and staff interview, the facility failed to notify the physician after Resident #27 experienced a significant change in condition. The resident experienced two (2) falls in a week, then had an onset of a new behavior. The physician was not notified of the onset of the new behavior. This was true for one (1) of sixteen (16) sampled residents. Resident identifier: #27. Facility Census: 55. Findings Include: a) Resident #27 Medical record review, at 9:10 a.m. on 08/26/14, found Resident #27's Minimum Data Set (MDS), with an assessment reference date (ARD) of 08/02/14, identified the resident was independent with bed mobility, transfers, and ambulation. No falls were coded as having occurred in the last quarter. Review of the nurses' notes revealed Resident #27 had a fall on 08/18/14 at 8:45 p.m. and on 08/21/14 at 6:00 p.m. The attending physician was notified after each fall. On 08/23/14 at 10:10 p.m., the resident was noted multiple times during the 3-11 p.m. shift to be repeatedly taking her clothes off. There was no indication the physician was notified concerning the onset of a change in the resident's behavior. In an interview on 08/26/14 at 11:30 a.m., Employee #51, the director of nursing (DON), confirmed the physician had not been notified after the resident experienced an onset of a new behavior after experiencing two (2) falls in the last week. She further confirmed the staff should have notified the physician of this change in condition because this was not normal behavior for her.",2018-05-01
6201,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2015-05-14,157,D,0,1,5FNV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately consult with residents' physicians when a significant change occurred in the physical conditions for two (2) of seven (7) residents whose medications were reviewed. Neither residents' physician was notified when their blood pressures were outside of the parameters established by their physician. Resident identifiers: #32 and #50. Facility census: 111. Findings include: a) Resident #32 On 04/23/15 at 8:07 a.m., a review of the medical record revealed Resident #32 had [DIAGNOSES REDACTED]. Resident #32 was admitted to the facility on [DATE]. A review of the physician's orders [REDACTED]. In addition, the admission physician orders, in the section entitled Ancillary Orders, noted vital signs (BP (blood pressure), pulse, respirations, and temperature) were ordered every shift x (times) 14 days then once weekly x 4 weeks then every month - notify MD (medical doctor) if SBP (systolic BP) > (greater than) 180 or 90 or 180 or 90 or A continued review of the medial record revealed vital signs (VS) were recorded in the nurses' notes. Review of the nurses' notes, for the period from 03/18/15 through 04/22/15, revealed the following blood pressures which were outside of the parameters for which the physician needed contacted: 03/18/15 at 1:20 a.m., BP 88/58 SBP 03/19/15 at 2:00 a.m., BP 128/95 DBP >90 03/19/15 at 4:30 a.m., BP 85/59 SBP 03/24/15 at 9:00 a.m., BP 102/48 DBP 03/25/15 at 3:00 a.m., BP 82/55 SBP 03/30/15 at 2:45 a.m., BP 86/63 SBP 03/31/15 at 4:00 a.m., BP 86/64 SBP 04/06/15 at 9:00 a.m., BP 138/96 DBP >90 04/10/15 at 1:00 a.m., BP 84/64 SBP 04/14/15 at 1:00 a.m., BP 88/63 SBP 04/14/15 at 10:25 a.m.BP 161/91 DBP >90 04/17/15 at 4:00 a.m., BP 60/37 SBP 04/18/15 at 2:55 a.m., BP 87/57 SBP 04/22/15 at 3:10 a.m., BP 88/49 SBP 04/22/15 at 2:25 a.m., BP 80/44 SBP There was no evidence the physician was notified of these critical BPs for which the physician should have been contacted. On 04/23/15 at 4:09 p.m., a discussion was conducted with licensed practical nurse (LPN) #60 and Registered Nurse (RN) #43. Upon inquiry, LPN #60 did not offer any explanation regarding why the physician was not notified of the critical BPs. The LPN stated VS, which included the BP, were taken twice daily for residents receiving skilled services. RN #43 stated the night shift nurse should have notified the physician of the low BPs. The RN confirmed the physician was not notified. b) Resident #50 On 04/27/15 at 10:23 a.m., a review of the medical record revealed Resident #50 had [DIAGNOSES REDACTED]. Resident #50 was admitted to the facility on [DATE]. A review, of the physician's orders [REDACTED]. On 03/28/15, the physician increased the [MEDICATION NAME] from 25 mg twice daily to 50 mg twice daily. On 04/15/15, the physician increased the dose of [MEDICATION NAME] to 75 mg twice daily. The physician also ordered the resident's BP to be taken twice a day for one (1) week. The March 2015 recapitulation (recap) orders, in the section Ancillary Orders, noted vital signs were ordered every shift x 14 days then once weekly x 4 weeks then every month - notify MD (medical doctor) if SBP >180 or 90 or 180 or 90 or There was no evidence the physician was notified of any of the following critical blood pressures between 02/08/15 and 04/23/15. 02/08/15 at 10:30 a.m., BP 149/93 DBP >90 02/10/15 at 2:00 p.m., BP 161/99 DBP >90 02/11/15 at 1:30 p.m., BP 148/96 DBP >90 02/13/15 at 4:00 a.m., BP 193/105 SBP >180 and DBP >90 02/13/15 at 12:35 p.m., BP 150/100 DBP >90 02/15/15 at 11:00 a.m., BP 157/84 DBP >90 02/17/15 at 1:35 a.m., BP 151/95 DBP >90 02/17/15 at 10:45 a.m., BP 170/98 DBP >90 02/18/15 at 1:25 p.m., BP 157/99 DBP >90 02/19/15 at 11:20 a.m., BP 184/87 SBP >180 02/20/15 at 2:00 a.m., BP 154/97 DBP >90 02/20/15 at 10:40 a.m., BP 169/98 DBP >90 02/21/15 at 10:30 a.m., BP 170/99 DBP >90 02/22/15 at 10:20 a.m., BP 170/97 DBP >90 02/23/15 at 2:10 a.m., BP 169/98 DBP >90 02/24/15 at 10:10 a.m., BP 151/97 DBP >90 02/25/15 at 4:00 p.m., BP 188/95 SBP >180 and DBP >90 02/27/15 at 3:15 a.m., BP 189/81 SBP >180 and DBP >90 02/27/15 at 10:30 a.m., BP 167/96 DBP >90 02/28/15 at 4:00 a.m., BP 169/92 DBP >90 02/28/15 at 1:30 p.m., BP 156/98 DBP >90 03/03/15 at 10:20 a.m., BP 204/96 SBP >180 and DBP >90 03/04/15 at 11:00 a.m., BP 175/94 DBP >90 03/06/15 at 2:20 a.m., BP 190/102 SBP >180 and DBP >90 03/07/15 at 2:05 a.m., BP 193/95 SBP >180 and DBP >90 03/08/15 at 1:25 a.m., BP 191/98 SBP >180 and DBP >90 03/11/15 at 4:00 a.m., BP 152/92 DBP >90 03/11/15 at 1:20 p.m., BP 199/93 SBP >180 and DBP >90 03/16/15 at 10:30 a.m., BP 201/94 SBP >180 and DBP >90 03/19/15 at 2:00 a.m., BP 150/98 DBP >90 03/21/15 at 2:30 a.m., BP 172/95 DBP >90 03/21/15 at 10:25 a.m., BP 191/97 SBP >180 and DBP >90 03/22/15 at 11:00 a.m., BP 185/97 SBP >180 and DBP >90 03/23/15 at 2:25 a.m., BP 148/96 DBP >90 03/25/15 at 10:25 a.m., BP 190/90 SBP >180 03/26/15 at 11:15 a.m., BP 190/90 SBP >180 03/28/15 at 1:00 p.m., BP 162/94 DBP >90 03/31/14 at 10:15 a.m., BP 190/84 SBP >180 04/02/15 at 9:00 a.m., BP 167/108 DBP >90 04/02/15 at 10:00 a.m., BP 156/100 DBP >90 04/06/15 at 9:00 a.m., BP 157/100 DBP >90 04/11/15 at 9:00 a.m., BP 198/96 SBP >180 and DBP >90 04/12/15 at 9:00 a.m., BP 190/98 DBP >90 04/12/15 at 2:00 p.m., BP 164/98 DBP >90 04/15/15 at 9:00 a.m., BP 202/110 SBP >180 and DBP >90 04/16/15 at 7:00 a.m., BP 155/98 DBP >90 04/21/15 at 3:40 p.m., BP 166/97 DBP >90 04/23/15 at 11:05 a.m., BP 155/104 DBP >90",2018-05-01
6307,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2015-04-28,157,E,1,0,J5M711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the family and/or responsible party of changes in condition in a timely manner for one (1) of ten (10) residents reviewed during a complaint survey ending on 04/28/15. There was no evidence Resident #87's family and/or responsible party was notified on multiple occasions when the resident had medication and diet changes, weight loss, and injuries of unknown origin. Resident identifier: #87. Facility census: 86. Findings include: a) Resident #87 Review of Resident #87's medical record, on 04/22/15 at 1:00 p.m., revealed the resident was admitted to the facility on [DATE] at 2:40 p.m. This ninety-one year old female had [DIAGNOSES REDACTED]. Further review of medical records, on 04/23/15, found a Brief Interview for Mental Status (BIMS) completed on 01/28/15. The BIMS score was eight (8). This score indicated a moderately impaired cognitive status. The resident's medical record indicated her son was appointed the Medical Power of Attorney (MPOA). Review of the medical records found no evidence Resident #87's MPOA was notified of the following changes in the resident's medication and diet, weight loss, and injury of unknown origin: - 01/26/15 at 2:40 p.m. - An order noted on admission for [MEDICATION NAME] 5/325 milligrams (mg) by mouth (po); give 0.5 (1/2) tablet every eight (8) hours as needed (prn). On 01/27/15 at 7:49 a.m., a clarification order for [MEDICATION NAME] 5/325 mg every 8 hours as needed for pain. Previous order for 1/2 tablet of [MEDICATION NAME] (2.5 mg) was discontinued. - 01/28/15 at 12:00 p.m. - The resident was seen by the Physician Assistant (PA). The PA's progress note read, . Patient seen today for lethargy . She was started on [MEDICATION NAME] 5/325 mg yesterday and today nursing noted this change and wanted her evaluated. She reports no pain complaints and is difficult to arouse but will speak. Assessment /Plan and Other information: 1) Lethargy: likely related to narcotic will hold today and cut dose to 2.5 mg one tablet po three times a day (tid) prn. Will monitor and discussed this with charge nurse. - 02/01/15 at 1:16 p.m. - The resident had three (3) loose, foul smelling stools. Physician was notified of the loose stool. New orders were obtained to stop [MEDICATION NAME] and obtain a stool sample for [MEDICAL CONDITIONS] to rule out [MEDICAL CONDITIONS]. - 02/04/15 - A new order was added for house supplement three (3) times daily with snacks - 02/11/15 at 2:37 - An order was written to decrease [MEDICATION NAME] to 0.5 mg by mouth (po) tid (three times a day). - 02/13/15 - The resident was seen by the psychiatrist in the facility. New orders were written to increase [MEDICATION NAME] to 20 mg po daily in the morning and increase [MEDICATION NAME] (antidepressant) to 30 mg po daily at night. - 02/22/15 at 10:34 a.m. - The resident was on [MEDICATION NAME] for pneumonia. The laboratory notified the facility of critical lab results. The urine culture showed bacteria that produced enzymes called extended-spectrum beta-lactamases (ESBLs). These are resistant to many [MEDICATION NAME] and cephalosporin antibiotics as well as other types of antibiotics. The white blood count (WBC) was 17.5 (normal value is 3.3 - 8.7). A Brain Natriuretic Peptide (BNP) Test result was 1433. BNP levels above 900 indicate severe heart failure. - 02/23/15 - New orders were written to discontinue [MEDICATION NAME] (antibiotic) and start [MEDICATION NAME] (antibiotic) 100 mg po twice daily for seven (7) days for treatment of [REDACTED]. - 03/06/15 - The physician was in the facility to examine the resident. New orders were written to change accuchecks to two (2) hours after the meal one (1) time daily and to use the standard sliding scale coverage. The order also indicated to repeat the hemoglobin A1c (HgbA1C) test, for [DIAGNOSES REDACTED]. - 03/09/15 at 2:40 p.m. - The PA was in the facility to examine the resident. A new order was written to obtain a Chest X-ray due to resident coughing. - 03/09/15 at 11:18 a.m. - Weight warning. Value: 87.8 pounds (#) obtained on 03/02/15 at 3:00 p.m. Minimum Data Set (MDS): loss of 5% change over thirty (30) days (9.5% or 9.2#) Loss of 7.5% change (9.5% or 9.2 #). Residents weight is the same as previous evaluation at 87#. Resident's appetite is fair with assistance from staff - 03/13/15 - The resident was seen by the psychiatrist in the facility. New orders were written to start [MEDICATION NAME] 5 mg po every night. - 03/18/15 at 11:00 a.m. - New orders from the Speech Therapist were written to discontinue nectar thickened liquids and to start honey thickened liquids. - 03/21/15 at 5:57 p.m. - The resident was screaming and indicated she was having pain in her right upper quadrant. The nurse's evaluation revealed the resident had a knot located underneath her rib cage on the right side. She was sent to the emergency room (ER). The resident returned to the facility at 11:35 p.m. Documentation from the ER physician indicated Resident #87's chief complaint was right rib pain. The discharge [DIAGNOSES REDACTED]. Instructions for the treatment of [REDACTED]. The MPOA was not notified of the hospital's findings On 04/24/15 at 10:30 a.m., the medical record was reviewed with the Director of Nursing (DON) related to the changes in Resident #87's condition. The DON verified the facility had no evidence the MPOA was notified of any of the changes in Resident #87's condition.",2018-04-01
6352,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,157,D,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to immediately inform a resident, identified through a random opportunity for discovery, when an accident resulted in bruising to her thigh and required physician intervention. The accident occurred while the resident was being lifted with a mechanical lift. The resident had no feeling in her lower extremities, so she was unaware the injury had occurred. Resident identifier: #26. Facility census: 61. Findings include: a) Resident #26 A review of medical records, on 05/21/14 at 2:30 p.m., revealed Resident #26 was a forty-seven (47) year old female admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Her admission comprehensive assessment, with an assessment reference date (ARD) of 12/12/13, indicated she had a Brief Interview for Mental Status (BIMS) score of 15, which indicated the resident was cognitively intact. The physician had determined the resident had capacity to make her own health care decisions. A nurse's note, entered on 12/01/13 at 4:07 p.m., by Employee #42, a licensed practical nurse (LPN), included: Type of nurse's note: Occurrence. Type of occurrence: bruising observed to left thigh (rear). Vital signs: blood pressure 116/73, temperature 97.4, pulse 85, respirations 20 and oxygen saturation on room air 93%. Nursing Assessment: purple bruising to left thigh 2 cm in length x 1 cm width with blistered area in center, skin intact. Actions taken: instruct staff to use caution with lift pads and report any further injuries. Treatment ordered: None. Attending physician notified. Equipment involved: full body lift pad. Further review found Resident #26 had not been notified of the presence of a wound on her left rear thigh, which was noted at 4:07 p.m. on 12/01/13, until 8:47 a.m. on 12/02/13. An interview with the resident, on 05/20/14 at 10:15 a.m., revealed the resident did not realize the injury had occurred because she had no feeling from her waist down due to paralysis. Employee #72, the director of nursing (DON), was interviewed on 05/27/14 at 2:00 p.m., concerning the delay in notifying the resident of the wound which occurred on 12/01/13. She said, I don't know. I was on medical leave until February 2014. She said, I signed them (the incident reports) electronically from home.",2018-04-01
6408,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2014-04-17,157,D,0,1,YDCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's standing orders, and staff interview, the facility failed to ensure the resident's physician was notified when a change in condition occurred. Residents #128 and #60 were transferred to the hospital as a result of a change in condition. The facility was unable to provide evidence the physician was aware of the significant changes in the residents' conditions resulting in the decision to transfer the residents to the hospital. This was true for two (2) of two (2) residents reviewed for changes in condition during Stage 2 of the Quality Indicator Survey. Resident identifiers: #128 and #60. Facility census: 114. Findings include: a) Resident #128 Review of the medical record on the afternoon of 04/16/14 found the resident was admitted to the facility on [DATE]. On 03/05/13 the resident was discharged to the hospital. Further review of all the nurses' notes, recorded on 03/05/13, found the following entries: - 03/05/14 at 2:25 p.m., Resident very lethargic this shift. This AM (morning) she was up ambulating hallway as she chose with steady gate observed. At lunch time resident was observed to be sleeping at table with head hung down and playing in her food. Residents vital signs are within normal range for this resident. Resident denies any pain at this time. Will continue to monitor. - 03/05/14 at 3:09 p.m., Resident more lethargic than she was. Resident now leaning sideways not at her baseline. Resident is normally up ambulating where ever she wants. I called the case manager and told her I was sending resident to (initials of the hospital) via (initials of the ambulance service) for evaluation. Called MPOA (medical power of attorney), (name of MPOA) left message for him to call the facility back. - 03/05/14 at 4:50 p.m., At 3:40 p.m. I called (initials of ambulance service) to transport resident to the (initials of hospital) ER (emergency room ) for evaluation. (Initials of ambulance service) in facility at 4:40 p.m. to transport to (initials of hospital) ER out of facility at 4:50 p.m. in route to (initials of hospital) I did try to call MPOA again but did not get any answer. Will continue to try to get in touch with MPOA. - 03/05/14 at 5:38 p.m., I called MPOA (name of MPOA) again and did get to speak with him I made him aware of residents condition and that I sent her to the ER for evaluation. I also gave (name of MPOA) the phone number to (initials of hospital) so he could call and check on her. Review of the hospital discharge summary, dated 03/07/14, found Resident #128 was admitted to the hospital on [DATE] for leukocytosis (elevated number of white cells in the blood) and was started on the antibiotic [MEDICATION NAME]. The resident returned to the facility on [DATE]. At 3:13 p.m. on 04/16/14, Employee #3, the director of nursing (DON), and Employee #97, the registered nurse case manager were interviewed. These employees were unable to provide evidence the resident's physician was notified of the transfer / admission to the hospital. Employee #3, the DON, provided a copy of the physician's standing orders which directed, All changes in the resident's condition must be reported to the physician, RN (registered nurse) on duty or RN on call and the resident's health care representative. . b) Resident #60 Review of Resident #60's medical record, on 04/17/14 at 1:00 p.m., revealed a nurse's note written by Employee #103, licensed practical nurse, (LPN) dated 04/13/14 at 11:11 p.m This note (typed as written) included, Staff observed resident's abdomen to be very distended and hard this shift. PEG (percutaneous endoscopic gastrostomy) tube placement checked, placement was good with no residual. Nurse gave resident medications through PEG tube and resident immediately vomited up the medications. Contacted POA and advised was sending resident to ER (emergency room ) to be checked out. Further record review found no evidence the physician was notified of the resident's change in condition. In an interview with Employee #3, the director of nursing (DON), 04/17/14 at 2:30 p.m., she verified there was no evidence the physician was notified of Resident #60's change in condition, or of her transfer to the emergency room .",2018-04-01
6421,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,157,E,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the attending physician and healthcare decision makers were promptly notified when there was a change in the health status of two (2) of five (5) sampled residents. Resident #59 complained of pain on several occasions for which the attending physician and/or the healthcare decision maker were not promptly notified. Resident #7 had weight losses for which the attending physician and the healthcare decision maker were not promptly notified. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 1. Review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found three (3) instances in August 2014 when Resident #59 made complaints of pain. On 08/20/14, 08/21/14, and 08/26/14, the resident complained of bilateral lower extremity pain. There was no evidence the attending physician and the healthcare decision maker were notified of the pain. 2. The medical record revealed Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14. There was no evidence Resident #59's attending physician was notified of the resident's daily pain until the morning of 09/08/14. In addition, there was no evidence Resident #59's healthcare decision maker was ever made aware of these daily complaints of pain. -- On 09/03/14 at 3:43 a.m., Licensed Practical Nurse (LPN) #60 noted Resident #59 received her prescribed as needed (PRN) pain medication twice that shift for complaints of abdominal pain. -- On 09/04/14 at 1:43 a.m., LPN #60 noted Resident #59 had complaints of abdominal pain and was given the PRN pain medication. -- On 09/05/14, Resident #59's Medication Administration Record [REDACTED]. -- On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. -- On 09/07/14, Resident #59's MAR indicated [REDACTED]. -- On 09/08/14 at 4:02 a.m., Resident #59's MAR indicated [REDACTED]. -- On 09/08/14 at 10:38 a.m., Registered Nurse (RN) #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain. This was the first time there was evidence the physician was made aware of the resident's complaints of pain, which began on 09/03/14. -- On 09/08/14 at 1:36 p.m., the resident received a second dose of PRN [MEDICATION NAME] for complaints of pain to the right side. The medical record indicated the resident was crying at that time. 3. At 10:54 a.m. on 10/06/14, LPN #5 noted Resident #59 had constant complaints that her side hurt. LPN #5 indicated the resident had been medicated by the medication nurse. The note indicated the LPN spoke with the resident's healthcare decision maker about the resident's complaints of pain, but there was no evidence the physician was contacted. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7, noted Resident #59 was guarding her stomach and crying in pain. The LPN noted this had been going on for the last two (2) nights. There was no evidence the physician or healthcare decision maker were notified of the resident's abdominal pain the last two (2) nights (10/04/14 and 10/05/14). LPN #7's note on 10/06/14 was the first mention Resident #59 experienced pain the nights of 10/04/14 and 10/05/14. The note dated 10/06/14 indicated a request was made for the physician to evaluate the resident's pain. The heath care decision maker also was not made aware of Resident #59's complaints of pain, on 10/04/14 and 10/05/14, until LPN #5 telephoned him at 10:54 a.m. on 10/06/14. 4. These failures to notify the physician and healthcare decision maker of Resident #59's pain were reviewed with the Director of Nursing and the Clinical Service Manager at 4:30 p.m. on 03/05/15. They were unable to provide evidence Resident #59's attending physician and healthcare decision maker were promptly notified of the resident's complaints of pain in August, September, and October 2014. b) Resident #7 A review of Resident #7's medical record, at 9:46 a.m. on 03/03/15, revealed the resident was admitted to the facility on [DATE]. She was discharged to the hospital on [DATE], then readmitted to the facility on [DATE], where she remained with no further discharges as of the time of the survey. Medical records contained several documented weights for Resident #7. The records indicated they were obtained at the facility through the use of a mechanical lift: -- 02/04/15 - 190.6 pounds (admission) to the facility). -- 02/09/15 - 191.8 pounds (the resident was in the hospital on this date) -- 02/11/15, 181.7 pounds (readmission weight) -- 02/20/15, 171.7 pounds (a severe weight loss of 5.5% in nine (9) days) -- 02/24/15, 158.4 pounds (a severe weight loss of 7.74% in four (4) days) -- 03/01/15, 153.2 pounds (a severe weight loss of 5.2% in five (5) days) On 03/03/15, review of the medical record found on 02/16/15, the physician and the medical power of attorney (MPOA) were notified the resident had a weight loss. There was no evidence the physician or the MPOA were notified the resident's weight records showed the resident had additional weight losses, each severe, recorded on 02/20/15, 02/24/15, and 03/01/15. In an interview with the Director of Nursing (DON) at 2:28 p.m. on 03/04/15, when asked if Resident #7's physician and MPOA were notified of the resident's continued weight losses since the notification on 02/16/15, the DON confirmed there was no evidence which indicated the physician and MPOA had been notified since 02/16/15. She confirmed Resident #7 had three (3) additional weights recorded since their notification on 02/16/15, which demonstrated additional weight losses. The DON confirmed the physician and Resident #7's MPOA should have been notified of each loss. .",2018-03-01
6442,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2015-03-31,157,D,1,0,O4DK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible party of changes in health status for Resident #157 on two (2) separate occasions. This was true for one (1) of eight (8) residents reviewed. Resident identifier: #157. Facility census: 156. Findings include: a) Resident #157 On 03/24/15 at 10:45 a.m., a review of Resident #157's medical record found this [AGE] year-old male was admitted to the facility on [DATE]. Further review of the medical record found upon admission to the facility, Resident #157's physician determined the resident did not have capacity to make informed medical decisions. A health care surrogate (HCS) was appointed to act on the resident's behalf. 1. On 03/24/15 at 11:30 a.m., review of nurses' progress notes for Resident #157 found a note written by Licensed Practical Nurse (LPN) #127, dated 12/19/14 at 4:38 p.m. The note included, CBC (Complete blood count) and BMP (basic metabolic panel) was reviewed by MD (medical doctor) and resident was seen and evaluated by MD with new orders to repeat the CBC and BMP in 2 weeks d/t (due to) [MEDICAL CONDITION] and hypertension. [MEDICATION NAME] 5/325 mg (milligrams) every 6 hours as needed for pain and discontinue [MEDICATION NAME] when [MEDICATION NAME] available There was no evidence of notification of the HCS regarding the resident's change of condition. 2. Further review, on 03/24/15, found another progress note, labeled Change of Condition, written by Registered Nurse (RN) #7. The nurse noted, 12/28/14 at 1:49 a.m. Patient has exhibited signs of flank pain, abdominal pain, agitation, exhaustion, [MEDICAL CONDITION], decreased urine output, diaphoresis, and increased respirations . Gastrointestinal: abdominal pain/tenderness, abdominal distention. [MEDICAL CONDITION]: pain/burning/itching, difficulty voiding, concentrated urine, and decreased urine output/oliguria . Actions: Physician notified of change in condition . New orders to obtain a urinalysis and C&S (culture and sensitivity), [MEDICATION NAME] 25mg po (by mouth) at night as needed for [DIAGNOSES REDACTED]. Again, there was no evidence of notification of the HCS regarding the resident's change of condition. b) An interview with RN #19, Assistant Director of Nursing (ADON), on 03/24/15 at 2:15 p.m., confirmed the facility did not notified the HCS of the changes in the resident's condition on 12/19/14 and 12/28/14. She further confirmed the facility should have notified the HCS on both occasions.",2018-03-01
6492,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,157,D,0,1,3WT411,"Based on record review, review of the facility's protocol for standing orders, and staff interview, the facility failed to inform the physician after a change in health status for one (1) of five (5) residents reviewed during the unnecessary medication review. The physician was not notified when Resident #48 had pain symptoms for more than twenty-four (24) hours. Resident identifier: #48. Facility census: 123. Findings include: a) Resident #48 1. Review of Resident #48's Medication Administration Record [REDACTED]. 2. Review of the whenever needed (PRN) pain management flow record, on 06/18/14 at 10:00 a.m., revealed on 06/12/14 the (time was not legible), the pain rating was 3-4, the location was knee, and the medication and dose was Tylenol 650 mg. The PRN pain management flow record was left blank for non-pharmacological treatment, pain rating, level of sedation and initials. The resident received the same dosage of Tylenol on 06/13/13, but the PRN pain management flow sheet was left blank. There was no indication the Tylenol was administered for fever. 3. An interview was conducted on 06/18/14 at 11:00 a.m., with Employee #98 licensed practical nurse (LPN). When LPN #98 reviewed the PRN pain management flow sheet, she stated LPN #51 administered the Tylenol on 06/12/14 for knee pain. For the Tylenol administered on 06/13/14 at 2:00 p.m., LPN #98 confirmed LPN #51 should have documented something on the PRN pain management flow sheet for the reason she administered the Tylenol on 06/13/14. 4. In an interview with LPN #51 on 06/19/14 at 7:50 a.m., when asked why the PRN pain management flow sheet was not filled out, she stated she just did not fill the information in correctly for 06/12/14 and 06/13/14. She stated the Tylenol was given for knee pain on both days. She said the resident had just received therapy and her knee was hurting. When LPN #51 was asked to review the MAR for the reason the Tylenol was given on both days, she stated, This order is for fever. She confirmed she did not notify the physician for the pain symptoms persisting more than twenty four (24) hours per the facility's protocol for standing orders. 5. Review of the facility's protocol for standing orders for Tylenol for mild pain on 06/19/14 at 8:00 a.m., revealed If symptom persist more than 24 hours, notify MD (medical doctor).",2018-03-01
6657,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,157,D,1,0,9WU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and family interview, the facility failed to ensure the power of attorney (POA) received timely notification of an accident resulting in injury. A resident fell and fractured his hip in the early morning hours. The facility notified the physician, who ordered x-rays of the affected hip. The X-ray results indicated a fracture. There was no evidence the POA was notified of the fall until approximately twelve (12) hours after the fall, when the resident was transferred to the hospital for surgical repair of the [MEDICAL CONDITION]. This affected one (1) of nine (9) sampled residents reviewed for changes in condition and /or notifications. Resident identifier: #2. Facility census: 84. Findings include: a) Resident #2 On 12/02/14 at 11:00 a.m., the medical record was reviewed. Resident #2 fell in his room at 1:30 a.m. on 09/14/14. The facility faxed the physician to alert him of the resident's fall. A nurse progress note, dated 09/14/14 at 4:26 a.m., communicated that the nurse obtained a telephone order from the physician for an x-ray of the affected hip. There was no evidence the power of attorney (POA) was notified of the fall, or of the new order for the x-ray. An x-ray, completed at the facility by a mobile x-ray unit, indicated Resident #2 had a [MEDICAL CONDITION]. A nursing progress note, dated 09/14/14 at 4:00 p.m., communicated the facility received a report from the mobile imaging unit which stated Resident #2 had a projected incomplete [MEDICAL CONDITION] head/neck junction, with recommendations for a computerized tomography (CT) scan. The facility notified the physician of the findings. The physician then ordered the resident be sent to a hospital emergency room for a CT scan. Resident #2 left the facility by ambulance, at 1:30 p.m. on 09/14/14, and a message was left for the POA at that time to contact the facility. According to a nursing progress note, dated 09/14/14 at 9:30 p.m., the facility had not received a return call from the POA, so the facility called the POA again, and left a message on voice mail to call the facility. Further medical record review revealed Resident #2 was admitted to the hospital on [DATE] for repair of a [MEDICAL CONDITION]. The resident was re-admitted to the facility on [DATE]. At 11:20 a.m. on 12/02/14, an incident report, dated 09/14/14, for the 1:30 a.m. incident was reviewed. The nurse documented the physician was notified at 4:00 a.m., left message. There was no evidence the resident's representative was notified. An interview was conducted with the administrator, at 11:25 a.m. on 12/02/14. The administrator agreed the POA's name and time and date of notification were missing. She said this document did not contain the administrator's signature. She said she may have sent back this document for re-submission because of missing data. On 12/02/14 at 4:20 p.m., the administrator and the director of nursing (DON) were interviewed. They said they believed the night shift nurse on 09/14/14 had contacted the POA about the resident's fall, but failed to document the POA's name and time the POA was called. They said they spoke with that night shift nurse today, but because it has been so long ago, the night shift nurse was not able to say for sure if or when the POA was notified of the fall. The administrator and DON were unable to produce evidence the POA was notified of the fall on 09/14/14, until the resident was being sent out from the facility to the hospital at 1:30 p.m. on 09/14/14. On 12/02/14 at 4:31 p.m., an interview with the POA was completed. The POA said he was not notified of the fall which occurred at 1:30 a.m. on 09/14/14, and a message was not left for him from the facility, until the afternoon of 09/14/14, when the resident was transferred to the emergency room . He said he also received a telephone call from the emergency room the same afternoon to notify him the resident required surgery, and would be admitted to the hospital.",2017-12-01
6703,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2014-11-05,157,D,1,0,YJ9E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, staff interview, and family interview, the facility failed to notify the physician and the resident's medical power of attorney (MPOA) when treatments ordered by the physician were not carried out by the facility. Two (2) separate physician's orders [REDACTED]. One (1) of eight (8) sampled residents was affected. Resident Identifier: #32. Facility Census: 94. Findings Include: a) Resident #32 On 11/04/14 at 11:00 a.m., a review of the physician orders [REDACTED]. At 12:00 p.m. on 11/04/14, a review of the resident's clinical record found no evidence of the results, and no evidence of the physician and/or MPOA notification, for both of the UAs/C&Ss ordered on [DATE] and 10/17/14. When no evidence could be located in the clinical record, the director of nursing services (DNS) was asked to provide the results of the ordered labs for review. The DNS said she could not as they were not obtained. Upon inquiry as to the reason the physician's orders [REDACTED]. She said the resident had refused on 09/09/14. On 11/04/14 at 2:10 p.m., it was brought to the attention of the DNS, no evidence had been found in the clinical record to identify the resident had refused to provide a urine specimen as ordered on [DATE], nor was there evidence the physician or the resident's MPOA had been notified. Also brought to the attention of the DNS was the lack of evidence in the clinical record as to the reasons the UA was not obtained as ordered on [DATE], as well as physician and MPOA notification. The DNS said the nurses chart by exception, and the resident's refusal to be straight cathed (catheterized) for the UA should have been documented. She further stated that the physician as well as the MPOA should have been notified when the facility was unable to obtain both of the ordered UAs. At 3:30 p.m. on 11/04/14, during a telephone interview with the resident's MPOA, she said she had been notified an order had been written to obtain a urine sample. The MPOA said she had not yet been notified of the results of the urine specimen, and she had thought she would have heard by this time. On 11/05/14 at 11:00 a.m., during a telephone interview with Resident #32's physician/facility medical director, he stated he had not been notified the UAs ordered on [DATE] and 10/17/14 had not been obtained, nor was he aware the resident continued to complain of urinary pain.",2017-11-01
6713,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,157,D,0,1,B5L311,"Based on family interview, record review, and staff interview, the facility failed to immediately notify the resident's medical power of attorney (MPOA) / daughter after an unwitnessed accident involving the resident. The accident resulted in an injury and required physician intervention. The resident's daughter / MPOA was not notified of the injury until three (3) days after the injury was identified. Resident identifier: #141. Facility census: 109. Findings include: a) Resident #141 During a family interview on 03/03/14 at 3:30 p.m., Resident #141's medical MPOA / daughter reported she was contacted on 01/27/14, and informed her mother experienced an unwitnessed injury to her right hand and fingers on 01/24/14. The injury required physician notification and a radiology screening. The MPOA / daughter visited her mother on 01/27/14 and found Resident 141's hand swollen, bruised, and tender to touch. On 03/06/14 at 3:00 p.m., medical record review found, on 01/24/14 at 12:15 p.m., a nursing assistant (NA) informed the medication nurse Resident #141 had a swollen and bruised right third finger. Documentation by the licensed practical nurse (LPN), Employee #695, noted the resident's right ring finger was swollen, bruised, and painful when bent. The resident's physician was contacted on 01/25/14 at 12:45 p.m. An order was written to obtain an x-ray of the right hand. A note dated 01/27/14 at 9:00 a.m., stated the MPOA / daughter was notified of the x-ray results. During an interview on 03/06/14 at 4:39 p.m., the assistant director of nursing (ADON), Employee #945, confirmed there was no evidence in the medical record to indicate the MPOA / daughter was notified of her mother's injury when first noted on 01/24/13.",2017-11-01
6924,PINERIDGE,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2014-10-22,157,D,1,0,X43Y11,"**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 a resident's worsening condition involving a bruise/injury in a timely manner. Nursing entries identified evolution of an injury of the resident's right hand. The resident's physician was not notified in a timely manner when nursing observations indicated there were signs/symptoms of worsening of the injury. This practice affected one (1) of eight (8) sample residents reviewed for this survey. Resident identifier: #25. Facility census: 115. Findings include: a) Resident #25 Medical record review for Resident #25 on 10/21/14 at 4:00 p.m., found Resident #25 was admitted to the facility with a [DIAGNOSES REDACTED]. A review of the nursing progress notes revealed documentation dated 09/03/14 at 1440 (2:40 p.m.) as a late entry written by Employee #72, Nurse Supervisor Licensed Practical Nurse (LPN) on 09/08/14. The documentation (typed as written) revealed, 3-11 staff up to the desk during shift report and reported res. (resident) has a bruise to outer right hand. Two (2) following entries, also documented as late entries for 09/03/14 and written by LPN #72 on 09/08/14, stated, message left for MPOA (medical power of attorney) to call facility and MD (doctor) aware of bruising. no new orders at this time. An entry in the nursing progress notes dated 09/04/14 at 1456 (2:56 p.m.) stated, Res has [MEDICAL CONDITION] to right hand and blue purple bruising, is tender to touch. Will monitor. The next entry, dated 09/05/14 at 1349 (1:49 p.m.) stated, Res. has bruising of rt. (right) hand the [MEDICAL CONDITION] is less, will monitor. The next entry, dated 09/06/14 at 0724 (7:24 a.m.) stated, Has bruising of rt. hand extending into rt FA (forearm), [MEDICAL CONDITION] decreasing, will monitor. The following entry, dated 09/06/14 at 2123 (9:23 p.m.) stated, MD aware of bruising and swelling. Res favoring hand. Xray ordered of right hand and obtained by (name of hospital) Xray dept. Left message for MPOA to return call. An entry dated 09/07/14 at 12:36 (12:36 p.m.) stated, Received x ray results of right hand which show recent fx. (fracture) of right fourth and fifth metacarpals. MD paged. Awaiting return call. Area yellow/green in color and slightly swollen. No s/s (signs/symptoms) of pain noted. An interview was conducted on 10/22/14 at 10:40 a.m. with the Director of Nursing. She stated, We were not made aware of the bruising until 09/08/14 and should have been notified sooner. She also commented the attending physician should have been notified sooner. The facility failed to notify the attending physician of a change/worsening of Resident #25's right hand becoming tender to touch, having [MEDICAL CONDITION] and an increase in the bruising to her right hand which extended up to her right forearm. This was documented on 09/04/14 and the physician was not notified after the initial notification on 09/03/14, until 09/06/14. .",2017-10-01
7074,GREENBRIER HEALTH CARE CENTER,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2014-09-12,157,D,1,0,H9YP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the resident's physician was immediately notified when there was an accident involving the resident which resulted in an injury and had the potential for requiring physician intervention or when there was a significant change in the resident's physical status. Resident #84 experienced a fall with an injury and began experiencing pain in her right hip. The physician was not notified until the next day. Resident #72 sustained a fall, had an elevated blood pressure, and later complained of hitting her head with the fall as well as continuing to have elevated blood pressures. The physician was not immediately notified. Two (2) of three (3) resident's reviewed had an accident that had the potential to require physician intervention. Both residents were sent to a hospital for x-rays once the physician was notified. Resident identifiers: #84 and #72. Facility census: 82. Findings include: a) Resident #84 Medical record review on 09/09/14 at 1:00 p.m., revealed the resident fell on [DATE] at 6:20 p.m. The progress note stated, (typed as written) Called residents room. Resident sitting bathroom shower floor. Blood on hands and wall. Resident stated she hit her head trying to go to the bathroom. 1/2 in (inch) laceration with bruise and goose egg. Resident alert and responds to commands speech normal. grips wnl (within normal limits). No other injuries. BP (blood pressure) 152/80, p (pulse) 100, sat (saturation) 89% room air temp 98.1. MOA (medical power of attorney) made aware will continue to follow. A note dated 08/15/14 9:40 p.m. stated PRN (as needed) [MEDICATION NAME] given to resident at 8 pm. Resident complaining of right hip pain when daughter was in room visiting. This nurse stated that if the pain medication didn't help her pain that we could send her to the hospital to be evaluated Another progress note dated 08/16/14 5:57 a.m. Resident received PRN [MEDICATION NAME] at 1:30 am for right hip pain. Resident was monitored closely throughout the night in which resident slept soundly. Resident received PRN Tylenol at 4:00 a.m. for pain prevention. When asked if the resident was hurting anywhere she shook her head no. Resident is resting well in bed at current time with no signs/symptoms of pain. A note dated 08/16/14 9:04 a.m. Per shift report from previous nurse resident had a fall on 08/15/14 and daughter wanted to 'wait and see how she did throughout the night before sending to the hospital.' This nurse went back to assess resident and at that time resident complained of 'really bad' pain in the right shoulder as well as in the right hip extending down the right leg. Resident was unable to stand up straight when attempted and stated 'Honey, I just can't. It hurts too bad.' This nurse contacted physician and obtained verbal order to send to hospital for x-rays to bilateral hips as well as right shoulder On 09/09/14 at 2:00 p.m., the director of nursing (Employee #1) indicated the nursing staff should have contacted Resident #84's physician prior to 08/16/14 at 9:05 a.m. b) Resident #72 Medical record review for Resident #72, on 09/10/14 at 11:00 a.m., revealed Resident #72 fell on [DATE] at 4:00 a.m. The progress note (typed as written) stated: Resident bathroom emergency light sounding. Entered room, observed resident lying in bathroom floor in doorway on her back. Range of motion within normal limits. Observed large skin tear on left elbow. Resident assisted to bed with assist x 3. Vital signs 250/100, 60, 20, 97.2, 93%, (blood pressure, pulse, respirations, temperature, and oxygen saturation) on 2 liters (of oxygen). Resident stated she did not hit her head. Pupils equal, reactive. Administered morning blood pressure medications for elevated blood pressure. Skin tear cleansed. 3 steri strips applied. Covered with mepore. Recheck blood pressure 0445 am with results 200/80. Resident states at this time that she did hit the back of her head. No swelling or redness noted. Recheck blood pressure again at 5:30 am with result 188/78. Order written for staff to observe frequently while in room. The progress notes revealed the facility contacted the physician at 7:30 a.m. on 08/27/14. The physician gave orders for the facility to send the resident to the emergency room for x-rays. The facility had not contacted the physician about the accident and the resident's condition prior to 08/27/14 at 7:30 a.m. On 09/10/14 at 12:00 p.m., the director of nursing (DON) was informed the facility had not consulted with Resident #72's physician when she had a fall, elevated blood pressures, and later complained of hitting her head with the fall as well as continuing to have elevated blood pressures. The director of nursing (Employee #1) had no further comments.",2017-09-01
7077,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2014-08-08,157,D,1,0,16RF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and interview with a resident's guardian, the facility failed to promptly notify the resident's legal representative of a change in the resident's condition for one (1) of seven (7) residents reviewed. The legal representative was not notified when Resident #115 was transferred to the hospital. Resident identifier: #115. Facility census: 113. Findings include: a) Resident #115 Review of the electronic medical record, on 08/07/14 at 8:07 a.m., revealed a nurse's note indicating Resident #115 was transferred to the hospital by ambulance on 10/24/13 for complaints of increased weakness. The minimum data set (MDS) with an assessment reference date (ARD) of 10/24/13, indicated an unplanned discharge to an acute hospital. Further review of the medical record revealed a psychiatric review, indicating the resident lacked capacity to make medical decisions. Additionally, the resident was appointed a legal guardian, who would make medical decisions on her behalf, until 11/16/13. During an interview, on 08/07/14 at 8:15 a.m., the legal guardian indicated she was not notified of the change in condition, or transfer to the hospital. Further review of the medical record, revealed no evidence the facility attempted to notify the resident's legal guardian. An interview with the director of nurses (DON) on 08/07/14 at 10:30 a.m., revealed the facility required staff to notify the medical power of attorney, guardian . of a change in condition. She indicated staff would enter a notation on the physician's orders [REDACTED]. She reviewed the medical record and confirmed no evidence was present to indicate the facility attempted to notify the legal guardian.",2017-08-01
7127,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,157,D,0,1,XBZ111,"Based on record review, staff interview, and resident interview, the facility failed to inform the physician of changes in health status for one (1) of fifteen (15) Stage 2 sampled residents. Resident #69 experienced a significant weight loss in one (1) month. There was no evidence the resident's physician was made aware of the resident's weight loss. Resident identifier: #69. Facility census: 53. Findings include: a) Resident #69 Review of the medical record revealed the following weights for Resident #69: -- 12/06/13 - 131.6 pounds (lbs) (this was the first weight since hospital readmission), -- 12/08/13 - 129.8 lbs, -- 12/16/13 - 127.4 lbs, -- 12/22/13 - 126.0 lbs, -- 12/30/13 - 120.7 lbs, and -- 01/05/14 - 120.7 lbs A review of the above weights revealed Resident #69 sustained a 10.9 pound weight loss over a thirty (30) day period; an 8.3 percent weight loss from 12/22/13 to 01/05/14. Further review of medical records found no evidence facility staff had notified the physician of this resident's weight loss. On 01/09/14 at 4:25 p.m., the director of nursing (DON) stated no evidence was available to verify the physician was notified of Resident #69's weight loss.",2017-08-01
7197,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-07-17,157,D,1,0,SS2T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to immediately inform a resident's family prior to sending the resident to the emergency room . This was identified through a random opportunity for discovery, when an accident occurred. Resident identifier: #50. Facility census: 84. Findings include: a) Resident #50 Observation on 07/16/14 at 10:30 a.m., found Resident #50 sitting in his wheelchair asleep with his head lying on his lap. During an interview with Resident #50's wife, on 07/16/14 at 10:30 a.m., she stated they were exhausted due to being in the emergency room all night (07/15/14). She said the resident had gone to the emergency room three (3) times since his admission to the facility on [DATE]. She further explained they had not notified her prior to transporting him to the emergency room the evening of 07/15/14. ?@ Review of Resident #50's medical record, on 07/16/14 at 10:45 a.m., revealed an incident report dated 07/15/14. The report included, Resident noted to be laying on left side on floor beside bed. No c/o (complaints of) pain. No apparent injury. Sent to ER (emergency room ) for eval (evaluation) because unwitnessed. Transported to (hospital name) at 10:00 p.m. on 07/15/14. There was no evidence Resident #50's wife was notified of the incident prior to his transport to the emergency room . Further medical record review, on 07/16/14, revealed a progress note which included, Resident had unwitnessed fall sent to ER. POA (power of attorney) voiced to ER staff she does not want (Resident #50's name) sent to the ER if he appears not hurt. Resident #50 returned to the facility on [DATE] at 1:16 a.m. During an interview with the director of nursing (DON), on 07/16/14 at 11:30 a.m., the DON confirmed the resident's wife (POA) was not notified by the facility prior to Resident #50's transport to the ER. She said the facility should have notified the resident's wife/ power of attorney prior to sending the resident to the emergency room .",2017-07-01
7209,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2014-07-03,157,E,1,0,4KCF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, and policy review, the facility failed to promptly inform the resident's physician or legal representative of a change in condition for three (3) of three (3) residents reviewed for change in status. Residents #36 and #65 required treatment for [REDACTED].#2 required further direction for [MEDICAL CONDITION]. Resident identifiers: #2, #36, and #65. Facility census: 72. Findings include: a) Resident #36 An observation, on 07/01/14 at 4:55 p.m., revealed Resident #36 was alert and verbal, but did not answer questions related to his medical condition. At the time of the observation, the resident's family was at his bedside. His family was unsure when he was diagnosed with [REDACTED]. Review of the electronic record, on 07/02/14 at 11:41 a.m., revealed the care plan and physician's orders [REDACTED]. On 07/02/14 at 11:50 a.m., review of nursing progress notes found a note, dated 06/04/14, indicating a blood sugar of 31/70. Review of the Medication Administration Record [REDACTED]. According to the progress note, the resident's blood sugar was 31. He was given a bolus of a supplement by gastrostomy tube and his blood sugar was rechecked after 30 minutes. At that time, the resident's blood sugar was 70. The medical record provided no indication the physician was notified on 06/04/14. b) Resident #65 Review of the medical record, on 07/02/14 at 8:25 a.m., revealed physician's orders [REDACTED].#65 received [MEDICATION NAME]per sliding scale coverage with Accuchecks four (4) times a day. The Accuchecks were scheduled for 6:00 a.m., 11:00 a.m., 5:00 p.m., and 9:00 p.m. Another order indicated staff were to notify the physician if the resident's blood sugar was less than 70 or greater than 300. Review of the Medication Administration Record [REDACTED]. There was no evidence the physician was notified of the resident's low blood sugar. Additional review of the MAR indicated [REDACTED] -- 03/28/14 at 6:00 a.m. blood sugar = 59 -- 03/29/14 at 11:00 a.m. blood sugar = 60 -- 03/30/14 at 6:00 a.m. blood sugar = 60 -- 04/02/14 at 11:00 a.m. blood sugar = 69 -- 04/05/14 at 6:00 a.m. blood sugar = 69 -- 04/16/14 at 6:00 a.m. blood sugar = 62 -- 05/13/14 at 9:00 p.m. blood sugar = 303 -- 05/23/14 at 11:00 a.m. blood sugar = 346 No evidence was present in the medical record to indicate the physician was notified of any of these, with the exception of 03/29/14 at 5:00 p.m., when it was documented the physician was notified. c) Resident #2 A review of Resident #2's medical record, on 07/01/14 at 4:11 p.m., revealed the resident's [DIAGNOSES REDACTED]. A general nursing progress note, dated 06/21/14, revealed an elevated glucose. Her fingerstick blood sugar (FSBS) was 303 at 4:00 p.m., and it was 387 at 4:00 p.m. on 06/23/14. Further review of the medical record found no evidence the physician was notified. MARS, reviewed on 07/01/14 at 10:01 a.m., revealed a low glucose reading of 41 (a critical level) on 06/04/14 at 6:00 a.m. The medical record indicated Glucoburst (used to treat low blood sugars) was administered. On 06/07/14 at 4:00 p.m. a low glucose reading of 67 was also noted on the MAR. Again, no evidence was present to indicate the physician was notified on either of these occasions. A nursing entry dated 05/29/14 at 5:18, also noted a low glucose level of 60, requiring administration of Glucoburst, and on 05/25/14 a hypoglycemic level of 67 at 4:00 p.m. The progress note indicated [MEDICATION NAME] held, and the BG (blood glucose) was rechecked at HS (bedtime). Again, no evidence was present to indicate the physician was notified of either hypoglycemic episode. d) An interview with Employee #73, a licensed practical nurse (LPN), on 07/02/14 at 11:00 a.m., revealed staff were required to notify the physician of blood sugars outside of specified parameters determined by the physician. The LPN related staff followed a hypoglycemic protocol for low blood sugars and called the physician for orders outside of acceptable parameters for high blood sugars. Review of the hypoglycemic protocol revealed physician notification was required for a blood glucose less than 70 or physician ordered low parameter. It also indicated staff documentation was required to document the notification and response. The director of nursing (DON) was interviewed on 07/02/14 at 1:30 p.m. She also related the nurses followed the hypoglycemic protocol and notified the physician per physician's orders [REDACTED]. The DON confirmed no evidence was present to indicate the physician was notified in a timely manner of the hypoglycemic and/or hyperglycemic episodes.",2017-07-01
7212,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2014-07-10,157,D,1,0,E6P811,"Based on staff interview and medical record review, the facility failed to immediately notify Resident #27's physician of an allegation of sexual abuse. This was found for one (1) of nine (9) sample residents. Resident identifier: #27. Facility census: 62. Findings include: a) Resident #27 Review of concern and grievances, on 07/08/14 at 12:16 p.m., revealed a concern indicating a male had entered Resident #27's room, removed his clothing, and climbed on top of her, but Resident #27 had been unable to confirm the incident. Additionally, review of the reportable allegation provided no information to indicate the physician was notified of the alleged incident. In interview with the director of nursing at 1:45 p.m. on 07/10/14, revealed a physical assessment was not completed when the alleged incident was reported. She also confirmed, no evidence was present to indicate the physician was notified.",2017-07-01
7239,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-07-22,157,G,1,0,BZ4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to notify the nurse in charge and/or nurse on call when Resident #4 sustained a change in condition and the physician could not be reached in a timely manner. Several hours later the facility reached the physician by telephone. The physician gave orders to maintain the resident's oxygen saturation level at 90%. The facility then failed to notify the physician in a timely manner when the resident's assessed condition failed to meet the parameter of 90% oxygen saturation that was set forth by the physician. The delays and/or omissions in notifying the physician and/or the registered nurse in charge resulted in delays in treatment and potentially avoidable stress to the resident mentally and physically which resulted in actual harm to Resident #4. The facility also failed to notify Resident #4's legal representative of the change in condition until the following day when the resident was transferred to the hospital emergency room . The resident was admitted to the hospital where he expired later that day. Additionally, the facility failed to inform the responsible party of a change in health status for Resident #1. Two (2) of five (5) sampled residents were affected. Resident identifiers: #4 and #1. Facility census: 83. Findings include: a) Resident #4 The resident's medical record was reviewed on [DATE] at 11:00 a.m. According to a nurse progress note, written at 2:30 p.m. on [DATE], Registered Nurse #70 assessed a change of condition in Resident #4. Health Service Workers reported the resident began to go out. The nurse assessed that the resident was pale, had rapid respirations of thirty-two (32) breaths per minute, and was hypotensive at ,[DATE]. The resident normally kicked his legs and yelled aloud, but he was not moving his legs or yelling. Employee #70 paged Physician #1. Thirty (30) minutes later, at 3:00 p.m., Employee #70 assessed the resident as very lethargic. His skin was pale and dry. The nurse checked his pulse oximetry and found his oxygen saturation level was quite low at 65%. The normal range is 90% to 100%. The nurse began oxygen at two (2) liters per minute per nasal cannula initially, then raised it to five (5) liters per minute. The resident's oxygen saturation level raised only into the low 80's. A second page was placed to Physician #1, and staff also called the physician's cell phone. There was no evidence the resident's legal representative was notified of these changes. (The legal representative was an employee of the local Department of Human Resources (DHHR), who had been assigned as the resident's legal representative.) At 4:45 p.m., Employee #70 assessed that although the resident was more alert, his oxygen saturation level was still only in the 80's. Also, the tips of his fingers were very pale with an occasional purple and bluish tint. Another cell phone call was placed to Physician #1. Physician #1 returned the call at 5:20 p.m. on [DATE]. He ordered oxygen via a nasal cannula to maintain oxygen saturation levels at 90%, and to continue to monitor. The next nurse's progress note occurred at 9:00 p.m. on [DATE]. Employee #70 assessed the resident's oxygen saturation level was 85% to 86% while on oxygen at five (5) liters. There was no evidence the nurse notified the physician the oxygen saturation level was below 90%. On [DATE] at 12:43 a.m., the night shift registered nurse, Employee #71, assessed that Resident #4's skin was cool and clammy. The lung sounds were diminished. Respirations were rapid at thirty-two (32) breaths per minute. The resident's oxygen saturation level was only 81% to 85% while on oxygen at five (5) liters per minute. It was not until 2:51 a.m. on [DATE] that Physician #1 was again notified of the resident's condition. The resident's oxygen saturation level was between 70% and 75% on oxygen at five (5) liters per minute. The resident was now mouth breathing, and the respiratory rate was rapid at thirty-two (32) breaths per minute. Physician #1 ordered to continue monitoring the resident, and he would see him in the morning. At 7:00 a.m. on [DATE], oncoming Registered Nurse (RN) #102 assessed that the resident appeared to be in respiratory distress and gasping for air. His respirations were shallow and rapid at forty-four (44) breaths per minute. The resident's nail beds were blue. His skin was yellow and diaphoretic (perspiring profusely) and cold to touch, especially the lower extremities. He had light mottling to the knees. His pulse was 122 beats per minute and bounding. Upon inquiry, the resident moaned in the affirmative that he was in pain. Employee #102 was unable to obtain the oxygen saturation level or blood pressure. Employee #102 placed an oxygen mask on his face, and increased the oxygen to eight (8) liters per minute. She notified the physician. The physician gave orders to send him to the emergency room for observation. The resident agreed he wanted to go to the hospital. Licensed practical nurse #120 notified the legal representative of the transport to Hospital #1 on [DATE] at 7:38 a.m. According to Employee #120's nurse progress note dated [DATE] at 11:51 a.m., the resident was admitted to Hospital #1 with comfort measures only. The resident reportedly had a [MEDICAL CONDITION] infarction,[MEDICAL CONDITION], and pneumonia. At that time, the charge nurse was notified. A message was left for the DHHR legal representative of the resident's admission to the hospital. At 2:36 p.m. on [DATE], the hospital notified registered nurse #102 that the resident had expired. An interview was conducted with the director of nursing (DON) and registered nurse #130 on [DATE] at 12:00 p.m. Upon inquiry, the DON said nurses have the authority to send a resident to the emergency room if a physician cannot be reached. Resident #4 had Physician order [REDACTED]. The POST directed no cardiopulmonary resuscitation (CPR). Medical interventions were comfort measures to treat with dignity and respect. It directed to transfer the resident to the hospital only if comfort needs could not be met in the current location. The DON said in her opinion, if a resident's respirations were thirty-two breaths (32) per minute, then that would be considered uncomfortable. The DON said the doctor always left pager and/or cell phone numbers where he can be reached on specific dates. She and registered nurse #130 said there was always a nursing supervisor available. The regular nursing supervisor was not working on Monday [DATE]. On her days off, and after 4:00 p.m. daily, administrative nurses rotated taking call. Employee #130 was on call [DATE]. She said she was not notified that a physician could not be located, or that the resident had sustained a change in condition. b) Resident #1 Review of the resident's medical record on [DATE], found a nursing entry, dated [DATE], noting Resident #1's foreskin was retracted and staff were unable to return the foreskin to its natural position. The head of the penis was noted to have swelling. The note also revealed the physician was notified and instruction were given to apply gentle pressure to the penis for several minutes and the foreskin would slip back into its natural position. On [DATE], a physician's note revealed Resident #1 had recently had some issues with his foreskin in which the foreskin was retracted and had not returned to its natural position. This same physician assessment revealed the physician applied gentle consistent pressure and to the penis but was unable to adequately return the foreskin. During an interview at 12:30 p.m. on [DATE] with Resident #1's wife, who was also his medical power of attorney (MPOA), she stated she was in the facility to visit her husband on [DATE] and found he was in a meeting with Adult Protective Services. She stated this was when she first was told by the facility her husband had a swollen glans penis and he might be sent out of the facility for an evaluation. She stated the facility staff had not reported to her that her husband had a problem with a swollen glans penis. She stated she had observed the swollen glans penis on [DATE] and called the physician to discuss the issue, but the facility had never informed her of the swollen glans penis. During an interview at 2:45 p.m. on [DATE], the facility's acting administrator, Employee #1 stated there was no evidence Resident #1's MPOA was notified concerning the swollen glans penis prior to [DATE].",2017-07-01
7246,GOLDEN LIVING CENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2014-06-17,157,D,1,0,I24N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to notify the physician of a change of condition in a timely manner. Resident #13 was noted to have a swollen area on her thigh with associated pain and tenderness. There was no evidence the physician was informed of this in a timely manner. This was found for one (1) of sixteen (16) sampled residents. Resident identifier: #13. Facility census: 97. Findings include: a) Resident #13 On 06/4/14 at 3:45 p.m., review of the resident's medical record found this [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The resident was determined to lack capacity to make informed medical decisions by the attending physician on 06/27/14. 1) Review of occurrences reported to State agencies found an unusual occurrence report involving Resident #13 dated 04/04/14. The notice was signed by the assistant director of nursing (ADON) #51. This report included, I am reporting an unusual occurrence that initially happened Monday, March 31, 2014 involving our resident Ms. (Resident #13's name), . and was recently re-admitted on [DATE] back to our facility. (Resident #13) was noted by staff to be having increased amounts of pain in areas of her left hip, resident was made comfortable in bed with positioning and administration of pain medication prior to her being assessed by Nurse Supervisor who noted no [MEDICAL CONDITION] or deformity of left hip with assessment. The resident was continuously monitored for pain and interventions were continued to assist with diminishing resident's pain level. (Resident #13) did receive an x-ray of her left hip which reflected left femoral head/neck fracture. Nurse Supervisor was then given a verbal order for a CT scan of left hip. This resident was ordered an orthopedic consultation and was continued on non weight bearing status until given the verbal ok via consult and facility doctor. After results of CT scan were received which reflected bilateral [MEDICAL CONDITION] resident was directly admitted to hospital for further evaluation and treatment. 2) A progress note, dated 03/29/14 at 05:30 (5:30 a.m.) included, (typed as written), Situation: Resident has guarding, crying and c/o (complained of) pain in left leg . Assessment: Resident has tender, swollen area to her left thigh. Resident afebrile, VS (vital signs) WNL (within normal limits), cries out when area is touched. No evidence of bruising or injury. Response: Currently monitor, will notify MD for further instructions. A progress note dated 03/29/14 at 10:43 (10:43 a.m.) included, Continues to guard left hip during care. Resident in bed with eyes closed post prn (as needed) pain medication. On 03/30/14 at 12:50 (12:50 a.m.), it was noted, Resident was in her bed crying, saying her back hurt. This entry also noted an order for [REDACTED]. [MEDICATION NAME] was given at that time and the resident was repositioned. The medication was noted to have been effective at 14:36 (2:36 a.m.). 3) On 03/31/14 at 13:09 (2:09 a.m.), a nursing entry noted an x-ray of the resident's left hip had been completed. On 03/31/14 at 16:39 (4:39 a.m.), a nurse noted the resident complained of back pain, but could not give a number. The nurse gave the resident [MEDICATION NAME] and at 17:56 (5:56 a.m.) noted it was effective. A nursing entry at 18:21 (6:21 p.m.) noted the resident complained of back pain and was medicated for pain with positive results. On 03/31/14 at 19:49 (7:49 p.m.), a change of condition note described, Situation: Recent left hip xray d/t (due to) c/o (complaint of) pain . Assessment: resident moaning, @ x's (at times), went (sic) asked to locate pain, resident changing answer with each question, c/o R (right) hip, abd (abdomen), r (right) leg, and l hip, no [MEDICAL CONDITION] or instability noted. @ x's moving BLE (bilateral lower extremities) without discomfort. Response: Notified MD of results, orders to obtain CT scan of left hip outpatient, Hoyer lift and bedrest until further notice . 4) A progress note of 04/01/14 at 13:43 (1:43 p.m.) stated (typed as written), Resident placed on complete bedrest following possible left hip Fx. (fracture) C/O pain to hip, unable to verbalize pain level, but continued to moan, facial grimacing and guarding during care. 5) The X-ray results showed an examination completed 03/31/14 at 14:48 (2:48 p.m.) suggested left [MEDICAL CONDITION] with impaction. A CT (computerized tomograhy) evaluation was recommended. The results of the CT scan completed on 04/02/14 at 14:39:12 showed the resident had a subcapital fracture right femoral neck, and impacted subcapital left femoral neck fracture. b) On 06/11/14 at 11:40 a.m. an interview was conducted with a nurse supervisor, Registered Nurse (RN) #50. She commented she was the supervisor on duty. She said she was not made aware of the resident's left hip being swollen on 03/29/14. She said the day shift nurse should have followed up on the swollen tender left hip. She said she contacted the doctor and got an order because of the pain on 03/30/14 for the x-ray to be done on 03/31/14 because it was not considered an emergency. She said the director of nursing told her to do a pain evaluation on 03/31/14 and she did evaluate her then. She agreed this was a delay in care and notification of the physician.",2017-06-01
7266,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2014-06-04,157,D,1,0,XIX811,"Based on medical record review, family interview, staff interview, and policy review, the facility failed to immediately inform a resident's family/medical power of attorney (MPOA) after a resident experienced an unwitnessed fall. The facility identified a potential head injury, began seventy-two (72) hour neurological checks, and notified the physician, but the family/MPOA was not notified until the following morning when the resident was found unresponsive with gasping respirations. This was true for one (1) of nine (9) sampled residents. Resident identifier: #84. Facility census: 83. Findings include: a) Resident #84 Review of this resident's medical record, on 06/03/14 at 9:00 a.m., found the resident had an unobserved fall on 05/22/14 at 10:45 p.m. The resident was assessed by a licensed practical nurse (LPN) #67, seventy-two (72) hour neurological checks were immediately started, and the physician was notified on 05/22/14 at 11:30 p.m. The computerized nurse's note, written on 05/23/14 at 3:39 p.m., noted attempts to contact the granddaughter/MPOA at work and on her cell phone began on 05/23/14 at 9:15 a.m., after the resident was found unresponsive. This was ten and one-half (10 1/2) hours after the fall. The computerized incident/accident report noted the granddaughter/MPOA was notified on 05/23/14 at 10:00 a.m. In a telephone interview with the granddaughter/MPOA, on 06/04/14 at 1:40 p.m., she said she was contacted the morning of 05/23/14, and told her grandfather had fallen the night before and was now unresponsive. The granddaughter stated she had been notified quickly the last time her grandfather had fallen and her expectation was that the facility would notify her any time her grandfather fell regardless of the time of day, so she could talk to him. The facility's fall management policy, revised May 2013, included under section 3-i, in the event a resident falls, the licensed nurse will: Notify the resident's healthcare decision maker. The facility's neurological assessment, revised June 2012, stated under section 6 of the procedure: Contact family/health care decision maker to inform them of the resident's change in condition. In an interview with the assistant director of nursing (ADON), Employee #57, on 06/03/14 at 9:15 a.m., she reported the facility's practice was to immediately assess a resident after an unobserved fall or a fall with a head injury, then notify the physician and family. She stated, It is best practice to notify family on off shifts. During an interview with registered nurse (RN) #86, on 06/03/14 at 1:25 p.m., she confirmed the family was to be notified after a fall and a message was to be left if they did not answer the telephone. .",2017-06-01
7328,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2013-10-22,157,D,0,1,TQVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, resident interview, and policy review, the facility failed to notify the physician when one (1) of two (2) residents reviewed for accidents during Stage 2 of the Quality Indicator Survey had an accident which resulted in injury and required medical intervention. The physician was not notified when the resident burned herself with a cigarette. Resident identifier: #38. Facility census: 87. Findings include: a) Resident #38 Medical record review, on 10/17/13 at 8:00 a.m., found a nursing note dated 09/23/13 at 1:20 p.m. which indicated when Resident #38 returned to the facility after a smoke break she had an orangish/black burn mark on her right middle finger. Further review of the medical record found no evidence the physician was notified of the injury. The resident confirmed, during an interview on 10/21/13 at 12:39 p.m., she had burned her finger while she was outside smoking. She said, The nurse treated it with burn cream. Employee #179, a licensed practical nurse (LPN) was interviewed on 10/21/13 at 12:50 p.m. She said she was not aware of a burn, but had noted brown nicotine stains on the resident's fingers. Another LPN, Employee #27, was interviewed on 10/22/13 at 12:50 p.m. She said she was aware of the burn / injury. Employee #27 stated the resident's burn was treated with triple antibiotic ointment. She related the protocol was to complete an incident report and to notify the physician. The LPN reviewed the medical record, including physician's orders [REDACTED]. She confirmed there was no evidence to indicate the physician was notified. The policy book, dated 2005, was reviewed with the director of nursing (DON) at 3:00 p.m. on 10/17/13. The DON confirmed a report was to be generated for each and every event/accident, and routed to the medical director for review/signature/date and /or investigation. The DON was unable to find the report which should have been generated after the resident's burn. The DON further reviewed physician's orders [REDACTED]. She acknowledged she was unable to find any evidence the physician was notified the resident burned herself with a cigarette and facility staff had treated the burn with triple antibiotic ointment. .",2017-06-01
7581,NELLA'S INC,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2014-04-03,157,D,1,0,K7DT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to promptly notify a resident's legal representative or a skin impairment which had the potential for requiring physician intervention. This was found for one (1) of four (4) residents reviewed with pressure ulcers. Resident #4's legal representative was not notified a pink area had deteriorated until the area was a Stage IV pressure ulcer. Resident identifier: #4. Facility census: 82, Findings include: a) Resident #4 Review of the medical record, on 04/01/14 at 2:01 p.m., revealed a physician's communication form dated 03/14/14. It noted, After resident's bath explained to resident to stay off right hip. area that was pink in color needed to rest and have no pressure, and was placed in gown to allow air to peri area to get some air. after staff left room resident dressed self. Nurses' notes were reviewed for the time period of 03/05/14 to 04/01/14. The first entry which referred to the resident's right hip was dated 03/18/14 at 6:30 a.m. The entry included, Resident was very stiff, could hardly move, noted he had urinated on floor and bed was also wet. Staff assisted him out of his bed, noted large decubitus measuring 5 cm x 7 cm area dark pink clear drainage. area cleansed and protective dressing applied. area is surfact or first layer of skin off. The note described the resident was assisted back into bed and turned off his right hip. The next assessment of the area on the resident's hip, documented by the director of nursing (DON) at 7:20 p.m. on 03/18/14, indicated the area had a small amount of bloody drainage. The physician was notified and the resident was transferred to the emergency room . The medical power of attorney (MPOA), was notified at that time. Further review of the nurses' notes, for the period of 03/14/14 to 03/18/14, revealed no evidence staff informed the medical power of attorney (MPOA) of the area on the resident's hip until the time of transfer to the hospital on [DATE]. An interview with Employee #47, a licensed practical nurse (LPN), on 04/03/14 at 1:00 p.m., revealed she had not notified the family. An interview with Employee #11, social services, on 04/03/14 at 1:30 p.m., revealed she thought the LPN contacted the family. Both confirmed the MPOA was not notified. In addition, during an interview, on 04/03/14 at 1:30 p.m., Employee #17 (LPN), said she initiated treatment on the area on 03/14/14. The LPN said she utilized standing orders, as no order was in place for a treatment. No evidence was presented to indicate the family was notified of the initiation of a new treatment.",2017-04-01
7627,STONE PEAR PAVILION,515130,125 FOX LANE,CHESTER,WV,26034,2013-02-07,157,D,0,1,KPH011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the family of a change in treatment for 1 resident (#30) out of 1 resident reviewed for concerns regarding notification of change out of three families interviewed. Findings include: Resident #30 was admitted on [DATE], with [DIAGNOSES REDACTED]. Review of the quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident scored a 3 on the Brief Interview of Mental Status (BIMS) which suggests severe impairment in cognition. A family interview with the resident's son was conducted on February 4, 2013. During the interview, the family member stated that he is not notified when resident #30's treatment is changed. Specifically, he was not notified when the resident's urinary catheter was discontinued or inserted since Christmas time. He stated, Sometimes it is in, sometimes it is out, and he is not informed prior to the insertion or discontinuation of the catheter. Review of the clinical record revealed nurses notes documenting that the resident's urinary catheter had been discontinued on December 28, 2012, and reinserted on January 22, 2013. Further review of the clinical record failed to reveal documentation that the resident's responsible party had been notified of the change in treatment. An interview was conducted with the charge registered nurse, Staff #779, on February 6, 2013. Staff stated that the family should be notified with changes in treatment such as the insertion or discontinuation of a urinary catheter. Staff stated that this communication should be documented in the nurses notes. Staff verified that the nurses notes did not include any documentation that the family had been notified when the resident's catheter was discontinued on December 28, 2012 and reinserted on January 22, 2013. Review of the facility policy regarding Charting and Documentation revealed that 6. Documentation of procedures and treatments shall include care-specific details and shall include at a minimum: .f. Notification of family, physician or other staff, if indicated.",2017-03-01
7711,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,157,D,0,1,Q01G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to notify the physician of medication refusals for 1 of 1 residents surveyor initiated for review (Resident #118). Findings include: Resident #118 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of admitting orders noted that Resident #118 was to receive an injection of [MEDICATION NAME] (anticoagulant) twice a day. Review of Resident #118's care plan noted no entry related to resident refusals of medication or noncompliance. Review of the monthly pharmacy reviews on 8/07/2012 and 9/11/2012 noted no irregularities. A notebook identified by the Director of Nurses (DON) as a communication book used between nursing shifts and for communication with the nurse practitioner was reviewed. An entry dated 8/29/2012 noted (Resident #118) wants someone to call the ortho (orthopedist) to see if they will d/c (discontinue) the [MEDICATION NAME] (anticoagulant). His stomach is getting sore. A review of the 24 Hour Report of Resident Change in Condition Book from 8/25/2012 through 9/08/2012 revealed an entry for Resident #118 on 8/25/2012 noting that he was receiving an antibiotic and an entry on 9/08/2012 that he was started on another antibiotic and was awaiting a chest x-ray. Resident #118 had no other entries on the report. There was an existing column on the report that could be checked titled, Refused Medications/Treatment, however, it had not been checked for Resident #118. A nurse's note dated 8/28/2012 at 2:00 PM revealed that Nurse #23 wrote, Resident has refused [MEDICATION NAME] SQ (subcutaneous injections) for the past 4 scheduled doses. The note did not mention any notification to the physician. A review of Resident #118's Medication Administration Record [REDACTED]. Nurse #23 noted the refused evening doses on 8/27, 8/28 and 8/30/2012. Review of progress notes from the Family Nurse Practitioner (FNP) revealed no notes from 8/21/2012 through 9/03/2012. A note dated 9/04/2012 did not note anything about refusals or that Resident #118 had stomach pain. A note dated 9/06/2012 from the FNP noted that Resident #118 was not taking the [MEDICATION NAME] and that she discussed the need to take the medication with Resident #118. Nurse's notes dated 9/10/2012 at 5:20 PM were reviewed. The nurse wrote that she was called to Resident #118's room by a nursing assistant. She found Resident #118 with complaints of shortness of breath and noted that he was sweating. She documented that the residents lips were cyanotic (bluish color) and his pulse was 146 breaths per minute. She was unable to register a blood oxygen saturation. The nurse also documented that Resident #118 was fighting attempts to apply supplemental oxygen. At 5:35 PM, the nurse noted that Resident #118 was transported to the hospital by Emergency Medical Services. At the time of the transport, staff were unable to register a blood pressure. At 6:15 PM, the nurse documented that the hospital supervisor reported that Resident #118 was pronounced dead on arrival to the emergency room . On 1/09/2013 at 9:23 AM, an interview was completed with Nurse #23. Nurse #23 said, I remember reporting it to the RN. I think it was Debbie. She told me that she had already talked to him and told him about the risks. I don't think I'm the first one he refused. I didn't notify the doctor. I think the protocol would be to call the doctor. The RN would do that. An interview was completed with Nurse Practitioner #135 (NP #135) on 1/10/2013 at 10:50 AM. NP #135 stated, The nurses told me that (Resident #118) wasn't taking his medication. He also said that he was having difficulty breathing. I ordered a chest x-ray. Later I found out that he had been refusing the [MEDICATION NAME]. He was always noncompliant. I would have talked to him on the day they (staff) told me. Normally the LPN reports to the charge nurse who will tell me what is going on. The LPNs can report to me, but they usually don't. I asked (Nurse #78) to tell me how much medicine he refused after (Resident #118) was gone. When she told me how many days he had refused, I told her that the nurses needed to make sure they let me know. An interview was completed with Nurse #34 on 1/10/2013 at 11:25 AM. Nurse #34 stated that she was familiar with Resident #118. He was refusing his [MEDICATION NAME]. I talked to him and told him I noticed he was refusing. I went to (NP #135) that same day. I would guess she went to talk to him. There could be a note on the back of the MAR, or maybe I didn't write one. I normally wouldn't write a note when I report things to (NP #135). I can't pin point if I told her on 8/29 or 9/06 that he wasn't taking his meds (medications). On 1/10/2013 at 12:10 PM, an interview was completed with Nurse #24. Nurse #24 said, If a resident is refusing a medication, I will let the doctor know. We would assess the medication to see if we can adjust it so the resident will take it or find an alternative. If the med nurse reports to the charge nurse, it would be put on the communication form, or we would just tell the next shift. An interview was completed with the Director of Nurses (DON) on 1/10/2013 at 12:26 PM. The DON stated that she was familiar with Resident #118. I heard about (Resident #118) refusing the [MEDICATION NAME] from (NP #135). She mentioned something to me about it in early September. She said that she had talked to him about his refusing. I, myself did not look at his chart after he was sent to the hospital. The nurse should notify the doctor after 4 days of missing a medication. The DON stated the medication being refused would not affect how soon the physician would be notified of the refusal. A follow up interview was completed with NP #135 on 1/10/2013 at 1:00 PM. NP #135 was asked about the 8/28/2012 entry in the communication book. NP #135 said, I may have missed the note. I look at it every day. I wouldn't discontinue the [MEDICATION NAME] since the orthopedist ordered it. Any of the nurses could have called the orthopedist. They didn't have to leave me a note for me to call. NP #135 said that she did not sign or initial the communication book notes. On 1/10/2013 at 6:20 PM, an interview was completed with Nurse #103. Nurse #103 said, I supervise the LPNs (Licensed Practical Nurses). Nurse #103 stated that she was familiar with resident #118. (Nurse #23) told me that (Resident #118) was refusing his medications. When she told me, I went in and talked to him. I told him about how important it was. He wanted me to talk to the doctor and see if he would stop it. I told him the doctor here wouldn't do that and he should talk to the orthopedist that he was seeing in Pittsburgh. I don't remember if I charted that or not. I left the (facility) doctor a note to talk to him. I either wrote it on a sticky note or passed on to the next nurse (verbally). I'm pretty sure I wrote it down in the notebook (communication book). I wanted someone to call the orthopedist the next day. He had an appointment coming up, but I didn't want him to refuse that long. That note would have been for the nurse the next day to call the orthopedist. (NP #135) reads all of the notes. My intent would for (NP #135) to go in and talk to him. I should have documented that whole conversation. Nurse #103 verified that she wrote the note in the communication book on 8/29/2012.",2017-02-01
7767,DAWN VIEW CENTER,515163,11 DIANE DRIVE,FORT ASHBY,WV,26719,2013-01-25,157,D,0,1,06UD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility did not notify the physician when the medication [MEDICATION NAME] was held for a resident for nineteen (19) consecutive days. The medication was ordered for weight loss and depression. One (1) of thirty-four (34) sample residents was affected. Resident identifier: #88. Facility census: 59. Findings include: a) Resident #88 Review of the resident's medical record, on 01/23/13 at 1:00 p.m., revealed a physician's orders [REDACTED]. The medication was also given for the resident's weigh loss. On 01/23/13, review of the Medication Administration Record [REDACTED]. Further review revealed documentation on the last page of the MAR indicated [REDACTED]. Review of nurses' notes found no evidence the physician was notified the medication ([MEDICATION NAME]) had been held since 01/05/13. An interview held with Employee #41, director of nurses (DON), on 01/23/12 at 3:00 p.m., confirmed there was no evidence the physician was notified. The DON, after checking with the nurses, reported the daughter wanted the medication held because she thought the medication was making the resident drowsy through the day time.",2017-02-01
7775,WEBSTER NURSING AND REHABILITATION CENTER,515165,411 ERBACON ROAD,COWEN,WV,26206,2013-07-11,157,D,0,1,BJ7R11,"**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 physician when the resident's pulse fell below the parameters specified by the physician's orders [REDACTED]. The resident's pulse was below 60 on two (2) separate occasions from 06/21/13, the date of admission, through 07/05/13. There was no evidence the facility had notified the physician. This was true for one (1) of ten (10) residents reviewed for unnecessary medications during Stage II of the Quality Indicator Survey. Resident identifier: #78. Facility census 57. Findings include: a) Resident #78 Medical record review found a physician's orders [REDACTED]. was less than 60. Further review of the nurses' notes found the resident's pulse was recorded as 59 on 06/29/13 at 7:26 a.m. Documentation in the nurses notes' found, No communication with physician concerning the patient during this shift. On 07/05/13 at 12:23 p.m., the resident's pulse was recorded as 54. Documentation in the nursing notes found, No communication with physician concerning this patient during this shift. Employee #79, a registered nurse, was interviewed on 07/09/13 at 3:40 p.m. She was unable to find verification the physician was contacted. The administrator was made aware of the situation on 07/09/13 at approximately 4:00 p.m. No further information was provided to verify the physician was aware of the resident's pulse on 06/29/13 and 07/05/13.",2017-02-01
7902,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2013-03-11,157,G,0,1,SBN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, interviews with the resident, and interview with the physician, the facility failed to notify the physician that one sampled resident (Resident #215) did not receive pain relief for a period of approximately five hours after a failed attempt to catheterize the resident. The physician had ordered that the resident be catheterized. Findings include: Resident #215 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The resident's MDS dated [DATE] identified that the resident had the ability to express ideas and wants and could make self understood. The BIMS (brief interview for mental status) concluded that the resident scored 15 indicating the resident was cognitively intact. An interview was conducted with Resident #215 on 3/05/2013 at 10:03 am. The resident stated that he had been at the facility for a little more than two weeks and stated, One night I couldn't pee. The resident also stated that he had gone approximately 7 hours without the nurse catheterizing him after he had notified the nurse that he was in pain and in need of a catheterization. The resident emphasized, I was in pain for 7 hours. The resident described his pain level as a 10 on the pain scale of 1-10 with 10 being the most severe pain. He also recalled that he had not gotten pain relief that night/early morning until the 3rd shift came in and catheterized him around 3:30 am. An interview was conducted with the resident's physician on 3/06/2013, at approximately 4:15 pm. The physician stated that the Resident #215's account of the incident was accurate with a few exceptions. The physician stated, I was actually in seeing the other resident in his room, but it was closer to 10 pm or maybe 9:30 pm, but it was not at 6:00 pm. I did palpate his bladder and it was distended. I finished up my paper work on the other resident, (Resident #215's roommate) then I wrote a progress note for Resident #215 to do Q 6 hour in-and-out-cath, but I did not write an order to do one immediately. On my way out, I told the nurse who was at the med cart when she got a chance to do a straight cath on him. Then I left and went out the door. I'm not sure what time that was. I'm sure it took me another 15 minutes to leave after I wrote notes on the resident. The physician went on to say, that the facility had not made him aware that the nurse had no success catheterizing Resident #215 or that the resident had been in pain until 4:00 am. The physician stated, I did not hear anything else until the following day when I heard about a significant amount of return - 1200 cc's. The physician also conveyed that he had not heard back from the nurse that she had been unsuccessful with her straight cath attempt or that the resident was in severe pain until 4 am. The physician acknowledged that his progress note included the resident's distended abdomen and that the resident was in pain at the time of his assessment. The physician stated that had he been notified that the nurse's straight cath attempt was unsuccessful, he would have asked to find someone that could (straight cath him) or send him out to the ER. A review of the physician's 2/21/13 progress note failed to indicate the time that the physician had assessed the resident. The note revealed the following assessment in part, Under the section entitled Chief Complaint/ History of Present illness: it was documented that resident #215 was complaining of decreased voiding, was drinking plenty of fluids, was not able to void, and the abdomen was full/tender . Under the section entitled Review of system the section for abdominal pain was checked as positive Under the section entitled Physical exam , the physician noted, suprapubic tenderness, bladder distended. Under the section entitled Assessment/plan the physician had noted, [MEDICAL CONDITION] - straight cath Q 6 hours PRN non voiding. May need GU ([MEDICAL CONDITION]) eval. Diagnosis: [REDACTED]. The facility failed to notify the physician and seek further direction regarding Resident #215's inability to urinate, staff's inability to catheterize the resident and the resident's extreme pain following the physician's visit to the facility on [DATE].",2016-12-01
7920,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2012-08-24,157,D,0,1,PYCQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview the facility failed to notify a resident's representative of changes in the resident's condition and treatment. One resident (#181), who had experienced a change of condition, was reviewed to determine whether adequate notification had been provided. Findings Include: Review of the medical record for Resident #181 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), a quarterly assessment dated [DATE], was reviewed. Resident #181 had scored a 9 out of 15 on the Brief Interview for Mental Status (BIMS), was documented to have difficulty focusing attention, and had disorganized thinking. The resident was also assessed to have an altered level of consciousness and an unusually decreased level of activity such as sluggishness, staring into space, staying in one position or moving slowly. Further review of the medical record for Resident #181 revealed a physician's orders [REDACTED]. On 07/19/12 the physician's orders [REDACTED]. On 08/21/12 a physician's orders [REDACTED]. Review of the 8/21/12 Medication Administration Record [REDACTED].M. On 08/22/12 and 08/23/12 the medication was given at 6:00 P.M., The nurses notes for Resident #181 were absent for any documentation of agitation, abnormal behaviors or notification of the resident's family or representative. During a confidential family interview on 08/21/12 at 11:25 A.M., it was stated that they had noticed a decline in Resident #181's cognition over the past week and the facility had not communicated any changes in the resident's condition or treatment. During an interview on 08/22/12 with the evening shift Certified Nurse Aide (CNA) #181 it was stated Resident #181 had recently experienced an increase in her episodes of confusion. During interview with Resident #181's family representative on 08/23/12 at 9:33 A.M., concern was expressed regarding the resident's recent changes in cognition and increase in confusion. The resident's representative also stated he was concerned Resident #181 may have another Urinary Tract Infection [MEDICAL CONDITION] causing her to have increased confusion. The family member also stated he has not been made aware of any changes in Resident #181's medication. During interview on 08/23/12 with the day shift CNA #77 it was stated Resident #181 had recently experienced an increase in confusion. When asked about her response to changes in resident condition, CNA #77 stated that she would tell the nurse on duty. However, CNA #77 stated she had not reported the increase in Resident #181's condition to the nurse. . During interview on 08/23/12 with Registered Nurse (RN) #158 it was stated that when she receives a physician's orders [REDACTED]. During interview on 08/23/12 with Licensed Practical Nurse (LPN) #149, it was verified she had received a physician's orders [REDACTED].#181. LPN #149 stated the resident had been throwing her meal tray, spitting on others and was verbally abusive to staff. LPN #149 stated the staff attempted to redirect Resident #181 without success. LPN #149 verified she did not contact Resident #181's family and did not document the residents behavior in the nurses notes. During interview with RN #78, the Director of Care Delivery, on 08/23/12 at 9:49 A.M., it was verified the staff should notify the residents family of any change in condition or medications. RN #78 also verified there was no documentation in the medical record of any changes in behavior for Resident #181. Additionally, there was no documentation that the resident's representative had been notified of the changes in medication. The last nurse's note for Resident #181 was dated 08/16/12.",2016-12-01
7955,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-12-19,157,D,1,0,KHS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and resident interview, the facility failed to ensure a resident's physician was notified of a resident's refusal of treatment. Resident #59 had physician's orders [REDACTED]. No evidence could be found to indicate the physician had been notified of the resident's refusal. One (1) of six (6) sample residents was affected. Resident identifier: #59. Facility census: 127. Findings include: a) Resident #59 On 12/18/13 at 9:30 a.m., a review of the physician orders, dated 12/05/13, found an order for [REDACTED]. A review of this resident's Medication Administration Record [REDACTED]. In an interview with Resident #59, on 12/18/13 at 10:10 a.m., this resident stated she did these flushes at home and did not like the way staff flushed her tube. On 12/18/13 at 1:30 p.m., the DON was interviewed. The DON stated she was aware Resident #59 had been doing her GJ tube flushes at home. She was also aware the flushes had not been done for thirteen (13) days. When asked if the physician had been notified of this, the DON stated No. The DON stated she would get a clarification from the physician and staff would observe Resident #59 doing the flushes.",2016-12-01
8080,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2013-10-22,157,D,1,0,KE9711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and an interview with the health care surrogate (HCS), the facility failed to ensure the responsible party was promptly notified when one (1) of five (5) residents reviewed for transfer/discharge had significant behavior changes. According to the facility, the changes in behaviors resulted in the facility seeking alternative placement at numerous nursing facilities. Eventually the resident was transferred to a psychiatric facility for treatment of [REDACTED]. Resident identifier: #66. Facility census: 121. Findings include: a) Resident #66 Medical record review found the resident was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Upon admission to the facility, the resident had a health care surrogate (HCS) which was appointed during the resident's stay at the referring hospital. Further review of the medical record revealed the resident was transferred and admitted to an out of state hospital's psychiatric unit for treatment of [REDACTED]. On the day of discharge (09/30/13), only three (3) entries were recorded in the resident's computerized medical record. -- The first entry was written at 2:15 p.m., (Name of health care surrogate) aware of new order to send resident to (name of hospital) for evaluation. -- The second entry was made at 3:59 p.m. by the social worker, Employee #80 which stated, A referral was made to (name of facility), there are no openings at the current time, requested documents will be faxed for review. A referral was made to (another name of a facility) documents will be faxed for review. A referral was made to (name of a third facility) documents will be faxed for review. Two (2) of these three referrals were made to out of state facilities. -- The third entry on 09/30/13 was made at 4:12 p.m., (Name of ambulance service) here to transport resident to (name of the state). Resident and family aware. On 10/21/13 at 12:05 p.m., the director of nursing (DON) was asked how the HCS surrogate was notified regarding the transfer of Resident #66. The DON stated the facility corresponded with the HCS surrogate by e-mail. She provided a copy of the e-mail correspondence on 09/30/13. The message sent to the HCS at 12:45 p.m. on 09/30/12 was, (Initials of the resident) new order for psych consult at (name of hospital) in (name of state). The DON further explained the resident had inappropriate sexual behaviors over the weekend prior to the transfer on Monday 09/30/13. She was asked to provide documentation verifying the behaviors which necessitated the transfer of the resident to the hospital. Review of the medical record from 09/17/13 to 09/30/13 found no evidence of any sexual behaviors displayed by the resident. Employee #103, the director of care delivery on the unit where the resident resided, was interviewed on 10/21/13 at 2:41 p.m. She stated she made the arrangement for the resident to go to the hospital, as she was told the resident had exhibited sexually inappropriate behaviors all weekend. Employee #103 stated the resident was being seen at the facility by a consulting psychiatric agency and she called a worker from that service who arranged the admission to the hospital. She was asked to provide evidence of the resident's behaviors. Employee #103 reviewed the medical record and stated she could find no documentation of any behaviors prior to the hospitalization . Further review of the medical record found Employee #60, a facility social worker, had contacted four (4) other area nursing homes in an attempt to make placement arrangements for Resident #66 on 07/31/13. According to the documentation in the medical record, the other facilities did not accept placement of the resident. Employee #60 was interviewed on 10/21/13 at 1:00 p.m. She stated the resident had displayed inappropriate sexual behaviors for some time but she did not know the actual behaviors that occurred on 09/30/13 because she was not working that day. She stated she had made referrals to other nursing homes for the resident. Employee #60 was asked to provide verification the HCS was made aware of the placement arrangements and of the inappropriate sexual behavior exhibited by the resident. At the close of the survey on 10/22/13 no further information had been provided. The HCS was interviewed by telephone on 10/21/13 at 2:30 p.m. The HCS stated the e-mail did not explain the resident was being admitted to an out of state facility on 09/30/13. She said she believed a psych consult would be completed in house by a psychiatrist, as that was the procedure in the past. She was also unaware the resident was exhibiting any inappropriate sexual behaviors. She stated she had been told the resident had a crush on a male resident. She did not believe a crush was inappropriate. During the telephone interview, on 10/21/13 at 2:30 p.m., the HCS stated she was unaware referrals were made to other facilities until she spoke with the DON via telephone on 10/02/13. She said she called the facility because the hospital had contacted her about Resident #66. She said she had just become aware the facility was also contacting out of state facilities for placement, and her HCS appointment would not even be recognized in an out of state facility. On 10/22/13, the DON and the administrator were interviewed at 9:30 a.m. The DON verified the facility could not produce evidence the HCS was notified the facility was seeking alternative placement at other facilities and she could not find evidence the HCS was notified of the resident's inappropriate sexual behaviors which the facility stated had occurred. The DON also acknowledged the facility had not documented the sexual behaviors exhibited by the resident that resulted in the resident's hospitalization .",2016-10-01
8103,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,ROUTE 103 VENUS ROAD,GARY,WV,24836,2012-10-30,157,D,0,1,QR3O11,"**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 health care surrogate of a dental appointment, resulting in the dentist's refusal to see the resident for his scheduled appointment. This was true for one (1) of one (1) resident who triggered notification of changes in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #64. Facility census: 97. Findings include: a) Resident #64 Review of the medical record found an oral evaluation had been completed on 05/12/12. The resident was experiencing oral concerns and the resident's teeth were described as broken and / or had carious. Further review of the medical record found a physician's orders [REDACTED]. The medical record contained no further information regarding the results of the dental appointment. On 10/25/12 at 10:30 a.m., the administrator presented a copy of a pick up order from the local ambulance company which verified the resident had been transported to the dentist on 06/11/12. The administrator stated the dentist had refused to see the resident because his legal representative had not accompanied the resident to the dentist appointment. The administrator stated no follow-up appointment had been scheduled because the resident had refused to go to the dentist and he had said his teeth were not hurting. The resident had been deemed to lack capacity to make health care decisions and his sister had been appointed as his health care surrogate on 08/25/08. On 10/29/12 at 11:00 a.m. the administrator and the director of nursing (DON) verified no further information could be located to verify the resident's sister had been made aware of his dental appointment on 06/11/12.",2016-10-01
8113,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2013-10-24,157,D,1,0,YU0K11,"Based on record review and staff interview, the facility failed to notify the responsible party, and did not consult with the resident's attending physician, about a skin tear for one (1) of six (6) sample residents. A skin tear was found on 09/04/13. There was no evidence the physician and family were informed of the skin tear until 09/06/13. At that time, the physician ordered an oral antibiotic and the family was informed. Resident identifier: #13. Facility Census: 57. Findings include: a) Resident #13 The Hospice Nursing Notes, dated 09/04/13, noted a skin tear was found on the resident's right arm above the inner aspect of her elbow when the arm protectors were removed for her shower. According to the Hospice note, the resident's primary nurse was notified and the Hospice nurse showed her the resident's right arm. The Hospice note indicted the nurse left the elbow protectors off to allow the wound to the right arm to dry/heal. The front sheet of the Hospice routine note, dated 09/04/13, stated the resident had a skin tear to her right arm above the elbow. The location of the skin tear made it difficult to see and/or assess. Due to contractures of the resident's arm, the skin tear required immediate attention because of moistness and skin to skin contact which would contribute to a worsening of the area if immediate care and treatment was not implemented. The facility nursing notes were reviewed for 09/04/13. There was no evidence the nurse recorded Resident #13 sustained a skin tear when the arm protectors were removed. In addition, there was no evidence the physician and the family were informed of the skin tear. Further review of nursing notes found a change in condition note, written on 09/06/13, regarding the skin tear which was found on 09/04/13. The note indicated the physician was notified there was pus, drainage, and redness to the open skin on the left and right antecubital area, and ordered an oral antibiotic. This was the first evidence the physician was notified of the skin tear. The notes indicated the family was notified of the new orders for the antibiotic. The Director of Nursing (DON), Employee # 17, was interviewed 10/23/13 at 2:00 p.m. regarding notification of the family and physician regarding this skin tear. She stated the facility completed incident and accident reports for skin tears, which prompted them to notify the family and physician. She was not able to find an incident report for this occurrence. The DON verified there was no evidence of prompt notification of the physician. She also confirmed the family was not made aware of the skin tear until the physician ordered the antibiotic for signs of infection.",2016-10-01
8133,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2012-08-07,157,D,0,1,XYXU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to notify the responsible party and/or physician when there were changes in the resident's medications, treatment, or condition. Two (2) of thirty-nine (39) residents on the sample were affected. Resident identifiers: #33 and #40. Facility census: 58. Findings include: a) Resident #33 In an interview with the responsible party for Resident #33, he said he was not notified when the facility changed a medication or treatment. Review of the resident's medical record did not find evidence the responsible party had been notified when medication or treatment changes had occurred. Interview with Employee #3, a licensed practical nurse, revealed a nurse's note was to be written and placed in the chart when the responsible party was notified of a change in a resident's care or treatment. In an interview with Employee #33, a registered nurse, regarding the procedure for notifying a resident's responsible party and what was to be documented, she described the same process as had Employee #3. She stated she did recall calling the responsible party for Resident #33, but she did not make a note. In an interview with the Assistant Director of Nursing regarding the policy on notification of changes, she stated a nurse's note was to be written in either a change of condition or general nurse's note. b) Resident #40 Review of the Medication Administration Record [REDACTED]. Review of the nurses' notes and physician orders [REDACTED]. The physician's orders [REDACTED]. In an interview with a registered nurse (RN), Employee #33, on 08/01/12 at 2:45 p.m., the nurse confirmed there was no documentation of notification of the physician on the morning of 07/14/12. During an interview with the Assistant Director of Nursing (ADON) (Employee #64), on 08/02/12 at 8:50 a.m., she acknowledged the lack of documentation for the low blood sugar on 07/14/12, and the failure of Employee #79 to notify the physician.",2016-09-01
8140,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2013-09-09,157,D,1,0,3Q1U11,"**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 notified when a resident's condition changed and medications were not administered due to a resident's acute illness. Routine medications for one (1) of ten (10) sample residents were not administered on 08/16/13 at 9:00 a.m., 11:00 a.m , or 9:00 p.m. There was no evidence the physician was made aware medications were held for Resident #120, so the physician could evaluate the resident to determine if the treatment plan needed altered while the resident was experiencing an acute illness. Resident identifier: #120. Facility Census: 116. Findings include: a) Resident #120 This resident's Medication Administration Record [REDACTED]. The medications not administered included medications for the resident's blood pressure, anxiety, [MEDICAL CONDITION], [MEDICATION NAME] medication to prevent blood clots following surgery, diabetic medications, medications for [MEDICAL CONDITION] reflux disease, and medication for diabetic [MEDICAL CONDITION]. Further review of the medical record revealed there was no physician's order, or evidence the physician had given instructions to not administer the medications. The medication that were held included injections as well as medications to be given by mouth. These include: Insulin Detemir 28 units subcutaneous every twelve (12) hours and Humalog Insulin ten (10) units three (3) times daily before meals for diabetes, Enoxaprin ([MEDICATION NAME]) 40 mg (milligrams /0.4 ml (milliliter) subcutaneous one (1) time daily for [MEDICATION NAME] ([MEDICAL CONDITION]. The Nurse Practitioner (NP) was interviewed 09/09/13 at 2:00 p.m., regarding the medications held for this resident. She stated the nurse may have told her they were holding this resident's medications; however, medical record review revealed no evidence of this. The NP stated the resident was having nausea and vomiting, and the nurse held the medications for that reason. She verified the subcutaneous medication for [MEDICAL CONDITION] should have been given. The NP confirmed she would not have held that medication. Also, she stated when insulin was held even one (1) time, the physician should always be notified. The NP verified this resident was not on scheduled finger stick blood sugars to monitor her glucose blood sugars. She said if they had told her they were holding insulin and the she was not receiving finger sticks, she would have had them monitor the resident's blood sugars for complications. There was no evidence the physician was made aware that these medications were held.",2016-09-01
8148,"REYNOLDS MEMORIAL HOSPITAL, D/P",515112,800 WHEELING AVENUE,GLEN DALE,WV,26038,2013-03-20,157,D,0,1,UVNX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, and medical record review, the facility failed to provide evidence the responsible party was notified when a change in treatment was ordered by the physician. This was true for one (1) of two (2) residents reviewed. Resident Identifier: #117. Facility census: 18. Findings include: a) Resident #117 During a family interview, conducted on 03/12/13 at 2:37 p.m., a family member of Resident #117 denied being informed of changes in treatment for [REDACTED]. Medical record review, on 03/20/13, determined Resident #117 had been determined to lack the capacity to make medical decisions on 03/04/13. The family member who was interviewed had been appointed as the resident's responsible party on 03/05/13. Employee #6 (Head Nurse) was interviewed on 03/18/13 at 1:00 p.m. She was asked where in the medical record did it provide evidence that a resident or responsible party was notified of changes in treatment. She stated a change in treatment would be documented in a nurse's note. When asked to provide the nurse's note of a randomly selected order for [MEDICATION NAME], received 03/16/13 at 10:15 p.m., she was unable to locate evidence the responsible party was notified. On 03/20/13 at 9:00 a.m., Employee #3, a Licensed Practical Nurse, Patient Services, was asked for evidence of notification of the responsible party for all order changes since admission. Three (3) nurses' notes were provided showing the responsible party had been notified of changes in the resident's treatment. However, orders for which no evidence of the responsible party having been notified included: -- 03/07/13 [MEDICATION NAME] as needed -- 03/11/13 [MEDICATION NAME] -- 03/13/13 Speech Therapy Consult -- 03/15/13 Pureed diet, [MEDICATION NAME] -- 03/16/13 [MEDICATION NAME] -- 03/17/13 [MEDICATION NAME], Normal Saline Flush, and Urine Culture",2016-09-01
8165,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2012-11-15,157,D,0,1,M8CD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to notify the physician timely with recommendations from the dietitian for a change in a dietary intervention to prevent further weight loss. This affected one resident (#19) of the 3 residents reviewed out of the 5 residents identified with weight loss. Findings include: Resident #19 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The most recent Minimum Data Set, dated dated dated [DATE], indicated the resident received set up help with her meal and was supervised when eating, had dysphagia, and had no weight loss. The resident's plan of care dated June 13, 2012, indicated the resident was new to the facility. Body Mass Index was 27%, present weight was 165 pounds, and resident was above her Ideal Body Weight of 120-140 pounds. The goal was that resident would maintain an adequate nutrition status as evidenced by maintaining a stable weight within five pounds with an intervention that the dietitian would review as recommended or as needed. Additional interventions included: May have resident choice menu one time per month, regular diet daily at meals as ordered, record food and fluid intake daily at meals, and record weight weekly for four weeks and then monthly. The resident's medical record was reviewed and included the following dates and weights: -6/12/12 165 pounds -6/13/12 161 pounds -6/20/12 161 pounds -7/1/12 157.5 pounds -7/4/12 157 pounds -7/11/12 156 pounds -7/18/12 157 pounds -8/1/12 154.5 pounds -9/1/12 153 pounds A dietary assessment was completed by the dietitian on June 27, 2012. The dietitian documented the resident's height 66 inches and that she weighed 161 pounds. The resident was on a regular diet with an average intake of 62% of meals. The resident had an oral intake of 1410 calories and 61 grams of protein, had no skin breakdown, no [MEDICAL CONDITION], and there were no recommendations made at this time by the dietitian. On July 25, 2012, the dietitian did an assessment on the resident. The dietitian documented the resident acquired a new Stage 1 pressure ulcer to the left heel. The resident had an oral intake of 1115 calories and 48 grams of protein and the oral intake needed to improve to promote wound healing. Documentation included that when the dietitian met with the resident she told the dietitian she didn't want to get fat and did not want foods between meals. The dietitian documented that she encouraged the resident to increase her oral intake to promote the healing of the pressure ulcer on her heel. The dietitian documented her plan to recommend Super Cereal at breakfast to increase protein and calories and would continue to monitor oral intakes, weights, and pressure ulcer healing. The dietitian completed a Registered dietitian to Physician Recommendation Form on July 25, 2012. The form included the resident's name, physician name, and room number. The form listed a Summary of Nutritional Concern and indicated that the resident had a new Stage 1 pressure ulcer on heel. Oral intakes were documented at 49%. The Recommendation of dietitian was for the resident to receive Super Cereal at breakfast. The form was signed and dated July 25, 2012, by the dietitian. On July 30, 2012, the physician wrote an order for [REDACTED]. On November 15, 2012, at 11:45 a.m., the Unit Manager, a Registered Nurse, staff #7 was interviewed. Staff #7 stated the dietitian comes to the facility every two weeks. If recommendations are made by the dietitian, the recommendations are kept until the physician comes to the facility on Mondays and Thursdays. The physician would then review the recommendations and write physician orders [REDACTED]. Staff #7 verified the physician was in the facility on the morning of July 25, 2012, the same day the dietitian made the recommendation for Super Cereal. Staff #7 stated the physician was not in the facility on July 26, 2012, which was a Thursday, so she did not see the dietitian's recommendations until July 30, 2012, which was the following Monday. The physician wrote an order based on the dietitian's recommendation five days after the dietitian assessed the resident and identified a nutritional concern due to the development of a Stage 1 pressure ulcer. On November, 15, 2012, at 1:10 p.m., the Director of Nursing (DON), Staff #2, was interviewed. Staff #2 verified the dietitian comes to the facility twice a month and the physician comes twice a week. She stated the dietitian gives the recommendations to the unit managers and they give them to the physician on the days that the physician is in the facility. The DON stated there was no specific policy and stated it was the facility's procedure for notifying the physician of the dietitian's recommendations.",2016-09-01
8187,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,157,D,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the responsible party of an administration of intravenous antibiotics for treatment of [REDACTED].#248) out of three sampled for urinary incontinence out of a eight residents identified as having a decline in urinary continence. Findings include: Resident #248 had [DIAGNOSES REDACTED]. The most recent Minimum Data Set ((MDS) dated [DATE] revealed the resident was always continent. The MDS dated [DATE] revealed the resident had a decline and was occasionally incontinent. The plan of care for incontinence dated 4/3/12 revealed the resident will have incontinence episodes managed without signs and symptoms of urinary tract infection and will have dignity maintained with incontinence care. The plan of care revealed to observe for signs and symptoms of urinary tract infection, monitor labs, and provide perineal care daily and as needed. Observations were made on 5/15/12 at 12:36 p.m. of the resident lying in bed and on 5/16/12 at 6:00 p.m. the resident was ambulating in the halls talking to staff. An interview was done with the resident and she stated she didn't feel well today, but she is a lot better than she used to be. She stated she walks and takes herself to the bathroom and doesn't need any help. During an interview on 5/15/12 with CNA #64 at 12:40 p.m., the CNA stated the resident will ask for help if needed, but very seldom, she stated, she can take herself to the bathroom and doesn't need help from the staff. The CNA stated the resident has been incontinent at times and had been ill awhile back. An interview with RN #32 at 1:45 p.m. was done. The RN stated the resident had a urinary tract infection in March and was started on antibiotic ([MEDICATION NAME]) intravenously (IV) for 10 days on 3/23/12. The RN stated she talks to the daughter all the time, but could not be certain that she notified her when the IV antibiotics was started. She verified there was no documentation anywhere in the chart that the daughter had been notified of the new orders for the IV antibiotics. Review of the clinical record revealed the resident had Escherichia Coli greater than 100,000 on the colony count on 3/21/12 and the physician ordered [MEDICATION NAME] 1.5 mg/kg IV every 8 hours. An interview with the daughter on 5/15/12 at 3:45 p.m. revealed she calls the facility everyday to check on her mother. She stated she was not notified of her mother having a urinary tract infection and receiving IV antibiotics until she called in one day after the resident had been on them (sic) for a few days and RN #32 informed her. Interview with RN #32 at 4:30 p.m. verified that she remembered the daughter calling and being upset that no one had called to tell her that her mother was sick and had to have IV antibiotics. The RN verified the family should have been notified of the resident having a urinary tract infection and of the physician's orders [REDACTED].",2016-07-01
8268,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2013-08-15,157,G,1,0,RDF011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of hospital records, and policy review, the facility failed to ensure the physician was notified as directed by facility policy when a resident's blood sugars were over 400. The resident's condition declined, she was sent to the hospital, and subsequently expired. One (1) of five (5) sampled residents was affected. Resident identifier: #63. Facility census: 62. Findings include: a) Resident #63 Medical record review on [DATE], noted the resident had a medical history of [REDACTED]. When she was transferred to the long term care facility on [DATE], she was placed on finger sticks twice a day at 7:00 a.m. and 9:00 p.m. upon admission for two (2) weeks and the nurses were instructed to draw a HgbA1c with the next lab draw on [DATE]. According to the Medication Administration Record [REDACTED]. Although the finger stick blood sugar results were elevated, the medical record contained no evidence of notification of the physician. On [DATE] at 9:00 p.m., the resident's blood sugar result was 416. On [DATE] at 9:13 p.m., the resident's blood sugar was 475. On [DATE] at 7:00 a.m., the resident's blood sugar was 408. On [DATE] at 12:30 p.m., (more than five (5) hours after the results of the finger stick was recorded), Employee #32, a registered nurse (RN), notified the physician of the elevated finger stick blood sugars and received an order for [REDACTED].>At 4:05 p.m. (16:05) on [DATE], an order was obtained to send the resident to the emergency room . At 8:26 p.m. (20:26) the resident expired at the acute care facility emergency room . This matter was discussed with the DON at 2:30 p.m. on [DATE]. She said a blood sugar value that was over 400 was considered an urgent value for a finger stick that required immediate notification of the physician. She provided the facility's policy on finger sticks. The Policy Diabetic Care Protocol 15.14, effective [DATE] revised [DATE], in Section 9.1.1 included If parameters are not ordered, report following to physician URGENT: Notify immediately if blood glucose is greater than 400 or less than 70 .",2016-07-01
8295,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,157,D,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to inform the responsible party and/or physician of changes in health status for one (1) of 45 sampled residents. Resident identifier: #33. Facility census: 52 Findings include: a) Resident #33 1. Review of the medical record revealed that Resident #33 had a fever of 99.1 axillary on 03/14/12. The nurse documented, on 03/14/12 at 3:25 a.m., that she had faxed the physician and requested an order for [REDACTED]. Further record review found no evidence of a fax copy sent to the physician with the request for the urinalysis or evidence the physician replied to the fax. There were no urinalysis reports for Resident #33 in March 2012. Interview with Employee #44, the director of nursing (DON), on 07/23/12 at approximately 11:00 a.m., found that she, assisted by Employee #17 (ward clerk) and Employee #43 (director of health information management), could find no evidence in the medical record of a fax to the physician on 03/14/12 related to Resident #33's temperature elevations or the need for a urinalysis. Additionally, they were unable to find any new physician orders [REDACTED]. Employee #17 stated that faxes were filed in the back of residents' medical records, but there was none found for the alleged 03/14/12 fax. Employee #44 stated the nurse, who documented she faxed the physician on 03/14/12 to alert him to the fever and to request a urinalysis to rule out a urinary tract infection, was no longer employed by the facility. She also stated they have no policy related to how frequently to recheck temperatures when there has been an elevation, and do not routinely notify the responsible party or physician for a fever below 101 degrees. When asked if the temperature elevations and the fax to the physician were placed on the 24 hour report for follow-up, Employee #44 said Those reports are not part of the medical record, so are kept for only a few days and then shredded. Therefore, that information was not available for review. 2. Record review revealed this [AGE] year old resident had [DIAGNOSES REDACTED]. Record review also revealed this resident was dependent on staff for feeding and fluid intake. Review of the most recent dietitian notes, dated 02/16/12, revealed the most recent laboratory (lab) report noted, Indicate pos (possible)/slight dehydration. She recommended to encourage fluid intake, and monitor for changes. Record review revealed the most recent basic metabolic profile (BMP) the dietitian referred to was completed on 01/28/12. The blood urea nitrogen (BUN) was elevated at 32, with the normal reference range between 8 and 27. The BUN/creatinine ratio was elevated at 42, with the normal reference range between 11-26. These are blood tests that can be indicative of dehydration. Review of a discharge summary from the hospital, dated 04/19/12, revealed Resident #33 was admitted to the hospital, on 04/16/12, with the [DIAGNOSES REDACTED]. Review of the 04/16/12 admission lab work at the hospital found her BUN was elevated at 70 (with the normal reference range between 6-19), and the urea/creatinine ratio was elevated at 65 (with the normal reference range between 12-20). During an interview with Employee #44 on 07/23/12, at approximately 11:00 a.m., the estimated daily fluid need, for this resident who weighed 120 pounds (50 kilograms), was discussed. At 30 cc per kilogram, she would have required 1500 cc of fluids daily. Review of the March 2012 and April 2012 intake reports for Resident #33 found there were no days in this time period which indicated she consumed 1500 cc of fluids daily. The daily average fluid and supplement intake recorded for March 2012 was 968 cc for 29 days; two (2) days had no recordings. The daily average fluid and supplement intake recorded for 04/01/12 through 04/15/12 was 701 cc. During an interview with Employee #44, on 04/23/12, at approximately 11:00 a.m., she checked with Employee# 46, then reported that Resident #33's fluid or food intake was not discussed in daily or monthly meetings in March, or in April prior to hospitalization on [DATE]. She explained this was because she did not trigger for weight loss in March or April. She said this resident was offered food and fluid frequently, but would often refuse. When asked if the responsible party was notified of her food and fluid decline and weight loss, she replied in the affirmative, noting that the resident's husband was here almost daily, and the resident's children visited frequently, so someone in the family was always kept informed, but it may not always have been documented. Record review found that the resident's son had been appointed the health care surrogate on 11/21/11. Review of the medical record found no evidence that the son had been notified of the weight loss, or the food and fluid intake decline, in March or April 2012. During the interview with Employee #43 on 04/24/12, a request was made to produce any part of the medical record going back to the first of the year where the medical power of attorney or health care surrogate had been notified of the resident's weight loss or food and fluid intake decline. Subsequently, copies of nurses' notes from 03/13/12 through 04/20/12 were produced by Employee #43, at approximately 11:30 a.m. None of the notes contained evidence of communication with the son related to the resident's food and fluid intake decline and weight loss. 3. Record review found that this resident, on 04/23/12, had changes in lung sounds as assessed by facility nurses. Further record review revealed that neither the responsible party nor the physician were notified in a timely manner of the change in condition, which was indicative of fluid volume excess in her lungs. Record review revealed that Resident #33 began receiving intravenous fluids (IV) at 75 cc per hour shortly after midnight on 04/20/12. Factors which placed her at higher risk of potential adverse reactions from receiving intravenous fluids included a [DIAGNOSES REDACTED]. Record review revealed that on 04/23/12 at 3:00 a.m., the nurse assessed diminished breath sounds in both lower lobes. At 8:45 a.m. the hospice aide notified the nurse that the resident was coughing. The nurse then assessed moist lung sounds with rhonchi present bilaterally, and called the hospice nurse to come in and evaluate the resident. The hospice nurse, upon her arrival at the facility at 10:30 a.m., assessed slight expiratory wheezing. Neither the physician nor the responsible party were notified of the changes in respiratory status. It was not until 12:10 p.m. when a laboratory technician from the hospital called to report a critically elevated potassium blood level, and a high creatinine blood level, that the intravenous infusion of fluids with potassium was stopped, and the physician and responsible party were notified. The resident was then transferred to the local emergency room . Review of the admission history and physical at from the hospital, dated 04/23/12, revealed in the admitting impression that she Seems to have volume in her lungs with bilateral pleural effusions and crackles. The physician noted the resident had acute [MEDICAL CONDITION]. The physician also noted she had [MEDICAL CONDITION] that appeared to be systolic. Comparatively, record review found a chest x-ray had been completed on 04/16/12, and revealed there was no acute infiltrates or effusions that were seen, and no acute cardiopulmonary process was identified at that time. Review of the hospital discharge summary dated 04/26/12, found discharge [DIAGNOSES REDACTED]. During the interview with Employee #44 on 07/23/12, at approximately 11:00 a.m., she said it was her expectation that nurses do lung assessments on each shift when a resident was receiving IV fluids. She said she would have expected the nurses to have notified the physician when there were lung sound assessment changes as there were on 04/23/12. She said they have no policy about assessing lung sounds on residents who are receiving IV fluids.",2016-07-01
8359,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2012-12-07,157,D,0,1,X9QJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to notify the physician of the results from an abnormal laboratory test report for one of ten sampled residents (Resident #17), who was reviewed for unnecessary medications. Findings include: Resident # 17 was originally admitted to facility on 7/01/2011 and was re-admitted on [DATE]. The resident had multiple [DIAGNOSES REDACTED]. The most recent full minimum data set (MDS) assessment dated [DATE], indicated that Resident # 17 received antipsychotic, anti anxiety, and anti-depressants medications. The MDS assessment did not list the anti-coagulants medications but added the following statement: See MD orders for current meds and consults, and that the resident is at risk for side effects associated with medications . The physicians orders dated 11/11/2012 included an order for [REDACTED]. Further review of the physicians monthly recapitulation orders dated 11/08/2012 through 12/06/2012 revealed a laboratory order for weekly monitoring of the anticoagulant via [MEDICATION NAME]/INR (International Normalized Ratio) QWK (every week) .[MEDICATION NAME] therapy. The plan of care dated 4/06/2012 through 1/02/2013 was also reviewed and listed as a problem area Potential for complications, injury related to anticoagulants medication. The care plan goal indicated that the resident Will be free from complications, bleeding, injury related to [MEDICATION NAME] thru next 90 days. The care plan also listed the following pertinent nursing interventions: 1). Administer medications as ordered and monitor effects ([MEDICATION NAME]) The care giver was listed as the licensed nurse. 2). Obtain and monitor lab/diagnostics work as ordered. Report results to MD (doctor of medicine) and follow up as indicated. The care giver was listed as the Nursing Department. A review of the clinical record revealed a laboratory report dated 11/29/2012. The laboratory report was initialed and dated by the RN coordinator on the same date 11/29/2012. There were no other initials, signatures, or comments noted on the report. The results of the laboratory report revealed the following abnormal lab values: The PT (pro [MEDICATION NAME] time) level was flagged as high at 42.5 seconds with a normal reference range of 10.1 -11.6 seconds. The high level was indicated on the report by the letter (H) next to the result. The INR was listed at 4.0 with no normal reference ranges noted on the report. The same lab report also indicated that the resident's potassium and chloride levels were abnormally low. The potassium level was noted on the report as 3.2. mEq/L (milliequivalents per liter). The normal reference range of potassium 3.6-5.1 mEq/L. The chloride level was also flagged as low indicated by an L on the report at 100 meq/L with a normal reference range of 101-111 mEq/L. An interview was conducted on 12/06/2012 at approximately 3:45 PM with the direct care nurse (staff member #35) that regularly provided care for resident #17. The licensed nurse voiced that she had not notified the physician of the abnormal lab results from 11/29/2012. The licensed nurse stated there was no documentation that she could find to support that the physician had been notified by anyone, An interview was also conducted on 12/06/2012 at approximately 3:55 PM with the Nurse coordinator (staff member # 103) who regularly monitors the facility's laboratory results. The nurse coordinator stated that she had signed the abnormal PT/INR laboratory report dated 11/29/2012 with a PT/INR result of 44.3/4.0, but stated that she had not notified the physician of the abnormal results. The nurse coordinator stated that instead of notifying the physician she followed the parameters and guidelines from a document she provided entitled Table 6 Recommendations for managing elevated INR's or bleeding in patients receiving VKA's (vitamin K agonists). The nurse coordinator further stated that the facility did not have a specific protocol for when to notify and when not to notify the physician of abnormal lab results. The nurse coordinator stated that the physician has a note book at the nurse's station that contained several documents like Table 6 referenced above, but no specific facility protocol as to when it would and would not be necessary to notify the physician of the abnormal lab results. The nurse coordinator stated, This (referring to Table 6) is what I go by, but there is no order that says don't call. The nurse coordinator did not address the abnormal potassium or chloride results on the same report. An interview was conducted with the director of nursing (DON) on 12/06/2012 at approximately 4:10 PM regarding the abnormal lab results from 11/29/2012. The DON stated that she had just been made aware by the RN coordinator that she had not notified the physician of the PT/INR results. The DON further stated that the facility did not have a written policy on when to report abnormal laboratory values to the physician, but stated that the facility uses the statement at the top of the facility's physicians standing orders which indicated, All changes in condition must be reported to the physician, RN on duty or RN on call and the residents health care representative. The standing orders document did not address when to report abnormal laboratory results or abnormal anticoagulant therapy laboratory results. The PT/INR results from the previous weeks results dated 11/21/2012 were also abnormal with PT/INR levels noted of 35.9/3.4. The physician was made aware of those results by the RN coordinator who in addition to signing the lab report and also noted the following comment, Message left for Dr. _____ (attending physician's name) 12:10 PM, 11/21/12. The lab report from 11/21/2012 was also signed and dated by the physician. The most recent MD progress note in the clinical record was dated September 30, 2012. There was no indication in the clinical record that the physician was aware of the abnormal lab results from 11/29/2012.",2016-07-01
8363,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,157,D,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, family interview, and physician interview, the facility failed to notify the responsible party and the physician when a resident developed pressure ulcers. Resident #79 was transferred to the hospital and the family was unaware she had developed pressure ulcers at the nursing home, until she arrived at the hospital. The physician was then made aware of the pressure ulcers by the family after the resident was sent to the hospital. This was true for one (1) of ten (10) sampled residents. Resident identifier: #79. Facility census: 82. Findings include: a) Resident #79 A review of the medical record identified Resident #79 was noted to have developed pressure ulcers to both heels on 07/01/03. There was no evidence the facility notified the resident's responsible party of the change in the resident's skin condition. The resident was admitted to the hospital on [DATE]. During an interview with the resident's responsible party, on 07/15/13 at 6:30 p.m., it was learned the family was not made aware of the resident's skin condition until she was admitted to the hospital and the hospital made them aware. The physician was interviewed on 07/17/13 at 10:00 a.m. It was confirmed he was not made aware of the pressure areas by the facility. He was not aware of this resident's skin condition until the family made him aware after the resident was sent to the hospital.",2016-07-01
8382,MADISON PARK HEALTHCARE,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2012-03-22,157,D,0,1,WTH511,"**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 and the resident's responsible party when one (1) of twenty-three (23) stage II sample residents experienced a significant weight decline. Resident identifier: #7. Facility Census: 41. Findings Include: a) Resident #7 This resident was admitted [DATE] with a weight of 125 pounds. Her weight on 12/08/11 was recorded as 113 pounds. Her weight on 03/21/12 was 100.8 pounds. There was no evidence the family or the physician had been notified of this significant weight decline. The dietitian was questioned regarding this weight decline at 2:00 p.m. on 3/21/12. She stated she had not been aware of this decline. At that time, she verified there had been no interventions initiated.",2016-06-01
8399,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2013-06-12,157,D,1,0,7PU311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the physician was notified when a resident's blood sugar was below sixty (60), or four hundred (400) or above, as directed in the physician orders. This was true for one (1) of five (5) sample residents. Resident identifier: #95. Facility census: 94. Findings include: a) Resident #95 1) Medical record review, on 06/12/13 at 11:40 a.m., revealed the resident's blood sugar was documented on 02/13/13 at 10:06 p.m. with a value of four hundred (400). Review of the resident's physician's orders [REDACTED].= none 11-140=1 unit 141-170=2 units 171-200=3 units 201-230=4 units 231-260= 5 units 261-290= 6 units 291-320= 7 units 321-350= 8 units 351-400 = 10 units 400 - call physician and send urine for [MEDICATION NAME] diabetes solution. No documentation could be located to indicate the physician was notified or that the ordered laboratory study had been performed. In an interview with the facility administrator, also a registered nurse, on 06/12/13 at 1:05 p.m., she stated she was unable to locate any follow up actions or coordinating nursing noted for the elevated blood sugar on 02/13/13. 2) Further review of the medical record found that on 04/26/13 at 6:20 a.m., an Accucheck reading of 58 was recorded. The resident had an order for [REDACTED]. There was no evidence found to indicate the physician was notified. There was no evidence the low blood sugar was monitored or reported to the physician. This incident was reported to the appropriate State Agency on 04/29/13 upon discovery, and disciplinary action was taken with the employee.",2016-06-01
8404,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,157,D,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and medical record review, the facility failed to ensure the physician was notified timely that an appetite stimulant medication ordered for weight loss for one of eighteen (R3) sampled residents was consistently refused by the resident. Findings: R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed the following: The Weigh Record revealed the following: 01/01/2012 130.5 pounds, 02/05/2012 120 pounds, and 03/08/2012 120.8 pounds. Physician order [REDACTED]. Review of Medication Administration Record [REDACTED]. An interview was conducted with the 300 Hall medication nurse (LPN3) on 04/11/2012 at 10:00am. The medication nurse acknowledged that R3 refused the medication frequently and the physician had not been notified. The nurse stated I will notify the physician today. An interview was conducted with the Director of Nursing (DON) and the Certified Dietary Manager on 04/11/2012 at 11:00am. Both staff members stated that they were unaware that R3 had consistently refused to take the [MEDICATION NAME] that was ordered by the physician. The DON confirmed that the physician should have been notified.",2016-06-01
8561,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2012-05-21,157,D,0,1,ZPPW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, and medical record review, the facility failed to ensure changes in medications and treatments were discussed with a resident who had capacity to make medical decisions. This was true for one (1) of thirty-seven (37) sampled residents. Resident identifier: #31. Facility census: 54. Findings include: a) Resident #31 During an interview with Resident #31, in stage I of the quality indicator survey (QIS), on 05/14/12, at approximately 4:45 p.m., the resident stated he never made any decisions about his care and changes in treatments and medications were never discussed with him by anyone at the facility. Medical record review found the resident was admitted to the facility on [DATE]. Information accompanying the resident upon admission found a physician from the referring hospital had determined the resident had capacity to make decisions. On 02/24/12 the facility physician also determined the resident had capacity to make medical decisions. Further review of the physician's orders [REDACTED]. 02/28/12-New order to cleanse the thumbnail to the right hand. 03/07/12-New order to change the diet order to a mechanical soft diet, ground meats and nectar thickened liquids. 03/11/12-New order to treat a stage II pressure area to the gluteal crease. 03/16/12-New order to discontinue the resident's Glucerna and add Ensure plus. 03/22/12-New order to discontinue the PRN (as needed) [MEDICATION NAME] and schedule [MEDICATION NAME] 0.5 mg (milligrams) to TID (three times a day). 03/25/12-New order to change the current treatment to the stage II pressure area to the gluteal crease. 03/30/12-New order to provide treatment to a skin tear. 04/02/12-New order for [MEDICATION NAME] and [MEDICATION NAME] for treatment of [REDACTED]. 04/10/12 New order to treat a Stage II pressure ulcer to the right anterior leg. 04/10/12-New order to discontinue the Ensure and add a Magic Cup. 04/20/12-New order to add a bed and chair alarm. 04/26/12-New order for [MEDICATION NAME] 0.5 mg BID (two times a day). 05/10/12-Side rails were added to aide in turning and repositioning. 05/19/12-[MEDICATION NAME] was increased from 0.5 mg to 1 mg BID (two times a day). Review of the nurses notes found the resident's medical power of attorney (MPOA) was notified of the changes in care which occurred on 03/25/12, 04/26/12, and 05/19/12. There was no evidence the resident was notified of the changes made to his care, treatments, and medications from 02/28/12 through 05/19/12. The director of nursing (DON) was interviewed at 9:30 a.m. on 05/21/12. She was unable to provide any evidence the changes in care were discussed with the resident, who was deemed to have capacity to make medical decisions by two (2) physician's.",2016-05-01
8596,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,157,D,1,0,BVS711,"Based on medical record review and staff interview the facility failed to notify the physician of changes in condition for two (2) of eight (8) residents in the sample. Resident #16 had a psychiatric evaluation and the physician was not made aware of the recommendations. In addition, the physician was not notified of Resident #60's change in condition related to abnormal vital signs. Resident identifiers: #16 and #60 Facility census: 78 Findings include: a) Resident #16 A medical record review, conducted on 05/30/13 at 2:00 p.m., revealed the resident had a consultation with a mental health professional on 01/04/13. The consultation sheet was in the resident's paper copy chart. It contained recommendations from the psychologist. There was no evidence the physician was notified of the recommendations. Nursing notes did not indicate the physician was notified, and the consultation sheet was not signed by the physician. An interview was conducted, on 05/30/13 at 3:00 p.m., with Employee #33, a registered nurse (RN) unit manager. When asked if the resident's consultation from 01/04/13 was followed up by the physician, the RN stated if there had been a follow up, there would be a nursing note or a signature on the consultation sheet. Employee #33 was unable to locate a note which described the physician was notified of the recommendations by the mental health professional. The facility's medical director was interviewed on 05/31/13 at 2:15 p.m. When asked how he was informed of information from a consultation, he stated nursing staff called him or placed the recommendations in his folder for him to review. When asked if he signed off on consultation sheets, he said he did, or the nurse marked he was notified. When he was shown the consultation sheet for Resident #16 from 01/04/13, he stated he had never seen the consultation, and was unaware of any recommendations prior to the resident's last admission to the hospital. b) Resident # 60 A nursing note, dated 05/02/13 at 4:59 p.m. stated, Called to hall outside resident's room per CNA (certified nursing assistant). Resident was entering another resident's room. Resident was out of wheelchair and started to collapse and aides got him under the arms and basket carried him to wheelchair. His eyes were rolling back in his head. Initial vital signs were 70/47 with pulse 84. Pulse started climbing as high as 237. RN (Registered Nurse) supervisor was called to room and examined resident. Left pupil was not reacting to light. Grips evened out bilaterally. Began to speak coherently. Blood pressure bumped up to 108/66 and pulse rate evened out at 81. This note further indicated the daughter was notified and the resident's code status was DNR (do not resuscitate). The note indicated staff will continue to monitor. There was no evidence the physician was notified of this resident's change in condition. During an interview with Employee #12, a licensed practical nurse, on 05/30/13 at 2:30 p.m., she verified there was no evidence the physician was notified of this resident's condition change and abnormal vital signs.",2016-05-01
8605,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,157,D,1,0,5M3K11,"Based on medical record review and staff interview the facility failed to notify the physician of changes in condition for two (2) of eight (8) residents in the sample. Resident #16 had a psychiatric evaluation and the physician was not made aware of the recommendations. In addition, the physician was not notified of Resident #60's change in condition related to abnormal vital signs. Resident identifiers: #16 and #60 Facility census: 78 Findings include: a) Resident #16 A medical record review, conducted on 05/30/13 at 2:00 p.m., revealed the resident had a consultation with a mental health professional on 01/04/13. The consultation sheet was in the resident's paper copy chart. It contained recommendations from the psychologist. There was no evidence the physician was notified of the recommendations. Nursing notes did not indicate the physician was notified, and the consultation sheet was not signed by the physician. An interview was conducted, on 05/30/13 at 3:00 p.m., with Employee #33, a registered nurse (RN) unit manager. When asked if the resident's consultation from 01/04/13 was followed up by the physician, the RN stated if there had been a follow up, there would be a nursing note or a signature on the consultation sheet. Employee #33 was unable to locate a note which described the physician was notified of the recommendations by the mental health professional. The facility's medical director was interviewed on 05/31/13 at 2:15 p.m. When asked how he was informed of information from a consultation, he stated nursing staff called him or placed the recommendations in his folder for him to review. When asked if he signed off on consultation sheets, he said he did, or the nurse marked he was notified. When he was shown the consultation sheet for Resident #16 from 01/04/13, he stated he had never seen the consultation, and was unaware of any recommendations prior to the resident's last admission to the hospital. b) Resident # 60 A nursing note, dated 05/02/13 at 4:59 p.m. stated, Called to hall outside resident's room per CNA (certified nursing assistant). Resident was entering another resident's room. Resident was out of wheelchair and started to collapse and aides got him under the arms and basket carried him to wheelchair. His eyes were rolling back in his head. Initial vital signs were 70/47 with pulse 84. Pulse started climbing as high as 237. RN (Registered Nurse) supervisor was called to room and examined resident. Left pupil was not reacting to light. Grips evened out bilaterally. Began to speak coherently. Blood pressure bumped up to 108/66 and pulse rate evened out at 81. This note further indicated the daughter was notified and the resident's code status was DNR (do not resuscitate). The note indicated staff will continue to monitor. There was no evidence the physician was notified of this resident's change in condition. During an interview with Employee #12, a licensed practical nurse, on 05/30/13 at 2:30 p.m., she verified there was no evidence the physician was notified of this resident's condition change and abnormal vital signs.",2016-05-01
8661,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,157,D,0,1,46GB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to notify the responsible party and physician of a resident's continued refusal to allow staff to obtain laboratory specimens. This practice affected one (1) of forty-two (42) sampled residents. Resident identifier: #10. Facility census: 76. Findings include: a) Resident #10 Review of this resident's physician's orders [REDACTED].#10 was ordered a basic metabolic profile (BMP) every four (4) months and a complete blood count (CBC) every six (6) months. Review of the medical record found no laboratory services. Further review of the medical record found the following nursing documentation entries: -- 06/08/11 at 536 -- Resident cont (continues) to refuse to let staff obtain routine schedule labs after several attempts made. Will continue to keep trying to obtain. -- 06/22/11 at 14:20 -- Resident refuses to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 07/22/11 at 12:39 -- Resident refuses to let staff obtain routine labs after several attempts made per staff. Will continue to keep trying to obtain. -- 07/27/11 at 13:27 -- Resident cont to refuse to let staff obtain routine schedule labs after several attempts made per staff. Resident states 'you are not getting any of my blood'. -- 07/29/11 at 09:34 -- Resident cont to refuse to let staff obtain labs after several attempts made. Will continue to keep trying to obtain. -- 08/04/11 at 13:12 -- Resident continues to refuse to let staff obtain labs after several attempts made per staff. will continue to keep trying to obtain. -- 08/12/11 at 12:13 -- Resident continues to refuse to let staff obtain routine labs after several attempt made per staff. Will cont to keep trying to obtain. -- 08/22/11 at 13:56 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. -- 09/08/11 at 11:37 -- Resident continues to refuse to let staff obtain routine schedule labs after several attempts made per staff. Will continue to keep trying to obtain. Review of the medical record found no attempts made by the facility to contact Resident #10's responsible party or the physician regarding the resident's refusals to allow blood drawn for ordered lab work. An interview conducted, during the afternoon of 01/09/12, with Employee #74, the minimum data set nurse, confirmed the facility did not notify the responsible party or the physician after Resident #10 refused laboratory services on the dates listed above.",2016-04-01
8709,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2013-04-25,157,D,1,0,0C5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the responsible party of a resident's change in condition. The resident was ordered antibiotics for a [DIAGNOSES REDACTED]. The facility failed to notify the responsible party related to the refusals of taking the antibiotics, and the refusals of therapy services. One (1) of three (3) residents reviewed was affected. Resident identifier: #71. Facility census: 70. Findings include: a) Resident #71 Resident #71 was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. On 04/03/13, she was ordered antibiotics to treat a left lung infiltrate. The physician ordered [MEDICATION NAME] 500 mg twice a day for ten (10) days, [MEDICATION NAME] 500 mg three (3) times a day for ten (10) days, and [MEDICATION NAME] 600 mg twice a day for ten (10) days. The Medication Administration Record [REDACTED]. Further review of the medical record identified the facility had failed to notify the responsible party of the resident's refusal to take the medications as ordered, and of her refusal to participate in therapy services. Review of the therapy notes for 04/05/13 found the resident had been refusing to participate. The notes included She spends most of her time in the bed. She is being transferred to a personal care home on 04/07/13. Resident was educated on the need to get out of bed more. Discussed discharge plan to personal care home and resident became mildly agitated. The resident was seen four (4) days from 03/30/13 to 04/05/13. Therapy progress note for 03/13/13 through 03/29/13 included Resident was seen ten (10) days during therapy progress period. Patient has been educated on need to participate with rehabilitation services and the effects of bed rest. Potential for achieving goals: Resident has poor potential to achieve goals due to refusals. Resident would benefit from continued physical therapy services, but refuses to participate. On 03/22/13, resident refused to participate with therapy with multiple attempts made to get resident to participate. A therapy progress note, dated 03/16/13 was, Attempted twice to get resident to participate with therapy. Resident stated, I just want to lay in bed and I do not want to be bothered. Nursing also attempted to to get resident to participate, stating to resident the importance of therapy to get her back home. Resident stated, nursing can not make her do something she didn't want to. Nursing staff continued to encourage her so she could get stronger to return to home with family. Resident continued to refuse. During an interview with Employee #42 (director of nursing), on 04/24/13, at 1:50 p.m., she confirmed the facility failed to notify the responsible party related to the resident refusing to take medications, and refusing to participate in therapy services.",2016-04-01
8822,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-03-27,157,D,1,0,UDUT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policy, and family interview, the facility failed to ensure a resident / responsible party received prior notice of a room move initiated by the facility. This was true for one (1) of three (3) residents whose medical records were reviewed for notice of room changes. Resident identifier: #67. Facility census: 111. Findings include: a) Resident #67 During an interview conducted with the resident's spouse, on 03/25/13 at 12:30 p.m., the resident's spouse alleged his wife had been moved to another room at the facility without proper notification. He stated, I came to visit one day and just found her in another room. According to the resident's spouse, his wife at been moved to two (2) different rooms since her admission at the facility. He stated he did agree to the second room move which occurred about a month ago, but he did not agree to, nor was he made aware of, the first room move. Medical record review found the resident lacked capacity to make medical decisions and the resident's spouse was her responsible party. Review of the medical record found Resident #67 was admitted to the facility on [DATE] to room [ROOM NUMBER]. Further documentation in the resident's medical record found the resident was moved to room [ROOM NUMBER] at some point during her stay at the facility. At the time of investigation, 03/25/13, the resident was residing in room [ROOM NUMBER]. Social services documentation in the medical record found the second room move, occurring on 02/15/13, was discussed with the responsible party. At 1:28 p.m. on 03/25/13, the administrator was asked when the resident's first room move occurred and for verification the responsible party had been notified of the resident's first room move at the facility. At 2:00 p.m. on 03/25/13, the administrator provided the minutes from a morning stand-up meeting which he said documented discussion of a room move on 01/31/13. The minutes of the meeting were not dated. The administrator verified the morning meeting held with department managers does not constitute verification the responsible party was notified of the room move according to the requirements in the facility's policy on, Room Changes. Further review of the facility's policy on Room Changes, revised on 11/01/09 found, . If the Center has a need to move a patient and the patient's needs are able to be met in a different room, notify the patient and / or responsible party. The administrator was unable to provide documentation in the resident's chart of the first room move. At first the administrator said he thought the resident was moved because the first room was too hot, then he said she was moved because the room was not big enough. Review of the medical record found no evidence of any problems with the first roommate or problems with the room. On 03/25/13 at approximately 3:00 p.m., the administrator stated he would take this issue to the quality assurance committee.",2016-03-01
8828,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,157,D,0,1,5Y7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to promptly notify a resident and a resident's legal representative when decisions and changes were made in the medical regimen for two (2) of forty-four (44) sampled residents. Resident #126, who was an alert and oriented resident who was determined to possess the capacity to understand and make medical decisions, was not included in a discussion to continue the use of [MEDICATION NAME] after psychiatrist recommended that it be discontinued. The medical power of attorney representative (MPOA) for Resident #68 was not notified when there was a change in a medication. Resident identifiers: #126 and #68. Facility census: 100. Findings include: a) Resident #126 Medical record review disclosed Resident #126 had been receiving [MEDICATION NAME] 25 mg po (by mouth) every eight (8) hours PRN (as needed) for anxiety and restlessness, which was ordered on [DATE]. Further review of the medical record disclosed the resident had a psychiatric consult on 08/02/11. Review of the psychiatrist's report found a recommendation to the attending physician to discontinue the use of the [MEDICATION NAME]. Review of the resident's current Medication Administration Record [REDACTED]. Review of nursing notes found an entry, dated 08/02/11 at 1630 (4:30 p.m.), documenting that staff notified the resident's MPOA of the recommendation to discontinue the [MEDICATION NAME] and MPOA requested the [MEDICATION NAME] be continued. Further review found Resident #126 was alert, oriented and had been determined, upon admission on 06/17/11, to possess the capacity to understand and make medical decisions. There was no evidence that Resident #126 had been consulted and involved in the decision about the continued use of the [MEDICATION NAME] after the psychiatrist recommended that it be discontinued. An interview with the unit nurse manager (Employee #96), on 08/29/11 at 10:30 a.m., confirmed Resident #126 had not been involved in the decision to continue taking the [MEDICATION NAME] and that the resident's MPOA was making medical decisions for this resident who still had the capacity to make these decisions. -- b) Resident #68 Medical record review revealed the resident was initially admitted to the facility on [DATE]. The physician determined the resident lacked the capacity to understand and make medical decisions and appointed a health care surrogate to make decisions on the resident's behalf. On 07/25/11, the resident began receiving hospice services for end-stage liver disease. Review of the medical record revealed, on 08/11/11, the resident was receiving one (1) [MEDICATION NAME] Patch 12 mg [MEDICATION NAME] every seventy-two (72) hours for abdominal pain. Review of the physician's notes revealed the nurse practitioner visited the resident on 08/18/11 and recorded the following note: [MEDICATION NAME] 50/0.5 two (2) tablets now. Please contact Hospice nurse. Pain level 8/10 (indicating severe / horrible to excruciating pain). Diagnosis: [REDACTED]. On 08/18/11, the facility contacted the hospice agency, and a new order was obtained to increase the [MEDICATION NAME] from 12 mg to 24 mg every seventy-two (72) hours. an order for [REDACTED]. Review of nursing notes revealed an entry, dated 08/18/11, stating: . MPOA needs to be made aware of new order, will notify next shift nurse to pass on in report. The interim administrator (Employee #119), when interviewed on the morning of 08/31/11, did not present any evidence to reflect the resident's health care surrogate was notified of the resident's increasing pain or changes made in his medication regiment to address this.",2016-03-01
8915,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,157,D,0,1,NP7N11,"Based on document review, medical record review, staff interview, observations, and physician interview, the facility failed to assure the physician and legal representative were immediately informed when a new Stage II pressure ulcer was discovered for one (1) of thirty-eight (38) residents on the sample. Resident identifier: #7. Facility census: 90. Findings include: a) Resident #7 Review of facility documents, intended for nursing assistant (NA) comments, found a comment, dated 12/05/11, written by the night shift NA. The NA documented the resident had a very large sore on the back of her right upper thigh. The NA documented the charge nurse had been made aware of the area. Review of the medical record found no nursing documentation related to the very large sore on the resident's right upper thigh. An interview with Employee #59, the registered nurse (RN) unit manager, at 10:46 a.m. on 12/05/11, confirmed no documentation was present in the medical record related to an assessment of the area, nor was there evidence of notification to the physician or the legal representative. The area on Resident #7's right upper thigh was observed at 2:45 p.m. on 12/05/11. Employee #59 determined the area was a Stage II pressure ulcer measuring 4.5 cm x 5.2 cm. x 0.1 cm. It was noted a dressing had been applied to the pressure ulcer. An interview with the treating physician, on the evening of 12/06/11, determined he was unaware the resident had a new pressure ulcer.",2016-03-01
9001,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-02-07,157,D,1,0,G0P011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to make proper notifications when there was an accident and/or an injury for two (2) of fourteen (14) Stage 2 sample residents. The family was not notified of an injury to one resident's foot and toes. The family was not notified of a change in condition for another resident. Resident identifiers: #89 and #106. Facility census: 118. Findings include: a) Resident #89 Review of a 01/02/13 nursing progress note revealed this resident was noted to have reddened areas to bony prominences to bilateral lateral hips. The physician was made aware. Review of a 01/02/13 physician's orders [REDACTED]. Review of Section M of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) 01/16/13, revealed this resident had two (2) Stage I pressure ulcers. Review of the medical record found no evidence of any family notification of this change in skin condition, until after the resident was assessed by a physician in the emergency roiagnom on [DATE]. Review of the hospital's emergency room record by the attending physician, dated 01/24/13, revealed this resident was assessed as having Stage 2 decubitus ulcer ischial tuberosity on left. Larger stage 2 decubitus ulcer over the right ischial tuberosity and in the center that has black eschar. Review of a nurse's progress note, dated 01/25/13, revealed the right hip had a necrotic area 3.0 x 6.0 centimeters (cms), and the left hip had eschar and a scab that measured 1.4 x 6.0 cms. During an interview with the administrator and the director of nursing on 02/06/13 at 4:00 p.m., they said they would look to see if there was any evidence the family had been notified of the Stage I pressure ulcer on 01/02/13, or of the new physician's orders [REDACTED]. No evidence of family notification was provided prior to exit. b) Resident #106 Review of Resident #106's medical record, on 02/05/13 at 10:00 a.m. and at 4:30 p.m. , revealed a general progress note dated, 01/01/13 at 13:24. The resident was noted to have discoloration of area on right foot along with great and 2nd toes. Nonblanchable. No pain nor loss of sensation. Faxed physician. Another general progress note, dated 01/01/13 at 21:54 noted, discoloration remains to right foot. No complaints of pain to area .able to move toes. Upon inquiry with Employee #23 and Employee #110, both registered nurses, at 11:30 a.m. on 02/07/13, they were unable to provide evidence the family was notified of the discoloration of Resident #106's foot and toes.",2016-02-01
9009,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,157,D,0,1,EZVZ11,"Based on staff interview and medical record review, the facility failed to ensure one (1) of forty-six (46) residents received the services and care necessary to promote their highest level of well-being. The facility failed to notify the resident's physician when the resident experienced hypoglycemic episodes. Facility census: 70. Resident identifier: #27. Findings include: a) Resident #27 Review of the resident's medical record found she had six (6) incidents of a blood sugar level below 60. This occurred on: -- 01/23/12 - blood sugar level 53 - no interventions documented by staff -- 01/07/12 - blood sugar level 43 - no interventions documented by staff -- 12/14/11 - blood sugar level 57 - orange juice was given by staff -- 12/26/11 - blood sugar level 43 - snack was given -- 11/18/11 - blood sugar level 42 - snack was given -- 11/20/11 - blood sugar level 50 - snack was given No evidence could be found the physician had been notified when the resident's blood sugar levels were found to be below 59. Review of the physician's progress note, dated 12/02/11, found he was aware of the glucose level being as low as 59, but no evidence could be found to confirm the physician was notified of blood glucose levels below 59. Employee #17 (director of nursing) was notified of this finding at 10:45 a.m. on 01/30/12.",2016-02-01
9063,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2011-05-18,157,D,0,1,MU6H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to immediately consult with the resident's physician when there was a significant change in the resident's condition potentially requiring a physician's intervention. The facility failed to notify the attending physician when a resident began experiencing drainage and redness to a surgical wound. One (1) of forty-nine (49) Stage II sample residents was affected by this practice. Resident identifier: #190. Facility census: 108. Findings include: a) Resident #190 Review of Resident #190's medical record revealed a discharge summary dated 05/01/11, on this discharge summary there was mention of a surgical wound with any redness or drainage. The following information was listed on the discharge summary: Daily Dry dressing changes should be performed to the surgical incision. Review of physician orders revealed she was admitted to the facility on [DATE] with the following wound treatment ordered: CLEANSE STAPLES TO LEFT HIP WITH NORMAL SALINE. COVER WITH DRY DRESSING. CHANGE DAILY- Day Shift Everyday. Further review of the medical recorded revealed an assessment dated [DATE], stating the surgical wound had a small amount of yellow drainage. Review of nursing notes dated 05/04/11 also recorded the presence of yellow drainage from surgical wound. A subsequent entry in medical record dated 05/09/11 revealed the resident had an incision wound to left hip that was red, warm to the touch, and with slight yellow drainage noted. On 05/16/11 at 2:20 p.m., an interview with the director of nursing (DON - Employee #55) revealed there was no evidence that the physician was notified of changes in the status of the surgical wound. On 05/17/11 at 10:35 a.m., an interview with a registered nurse (Employee #72) confirmed the physician was not contacted when yellow drainage was noted; she further stated it was a small amount of drainage.",2016-02-01
9082,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-02-21,157,D,1,0,RESW11,"br>Based on medical record review, and staff interview the facility failed to notify the resident's healthcare decision maker of changes when there was a change of condition. One (1) of four (4) sampled residents had a change of condition in which the facility failed to promptly contact the resident's healthcare surrogate. Resident Identifier: #108. Facility Census: 107. Findings include: a) Resident #108: Medical record review, completed on 01/22/13 at 2:00 p.m., revealed a Health Care Surrogate (HCS) appointment which appointed Resident #108's daughter as his health care decision maker. The HCS appointment was completed on 06/08/10. Also contained in the medical record was a hand written note which read as follows: Call Daughter (the note identified the HCS by first name), with any issues. Some examples were listed in parentheses and included, Med refusals, shower refusals, low blood sugars, and med changes. The note further stated, Anything and Everything and FNP is to phone daughter after seeing the patient. The medical record for Resident #108 contained a change of condition form which was dated 12/26/12. The change of condition was related to the resident's blood sugar level being 32. The change of condition form was completed by Licensed Practical Nurse (LPN), Employee # 64. Employee #64 documented she contacted the physician, but there was no evidence Employee #64 notified the HCS of the change of condition at this time. Review of the medical record review also revealed another change of condition form completed by Employee #64 concerning Resident #108. This change of condition was completed related to the resident having a decrease in oxygen saturation and complaints of not being able to breath. Employee #64 contacted the physician and a new order was obtained for the resident to have oxygen at three (3) liters per minute. There was no evidence Employee #64 contacted the resident's HCS concerning this change of condition. An interview was conducted with Employee #64 on 01/23/13 at 8:00 a.m. During this interview, Employee #64 stated she had not contacted the resident's HCS because she did not want to call the HCS in the middle of the night. Employee #64 reported she typically did not have good results when she contacted the family in the middle of the night, because the family did not want to be woken up. She denied seeing the note in the front of the chart which directed facility staff to contact the HCS with any change of condition.",2016-02-01
9133,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-02-06,157,E,1,0,EVNT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review, review of facility policy for notification of changes, and staff interview, the facility failed to notify the responsible parties for three (3) residents, who had been determined to lack capacity to make medical decisions, when the residents' treatments were altered due to changes in the resident's condition or when there was a medication change. This was true for three (3) of ten (10) sampled residents. Resident identifiers: #11, #43, and #40. Facility Census: 54. Findings Include: a) Resident #11 A medical record review, conducted at 9:10 a.m. on 02/06/13, revealed Resident #11 had been determined to lack the capacity to make health care decisions since 06/03/12. Further review of the medical record found a Medical Power Of Attorney (MPOA) was completed by the resident on 08/14/98. The medical record review, conducted at 1:30 p.m. on 02/05/13, revealed the resident had a [MEDICATION NAME] time and international normalized ratio (PT/INR) laboratory test completed on 01/28/13. Based on the results of this test, on 01/30/13, the resident's physician ordered, D/C (discontinue) [MEDICATION NAME] 2 MG (milligrams) and start [MEDICATION NAME] 1 MG. There was no evidence the resident's MPOA was notified of this medication change. This medical record review also revealed a new order dated 12/03/12 for [MEDICATION NAME] to the resident's peri-area due to redness X (for) 14 days. There was no evidence the resident's MPOA was notified of this treatment change. On 12/03/12, a nurse documented this resident had experienced a fall. A new order was written for neurochecks to be done. There was no further documentation to indicate the resident's MPOA was informed of the resident's fall or of the new order for neurochecks. In an interview with the Director of Nursing (DON), Employee # 62, at 11:00 a.m. on 02/06/13, the DON confirmed there was no evidence the MPOA was notified of the changes in the resident's care and her fall. b) Resident #43 Medical record review, conducted at 4:00 p.m. on 02/05/13, revealed Resident #43 had been determined to lack capacity to make health care decisions since 06/30/10. Further review of the medical record found a Medical Power Of Attorney (MPOA) which had been completed by the resident on 09/07/06. A nursing entry, dated 11/22/12, noted the resident's wife had reported his urine was foul smelling and he had painful urination. The nurse obtained an order for [REDACTED]. A nurse's note, dated 11/25/12, revealed the physician had come to the facility and given an order for [REDACTED]. There was no evidence the MPOA was notified of the initiation of this new treatment. On 12/17/12, a nurse documented the physician was in to see Resident #43. During the visit, the resident complained of left lower chest pain, so the physician ordered a chest x-ray. The physician reviewed the resident's X-ray on 12/18/12 and wrote an order for [REDACTED]. Further review of the medical record revealed the resident had a PT/INR laboratory test completed on 12/24/12. As a result of this test, a new order was obtained on 12/24/12 for D/C (discontinue) [MEDICATION NAME] 6 MG (and start) [MEDICATION NAME] 7 MG. There was no evidence contained in the medical record to indicate the MPOA was made aware of this new order. The resident had another PT/INR test completed on 01/07/13. The physician gave a new order as a result of this test. The order was given by the physician on 01/07/13 which read as follows: D/C [MEDICATION NAME] 7 MG (and start) [MEDICATION NAME] 4 MG daily on 01/09/13. There was no evidence the MPOA was notified about this medication change. Resident #43 had another PT/INR collected on 01/14/13. As a result of this lab report, the physician gave another [MEDICATION NAME] order. The physician order [REDACTED]. There was no indication the MPOA was notified of this medication change. The medical record review also revealed the resident had another PT/INR lab test on 01/28/13. This lab result also resulted in another physician order [REDACTED]. On 01/30/13, the physician ordered D/C [MEDICATION NAME] 5 MG (and start) [MEDICATION NAME] 6 MG daily. There was no evidence the resident's MPOA was notified of this change in medication. The medical record also contained a nurse's note, dated 02/02/13, which revealed the resident had a fall while attempting to transfer from his bed to his wheelchair. As a result of this fall, a standing order to begin neurochecks was initiated and the neurochecks were started. There was no evidence which indicated the resident's MPOA was notified of this fall or the initiation of the neurochecks. An interview with the DON, Employee #62, at 11:00 a.m. on 02/06/12, confirmed the documentation of the notification of the MPOA for this resident was not contained on the order or the nurse's notes related to these changes in his plan of care. The facility's policy titled, Change in a Resident's condition or status, directed the facility's staff to notify the resident's family of changes with in twenty-four hours of a change occurring in the resident's mental/medical condition or status. c) Resident #40 Medical record review, on 02/04/13, found a nurse's note, dated 12/21/12 at 11:55 a.m., (name of physician) in facility. See new order for chest x-ray d/t (due to) chest congestion. Further review of the medical record found the chest x-ray was completed on 12/21/12 as ordered. The results of the chest x-ray found, Since 11/08/12, worsening bibasilar lung infiltrates, right greater than left. The physician was contacted by telephone on 12/21/12 and made aware of the results of the x-ray. The physician ordered [MEDICATION NAME] 500 milligrams, daily, for ten (10) days for a [DIAGNOSES REDACTED]. On 12/04/07, a Health Care Surrogate was appointed for this resident due to the resident's inability to process information related to a [DIAGNOSES REDACTED]. Subsequent evaluations found the resident continued to lack capacity to make health care decisions. The administrator, Employee #47, was interviewed at 12:59 p.m. on 02/04/13. The administrator was unable to provide evidence the resident's health care surrogate was notified of the resident's change in condition and the addition of the new antibiotic on 12/21/12.",2016-02-01
9364,GOLDEN LIVINGCENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2010-02-25,157,D,0,1,2RPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to assure proper notification of the physician and the resident ' s responsible party when changes occurred in a resident's health care status and/or services. This was evident for one (1) of thirty-two (32) Stage II sampled residents. Resident identifier: #58. Facility census: 87. Findings include: a) Resident #58 During a family interview on 02/21/10 at 4:29 p.m., Resident #58's wife stated he was admitted to the hospital on [DATE], due to complications of a urinary tract infection [MEDICAL CONDITION]. At that time, she was allegedly told by the emergency room (ER) physician that his UTI, which had been diagnosed earlier that week at the facility (01/22/10), showed a colony count greater than 100,000. The wife stated she had signed the pink POST (Physician order [REDACTED]. The resident was subsequently hospitalized and treated for [REDACTED]. Review of the physician's progress note, dated 01/12/10, revealed, H/O (history of)[MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus) UTI: monitor for symptoms. There is also a handwritten note stating, Family wants pt. (patient) to be kept comfortable and avoid re-hospitalization s. Medical record review revealed a nurse's note in the resident's electronic medical record, dated 01/19/10, stating the certified physician's assistant (PA-C) was in the facility and ordered a urinalysis, complete blood count, and other labs, and the wife was aware. The nurse (Employee #1) found this note in the computer on 02/24/10 at 10:10 a.m., but record review did not find the note had been printed and placed inside the medical record. The note did not say why the lab testing was ordered. A nurse's note, dated 01/21/10, stated the physician was notified of the lab results on 01/20/10, and culture results were pending. A urine culture and sensitivity (C&S) report, dated 01/22/10, noting [MEDICAL CONDITION] culture of greater than 100,000, was signed by the PA-C, with a notation stating: Will not Tx (treat). A nurse's note, dated 01/23/10 at 7:22 p.m., recorded a change in the resident's condition; the physician was notified of drainage under the foreskin and reddened skin, an antifungal powder ([MEDICATION NAME]) was ordered, and the spouse made aware. Medical record review revealed no nursing documentation entered on 01/24/10. Employee #1 checked the computer, on 02/24/10 at 10:10 a.m., and found there were also no nursing notes in the computer for that date. Medical record review revealed a nurse's notes, dated 01/25/10 at 1:55 a.m., citing the resident had frequent loose stools. There was no documentation of the physician having been notified. Nurses' notes, dated 01/25/10 at 10:43 a.m. and 1:45 p.m., cited the resident refused breakfast (and the offer of an alternative) and lunch (and alternative), but there was no documentation the physician was notified. By comparison, a weekly charting note, dated 01/21/10 at 1:19 a.m., indicated appetite good. A nurse's notes, dated 01/25/10 at 9:37 p.m., revealed the spouse asked for PRN (as needed) [MEDICATION NAME] (an opioid pain medication) at 3:20 p.m. and at 8:30 p.m., which was in addition to his scheduled [MEDICATION NAME] every six (6) hours at noon, 6:00 p.m., midnight, and 6:00 a.m. The nurse also documented at this time that his penis was oozing yellow drainage and she (p)ut it in the Dr. (name) to look at it tomorrow. Will monitor. Medical record review, for all nurses' notes entered on 01/25/10, found no entries indicating a physician was notified of any of these changes in condition. A nurse's note, dated 01/26/10 at 10:16 a.m., stated the spouse called at 8:10 a.m. to see how he was doing and was told he did not eat breakfast but rather let it run out of his mouth, and he ingested only 75% of the medications that were crushed and placed in thick liquids. At this point, the wife asked that the PA-C be called to inform him she wanted the resident sent out to the hospital. This was done, and the resident left the facility at 9:30 a.m. Review of the resident's care plan, dated 01/16/09, found the following problem area: Potential for UTI due to UTI hx. (history). Interventions included: Assess for signs / symptoms of UTI and Notify MD (medical doctor) of problems / changes. Additionally, the care plan listed a problem of: Potential for complications due [MEDICAL CONDITION], with an intervention of: Keep MD informed. The discharge summary, dated 01/29/10, noted: The plan is to keep him comfortable. It seems that this [MEDICAL CONDITION]-Resistant Staphylococcus Aureus urinary tract infection was causing some discomfort and, therefore, seems appropriate to receive antibiotic treatment for [REDACTED]. There was also a notation indicating the spouse was comfortable with this plan per phone discussion. Review of the physician's progress note, dated 02/02/10, found a summary of the preceding two (2) weeks and a notation that the patient had a complication [MEDICAL CONDITION] UTI. The physician noted the patient was comfortable and [MEDICAL CONDITION] did not require treatment, but eventually the patient did have some symptoms of the UTI and since would require an inpatient consult the patient was treated in (the) hospital. The pt returned to baseline. Interview with the administrator and the director of nursing, on 02/24/10 at 4:15 p.m., revealed the physician was aware of the urine C&S of greater than 100,000 [MEDICAL CONDITION], and the physician was not going to treat the UTI, because the resident was asymptomatic. The resident had no flank pain, no fever, no symptoms, and had been diagnosed with [REDACTED]. They said the spouse was not notified of the results of the urine culture on 01/22/10, because the doctor did not see the need to treat an [MEDICAL CONDITION] on a patient who had a history of [REDACTED]. They agreed that, when he developed pus, this was a symptom, and he was sent to the ER the same morning as when the doctor was notified of the spouse's request to send him out. They said they did not re-culture the urine, as he has been colonized and treated with intravenous (IV) antibiotics. Since he has remained asymptomatic, his isolation was discontinued on the morning of 02/24/10.",2015-11-01
9379,HEARTLAND OF PRESTON COUNTY,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2010-06-15,157,D,0,1,KN1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the responsible party for one (1) of thirty-eight (38) sampled residents was not informed / consulted prior to the commencement of a Medicare Part B skilled service. Resident identifier: #112. Facility census: 112. Findings include: a) Resident #112 During an interview of the daughter / medical power of attorney representative (MPOA) of Resident #112 at 10:00 a.m. on 06/09/10, the MPOA stated that, for the last month, the therapist had been treating the resident for swallowing problems and she questioned why this had been done. When asked if anyone had spoken to her prior to starting this treatment, she said, No. and stated she only found out when she received a bill for $20.00 and another for $535.00. She stated there has been no change in the way her mother eats and swallows in over a year, and when she did ask the nurse about this last week, she was told that her mother was going to have her diet changed from all pureed foods and thickened liquids to chopped foods and regular liquids. She said she was very happy about this, because her mother does not always eat the pureed foods; she did not believe they were needed, because she brought the resident food from McDonalds which the resident ate with no problem. There was no mention of any swallowing difficulties in the nurses' notes and no evidence that the therapy evaluation and treatment had been discussed with the MPOA. During an interview with the speech language pathologist (Employee #110) at 9:30 a.m. on 06/10/10, she stated she had been asked to see the resident by the occupational therapist (OT - Employee #122) and had secured a physician's orders [REDACTED]. The evaluation was completed on 05/13/10. After reviewing the documentation on the Eating & Swallowing Evaluation form, she stated she believed she had spoken to the resident's granddaughter, who was visiting, about the evaluation. She acknowledged she had not spoken to the resident's daughter. The OT, when interviewed at 9:45 a.m. on 06/10/10, stated she had requested the evaluation, because the nursing assistants told her the resident had quit feeding herself, and she could see no physical reason for this, but she also admitted she had not spoken to the family about the request. The social worker (SW - Employee #2), when interviewed at 10:45 a.m. on 06/10/10, stated she had not spoken to the resident's family about the speech therapy services. She said the resident's daughter was very active in her care and that she would talk to her as soon as possible. She did verify the facility's practice was to notify the family prior to any change of services.",2015-11-01
9467,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-02-02,157,D,0,1,U0V411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to notify the attending physician and/or responsible party of when two (2) of thirty-seven (37) Stage II sample residents experienced significant weight losses. Resident #44 experienced an 11 pound (#) unplanned weight loss in a 10-day period, and Resident #26 experienced a 12# (12.5%) unplanned weight loss in a 3-month period. There was a lack of evidence to reflect staff notified each resident ' s attending physician and/or responsible party of the significant weight loss. Facility census: 63. Findings include: a) Resident #44 1. Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident was recently hospitalized from [DATE] through 01/13/11 for an irregular heart rate. Resident #44, when readmitted to the facility on [DATE], weighed 94#. On 01/22/11, she again weighed 94#. On 01/28/11, the resident weighed 86#; this represents an 8# weight loss over a 6-day period. On 01/29/11, the resident weighed 84#. On 02/01/11, the resident was weighed at the surveyor's request, and the resident's weight was 82.8#. -- 2. Review of the resident's nursing notes revealed the following entries: - On 01/14/11 at 8:34 p.m. - . ate poorly at dinner - took evening snack. - On 01/19/11 at 11:58 a.m. - . Of her 1800 ADA pureed with nectar liquid diet res (resident) ate an average of only 20.1% over last 7 days. Does not take supplements well. Weight on 1/14/11 was 93.4 lbs. - On 01/20/11 at 11:06 a.m. - . Taken to dining room to eat - encouraged to feed self - declined. Assist x 1 for feeding. - On 01/26/11 at 11:11 a.m. - . of her 1800 CAL pureed with nectar liquid diet Res ate ave (average) of 27%. Weight on 1-22-11 was 94%. - On 01/28/11 at 1:45 p.m. - Skilled for PT/OT. Wt 86 lbs. No s/s (signs / symptoms) distress noted. Continues to have poor PO (oral) intake. Up in w/c (wheelchair) for meals in dr (dining room) and is fed per staff. - On 01/29/11 at 12:20 p.m. - Resident was a Re WT (re-weigh) today. WT 84.0 lbs. Skilled for PT/OT. - On 01/30/11 at 11:17 a.m. - .Resident up to W/C for meals with assist of x 2 staff. PO Intake remains poor. Resident refuses any supplement or snack. - On 01/30/11 at 8:11 p.m. - Res was screened for ST (speech therapy) on 1-18-11 Post hospitalization . Res on diet of puree with nect liq and continues to tolerate current diet level. No changes at this time. - On 01/31/11 at 12:28 p.m. - 3rd Weekly Pressure Risk Eval completed. High score of 23 unchanged. Labs reflect a TLC of 769.3 on 01/12/11. Of her 1800 CAL ADA Pureed diet with Nectar liquids Ave intake over last 7 days was 35.2 %. 1-29-11 weight was 84.0 lbs. No documentation was found in the record to reflect efforts by staff to notify the resident's attending physician or responsible party of this weight loss. -- 3. In an interview on 02/01/11 at 11:30 a.m., the dietary manager (Employee #9) indicated she was unaware of the resident's weight loss. Additional information was requested from her, as well as from the director of nursing (DON), at this time. On 02/01/11 at 1:30 p.m., the DON confirmed the physician had not been notified of Resident #44's weight loss, and she presented a fax sent to the physician regarding the resident's weight loss dated 12:13 p.m. on 02/01/11. -- 4. Subsequent review of the resident's record found the following entries in the nursing notes: - On 02/01/11 at 1:20 p.m. - Monthly weight is 82.4 pounds and decrease of 1.2 pounds from last weight has lost 11.2 pounds from 1/22/11. Faxed out to Dr. (name). Tried to speak with (name) daughter via phone to inform not at home and has no answering machine. - On 02/01/11 at 6:32 p.m. - . At 2:30 p.m. Dr. (name) informed of weight loss. Refuses to assist self. Fed dinner - ate approx 25% - Declined to eat more. Max assist for transfers and bed mobility. - On 02/01/11 at 8:53 p.m. - New order per Dr. (name). Change diet to regular diet as tolerated. Resident will continue pureed with nectar thickened liquids - snacks TID. Attempted to contact (name), POA (power of attorney) - No answer. Dietary Informed. -- b) Resident #26 Review of the dietician's nutrition assessment, dated 06/16/10, revealed Resident #26 returned from a hospitalization with the same tube feeding orders as before the hospitalization , but the feedings and water flushes were discontinued on 06/11/10 per the resident's request. Record review revealed this 63 inch tall resident experienced a severe weight loss greater than 7.5% over a 3-month interval. On 10/24/10, the resident weighed 95#, and on 01/23/11, the resident weighed 83#; this represents a 12# (or 12.5%) weight loss. From 12/07/10 to 12/23/10, the resident dropped from 93# to 87.6#; this represents a 5.40# weight loss (greater than 5%) in a 2-week period From 12/23/10 to 01/23/11, the resident dropped from 87.6# to 83#; this represents an additional 4.6# (5%) weight loss in a 1-month period. Interview with a nurse (Employee #39), on 02/01/11 at 3:00 p.m., revealed she found no evidence, after reviewing Resident #26's nursing notes that the resident's medical power of attorney representative (MPOA) had been notified of the resident's recent weight loss. During an interview on 02/01/11 at 3:15 p.m., the DON said she did not know whether the MPOA was notified of the weight loss, or if they had a policy that required MPOA notification of her weight loss. Review of facility's policy entitled Weights (revision date 02/22/09) revealed: . weight will be obtained on a monthly basis. If there is a weight change of 5 or more pounds, either loss or gain, a re-weigh will be done the following day. The physician and MPOA will be notified of the weight change. Restorative nursing assistants will obtain the weight, document weight in Care Tracker, and notify the assigned nurse. The nurse will document the weight on the flow sheet in the nurses' notes and notify appropriate contacts. Further review of the facility's weight policy found no instructions regarding MPOA notification of the percentage of weight loss if it did not amount to more than a 5# weight change in a given month.",2015-11-01
9517,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2012-10-17,157,D,1,0,L6DP11,"Based on record review, staff interview, and policy review, the facility failed to notify the physician and responsible party of a change in condition related to the worsening of a resident's pressure ulcer. One (1) of four (4) sampled residents was affected. Resident identifier: #83. Facility Census: 92 Findings include: a) Resident #83 At 7:45 a.m. on 10/17/12, the facility's Pressure Ulcer Documentation Form was reviewed. A stage one (1) pressure ulcer to the right hip was identified for this resident. It had an onset date of 09/30/12. On 10/02/12, the same form indicated three (3) Stage II pressure ulcers were identified to the right hip. The notification of change was left unchecked, although the number of pressure ulcers had increased, and had progressed from Stage I to stage II. (Note: A Stage II is defined as a partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed.) An interview with multiple employees was conducted on 10/17/12 at 10:30 a.m. in the Director of Nursing's (DON) office. 1) The Unit Coordinator (Employee #74) reviewed the resident's chart and confirmed no interdisciplinary notes were present to indicate the physician or responsible party had been notified. After reviewing the Pressure Ulcer Documentation Form, she agreed the notification of change was not marked. 2) The Minimum Data Set (MDS) Coordinator (Employee #1) confirmed notification was not made because the areas never opened. Employee #1 performed the staging of the pressure ulcers. Further corroboration was given by the Regional Director of Clinical Operations (Employee #108). A review of the risk management system (RMS) by her further established the absence of notification. Employee #108 and the DON (Employee #12) informed Employee #1 and Employee #74 of the need to notify the physician and responsible party when a change in condition occurred. On 10/16/12 at 8:00 p.m., the facility Skin Care and Pressure Ulcer Management Program policy was reviewed. The policy specifically stated any new skin issue is an incident which requires an investigation. Follow these steps to investigate . notify the physician and responsible party and collaborate on a treatment order.",2015-10-01
9735,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2010-05-19,157,D,0,1,QP8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to notify the medical power of attorney representative (MPOA) of one (1) of twenty-nine (29) Stage II residents of a change in condition requiring scheduled diagnostic testing. Resident identifier: #5. Facility census: 53. Findings include: a) Resident #5 On 05/12/10 at approximately 3:00 p.m., medical record review revealed Resident #5 lacked the capacity to make informed health care decisions for herself due to her inability to process information. The resident had executed a West Virginia medical power of attorney document dated 03/25/02, designating her daughter as the representative to act on her behalf, giving, withholding or withdrawing consent to health care decisions in the event the resident could not do so herself. The document further stated that, if the chosen representative would became unable, unwilling or disqualified to serve, the resident's son would become the successor representative. The medical record did not indicate the daughter had became unwilling, unable or disqualified to serve as her mother's MPOA. The medical record's record of admission (face sheet) indicated the daughter was the resident's MPOA; her name and telephone number were listed as the primary contact. On 05/12/10 at approximately 5:00 p.m., a telephone call to the resident's MPOA revealed she had not received notification of the procedures her mother had scheduled on 05/11/10. She indicated she did know about Resident #5's scheduled medical appointment on 04/29/10; however, she denied being told the exact procedures the resident needed to have performed. A nursing note, dated 04/29/10 at 5:45 p.m., stated, Rtd. (returned) to facility from Dr. (name) office - to return May 11/10 - dtr (daughter) (name) notified. The daughter stated she knew Resident #5 would return to the physician's office on 05/11/10, but the facility did not tell her what procedures the physician wanted to perform on that date. A review of the consultation report from the urologist revealed findings and recommendations for treatment. The consulting urologist had dated the form 04/29/10. The facility physician had reviewed the orders on 05/03/10. The licensed practical nurse had transcribed the order onto a physician's telephone orders form on 05/03/10. The transcribed order indicated the resident would receive a cystoscopy, EMG, pelvic exam, HgbA1c check (a blood test that reflects one's average blood glucose levels for a two (2) to three (3) month period), folic acid, vitamin B12, and [MEDICATION NAME]. The physician's telephone order had a place at the bottom where the nurse could check if the family had received notification of the change in treatment; this section was left blank. The director of nursing indicated, on 05/12/10 at approximately 4:00 p.m., that the nurse should have completed this section for verification that the MPOA had received notification of the tests to be performed.",2015-10-01
9829,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2012-05-24,157,D,1,0,4S5211,". Based on review of review of medical records and staff interviews, the facility failed to immediately notify the attending physician and the family when there was a significant change in heath status. This affected one (1) of ten (10) sampled residents whose health status required physician intervention and hospitalization . Resident identifier: #105. Facility census: 103 Findings include: a) Resident #105 Review of this resident's medical record revealed a nurse's note, by Employee #115, a registered nurse, dated 03/04/12 at 2:00 p.m., which described, ""Resident c/o (complains of) burning with urination. Will obtain clean catch UA (urinalysis) with resident's next void."" -- There was no evidence the physician was notified. At 11:25 a.m. on 03/07/12, the record revealed notes describing an unwitnessed fall in the bathroom by the resident with a 2 inch scratch to the top of his head. The physician was notified and the resident was sent to the emergency room for evaluation. The resident was returned to the facility at 4:30 p.m. At 11:00 p.m. on 03/07/12, the nurse's notes stated: ""Resident rested most of evening taking clothes off - throwing empty cups and other items on floor - "". This was the first entry of these behaviors in either the nurses' notes or the social service notes since admission. At 12:45 a.m. on 03/08/12, the notes indicted that the resident ""...had emesis X 1."" At 11:00 p.m. on 03/09/12, a nurse's note described the resident, ""...refused to eat supper...Very hard to wake resident up tonight. Temp (temperature) was taken at 11p 100.5 ax (axillary) - cool wash cloths applied at this time..."". On 03/11/12, the nurse's notes described the resident had ""difficulty swallowing pills..."" At 2:30 p.m. on 03/12/12, Nurse #109 notified the physician the resident had a temperature, was lethargic, and ""was still not doing well."" Orders were received to stop the antibiotic and obtain urine for testing in the morning. -- The physician was not notified of any of these changes in condition until 2:30 p.m. on 03/12/12, although changes in the resident were documented, beginning 03/07/12, after the resident's return from the emergency room for an evaluation regarding a fall. -- The resident's family was not notified until the resident was transferred to the hospital at 7:00 p.m. on 03/13/12. This information was presented to the administrator and Employee #5 during an interview at 2:30 p.m. on 05/24/12. No additional information was provided by the time of exit. .",2015-08-01
9907,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2012-06-18,157,D,1,0,HT0511,". Based on record review and staff interview, the facility did not ensure that a resident's legal representative was notified timely of a change in condition. Resident #61 had a fall with injuries. After an initial unsuccessful attempt to contact the responsible party, no further attempts were made until the resident was transferred to the hospital. One (1) of a sample of five (5) residents was affected. Facility census: 60. Findings include: a) Resident #61 Nursing documentation, on 06/03/12 at 4:00 a.m., indicated the resident had a fall with injuries. The resident was noted to have sustained skin tears and a hematoma to the right side of the forehead. The physician was notified at 4:15 a.m. and ordered neuro checks according to facility policies. At 8:00 a.m., a nursing note indicated, an attempt was made to notify the resident's legal representative of the resident's fall. No further documentation was found to support the facility had continued to try to notify the the resident's legal representative of the fall with injuries. A nursing note, on 06/03/12 at 7:45 p.m., indicated the resident was transferred to the hospital and the legal representative was notified of the transfer. .",2015-08-01
9913,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2012-06-08,157,D,1,0,D9VT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the treating physician was notified when nursing staff members were unable to administer ordered intravenous therapy for fluid replacement purposes. One (1) of six (6) sampled residents was affected. Resident identifier: #202. Facility census: 123. Findings include: a) Resident #202 Review of the medical record found the resident was admitted to the facility on [DATE] for treatment of [REDACTED]. The resident was determined to lack the capacity to make medical decisions by the treating physician on 04/25/12, with adult protective services (APS) appointed as the resident's health care surrogate. On 05/10/12, laboratory results were positive for a [MEDICAL CONDITIONS] infection. The resident was ordered and began receiving [MEDICATION NAME] 500 mg three (3) times a day (tid) on 05/10/12. The nursing notes documented loose, thin, liquid stools on 05/10/12, 05/11/12, 05/12/12, 05/13/ 12, and 05/14/12. treatment for [REDACTED]. On 05/14/12, the resident was visited by the nurse practitioner who documented the resident to be lethargic and hypotensive. The nurse practitioner ordered 2000 cc normal saline intravenous (IV) fluids on 05/14/12. The order, written at 10:20 a.m. on 05/14/12, specified a bolus of 1000 cc of normal saline for the first liter, then 85 cc/hr for the second liter of fluids. Review of the nursing notes found IV access was was obtained at 12:23 p.m. for administration of the first bolus liter of normal saline. Further review of the nursing notes found a note written at 2:07 a.m. 05/15/12, which documented, ""Attempted IV access X 2 which was unsuccessful..."". The medical record contained no documentation of what circumstances prompted nursing to again attempt IV access. A late entry note, by the nurse practitioner on 05/15/12, documented ""nursing reports pulled out IV, received 900 ml of normal saline"". The medical record contained no evidence the treating physician was notified the IV site was no longer patent, nor the resident was not receiving the ordered IV fluids. The resident was sent to the emergency room at 1:50 p.m. on 05/15/12 with [MEDICAL CONDITION], altered mental status, and [MEDICAL CONDITION]. An interview with the nurse practitioner, Employee #153, was conducted on 06/07/12 at 1:50 p.m. She stated she did not take calls after leaving the facility and nursing would have to notify the treating physician of the resident's condition and the inability to administer IV fluids. An interview with the director of nursing (DON), Employee #121, on 06/07/12 at 2:00 p.m., verified the resident had pulled out his IV at approximately 9:30 p.m. with no attempts by nursing staff to restart the IV fluids until the unsuccessful attempts at 2:07 a.m. on 05/15/12. She agreed the treating physician should have been notified of the resident's condition and the inability to administer ordered IV fluids. .",2015-08-01
10054,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,157,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interviews, the facility failed to notify the physician of a resident's repeated refusal to take the medication [MEDICATION NAME]. Additionally, this resident's nursing notes identified attempts to inform the resident's physician when her heart rate was 44 beats per minute, but it was not noted whether the physician was ever made aware, nor was the physician notified of the results of a positive urine culture or the recommendation that the urine culture be repeated. One (1) of fourteen (14) current residents on the sample was affected. Resident identifier: #42. Facility census: 89. Findings include: a) Resident #42 1. review of the resident's medical record revealed [REDACTED].e., the resident refused the medication, it was not available, etc. The MAR for October 2009 was also reviewed and, again, all documented doses had been circled. There was no evidence the physician had been informed of the resident's repeated refusal to take the stool softener. 2. This resident's [DIAGNOSES REDACTED]. (name) to advise of Resident's [MEDICAL CONDITION]. Apical heart rate remains @ 44 beats per minute. No other S/Sx (signs or symptoms) noted R/T (related to) heart rate."" It was noted at 10:10 p.m., ""Gave report to oncoming LPN (licensed practical nurse) - monitor closely - pg (paged) Dr. again to give report on Resident's Sx."" The next entry was: ""Pulse 45 @ 12 A (a.m.) Paged Dr. (name). Dr. (name) has not called back. No s/s (signs/symptoms) of distress or discomfort. . . . Will continue to monitor."" Although the resident had a [DIAGNOSES REDACTED]. The resident was receiving [MEDICATION NAME] for hypertension, and a side effect of this medication is slow heart rate. There was no evidence the physician had ever been made aware of the resident's low heart rate. 3. Review of the resident's medical record noted she had been treated for [REDACTED]. coli at the emergency roiagnom on [DATE]. A physician's orders [REDACTED]. The specimen was not collected until 10/05/09. On 10/07/09 at 10:11 a.m., the lab had faxed the culture report to the facility. Under the comments section, it was noted, ""This is a mixed culture of 3 or more species. The probability of contamination is high. Suggest a repeat specimen. . . . "" The physician had not signed the report. Further review of the medical record did not find evidence the physician had been informed of the report or that another specimen had been submitted for culture. On 10/16/09 at 8:45 a.m., Employee #11 was asked why the culture had not been done until 10/05/09, although it had been ordered on [DATE], which was a Wednesday. She also was asked whether the culture had been repeated. She did not know why the specimen collection had been delayed and was unable to locate any record of a repeat culture. On 10/16/09, in mid-morning, Employees #40 and #41 were asked to see whether they could find whether the culture had been repeated and/or if the physician had been notified. At approximately 10:30 a.m., Employee #41 reported the culture had apparently not been repeated. Neither Employee #40 or #41 could find evidence the physician had been notified. Review of the nursing entries did not find any evidence the physician had been informed of the results. .",2015-07-01
10162,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-02-01,157,D,1,0,RZ6L11,". Based on medical record review and staff interview, the facility failed to ensure the treating physician was notified of a significant change in physical status indicating a deterioration in health or clinical complications for one (1) of forty-nine (49) Stage II sampled residents. Resident identifier: #87. Facility census: 82. Findings include: a) Resident #87 Review of the resident's medical record found a nursing note written at 10:58 p.m. on 01/03/12. The nursing note contained the following language, ""Resident hasn't voided this shift times eight hours will pass onto oncoming nurse to monitor urine output. Abdomen nondistented (sic), staff continues to encourage fluid intake with some success..."" The nursing note contained no evidence the treating physician was notified of this resident's failure to urinate. Review of the voiding report roster found no evidence the resident had urine output as of 9:07 a.m. on 01/03/12. This was nearly twelve (12) hours, not eight (8) hours as stated in the 01/03/12 nursing note written at 10:58 p.m. The medical record contained no evidence of further monitoring of the resident's condition until 3:39 a.m. on 01/04/12. The nursing note written at 3:39 a.m. on 01/04/12 described the resident was found with an oxygen saturation around 70, blood pressure of 84/54, and a temperature of 100.3 degrees Fahrenheit. The physician was then notified of the resident's condition. At that time, the physician ordered Resident #87 transported to the hospital for evaluation. .",2015-06-01
10203,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,157,D,0,1,D6IF11,"Based on record review and staff interview, the facility failed fully inform one (1) of sixteen (16) sampled residents when discontinuing Medicare coverage of a skilled service, by not identifying either the service or the reason for its discontinuance. Resident identifier: #37. Facility census: 95. Findings include: a) Resident #37 A review of the record for Resident #37 revealed she intermittently received physical therapy skilled services when ordered by the physician. After a significant change in healthcare status in May 2009, she received physical therapy services until 06/12/09. Documentation of the telephone notification of Medicare provider non-coverage, delivered on 06/04/09 to the resident's medical power of attorney representative (MPOA), stated only that ""therapy"" services were being discontinued but failed to indicate which ""therapy""; and, after the statement: ""I explained that the reason we believe Medicare probably will not pay for 'therapy' services is:________."", there was no entry. Therapy was again instituted in August 2009 and discontinued on 08/26/09. The Notice of Medicare Provider Non-coverage, provided to the MPOA on 08/29/09, failed to identify which ""therapy"" services were being discontinued and/or the reason(s) why. During an interview with the administrator at 2:30 p.m. on 11/10/09, he acknowledged, after reviewing the notice, that the reasons for non-coverage were not stated. .",2015-06-01
10372,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,157,D,0,1,FGH911,"**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 physician was notified when one (1) of twenty (20) sampled residents had an acute change in condition evidenced by vomiting, elevated temperature, and a fecal impaction. Resident identifier: #43. Facility census: 112. Findings include: a) Resident #43 Resident #43's medical record, when reviewed on 08/03/09 at 2:00 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. The quarterly minimum data set assessment (MDS), with an assessment reference date of 06/26/09, reported the resident had a fecal impaction. Further record review revealed the physician ordered Senna S two (2) tablets daily for constipation. A nursing note, dated 06/17/09 at 1:00 p.m., stated, ""Emesis x 1. Temp 101.5. Med given per order."" A subsequent nursing note, dated 06/18/09 at 4:25 a.m., stated, ""This nurse assisted resident with digital removal of large BM (bowel movement)."" There was no mention in either note that the nurse notified the physician of a change in the resident's change in condition on 06/17/09 or 06/18/09. Review of the nursing notes and physician's orders [REDACTED]. The care plan nurse (Employee #24), when interviewed on 08/04/09 at 10:00 a.m., stated the resident had a fecal impaction on 06/18/09. Employee #24 provided a copy of the facility's policy on fecal impaction. The policy titled ""Fecal Impaction: Removal of"" (revised 01/01/04) stated, ""Digital removal of stool will be performed by a licensed nurse per physician order."" Review of the facility's ""Standing Orders Template"" found no order for the digital removal of stool as an intervention to treat constipation. The director of nurses (DON - Employee #25), when interviewed on 08/05/09 at 10:00 a.m., confirmed the policy titled ""Fecal Impaction: Removal of "" (revision date 01/01/04) was the facility's current policy. The DON did not provide any additional evidence to reflect the physician was notified of an acute change in the resident's health status and/or ordered the digital removal of a fecal impaction. (See citation at F281.) .",2015-04-01
10373,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-12-21,157,D,1,0,1TX511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on resident interview, family interview, medical record review, care plan review, and staff interview, the facility failed to ensure an interested family member received notification when one (1) of fourteen (14) residents on the sample experienced a change in condition that resulted in a transfer to a local hospital. Resident #29 required medical intervention and was transfer to the hospital due to episodes of [DIAGNOSES REDACTED] on 11/16/11. The facility did not notify the resident's interested parties to inform them of the resident's change in condition, or of her transfer / admission to the hospital. The resident's care plan included that it was very important to have her two (2) sisters involved in care discussions. Resident identifier: #29. Facility census: 157. Findings include: a) Resident #29 On 12/19/11, at approximately 1:30 p.m., during an interview the resident recalled the events that happened to her on 11/16/11. She said her blood sugar had dropped more than once on 11/16/11. A housekeeper had found her and notified staff on one (1) of those occasions. She indicated by the time emergency medical services (EMS) arrived at the facility to take her to the hospital, she had some level of consciousness / awareness. She specifically remembered asking a nurse (Employee #179) to give her the glucometer she kept in her personal possession to take with her. She wanted the glucometer because she kept a small amount of money and a calling card in the case that held the glucometer. She said she also asked the nurse to call her sister. Resident #29 said after she arrived at the hospital, she waited for her sister to show up. As time passed, she realized the room had a telephone, so she used the telephone to contact her sister. Her sister told her she had just called the facility and learned she was at the hospital. During a telephone interview with Resident #29's sister, on 12/20/11, at approximately 6:00 p.m., she confirmed the resident's accounting of what had happened on 11/16/11. She said the facility had not contacted her to let her know Resident #29 had been sent to the hospital. She found out when she called the facility after being unable to contact Resident #29 on her personal telephone. Medical record review, conducted on 12/20/11, at approximately 10:00 a.m., revealed two (2) sisters were listed as as emergency contacts. These two (2) sisters were also designated as medical powers of attorney. However, the resident had capacity and made her own medical decisions. A nursing note for 11/16/11 stated (typed as written) ""At [MEDICAL CONDITION]:30 p.m. housekeeping notified nursing that resident was not responding to verbal stimuli. Blood sugar 21 at this time per meter. Administered 2 Tubes of instant-glucose, Blood sugar read LOW per meter. Admin. an IM (intramuslcar) injection of [MEDICATION NAME] in L. Deltoid (muscle forming rounded contour of shoulder). Blood sugar continued to red low. After multiple attempts at starting IV, Site was obtained in R A.C. (right antecubital) Fossa (anatomical pit, groove or depression) with good Backflash of blood noted. Administered ? vial of [MEDICATION NAME] 50% when IV site Lost. 2nd IM of [MEDICATION NAME] Administered in R. Deltoid. Resident is diaphoretic, responding at intervals. Blood sugar at this time was 130. 911 was called, (name). Paramedics arrived at this time. Resident transferred via Stretcher with assist of 4 without incident. Transferred to (name of hospital). Confused and verbalizing when being transferred."" A nursing entry, dated 11/15/11 at 5:00 p.m., noted (typed as written) ""entered room to obtain one touch pt (patient) unresponsive, flushed, dypharic, and cool to touch. One touch taken 16 attempted to administer insta glucose. IV started and amp of d50 (50 % [MEDICATION NAME] = 50g/100 ml) given 1 injection of [MEDICATION NAME] one touch retaken 289 pt still lethargic call to on call MD stated to assess pt in 15 mins if no mental status change call back. Assisted pt to eat egg sandwich 6p one touch 254. Pt becoming more alert pt is able to voice wants and needs at this time ox3 (oriented times three)."" A nursing note, dated 11/15/11 at 12:02 p.m. stated (typed as written) ""notified by CNA (nurse aide) that patient wont wake up to eat lunch entered room pt flushed and lethargic and clammy to touch one touch taken 36 able to wake pt to sip on oj one touch retaken after 5 mins down to 26 insta gluclose given x2 and 2 injections of [MEDICATION NAME] given one touch up to 78 pt able to verbalize wants and needs at this time pt alert and ox3 (oriented times three) assisted pt to eat a peanut butter sandwich 45 min later pt up in room ambulating and eating one touch retaken 164."" On 12/20/11, at approximately 1:00 p.m., the second floor unit manager (Employee #179) indicated she did work with the resident on 11/16/11. She said she did not remember Resident #29 asking her to call her sister as she was being prepared to leave the facility with EMS. She said she did have a conversation with the resident's sister after she had contacted the facility and was upset because of the situation regarding the facility not contacting her at the time the resident was sent to the hospital. She said she apologized to the resident's sister for not having contacted her. On 12/21/11, at approximately 1:15 p.m., the director of nursing (Employee #116) indicated the resident had never requested her sisters not be informed of significant changes in her medical status. The care plan review conducted on 12/20/11, at approximately 2:00 p.m., reflected the following statement: ""(Resident #29) has stated it is important to have her 2 sisters involved in care discussions."" Resident #29 experienced a significant change in medical status on 11/16/11. She required transport to a local hospital. The facility did not contact her interested party in. The family member learned the resident had been sent to the hospital after calling the resident's room and being unable to reach her. .",2015-04-01
10385,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2011-12-08,157,D,1,0,3LSH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed, for one (1) of six (6) sampled residents, to notify the Health Care Surrogate (HCS) when commencing a new treatment and to make the HCS aware of an out of facility appointment. A resident developed a dental problem which required an out of facility appointment for treatment and also was scheduled for an out of county follow-up neurology appointment. There was no evidence that the resident's health care decision maker had been notified. Resident identifier: #101. Facility census: 100. Findings include: a) Resident #101 Record review revealed that Resident #101 had a dental visit out of the facility on 03/15/11 for complaint of lower tooth discomfort which required a filling, and for repair of his partial plate. Resident #101 had been determined to lack capacity to make his own medical decisions and a HCS had been named to make medical decisions. Review of nurse's notes and physician's orders [REDACTED]. During an interview with a nurse manager (Employee #35) on 12/08/11 in the early afternoon, she stated the HCS for Resident #101 was often difficult to reach. She cited an example where she called the HCS approximately fifteen (15) times in an attempt to obtain permission to administer his flu vaccine this fall. After reviewing the medical record, she admitted she could find no evidence that attempts had been made to notify the HCS about his 03/15/11 dental appointment. Interview with the director of nursing, Employee #37, on 12/08/11 in the early afternoon, revealed she could find no evidence that the HCS had been notified of the 03/15/11 dental visit. She said staff always notify the family representative of appointments out of the facility, and most likely staff failed to document notification. ------------ Record review also revealed that Resident #101 had a neurology appointment at West Virginia University hospital on [DATE]. Review of the consultation report revealed this was a follow-up visit related to his [MEDICAL CONDITION] disorder. Interview with the Licensed Social Worker (LSW) on 12/08/11 in the afternoon, revealed that the neurology follow-up appointment had been set up prior to his September 2010 admission to the facility. The LSW stated also she could find no evidence that the HCS had been notified of the 05/19/11 neurology appointment.",2015-04-01
10418,"E.A. HAWSE NURSING AND REHABILITATION CENTER, LLC",515173,P.O BOX 70,BAKER,WV,26801,2011-12-06,157,D,1,0,H3SV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to notify the resident's legal representative, a family member, and/or the resident's physician when there was a deterioration in the health status of one (1) of six (6) sampled residents until the resident became unresponsive and required hospitalization . Resident identifier: #60. Facility census: 56. Findings include: a) Resident #60 A review of the closed medical record revealed that Resident #60 was an [AGE] year-old female who was admitted to the facility on [DATE], and discharged to an acute care facility on 09/13/11. Her [DIAGNOSES REDACTED]. A review of the nurse's notes revealed the following: -- 08/30/11 at 12:34: Multidisciplinary Care Conference held. The notes state, "". . . met goal for cognition . . . continues to make needs known . . . intake is less than 25% . . . . Patient visits with family, and staff. She watches the birds outside, strolls throughout the building in her wheelchair, eat chocolate and just people watch."" -- A second note, at 11:44, stated only that due to a pulse of ""47"", the resident's [MEDICATION NAME] was held. -- 08/31/11 at 10:56: ""(Resident's physician) in to see resident new orders to D/C (discontinue) [MEDICATION NAME] Give Tylenol 650 mg po q 4hrs (by mouth every 4 hours) while awake."". . . ""Daughter (health care surrogate's name) notified of new orders."" It was also noted the resident's blood pressure medications were held due to pulse rate of ""47"". -- 09/01/11 at 23:18: It was again noted the resident's blood pressure (BP) medications were held due to low BP of 137/62 and pulse rate of 46. The notes contained no additional nursing assessment or observations. -- 09/02/11 at 14:34: ""Physical Evaluation: lethargic, weak. MD (physician) made aware."" The entry did note the physician and the responsible party had been notified. It is also noted the resident had been determined to have a significant weight loss (9 pounds in 30 days). -- 09/03/11 at 01:28: A summary note stated: "". . . Due to increased drowsiness, her dose (of [MEDICATION NAME]) was decreased back down from 2mg to 1mg."" -- A second note at 19:38 stated: ""[MEDICATION NAME] med held due to pt (patient) status. Pt is difficult to arouse, pt assessed and vital signs within normal limits."" -- 09/04/11: There were no entries for that date. -- 09/05/11 at 10:40: ""Resident lethargic hard to arouse. [MEDICATION NAME] held. VS (vital signs) 121/71-100.4 ax (axillary) -85- 16 . . . Congestive cough."" -- 13:20: ""Resident remains lethargic not eating or drinking. Opens eyes when name called. Dr. (name) notified . . . Daughter in visiting. Requesting that resident be sent to hospital."" -- 14:15: ""New order to transfer to (hospital) . . . due to unresponsive, congestive cough, (up arrow) temp. Daughters in room with resident."" (notes by Nurse #1). During an interview with a daughter of the resident (not the health care surrogate (HCS)), at 10:30 a.m. on 12/06/11, she stated her younger sister had visited the resident and found her hard to awaken on 09/04/11. Her sister told her the staff said the resident had not eaten for three (3) days. She stated no one from the facility had contacted them about these changes. She also stated when she visited on 09/04/11, Nurse #1 told her they had been attempting to reach the resident's physician for three (3) days without success. During an interview with the daughter who was the HCS for Resident #60, at 10:50 a.m. on 12/0611, she stated she had visited her mother prior to leaving for vacation on 08/31/11. She stated her mother had been awake on that visit and the staff had not voiced any concerns about her health status. She stated she had left the state on vacation the next day. She had no further contact about her mother until her sisters contacted her from the hospital after the resident was transferred there on 09/05/11. She also stated she had examined her telephone for messages and found none. The hospital admission record revealed the resident had arrived there unresponsive with an oxygen saturation level of ""61"" (normal = 95-100%). Her BUN was ""68"" (normal = 7.0 - 22.0). Her [DIAGNOSES REDACTED]. During an interview with the director of nursing and the administrator, at 3:30 p.m. on 12/05/11, they were asked to explain why the physician had not been informed earlier of the resident's deteriorating status and why the family had not been notified. They stated they had no information the physician had been unavailable, but would check. They also stated, after reviewing the record, that the responsible party had been notified of weight loss on 09/02/11, per nurse's notes. In a follow-up meeting with the director of nursing and the administrator at 11:45 a.m. on 12/06/11, they acknowledged, after having completed a review of the entire record, that the last contact with the physician prior to the day of transfer, was on 09/02/11. They had no answer when told that none of the daughters had received a call from the facility on 09/02/11, and the HCS had been out of town. The daily entries were reviewed along with the hospital admission record, but they had no additional evidence to indicate additional assessments or attempts to notify the physician and/or family during the week prior to the resident's emergency transfer to acute care.",2015-04-01
10439,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2011-03-16,157,D,0,1,JSOV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, resident interview, staff interview, observation, and responsible party interview, there was no prior notification of room transfers and/or roommate consideration for three (3) of forty-four (44) Stage II sample residents. Resident identifiers: #78, #51, and #66. Facility census 66. Findings include: a) Residents #78 and #51 Record review revealed this [AGE] year old female was admitted to the facility on [DATE]. Although she had been determined by her physician to lack the capacity to form her own health care decisions, she was also noted to be alert and oriented to person and place, have no communication difficulties, and make her own day-to-day care decisions. The original Room Roster, presented to the surveyors shortly after entry at 11:45 a.m. on 03/07/11, indicated the resident was one room, but when that room was visited during the general tour at 12:10 p.m. on 03/07/11, the bed was unmade except for a filled bag sitting on it and a stack of books and other items on the bedside table. There was no name signage by the door indicating that Resident #78 resided there. However, the room was currently occupied by Resident #51 During an interview of Resident #51 in her room at 1:00 p.m. on 03/07/11, she was asked if she had a roommate; Resident #51 replied that she did not have a roommate but was going to get one. She stated that a nurse aide had brought in someone's things, and she pointed out a full plastic bag on the unmade bed in her room and a stack of books and things on the bedside table. When asked if she knew who her new roommate was to be, she stated that no one had told her. When questioned about the location of Resident #78 at 12:15 p.m. on 03/07/11, a licensed practical nurse (LPN - Employee #72) took the surveyor back to Resident #51's room and pointed to Resident #78, who was sitting in a chair beside the other bed. Employee #72 did not know why the survey team had been told Resident #78 was on the South side and stated the resident had only been in the present room a few days, because the facility had vacated the ""North Back"" Hall due to low census. During an interview with Resident #78 at this time she stated she had been at the facility for about 1-1/2 years. She stated she was in one (1) room on the North side, then she was moved to another room on the North side, and then was moved to the present room (on the South side) two (2) days ago. She did not know why she was moved, but she stated she had no objections. A review of Resident #78's medical record failed to show any evidence of room changes, the reason for the move, or that the resident's guardian (WV Department of Health and Human Resources - DHHR) or her family had been notified. Because of the lack of documentation, the lack of room numbers on chart forms, and the inconsistency of the staff's answers, it was not possible to determine the actual dates of these transfers. During an interview with the facility's social worker (SW - Employee #83) and one (1) of the facility's directors of nursing (DON - Employee #21) at 4:08 p.m. on 03/07/11, they were asked who was being moved into the room with Resident #51. The SW denied that anyone was being transferred to that bed and was surprised when told there were someone's belongings already there, because they had kept Resident #51 alone due to the resident's complaints about roommates in the past. The DON offered no explanation either, when told that there was no evidence in the record of any room changes or that the resident knew of a new roommate. The SW and the DON denied any knowledge that Resident #78 was being transferred. The SW said that Resident #78 had been transferred from one room to another on the North side due to problems between her and her roommate (Resident #66). The SW was asked at this time to furnish the surveyors with a corrected listing of room numbers for each resident. A social services note, dated 02/04/11, stated: ""Resident in conflict with roommate. From time to time there has been verbal conflict easily resolved, staff indicate it is escalating. SW provided intervention. Talked with both residents. A move is necessary to restore psychosocial well being."" This entry was signed by Employee #83. Nursing notes, recorded by a registered nurse (RN - Employee #68) on 02/04/11, stated: ""6:10pm. Resident transferred to (a room on North Back Hall) with belongings."" These are the only entries located referring in any way to either roommate problems or room changes. No additional information from either the SW or the DON was received regarding the room changes. A census dated 03/08/11 was received the following day, showing Resident #78 as residing in the same room with Resident #51 on the South side. At 9:00 a.m. on 03/08/11, Resident #78 was observed in the room she shared with Resident #51. Her chart was located in the rack at the South nurses' station, but it contained no nurses' note since 03/03/11, no SW note since 02/04/11, and no physician's order (either on chart or in ""pending order file"") for the room change or evidence of the physician or the resident's responsible party was notified of the room change. In an interview at 10:30 a.m. on 03/08/11 in room where they were now both residing, Residents #51 and #78 told the surveyor that Resident #78 had been transferred into this room the prior evening after supper. At the time of this interview, Resident #51 was sitting in her wheelchair by the far bed with a [MEDICATION NAME] over her legs and was watching Resident #78 with a frowning face, as Resident #78 paced back and forth at the foot of the beds stopping at the sink often to wipe her neck and forehead with a wet washcloth. Resident #78 was complaining about the heat in the room (it was very warm) and stated she would probably have to move again soon because of the heat. Resident #51 stated she had made the maintenance man turn her heat back on, because she had to have it warm due to her poor circulation and it was her ""room"". When asked if they had discussed their room temperature preferences before the room change occurred, both women stated they had not met prior to the transfer of Resident #78. In an interview at 8:20 a.m. on 03/09/11, an LPN (Employee #46) stated Resident #78 was in a room on the North side and was moved last week (she was not sure of date) into another room with Resident #10 (also on the North side), because ""administration"" wanted all residents off that wing. When they discovered that Resident #10 had re-opened wounds on her legs and a history [MEDICAL CONDITION] which required contact isolation, Resident #78 was moved into the room with Resident #51 on the evening of 03/07/11. When the local WV DHHR office (Resident #78's legal guardian) was contacted at 1:45 p.m. on 03/09/11, the WV DHHR representative stated the SW assigned to this resident was not available but stated that it was the practice for the nursing home to call the DHHR office and leave a voice mail message whenever there was a change in status, and to her knowledge, there had been NO messages left yesterday or today regarding this resident. This was confirmed in an e-mail from the SW assigned to Resident #78 at 11:44 a.m. on 03/17/11. During an interview with the administrator, the DON, and an RN (Employee #7) at 3:15 p.m. on 03/09/11, the administrator stated that North Back Hall residents were transferred last week due to low census and the need [MEDICAL CONDITION] isolation of some residents. She stated that all residents were given a 24-hour notice and asked about any room requests they might have. The residents were also told this was temporary and they could go back if they wanted when census went up. When asked about Resident #78, the administrator said that she, herself, had taken the resident to meet her future roommate (Resident #51) after the surveyors had left the faciity on [DATE]. She said she told the resident that she could stay in her present room this night and the move would not take place until the next day. She stated that Resident #78 was moved after her bath on 03/08/11. (This was contrary to statements documented above from the residents involved and from Employee #46.) When asked if there was any documentation that would reflect that the residents, their responsible parties, or the physician had been notified of the moves, the administrator stated that they did not require a physician's order for room changes, but he had been told. No documentation was presented. At 8:00 a.m. on 03/10/11, the administrator brought the activities director (Employee #24) to present copies of an activity progress note, containing a standardized typed statement regarding notification of room change with the resident's name added at the bottom, for the residents who had been moved off of North Back hall. The forms were dated 03/01/11 except for Resident #78's form, which was dated 03/07/11. All were signed by either Employee #24 or Employee #77 (another employee in the activities department). The administrator stated these forms had been located in the activities office and the activities staff members were the ones who explained the moves to the residents. The activities director added that the notes were for their use only and were not added to the chart. In a follow-up interview in the activities office with Employee #24 at 8:13 a.m. on 03/10/11, she was asked if there was a form showing that Resident #78 had been notified prior to the original transfer from North Back on 03/01/11 (when the other residents had been notified). She searched her files and could find none. -- b) Resident #66 Medical record revealed Resident #66 was a [AGE] year old female who was admitted to the facility on [DATE]. She had been determined to lack the capacity to form her own health care decisions, but who was alert, oriented, and able to participate in decisions regarding her day-to-day care. A SW at WV DHHR was her health care surrogate (HCS). Resident #66 was observed sitting in a wheelchair in her room with a fan pointed toward her at 12:15 p.m. on 03/07/11. She stated she had asthma and the room was too hot (it was very warm), but that maintenance had been in and disconnected the heat a short time ago and it was getting cooler. She stated she had been moved last week on Wednesday (03/02/11) because: ""There weren't enough people to fill the other end of the hall."" She stated she did not like this room, because the people across the hall were always bothering her with their wandering and yelling. When asked if she had agreed to the move, she said she wasn't asked. A review of the medical record failed to show any evidence of room changes, the reason for the move, or that the resident's HCS had been notified. Because of the lack of documentation, the lack of room numbers on chart forms, and the inconsistency of the staff's answers, it was not possible to determine the actual date of this room change. During an interview with the SW and the DON at 4:08 p.m. on 03/07/11, the SW stated Resident #66 had been moved because she and her former roommate did not get along. When asked, the SW could not supply any documentation of this. During an interview with the administrator, the DON, and Employee #7 at 3:15 p.m. on 03/09/11, the administrator stated that North Back (N112 - N125) residents were transferred last week due to low census and the need [MEDICAL CONDITION] isolation of some residents. She stated that all residents were given a 24 hour notice and asked about any room requests they might have. The residents were also told this was temporary and they could go back if they wanted when census went up. At 8:00 a.m. on 03/10/11, the administrator brought the activities director (Employee #24) to present copies of an Activity Progress Note, containing a standardized typed statement regarding notification of room change, including a form with Resident #66's name added at the bottom. The form read as follows: ""3-1-2011 Resident / responsible party was notified of a room change this A.M. Explained to resident that the move would take place on 3-2-2011. They were informed when census increase, they would be the first to move back to their room if they choose to. He / she was shown his room and he voiced no complaints or S/S of distress."" All of the forms were signed by either Employee #24 or Employee #77. The administrator stated these forms had been located in the activities office and that they were the ones who explained the moves to the residents. The activities director added that the notes were for their use only and were not added to the chart. When the facility was entered at 10:30 a.m. on 03/14/11, the census reflected the North Back Hall had been re-opened and was now occupied by seven (7) residents. During a follow-up interview at 12:15 p.m. on 03/14/11, Resident #66 was asked how she was settling into her new room. She said she was doing better now that the heat was off. When asked if anyone had asked her if she still wanted to go back to her previous room, she stated she would like to do so, but no one had asked her. c) There was no evidence in the medical records to reflect three (3) alert residents were consulted prior to room changes, either about the actual transfer or about the change of roommate. There was no documentation in the nurses' notes about the actual transfer or of each resident's reaction to the transfer. .",2015-04-01
10514,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2011-10-27,157,D,1,0,YU5611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the physician in a timely manner of a change in resident condition with potential to require medical intervention for one (1) of eight (8) sampled residents. Resident identifier: #58. Facility census: 96. Findings include: a) Resident #58 Review of nursing notes in Resident #58's medical record revealed an entry, at 8:00 p.m. on 10/20/11, by a licensed nurse (Employee #104) who ""observed a large raised area hard to touch c/o (complains of) being sore, not open, on left upper thigh next to his buttock"". Further review of nursing notes revealed, on 10/21/11 at 10:20 a.m., a licensed nurse (Employee #187) documented she had administered pain medication after Resident #58 stated the ""boil like area on my a** hurts"". The nurse wrote he refused therapy at 9:00 a.m. and was assisted to bed as he requested, then the nurse applied warm compresses to a ""hard raised area noted to back of L (symbol for left) leg under buttocks"". Review of the Medication Administration Record [REDACTED]. Review of nursing notes also revealed, at 5:00 p.m. on 10/21/11, Employee #104 applied warm compresses to a ""large area l (symbol for left) upper thigh near buttock"". Review of nursing notes, dated 10/23/11 at 5:30 p.m., found Resident #58 was ""very lethargic"", ""sweating and slow to respond"", and the family reported his ""speech is really slurred"". The physician on-call was notified, and orders were received to send him to the emergency room where he was later admitted . A nursing note, dated 10/23/11 at 10:00 p.m., stated he was admitted to the hospital with [REDACTED]. During an interview with a licensed nurse (Employee #108) on 10/27/11 at 11:40 a.m., she said she worked with Resident #58 on 10/22/11 and was not aware he had a boil. She looked at the treatment book and found no treatment orders for a boil and no orders for warm compresses. When asked, she said one would need to get an order for [REDACTED]. Interview with a nurse manager (Employee #142), on 10/27/11 at 11:45 p.m., revealed she was aware Resident #58 had a boil, but she did not work over the weekend of 10/22/11. She stated the nurse on duty on Sunday 10/23/11 saw a change in the resident and reported to the physician; although he had periods of intermittent confusion, he was not normally lethargic as he was the evening of 10/23/11. Review of the medical record found no evidence of physician notification of the hard raised area described as located on or under the left buttock. Interview with the director of nursing (DON), on 10/27/11 at 10:20 a.m., found she had the names of the nurses who worked the weekend of 10/22/11, but she had not spoken with them yet; an investigation was in process. Discussion also took place with the administrator on 10/27/11 at approximately noon, with no further information obtained. Interview with Resident #58's physician, on 10/27/11 at approximately 1:30 p.m., found he was not notified of the area on the left buttock; although he was out of town over the weekend 10/21/11 through 10/23/11, other physicians were on-call to cover the residents. He stated the lesion on the buttock was incised and drained in the hospital, was located only a few inches from the rectum, and may have begun as a perirectal abscess. He said the resident told him in the hospital this area had hurt for not more than a day or two (2) before being hospitalized . When asked, he agreed the resident had had intermittent periods of confusion since admission. .",2015-02-01
10546,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2011-10-27,157,D,1,0,Q1UQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, interview with the resident's guardian (a representative of the local West Virginia Department of Health and Human Resources - WVDHHR), and staff interview, the facility failed to notify the responsible party when one (1) of ten (10) residents was transferred to the hospital. Resident identifier: #67. Facility census: 84. Findings include: a) Resident #67 Medical record review for Resident #67 revealed this [AGE] year old female was originally admitted to the facility on [DATE]. She was adjudicated incapable of making medical and financial decisions, and the court appointed WVDHHR to act as her guardian and the County sheriff to act as her conservator. On 10/19/11, a local hospice agency evaluated and accepted Resident #67 to receive their services at the facility. Her terminal condition was related to an overall decline due to dementia and [MEDICAL CONDITION]. Further review of the medical record revealed Resident #67 was transferred to the hospital on [DATE] at 20:30 (8:30 p.m.) for: ""Resident abdomin (sic) (abdomen) distented (sic) (distended). Complaint of pain in abdomin (sic). Not have fequent (sic) (frequent) bowel movements. Not eating well. Decreased bowel sounds."" The nurses note stated the resident's physician and APS (WVDHHR) was notified of the transfer. On 10/26/11, the resident's court-appointed guardian, a representative from WVDHHR verified she learned of the resident's transfer to the hospital when she was notified the next day (10/26/11) by the hospice nurse. She denied having been notified by the facility on the evening of the transfer to the hospital. The WVDHHR representative stated she checked her e-mail, the hotline (used for reporting after hours) and her voice mail, and there was no message from the facility regarding Resident #67's transfer to the hospital. On 10/27/11 at 10:00 a.m., the director of nursing (DON) stated she spoke with Employee #43, the author of the nurses note on 10/25/11, and reported this employee called the local DHHR telephone number when the resident was transferred to the hospital at 8:30 p.m. on 10/25/11. According to the DON, Employee #43 thought she was leaving a message because the telephone ""made a clicking sound"". Employee #43 stated she was not instructed to leave a message but thought the answering machine was working. According to the DON, the protocol for leaving messages after hours (after 5:00 p.m.) for WVDHHR is to call the hotline to report any changes in resident condition. .",2015-02-01
10592,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2011-09-13,157,D,1,0,XZJR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility did not notify both interested family members when one (1) of five (5) sampled residents had a change in medication, in accordance with the resident's wishes. Resident #66 had informed the facility that two (2) family members were to be notified with any change in condition or treatment. The resident's physician discontinued a pain medication and prescribed another medication. The two (2) family members were not notified of these changes in medication regimen. Facility census: 73. Findings include: a) Resident #66 Record review revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The physician determined this resident possessed the capacity to understand and make her own informed health care decisions. According to documentation on the resident's admission form, her two (2) sisters were to be notified whenever changes occur in her condition and/or treatment. Further record review revealed the resident was receiving [MEDICATION NAME] 7.5-500 mg once daily for pain beginning on 03/25/11. The order was changed to three (3) times daily with an as needed dose. According to pain assessments, the resident was continuing to have pain, and the physician ordered [MEDICATION NAME] 60 mg daily for the increased pain. The [MEDICATION NAME] was discontinued. The resident started the [MEDICATION NAME] 60 mg daily on 04/09/11. There was no evidence in the resident's chart to reflect the two (2) family members listed on the admission form were notified of changes in the resident's medication regimen. The resident was sent to the hospital on [DATE]. A hospital report dated 04/17/11 revealed: ""Hospital Course - This lady is admitted to the hospital with [REDACTED]. She was treated with intravenous [MEDICATION NAME] and [MEDICATION NAME]. She received nebulizer. She has some upper airway sounds, but her lungs themselves are clear. I believe she needs more help being encouraged to cough. She has difficulty cleaning her secretions. While she was in the hospital she had some right shoulder pain. The above x-rays were done. Nothing in particular was seen. The family became aware that she was on long-acting [MEDICATION NAME]. They wished that to be stopped. I suggested that we simply decrease the dose and this was done. All in all she is improved on discharge. "" According to her hospital records, her discharge [DIAGNOSES REDACTED]. The resident returned to the facility on [DATE], and the [MEDICATION NAME] was discontinued and the [MEDICATION NAME] 7.5-500 mg 4 times a day starting on 04/21/11. A physician's progress note, dated 04/18/11, stated: ""Resident (name) was sent to the hospital (name) on 04/11/11 because of increasing confusion and congestion. There were no infiltrates. They felt she had [MEDICAL CONDITION] with exacerbation and acute [MEDICAL CONDITION]. She also has diabetes mellitus which is well controlled with recent hemoglobin A1C of 5.5, hypertension, mild [MEDICAL CONDITION], previous stroke with left sided paralysis and dementia. Her [MEDICATION NAME] stopped at the request of the family and we put her back on the [MEDICATION NAME]."" An interview with the director of nursing, on 09/13/11 at 10:30 a.m., found the resident's two (2) sisters were not notified by the nurse who took off the changes in medication orders. She further stated, ""I spoke with the social worker and she said, the stars were placed on the admission form beside each of the family members' names, and nursing was to call them with any change.""",2015-01-01
10692,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,157,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to immediately notify an interested family member when one (1) of forty-five (45) Stage II sample residents, who was alert and oriented, experienced an acute change in condition resulting in transfer to a local hospital emergency department. Resident identifier: #162. Facility census: 105. Findings include: a) Resident #162 On 08/08/11 at approximately 1:00 p.m., medical record review for Resident #162 revealed he had the capacity to make his own medical decisions. The review also revealed two (2) nursing notes pertaining to an acute change in the resident's physical condition. - A nursing note, dated 07/04/11 at 12:15 p.m., stated: ""Called (physician name) on his cell phone. Rec'd (received) order to send to ER (emergency room ) for eval (evaluation) 911 called. Res (resident) sent via stretcher with 2 attendants noted to have left side weakness and slight facial droop. Remains alert and responsive. 02 NC (nasal cannula) on with 02 sat 92-94. Ambulance personnel failed to take med (medical) records packet (transfer, md orders and d/c summary with them)."" - A nursing note, dated 07/04/11 at 17:05 (5:05 p.m.), stated, ""This nurse informed (resident's sister's name) that res. was transferred to (name of hospital) for eval (evaluation) at approx (approximately) 12:15 p.m. Res. sister approached this nurse to ask if res. (resident) had gone to ER. This nurse informed her 'yes.' Call placed to (name of hospital) ER. Res. has been admitted to (name of hospital) for [MEDICAL CONDITION] and [MEDICAL CONDITION] ischemia. Sister completely updated on status."" On 08/08/11 at approximately 2:00 p.m., the director of nursing (DON - Employee #27A) reviewed the nursing notes in the medical record and reported her belief that the family had received notification of the resident's change in condition. She also felt that the resident's capacity status relieved the facility of any further duties regarding notification. However, the nursing notes did not indicate the resident's sister had received notification on 07/04/11 at 12:15 p.m., when her brother experienced the change in condition and required transfer to the hospital. The nursing notes reflected the resident's sister did not receive notification of his transfer until approximately 5:05 p.m. on 07/04/11. .",2014-12-01
10706,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,157,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed, for one (1) of twenty-one (21) sampled residents, to ensure a resident's oncologist was notified when both pain and nausea medications were not effective. Resident identifier: #13. Facility census: 138. Findings include: a) Resident #13 1. During an initial tour of the facility on 08/17/09 at 1:00 p.m., observation found Resident #13 lying in bed with facial grimacing and guarding. A meal tray was observed on the bed side table set up, but the food was not touched. When interviewed at this time, Resident #13 reported, ""I am so sick at my stomach."" When asked if she had pain, she reported having intermittent stomach pain and pain in her breast, pointing to her right breast. When asked if they were giving her medications, she said yes but reported the pain and nausea medications were not working. On 08/17/09 at 2:00 p.m., medical record review revealed Resident #13 had been diagnosed with [REDACTED]. In July 2009, she was admitted to the hospital and had surgery on her breast, for which a drain was placed. The medical record also noted she had a abscess of the breast, and the [MEDICAL CONDITION] treatments had left [MEDICAL CONDITION] her breast abdomen and back. The orders for [MEDICAL CONDITION] and [MEDICAL CONDITION] were placed on hold. She returned to the facility on [DATE] and, since then, the [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments have remained on hold. The medical record indicated that, on 07/30/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her pain. On 07/30/09, an order was received to increase the frequency of the [MEDICATION NAME] from every six (6) hours to every four (4) hours for pain. On 08/14/09, her family physician (not her oncologist) was notified the medication [MEDICATION NAME] was not effective in relieving her nausea, and he increased the frequency from of that medication from every eight (8) hours to every four (4) hours for nausea. -- According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm, [MEDICATION NAME] is indicated for use for the following: - Prevention of nausea and vomiting associated with highly [MEDICAL CONDITIONS], including cisplatin ? 50 mg/m?. - Prevention of nausea and vomiting associated with initial and repeat courses of moderately [MEDICAL CONDITIONS]. - Prevention of nausea and vomiting associated with radiotherapy in patients receiving either total body [MEDICAL CONDITION], single high-dose fraction to the abdomen, or daily fractions to the abdomen. - Prevention of postoperative nausea and/or vomiting. As with other antiemetics, routine [MEDICATION NAME] is not recommended for patients in whom there is little expectation that nausea and/or vomiting will occur postoperatively. In patients where nausea and/or vomiting must be avoided postoperatively, [MEDICATION NAME] Tablets, [MEDICATION NAME][MEDICATION NAME](orally disintegrating tablets), and [MEDICATION NAME] Oral Solution are recommended even where the incidence of postoperative nausea and/or vomiting is low. The facility failed to contact the resident's oncologist in order to inform him that the [MEDICATION NAME] was not effective for nausea, especially since this medication is specific to use in conjunction with [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments, which had been placed on hold. -- According to http://www.rxlist.com/[MEDICATION NAME]-drug.htm., for [MEDICATION NAME] indications and dosages: - Dosage should be adjusted according to the severity of the pain and the response of the patient. However, it should be kept in mind that tolerance to [MEDICATION NAME] can develop with continued use and that the incidence of untoward effects is dose related. - The usual adult dosage is one (1) or two (2) tablets every four (4) to six (6) hours as needed for pain. The total daily dosage should not exceed eight (8) tablets. Review of the Medication Administration Record [REDACTED]. On 08/17/09 at 3:00 p.m., a licensed nurse (Employee #119), when interviewed at the nursing station, identified that Resident #13's [MEDICAL CONDITION] and [MEDICAL CONDITION] treatments had been on hold for approximately two (2) weeks, and she confirmed Resident #13's oncologist had not been notified that the nausea and pain medications were not effective. Employee #119 also identified Resident #13 was getting two (2) [MEDICATION NAME] tablets every four (4) hours for pain, she had not been eating much, and Employee #119 was not sure if the [MEDICATION NAME] was causing Resident #13's nausea. The facility failed to contact the oncologist when Resident #13 was experiencing unrelieved pain and nausea, in order to identify alternative interventions. 2. On 08/17/09, following surveyor intervention, the oncologist was called and the nausea medication was changed to [MEDICATION NAME] 10 mg by mouth three (3) times a day. When interviewed on the morning of 08/18/09, Resident #13 related that the new nausea medication was working and this was the first time in days she was not nauseated. 3. On the morning of 08/18/09, facility management staff (Employees #138 and #139) were questioned about the high dosage of [MEDICATION NAME] with unrelieved pain and the possibility that the [MEDICATION NAME] may have been causing or contributing to the resident's nausea. The physician was notified, and Resident #13 was started on a [MEDICATION NAME] 25 mg pain patch and [MEDICATION NAME] sulfate liquid medication for pain. On 08/19/09, following an outside appointment, observation found Resident #13 resting quitely in bed with no grimacing, guarding, or nausea noted. .",2014-12-01
10723,"GLEN WOOD PARK, INC.",515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2011-08-24,157,D,1,0,HTIL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and record review the facility failed to immediately notify the physician of one (1) of six (6) sampled resident's death. Resident #60 was a full code. She was found by nursing staff with no pulse and no respirations on [DATE]. Resident identifier: #60. Facility census: 59. Findings include: a) Resident #60 Resident #60 had elected to be a full code. Review of the nurses' notes for [DATE] revealed the following entries (quoted as written): - On [DATE] at 4:40 a.m.: ""nursing assistants entered resident's room and found resident unresponsive and came to get nurses. Upon examining resident - 0 pulse or heartbeat noted no breathe sounds notes. Tongue hanging out of mouth - head turned to L side Body cold and stiff. Resident obviously expired."" - On [DATE] at 4:41 a.m.: ""Family was notified of death."" - On [DATE] at 4:42 a.m.: ""Funeral Home was notified of death."" - On [DATE] at 4:44 a.m.: ""Senior vice president was notified of death."" - On [DATE] at 4:45 a.m.: ""Vice president of resident services was notified of death."" - On [DATE] at 5:00 a.m.: ""RN on call was notified of death."" Review of the nursing notes found no evidence that the physician was notified. - On [DATE], interviews were conducted with the following employees: - Employee #52 (certified nursing assistant), when interviewed at 1:30 p.m., stated he had entered the room at 4:40 a.m. to reposition the roommate of Resident #60. At this time, he noticed Resident #60 was turned sideways and ""... her tongue was drooped and purplish colored."" He stated he told Employee #73 (certified nursing assistant), ""She looks like she passed away."" He left the room to tell the nurse (Employee #64). - Employee #73, when interviewed at 2:30 p.m., verified she and Employee #52 found Resident #60 around 4:00 a.m. She stated, ""She felt cold and her tongue was hanging out of her mouth."" - Employee #64 (licensed practical nurse) was interviewed at 10:30 a.m. When asked if she knew the code status prior to Resident #60's death, Employee #64 replied, ""No, I thought she was comfort measures."" Employee #64 further stated, ""I didn't call the doctor."" - On [DATE] at 9:24 a.m., the director of nursing (Employee #80) stated, ""We do not have to call the physician, we tell him on his next round."" She further stated, ""They do not have to call him if they are a full code."" .",2014-12-01
10780,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-06-08,157,D,1,0,MZQB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made ""do not resuscitate"" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use"" (created on [DATE]) G - ""minimize skin breakdown risks"" (created on [DATE]) I - ""... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..."" (created on [DATE]) - P - ""Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising"" (created on [DATE]) G - ""Will have no adverse effects"" (created on [DATE]) and ""Will maintain lab values within therapeutic range (created on [DATE]) I - ""Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and reports adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care."" (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P - ""At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]"" created on [DATE]) G - Minimize risk for falls"" (created on [DATE]) I - ""Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). "" - 4. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident ""missed his chair"" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed): ""resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning."" The LPN also noted the type of incident as a ""(f)all without injury (or minor injury)"". Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and ""resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. "" - 5. The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot."" An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue."" At 6:00 p.m. on [DATE], another nurse wrote: ""Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. "" At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 6. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 7. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written): ""Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%."" The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated: ""Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. "" The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated: ""(Name of transport service) here to p/u (pick up) for ortho appt. "" There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 8. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 9. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141 ""underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm."" The report read: ""The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding."" He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. - 10. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was ""old"" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was ""probably"" old and that a ""large amount of acute bleeding"" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). - 11. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, who would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was ""old"", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's ""right"" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 12. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: ""Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H2O given with meds. ..."" There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: ""Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain."" There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: ""Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility."" The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):""... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..."" Under the heading ""Assessment and Plan"" was: ""1.[MEDICAL CONDITION]ly of urinary origin. ..."" - The facility's policy titled ""Catheter Care: Indwelling Catheter"" (dated "",[DATE]""), provided by the facility on [DATE], contained the following under the heading ""Suggested Documentation"": ""- Care provided and reaction to procedure, size of catheter and balloon. ""- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians."" - Review of the resident's care plan, with a print date of [DATE], found the following problem statement: ""Use of indwelling urinary catheter D/T (due to) [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder places him at risk for bladder infections, trauma / urethral erosion."" This problem statement had a ""created"" date of [DATE]. Interventions associated with this problem included: ""... Monitor and report to physician any signs of UTI (urinary tract infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain / burning. ... Monitor for and report any changes in amount, color, or odor of urine. ..."" Both of these interventions had ""created"" dates of [DATE]. - On [DATE] at approximately 4:00 p.m., the DON, the DCD (Employee #24), and a corporate nurse consultant (Employee #195) were presented with the nursing notes from [DATE] and [DATE]. They had no information to offer as to why the resident's attending physician was not notified when these abnormal findings, indicative of an acute change in condition, were documented in the resident's medical record. .",2014-12-01
10781,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-08-25,157,D,1,0,1HRH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, and staff interview, the facility failed to immediately and fully inform the physician of significant findings associated with the health status of two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. Upon leaving the orthopedist's office on [DATE], the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made ""do not resuscitate"" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use"" (created on [DATE]) G - ""minimize skin breakdown risks"" (created on [DATE]) I - ""... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..."" (created on [DATE]) - P - ""Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising"" (created on [DATE]) G - ""Will have no adverse effects"" (created on [DATE]) and ""Will maintain lab values within therapeutic range (created on [DATE]) I - ""Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and reports adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care."" (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P - ""At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]"" created on [DATE]) G - Minimize risk for falls"" (created on [DATE]) I - ""Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). "" - 4. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident ""missed his chair"" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed): ""resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning."" The LPN also noted the type of incident as a ""(f)all without injury (or minor injury)"". Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and ""resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. "" - 5. The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot."" An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written): ""Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue."" At 6:00 p.m. on [DATE], another nurse wrote: ""Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. "" At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 6. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 7. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written): ""Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%."" The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated: ""Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. "" The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated: ""(Name of transport service) here to p/u (pick up) for ortho appt. "" There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 8. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 9. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141 ""underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm."" The report read: ""The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding."" He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. - 10. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was ""old"" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was ""probably"" old and that a ""large amount of acute bleeding"" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). - 11. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, who would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was ""old"", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's ""right"" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 12. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: ""Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. ..."" There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: ""Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain."" There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: ""Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility."" The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed): "" ... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..."" Under the heading ""Assessment and Plan"" was: ""1.[MEDICAL CONDITION]ly of urinary origin. ..."" - The facility's policy titled ""Catheter Care: Indwelling Catheter"" (dated "",[DATE]""), provided by the facility on [DATE], contained the following under the heading ""Suggested Documentation"": ""- Care provided and reaction to procedure, size of catheter and balloon. ""- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians."" - Review of the resident's care plan, with a print date of [DATE], found the following problem statement: ""Use of indwelling urinary catheter D/T (due to) [MEDICAL CONDITION] and [MEDICAL CONDITION] bladder places him at risk for bladder infections, trauma / urethral erosion."" This problem statement had a ""created"" date of [DATE]. Interventions associated with this problem included: ""... Monitor and report to physician any signs of UTI (urinary tract infection) such as blood, cloudy urine, fever, increased restlessness, lethargy, c/o (complaints of) pain / burning. ... Monitor for and report any changes in amount, color, or odor of urine. ..."" Both of these interventions had ""created"" dates of [DATE]. - On [DATE] at approximately 4:00 p.m., the DON, the DCD (Employee #24), and a corporate nurse consultant (Employee #195) were presented with the nursing notes from [DATE] and [DATE]. They had no information to offer as to why the resident's attending physician was not notified when these abnormal findings, indicative of an acute change in condition, were documented in the resident's medical record. .",2014-12-01
10786,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,157,D,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the responsible party and/or physician, for one (1) of seven (7) sampled residents, when acute changes in condition occurred, and failed to notify the responsible party when changes were made in medication and treatment orders as a result of this acute changes in condition. Resident #14 developed a ""blister"" on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. There was no evidence the family was informed of the ""blister"" or the topical antibiotic that was ordered on [DATE] to treat this area. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). There was a lack of evidence to reflect the family had been notified of this new medication or the reason for its use. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be ""blackish / brownish"" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to ""awaiting delivery from pharmacy"". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a ""blister"" on the left great toe, to which the podiatrist applied [MEDICATION NAME] (a topical antibiotic); the podiatrist also recorded the need for follow-up by the facility's physician. A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): ""Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated."" -- 2. A review of the resident's treatment administration records (TARs), medication administration records (MARs), and physician orders [REDACTED]. - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - ""Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing."" The order was discontinued at 1:50 p.m. on 05/27/11. - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml (""Instructions: Great toe on left foot""); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. According to the physician order [REDACTED]. - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for ""UTI"" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. - Order Date: 06/02/11 at 5:00 p.m. - ""TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed."" - Order Date: 06/04/11 - ""... D/C Skin prep to tip of (lt) gt (great) toe. ..."" - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml (""Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. -- 3. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11. There was no entry to correspond with notification of the attending physician of the podiatrist ' s findings on 05/12/11, no entry to correspond with notification of the family of the order for [MEDICATION NAME] and a dry dressing on 05/14/11, and no entry to reflect nursing staff notified the resident's family of a verbal order from the physician for Keflex to treat ""possible infection / [MEDICAL CONDITION]"" of the left great toe on the evening of 05/19/11. - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): ""05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..."" There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding. - An entry, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area. - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. There were no entries in the nursing progress notes to reflect the resident's family was notified that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infected left great toe, had been discontinued. - On 06/03/11 at 2:30 a.m., Employee #30 (an LPN) recorded: ""... resident has new order for arterial ultrasound of left lower leg stat. ..."" On 06/03/11 at 6:21 p.m., Employee #11 recorded: ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" On 06/05/11 at 8:23 a.m., Employee #11 recorded: ""Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t (due to) his overall condition. ..."" - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): ""... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... "" Documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; ""awaiting delivery from pharmacy"" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): ""Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11."" -- In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. (See also citation at F224.) .",2014-12-01
10815,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2011-08-17,157,E,1,0,YCK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of self-reported allegations of abuse / neglect, staff interview, and policy review, the facility failed to notify the physician timely when a resident did not receive medications in accordance with physician orders [REDACTED]. This affected ten (10) of ten (10) sampled residents. Resident identifiers: #4, #8, #41, #44, #57, #62, #75, #78, #79, and #80. Facility census: 77. Findings include: a) Resident #78 1. Review of the resident's medication administration records (MARs) from October 2010 found the resident had a history of [REDACTED]. - [MEDICATION NAME] 100 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 13 doses and missed 1 additional dose (reason unspecified); med discontinued on 10/14/10 - [MEDICATION NAME] 2 mg 1 tablet by mouth at bedtime for dementia with behavior disturbances - refused 9 of 15 doses and missed 4 additional doses (reason unspecified); order changed on 10/16/10 - [MEDICATION NAME] 10 mg 1 tablet by mouth twice daily for dementia with behavior disturbances - refused 12 of 62 doses and missed 6 additional doses (reason unspecified) - [MEDICATION NAME] 2 mg 1 tablet by mouth for hypertension - refused 3 of 31 doses - [MEDICATION NAME] XL 300 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 - [MEDICATION NAME] sodium 200 mg 1 by mouth at bedtime for constipation - refused 12 of 31 doses and missed 3 additional doses (reason unspecified) - [MEDICATION NAME] 25/200 1 tablet by mouth twice daily for hypertension - refused 14 of 62 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 17 grams in 8 oz water by mouth for constipation - refused 3 of 31 doses - [MEDICATION NAME] OTC 20 mg 1 tablet by mouth for [MEDICAL CONDITION] reflux - refused 3 of 31 doses - [MEDICATION NAME] liquid 400 mg by mouth twice daily as an appetite stimulant - refused 20 of 62 doses, missed 8 additional doses (reason either unspecified or unclear), and no initials were present to indicate whether 1 doses was administered or not - [MEDICATION NAME] 10 mg by mouth at bedtime for dementia with behavior disturbances - refused 11 of 31 doses and missed 5 additional doses (reason not specified) - [MEDICATION NAME] 10/100 1 tablet by mouth three-times-daily for [MEDICAL CONDITION] - refused 43 of 93 doses and missed 5 additional doses (reason either unspecified or unclear) - [MEDICATION NAME] 7.5 mg 1 tablet by mouth for [MEDICAL CONDITION] - refused 1 of 14 doses; med discontinued on 10/14/10 On the reverse side of the MAR for the medications ordered for administration on an ""as needed"" (PRN) basis, nurses recorded that medications offered at 9:00 p.m. on the following dates were not administered because the resident would not awaken to take them - 10/01/10 through 10/06/10, 10/11/10, 10/12/10, 10/15/10, 10/16/10, and 10/22/10. Further review of MARs, from November 2010 through January 2011, found documentation reflecting multiple doses of medications were not being administered as ordered by the physician. Coding on the MARs indicated the resident would frequently refuse to take his scheduled doses of medications; however, he had multiple additional missed doses, the reasons for which were either unspecified or not clearly stated. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered - for whatever reason. - 2. On 02/10/11, the following medications were discontinued: [MEDICATION NAME] sodium, [MEDICATION NAME], [MEDICATION NAME], [MEDICATION NAME] 7.5 mg twice daily (which was started on 12/29/10), and [MEDICATION NAME]. (Previously, [MEDICATION NAME] had been discontinued on 01/07/11.) On 02/21/11, the physician ordered [MEDICATION NAME] 2 mg by mouth twice daily for tremors. Review of the MARs from February to April 2011 revealed multiple missed doses for which staff failed to record the reason for not administering them, and the [MEDICATION NAME] was discontinued on 04/14/11. - 3. On 04/14/11, the physician ordered the following medications: [REDACTED] - [MEDICATION NAME] 10/100 1 tablet by mouth three-times daily for [MEDICAL CONDITION] - [MEDICATION NAME] 200 mg by mouth for arthritis - Klonopin 0.5 mg 1 tablet by mouth three-times-daily for agitation (which was subsequently changed to 0.25 mg twice daily on 04/28/11, and back to 0.5 mg three-times-daily on 06/17/11) On 06/14/11, the physician ordered [MEDICATION NAME] SR 150 mg by mouth daily for depression. Review of the MARs for April, May, and June 2011 found virtually all scheduled doses of these medications were not administered. Review of the nursing notes found no evidence to reflect either Resident #78's responsible party or his attending physician was notified of the fact that he frequently did not receive medications as ordered over this 2-1/2 month period. - 4. Review of Resident #78's care plan, last revised on 07/05/11, revealed the following intervention (created on 07/02/11) to address problems associated with unrelieved pain: ""Resident to be given all medications with MPOA (medical power of attorney) and second nurse present per MPOA request."" There was no evidence of any plan having been implemented prior to 07/05/11 to address the need to monitor the resident's overall health status related to various health conditions (e.g., hypertension, constipation, [MEDICAL CONDITION], etc.) that would have been affected by frequent missed doses of scheduled medications and/or by the discontinuation of medications to treat these conditions. - 5. Review of the facility's self-reported allegations of abuse / neglect found an report of an allegation of neglect made by Resident #78's spouse, dated 07/05/11, stating (quoted as written), ""Resident Responsible party reported to this social worker on this date alligations of neglect stating nursing failed to give medications per order and neglected to notify responsible party & physician when documented refusal to take medications. Investigation being conducted."" - 6. During an interview with the administrator and the director of nursing (DON) on 08/16/11 at 11:30 a.m., the DON presented policies about medication administration, but the policies did not address what actions staff was to take when a resident repeatedly refused medications - beyond the action of documenting the refusal by circling the nurse's ""initials in the date and time space where that medication is ordered, and document(ing) patient's refusal of medication on the back of the MAR"". (Policy titled ""8.4 Medication Administration: General"" revised 05/01/11.) The DON stated they implemented a new practice whereby, if a resident misses 3 doses of any medication, the physician is to be notified as well as the resident's responsible party. They verified Resident #78 did not receive his medications as ordered over an extended period of time and that neither the physician nor the resident's responsible party had been notified when this occurred. - 7. Residents #4, #8, #41, #44,57, #62, #75, #79, and #80 Further review of the facility's self-reported allegations of abuse / neglect found the facility identified, upon investigating concerns about medication administration with Resident #78, nine (9) other residents who did not receive their medications as ordered. An interview with the administrator and DON, on 08/16/11 at 11:30 a.m., found they identified a total of ten (10) residents (including Resident #78) who frequently did not to receive their medications as ordered. They said they implemented a plan to address this, which included notification of the resident's physician and notification of the resident's responsible party (in the event the resident had a surrogate decision-maker acting on his or her behalf due to a determination of incapacity). .",2014-12-01
10876,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2011-07-27,157,D,1,0,WXEM11,"**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 an acute change in condition for one (1) of forty-six (46) Stage II sample residents. Resident #101 had treatment orders to assess her skin every shift and note any problem areas in the nurses notes. Nursing staff documented, on 07/01/11, the presence of a red raised area with a yellow center on the resident's lower left abdomen, but no further documentation was recorded in the nursing notes regarding the status of this alteration in skin integrity until 07/04/11, when the area was noted to have thick yellow exudate. Although a licensed practical nurse (LPN) documented having faxed information about this area to the on-call physician on 07/04/11, there was no evidence in the facility's fax book of this communication with the on-call physician, there was no evidence that any nursing staff communicated this information to the registered nurse (RN) on-call or to nurses on subsequent shifts, and there was no evidence that any nursing staff followed up with the resident's attending physician when no response was received from the on-call physician. No further documentation was found in the nursing notes about the abdominal wound from 07/04/11 until 07/08/11, when the resident was transferred to the hospital and admitted for treatment including surgical excision of a large abdominal mass. Resident identifier: #101. Facility census: 134. Findings include: a) Resident #101 Review of the July 2011 treatment administration record (TAR) revealed an order, dated 05/05/11, to assess the resident's skin and circulation every shift and note any problem areas in nursing notes. Each block on the TAR for all three (3) shifts from 07/01/11 through 07/08/11 was initialed by a nurse, indicating that a skin assessment had been completed on each shift. Review of nursing notes found an entry, dated 07/01/11 at 8:00 p.m., describing a red raised area with a yellow center and no drainage on the resident's lower left abdomen. The resident was [MEDICATION NAME] this time for a urinary tract infection and had previously been treated with another antibiotic (Z-Pak) from 06/16/11 through 06/20/11. Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/04/11 at 8:45 p.m., at which time an LPN (Employee #172) documented that she had faxed the on-call physician (who was covering during the absence of the attending physician) information regarding the presence of a ""red raised area, resembling a boil on lower left abdomen ... with occasional thick yellow exudate noticed"". Review of nursing notes revealed no additional entries to indicate there was any monitoring of the left abdominal wound until 07/08/11 at 8:45 p.m., when a nurse recorded, ""See transfer sheet."" Review of the nursing transfer / discharge note, dated 07/08/11 at 8:45 p.m., revealed Resident #101 was transferred to the emergency room and subsequently admitted to a local hospital because of increased confusion and a large, painful, red area to the left abdomen. This reddened area measured 3 cm x 2 cm with a white center. A ""Body Check"" form, dated 07/08/11, described the left abdominal wound as a red area with a white center, warm, hard, and painful to touch. Review of an operative report from the hospital revealed a preoperative and postoperative [DIAGNOSES REDACTED]. An excision of a large mass on the anterior abdominal wall was performed on 07/11/11. Review of nursing notes, dated 07/11/11 at 10:15 p.m., found the resident returned to the facility by ambulance, was prescribed an antibiotic, was ordered to have a wound vac the following morning, and was to attend a follow-up appointment at the wound clinic on 07/25/11. During an interview on 07/26/11 at 11:20 a.m., the ward clerk (Employee #241) said faxes were filed in the fax book to show, if asked, that staff had sent notifications to the physician. She looked through the fax book and said there was no fax filed in the book of any communication to the on-call physician caring for Resident #101 on 07/04/11. When asked if the physician's response or outcome was always written on the fax in the book, she said, ""Not always."" During an interview with an RN supervisor (Employee #234) on 07/26/11 at 2:40 p.m., she said she would have expected the nurses to document the resident's skin condition each day after the redness on the abdomen was first discovered on 07/01/11. She agreed there was no fax on file related to the nurse notifying the on-call physician of the resident's abdominal wound with exudate. She said filing of the faxes in the book was not a policy - rather, it was a nursing measure to show proof that a fax had been sent - and that the unit secretary was responsible for filing them. She stated the nurse on 07/04/11 should have communicated to the next shift about the status of the resident's abdomen, followed up with the physician, and notified the RN on-call of the exudate. She stated their infection control program specifies the RN supervisor is to be notified when there is a wound with drainage. It was she (Employee #234) who was the RN on-call that day, and she confirmed she was not notified of the wound. She said a culture and sensitivity should have been done on the exudate and treatment should have been initiated at that time. During an interview with the administrator on 07/27/11 at 7:30 a.m., she said the nurse should have spoken with the physician about the drainage and should have inquired whether he wanted to order a culture. No further information was presented related to the absence of the fax in the book regarding communication the nurse had with the on-call physician about the wound on Resident #101's abdomen on 07/04/11, and no further information was presented related to having no follow-up communication with the attending physician or other nursing staff about the wound. During an interview with an LPN (Employee #176) on 07/27/11 at 9:40 a.m., she clarified that Resident #101's physician called with new orders for lab tests for the resident on 07/07/11, and that he did not say anything about Resident #101's abdomen during that telephone call. She further stated she knew nothing about a fax by Employee #172 to the on-call physician regarding the resident's abdomen, and she verified that information about the abdominal wound was not passed along to nursing staff on the subsequent shift. (See also citation at F309.) .",2014-11-01
10927,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-09-08,157,D,1,0,34ZP12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to notify the physician when a resident's fingerstick blood glucose level was elevated, in accordance with the physician's orders [REDACTED]. Resident #87 had a physician's orders [REDACTED]."" The result of the fingerstick on 09/05/11 was 314, and there was no evidence to reflect staff notified the physician of this elevated result. This practice affected one (1) of seventeen (17) sampled resident. Resident identifier: #87. Facility census: 98. Findings include: a) Resident #87 Review of the medical record for Resident #87 disclosed a physician's orders [REDACTED]. This order was given to change the parameters by which the doctor was to be notified. The prior order, dated 08/01/11, specified to notify the doctor if the fingersticks were below 60 ml/dl or over 200 ml/dl. Further record review disclosed that, on 09/05/11 at 6:00 a.m., the result of the resident's fingerstick blood sugar was 314 mg/dl. There was no evidence to reflect staff notified the physician of this elevated result, as specified in his order. During an interview with the administrator on 09/07/11 at 3:00 p.m., she reported that she questioned the nurses about this, and she verified that staff did not notify the doctor of this elevated blood sugar as specified in the physician's orders [REDACTED]. .",2014-11-01
10946,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2009-05-22,157,D,0,1,T34S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, the facility failed to notify the physician when a resident repeatedly refused a medication in the evenings. The resident's medication administration records (MARs) indicated she had refused an evening dose of [MEDICATION NAME] for at least the last four (4) months. There was no evidence the physician had been notified of the resident's continued refusal to take the medication. Resident identifier: #51. Facility census: 86. Findings include: a) Resident #51 A nurse (Employee #7) was observed administering medications to this resident at approximately 7:10 p.m. on 05/20/09. She poured the resident's dose of [MEDICATION NAME], then initialed and circled the space for the resident's evening dose of [MEDICATION NAME] (ordered for constipation). As she did so, she explained the resident had been refusing to take the medication. On 05/22/09, the resident's MARs for February, March, April, and May 2009 were reviewed. The medication had consistently been circled, and an ""R"" had been written under the nurses' initials to indicate she had refused the medication. There was no evidence the physician had been notified so that he/she would be aware and might determine whether the resident's medication regimen needed to be changed. .",2014-11-01
10971,"WORTHINGTON NURSING AND REHABILITATION CENTER, LLC",515047,2675 36TH STREET,PARKERSBURG,WV,26104,2011-06-02,157,D,1,0,9FE011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, facility record review, and staff interview, the facility failed to notify the family member / legal representative of one (1) of five (5) sampled residents (who recently passed away), when a significant change in a resident's physical condition occurred and a new and/or altered treatment was ordered by the physician. Resident identifier: #102. Facility census: 100. Findings include: a) Resident #102 Review of Resident #102's closed record found a nursing note, dated [DATE] at 6:50 p.m., stating Resident #102 developed a fever of 101.3 degrees Fahrenheit, his oxygen saturation level was low at ,[DATE]%, and his lung sounds were diminished. The physician was notified by the registered nurse (RN - Employee #54), but there was no evidence the resident's medical power of attorney representative (MPOA) had been notified. In a telephone interview with Employee #54 on [DATE] at 11:30 a.m., the RN revealed that Resident #102 experienced a change of condition on [DATE] at 6:50 p.m., whereby he developed a fever and his lungs sounded congested. She said she notified the physician via fax at 6:50 p.m., and then got busy while awaiting the physician's response. Then it got late, so she did not call the MPOA. Her shift ended at 10:00 p.m., and she gave a report of his condition change to the night shift RN (Employee #69). The physician faxed orders to the facility at 10:30 p.m., after her shift had ended. Review of a physician order [REDACTED]. In an interview on [DATE] at 2:30 p.m., Employee #69 confirmed she was on duty at 10:30 p.m. on [DATE] when the physician's orders [REDACTED]. When asked if she called the MPOA of the new order for the chest x-ray to be done the following morning, she stated that she normally does not call people late at night unless something really bad is going on, and she did not want to alarm the family, so she did not call the MPOA about the new order. She said she was completely shocked that Resident #102 passed away on [DATE]; his death was not expected. Review of Nurse's Notes dated [DATE] at 1:35 p.m. revealed Licensed Practical Nurse (LPN) #53 assessed Resident #102 as having a low oxygen saturation level of 82- 84% on room air and 93% on 2 (two) liters of oxygen; unable to eat; not responding; lethargic; temperature 100 degrees; no signs or symptoms of shortness of breath or distress noted. During an interview on [DATE] at 2:15 p.m., a licensed practical nurse (LPN - Employee #53) recalled having told an RN on [DATE] that Resident #102 was not doing well, but she did not recall which RN she told. She described Resident #102 on [DATE] as being pale, using oxygen, having no intravenous fluids. She said, in the morning, he had a chest x-ray and he seemed fine, although he was sleeping a lot and had a fever; he had no shortness of breath even when his his oxygen saturation level was at 82% on room air. She said the oxygen concentrator was already in his room, so she began oxygen at 2 liters per minute per nasal canula. She explained that his oxygen level would drop sometimes even when he was not sick. She said staff just happened to check the oxygen saturation level that day, but for no particular reason that she recalled. Review of a physician's orders [REDACTED].#111), revealed a new order for an antibiotic, [MEDICATION NAME] nebulizer treatments three (3) times daily for five (5) days, to check his temperature every shift for the next twenty-four (24) hours then daily while on the antibiotic, and recheck the chest x-ray in three (3) weeks. In an interview on [DATE] at 10:10 a.m., Employee #111 revealed she was the day shift supervisor on [DATE]. She said she did not recall Employee #53 telling her that Resident #102 was fevered or had lowered oxygen saturation levels. She stated she received the chest x-ray results that morning and immediately faxed the report to the physician. She acknowledged that she received orders from the physician at 1:45 p.m. on [DATE] for antibiotic therapy, [MEDICATION NAME] nebulizer treatments, temperature monitoring, and to repeat the chest x-ray in three (3) weeks. She said she passed that information along to the oncoming RN supervisor (Employee #54), as her own shift ended at 2:00 p.m. She said she did not recall telling Employee #54 anything about family notification, but she recalled that Employee #54 told her she would go in and check Resident #102. She said she was shocked to learn the following day that Resident #102 had expired on [DATE], noting his death was unexpected. In an interview on [DATE] at 11:30 a.m., Employee #54 stated she reported to work at 2:00 p.m. on [DATE]. She stated Employee #111 had received orders from the physician at 1:45 p.m. (around the change of shift) on [DATE]. She did not recall whether Employee #111 left out the 1:45 p.m. physician order [REDACTED]. She said when she called the family at 4:30 p.m. on [DATE] to report that Resident #102 had expired, it was then that she realized the family had not been notified of his condition change. She said, normally, nurses notify the family of condition changes, new orders, and changes in treatments, but this was not the case this time due to miscommunication among staff. Review of a grievance / complaint report dated and signed on [DATE], and produced by the director of nursing (DON) on [DATE] at 3:10 p.m., acknowledged that Resident #102's MPOA reported she was not notified in a timely manner of a significant change in condition with Resident #102, and she felt she could have spent the last moments with him had she been notified her in a timely manner at 6:50 p.m. on [DATE]. Attached to the complaint was an Employee Education Document noting this form was being completed to offer support of education provided to Employee #111. A description of the education being provided to this employee regarded notification of family / MPOA when there is a significant change with a resident; it noted the physician was notified in this case, but the MPOA was not notified. During an interview on [DATE] at 10:00 a.m., the DON said she was unable to find a policy related to family notifications of significant changes, but she found a ""Bill of Rights"" in-service handout that the licensed social worker (LSW) presents annually, and most recently presented to nursing staff on [DATE]. She said, in part, this handout states the facility shall immediately inform the resident and consult with the resident's legal representative of a significant change in the resident's physical, mental, or psychosocial status. Also, she produced a copy of the RN supervisor's job description. On page 2, the duties were found to include: ""Contact POA (Power of Attorney) or appropriate family member when there is a change in Resident's condition."" When interviewed on [DATE] at 12:40 p.m., the LSW (Employee #52) revealed that significant change care plan meetings are held if a resident is terminal or declining, and the option of hospice is discussed. She stated if there is a decline in a resident, the family should be notified. She said she thought that Resident #102's MPOA should have been notified of a change in condition when it occurred that weekend in April. She looked at the inservice handout on ""Bill of Rights"" and acknowledged that she gave that inservice on [DATE], and that it was given every year for nursing staff. .",2014-10-01
11003,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,157,E,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to notify the attending physician and the responsible parties of eight (8) residents as having experienced mistreatment / abuse / neglect by Employee #81, as witnessed by staff. Resident identifiers: #12, #15, #30, #59, #60, #62, #61, and an unidentified resident who was no longer at the facility (""X""). Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #62, #61, and X 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed the following allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency: - Employee #81 was alleged to have audio-taped Resident #12 on her cell phone as she cursed (Reported to State survey agency on 01/25/10; date of incident was not known) - Employee #81 was alleged to have squirted water on Resident #62 (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have pushed Resident #15 quickly down the hallway in her wheelchair (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #12 to ""yell and cuss"" and to have given medications to this resident in an ""inappropriate manner"" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have encouraged Resident #61 to ""yell and cuss"" (Reported to State survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have tied Resident #30's wheelchair to a side rail (Reported to state survey agency on 01/26/10; date of incident was not known) - Employee #81 was alleged to have put Resident #60 to bed in a ""rough manner"" (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to be ""verbally inappropriate"" to various unidentified residents (Reported to state survey agency on 01/27/10; date of incident was not known) - Employee #81 was alleged to have used ""inappropriate restraints"" on Resident #12 (Reported to state survey agency on 01/28/10; date of incident was not known) Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated the following allegations: - Administering medications (laxatives) to an unidentified number of residents without a physician's order - Recording the voice of Resident #12 as she screamed and cursed while Employee #81 digitally removed stool from her rectum, and playing the recording for others to hear - Encouraging Residents #12 and #61 to curse - Tying Resident #30's wheelchair to a rail for staff convenience, to keep the resident from wandering -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) - In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds. "" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ... "" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ... "" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61) "" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them. "" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""... Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in /wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- Review of Resident #12's medical record, including nursing notes and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status (including signs / symptoms of the presence of a fecal impaction necessitating this procedure), and no nursing note entries detailing the performance of the procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 discomfort and distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. -- The facility's titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09) stated, on Page 3: "" ...The family / responsible party and attending physician shall be notified and recommendation(s) shall be followed. Documentation of notifications, recommendations and actions taken shall be documented as part of the investigation. ... With respect to notifying the physician and family of the mistreatment / abuse / neglect experienced by Residents 59, #60, #61, #62, #15, #30, and #12, the administrator reported, on the afternoon of 06/09/11, that she had contacted both the physician and the responsible parties; however, documentation to support this could not be located. .",2014-10-01
11014,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,157,D,0,1,2I6B11,"Based on medical record review and staff interview, the facility failed to immediately notify the physician when Resident #171's right arm and elbow were noted to be red and warm with extensive inflammation. Resident identifier: #171. Facility census: 187. Findings include: a) Resident #171 Medical record review,on 10/13/09, found a nursing note, dated 08/18/09 at 2130 (9:30 p.m.), stating the resident was noted to have redness and warmth on the right arm and elbow, and the resident's medical power of attorney was notified at that time of extensive inflammation. A subsequent nursing note, dated 08/19/09 at 0715 (7:15 a.m.), revealed, ""Rt (right) elbow has skin tear which is scabbed no drainage. Surrounding skin very swollen pink and warm from mid forearm posterior to above elbow."" The nurse also indicated a fax was sent to the physician and a new order for antibiotic therapy was received at 0800 (8:00 a.m.). During an interview on 10/14/09 at 4:30 p.m., the director of nursing (Employee #136) confirmed the physician was not immediately informed of the extensive inflammation to the resident's right arm when this change in condition was first noted at 9:30 p.m. on 08/18/09. .",2014-09-01
11112,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,157,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, and staff interview, the facility failed to notify the legal representative of one (1) of three (3) sampled residents when she had been restrained to her bed without a physician's order. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found that, on 03/10/11 at approximately 9:00 p.m., a quality assistant (QA - Employee #0) reported Resident #65's was restrained in her bed by a tightly tucked blanket / sheet. Review of Resident #65's medical record found no physician's order or care plan for the resident to be restrained in her bed by the use of tightly tucked sheets or blankets. Review of the facility's interview investigation, and interviews with facility staff and former staff conducted on 03/30/11, 03/31/11, and 04/01/11, confirmed the blanket / sheet on Resident #65's bed had been tightly tucked beneath her bed to the point that staff had to tear the blanket / sheet in order to free the resident. An interview with the director of nursing (DON), on the afternoon of 03/31/11, elicited that Resident #65's legal representative was not contacted about the incident nor informed that the resident had been restrained without a physician's order, until he came into the facility on [DATE]. The DON stated the legal representative relayed that a woman had called him and told him Resident #65 had been found tied to her bed. .",2014-08-01
11123,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2011-04-13,157,E,1,0,2HR511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, family interview, and staff interview the facility failed to notify the physician of a need to discontinue isolation precautions when two (2) of five (5) sampled residents in isolation had negative lab results and/or absence of symptoms of infection, and failed to notify the physician and/or family when one (1) of nine (9) sampled residents did not have an indwelling suprapubic urinary catheter changed monthly as ordered and was exhibiting symptoms of a urinary tract infection. Resident identifiers: #105, #103, and #68. Facility census: 111. Findings include: a) Resident #105 During the general tour at 10:30 a.m. on 04/11/11, observation found Resident #105 sitting in a chair in his room on the South unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #79) confirmed Resident #105 was in isolation. A review of the treatment book revealed Resident #105 was in contact isolation since 12/14/10 for [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in the urine. Review of Resident #105's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Neither the hospital discharge summary dated 10/18/10, nor the facility's history and physical dated 10/22/10, provided documentation that [MEDICAL CONDITION] infection had been present at the time of his admission, and a urine culture completed on 11/19/10 was negative [MEDICAL CONDITION]. The resident was ordered Bactrim on 12/09/10, and a urine specimen for culture and sensitivity (C&S) was sent to the laboratory. The urine culture was reported as positive [MEDICAL CONDITION] on 12/13/10, and the physician ordered ""Contact Isolation [MEDICAL CONDITION] in urine"" on 12/14/10. The lab report revealed Bactrim was an appropriate treatment for [REDACTED]. A urine culture completed on 12/23/10 was negative for growth. During an interview with the director of care delivery (DCD) for the South unit (Employee #67) at 3:10 p.m. on 04/11/11, she stated, after reviewing the resident's medical record, that she could find no reason for the isolation precautions to remain in place. An observation, at 1:20 p.m. on 4/12/11, revealed Resident #105's room was still posted with a contact isolation sign. A review of the resident's comprehensive assessments, at 2:45 p.m. on 04/12/11, with the assistance of the assessment coordinator (Employee #168), revealed Resident #105's abbreviated quarterly assessment dated [DATE] contained no evidence of either a urinary tract infection or the presence of a multi-drug resistant organism (MDRO), such [MEDICAL CONDITION]. During an interview with the director of nursing (DON - Employee #166) at 9:30 a.m. on 04/13/11, she acknowledged Resident #105 was in isolation, but she expressed surprise that it had been in effect for so long and stated she would follow up on it. The DON (who was the facility's infection control coordinator) also acknowledged that Resident #105 had not been listed on any of the 2011 monthly surveillance reports due [MEDICAL CONDITION]. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #67, and the DCD for the North unit (Employee #20) at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #105's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. -- b) Resident #103 During the general tour at 11:00 a.m. on 04/11/11, observation found Resident #103 sitting in a chair in his room on the North unit. At the entrance to his room was posted a sign indicating the resident was in contact isolation. A nurse (Employee #112) confirmed Resident #103 was in isolation. A review of the treatment book revealed Resident #103 was in contact isolation since 11/14/10 [MEDICAL CONDITION] in urine. Review of Resident #103's medical record revealed this [AGE] year old male was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The physician ordered Bactrim to treat a urinary tract infection [MEDICAL CONDITION] on 11/10/10, and contact isolation due [MEDICAL CONDITION] on 11/14/10. No laboratory reports for this date were found on the chart. The monthly recapitulation of physician orders [REDACTED]. Further review of the medical record revealed a urine culture completed on 01/08/11, indicating the presence of ""Normal Skin Flora. No potential pathogens isolated."" A urine culture completed on 03/14/11 revealed the presence of [MEDICATION NAME] faecalis but [MEDICAL CONDITION]. The 2011 monthly surveillance reports did not identify Resident #103 as having an infection due [MEDICAL CONDITION]. During an interview Employee #67 at 2:00 p.m. on 04/12/11, she was asked to provide documentation of the initial reason for placing the resident in isolation. She returned at 3:30 p.m., stating she had located nothing on the chart, but she presented laboratory reports that had been received by fax at 2:36 p.m. on 04/12/11. A urinalysis, collected on 11/10/10, indicated the resident had a urinary tract infection and the resulting culture reported the presence [MEDICAL CONDITION] on 11/13/10. The resident's care plan contained the following: ""RESOLVED: Notify physician and family / responsible party of condition and/or changes in condition - 12/21/10"" and ""RESOLVED: Contact isolation due [MEDICAL CONDITION] of urine - 12/21/10."" The resident's abbreviated quarterly assessment dated [DATE] and comprehensive assessment dated [DATE] contained no indication of the presence of a UTI, the use of isolation precautions, or the presence of an MDRO (e.g.,[MEDICAL CONDITION]) for Resident #103. This was verified at 2:45 p.m. on 04/12/11 by Employee #168, who retrieved the information. Although the monthly recapitulation of physician's orders [REDACTED]. During an interview with the DON, Employee #20, and Employee #67 at 12:10 p.m. on 04/13/11, they were asked to produce evidence that staff had notified Resident #103's physician that he no longer exhibited signs / symptoms of a urinary tract infection and/or his most recent lab report was negative [MEDICAL CONDITION]. None was offered at the time of exit. An observation of Resident #103's room, at 9:30 a.m. on 04/13/11, revealed the contact isolation sign had been removed from the door. -- c) Resident #68 Medical record review revealed Resident #68 was a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had in place a suprapubic catheter. physician's orders [REDACTED]. Documentation in the medical record found the catheter was changed on 08/24/10 and was not changed after that until 02/03/11. Prior to that, on 02/01/11, the resident was seen by his attending physician, who diagnosed the resident as having a UTI. There was no documentation in the record by the attending physician to reflect his awareness the monthly catheter changes had not been done as ordered. There was no documentation to reflect the nursing staff had acknowledged this failure to comply with the order, to include evidence of an investigation into this failure and/or notification by staff of this failure to the attending physician and/or the resident's medical power of attorney representative (MPOA). During an interview with a family member of Resident #68, he stated he had become concerned about his father's health on 02/01/11, when the resident was seen by his attending physician and found to have a UTI. On the following day (02/02/11), he questioned a nurse as to when the resident's suprapubic catheter had last been changed. The nurse did not know, and he contacted the resident's urologist who changes the catheter in his office. He reported the urologist told him the most recent catheter change, according to his records, had been 08/24/10. The family member stated he relayed this information to a nurse at the facility, and they arranged for the resident to go to the urologist's office the next day and have it changed. He stated he was very upset, because this was not the first time this had happened, and he contacted the facility's regional office. He stated he had been assured last year that the monthly catheter change would not be missed again, but it was. He reported that no one from the facility had informed him or Resident #68's MPOA that the incident had been investigated. A urine culture, collected on 01/17/11, reported growth of Proteus mirabilis, and the attending physician ordered Bactrim DS on 01/18/11. This antibiotic was discontinued when the sensitivity report indicated the organism was resistant to Bactrim, and on 01/20/11, the physician ordered another antibiotic ([MEDICATION NAME]), which was completed on 01/25/11. The resident was seen by the attending physician on 02/01/11 and was noted to have a UTI, but there was no evidence in the medical record that staff had notified the attending physician that the resident's suprapubic catheter had not been changed since 08/24/10. The resident was seen by his nephrologist on 02/10/11, and was also diagnosed with [REDACTED]. There was no evidence in the medical record that either the attending physician or the resident's MPOA received a full report regarding the amount of time that had lapsed between catheter changes. During an interview with the administrator at 11:15 a.m. on 04/12/11, she acknowledged she knew of no record of the incident except an e-mail, which she produced. The e-mail, dated 02/04/11, was from the regional director of operations to the administrator and relayed the son's complaint of missed physician appointments with his urologist and missed services. She stated this was her first knowledge of the missing urology visits and catheter changes. .",2014-08-01
11178,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2011-03-08,157,D,1,0,2ZE411,"**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 notify the legal representative one (1) of six (6) sampled residents after the resident sustained [REDACTED]. Resident identifier: #77. Facility census: 106. Findings include: a) Resident #77 Review of Resident #77's medical record revealed a Combined Medical Power of Attorney and Living Will document, dated 03/23/05, in which the resident designated a niece to serve as primary medical power of attorney representative (MPOA). In the event the niece was unable or unwilling to serve as a surrogate health care decision-maker, the resident designated a nephew to serve as the successor MPOA. Record review also revealed, on 09/13/06, the physician determined Resident #77 lacked the capacity to understand and make informed health care decisions. On this date, the MPOA document would have sprung into effect, with the resident's niece having the authority to make health care decisions on the resident's behalf. Review of the facility's records revealed an incident / accident report, dated 02/06/11, documenting that Resident #77 received a skin tear to the left upper arm measuring 1.5 cm x 0.5 cm. The resident's successor MPOA was notified of the skin tear at 1:00 p.m. that same day. There was no evidence in the resident's medical record to reflect the primary MPOA was unable or unwilling to serve; therefore, the primary MPOA (not the secondary MPOA) should have been notified of this injury. An interview with the director of nursing, on 03/09/10, confirmed staff notified the secondary MPOA, instead of the primary MPOA, of the resident's injury.",2014-07-01
11200,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26505,2010-05-19,157,E,1,0,7YYR11,". Based on medical record review, review of incident / accident reports, and staff interview, the facility failed to notify the legal representative immediately following an incident / accident. This practice affected four (4) of twenty-seven (27) sampled residents. Resident identifier: #15, #50, #57, and #60. Facility census: 61. Findings include: a) Residents #15, #50, #57, and #60 The previous three (3) months of facility incident / accident reports were reviewed at 11:30 a.m. on 05/18/10. Reports involving four (4) residents (#15, #50, #57, and #60) were observed to lack evidence of notification of the legal representative following an incident / accident. Review of these residents' medical records also did not find documentation to reflect their legal representatives had been informed. In an interview with the administrator (Employee #59) and the director of nursing (DON - Employee #54) at 12:30 p.m. on 05/19/10, both employees agreed there was no documentation to reflect the legal representatives of Residents #15, #50, #57, and #60 had been contacted following the incidents referenced above. .",2014-07-01
11252,GRANT COUNTY NURSING HOME,515151,27 EARLY AVENUE,PETERSBURG,WV,26847,2010-07-16,157,D,1,0,F0GM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, incident report review, family interview, and staff interview, the facility failed to notify the resident ' s legal representative or an interested family member and/or the physician in a timely manner of an accident with injury and/or potential for the need of medical intervention for one (1) of eight (8) sampled residents. Resident identifier: #19. Facility census: 107. Findings include: a) Resident #19 A review of Resident #19's medical record revealed she fell at 1:30 a.m. on Saturday, 05/22/10, and sustained a hematoma over the left eye. The incident report filed by the nurse (Employee #13) indicated the physician was not informed and that the daughter (not the resident's legal representative) was informed of the fall over thirteen (13) hours later at 2:40 p.m. on 05/22/10. At 8:20 p.m. on 05/23/10, a nurse recorded the following assessment in the resident's nursing notes: ""97.8 122/58 76 21 (these are temperature, blood pressure, pulse, and respirations) Sats (blood oxygen saturation level) 80% room air; res (resident) up ambulating per normal; 0 (no) C/O (complaints of) discomfort except when palpating small hematoma upper medial L (left) eyebrow; retook Sats (sign for after) 5 min Sats now 70% then dropped to 64%; res with C/O feeling cold; fingers with bluish tinge and cold; O2 (oxygen) @ 2L (liters) via concentrator via N/C (nasal cannula) attached to res."" This entry was made by entered by a licensed practical nurse (LPN - Employee #15). An assessment of the resident, at 5:00 a.m. on 05/24/10, stated: ""... bruising remains to L eye and L side of face, bruising noted under R (right) eye also - has quarter size knot on inner side of eye brow L which is tender to touch."" At 10:45 a.m. on 05/24/10, the resident's daughter filed a complaint with the social worker (Employee #14), because of the thirteen (13) hours that had lapsed before she was contacted. During a telephone interview with the daughter at 8:00 p.m. on 07/01/10, she verified she had not been notified until 2:40 p.m. and that she knew her brother (the resident's legal representative) had not been called. The attending physician was notified at 2:15 p.m. on 05/24/10 of the recent fall and the hematoma and [MEDICAL CONDITION] to lower eyelid. An x-ray was ordered at that time and neurological monitoring was started. The resident's son was not notified until 2:20 p.m. on 05/24/10, after the complaint was filed, at which time he was also notified that an x-ray had been ordered. The x-ray was completed later the same day. This was verified by the director of nursing (DON) and by the documentation attached to the complaint. The nurse who had failed to notify the family was disciplined. During an interview with the DON at 2:10 p.m. on 07/15/10, she acknowledged the accuracy of the documentation but stated she did not know why the nurses had waited to notify the family or the physician, except that it was the weekend and she was not present in the facility. .",2014-07-01
11261,"FAYETTE NURSING AND REHABILITATION CENTER, LLC",515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2011-03-16,157,D,1,0,R8P711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of medical records, staff interviews, observations, and resident comments, the facility failed to notify the physician of a resident's repeated refusal of [MEDICATION NAME] eye drops (for reduction of elevated pressure in the eyes). The facility also failed to notify the responsible party when a resident was sent out for an appointment at a local hospital for repair of her [MEDICAL TREATMENT] access. Two (2) of thirty-four (34) residents on the Stage II sample were affected. Resident identifiers: #13 and #11. Facility census: 55. Findings include: a) Resident #13 During observation of medication administration pass on 03/08/11 at 8:37 a.m., Employee #21, a registered nurse (RN), took Resident #13's [MEDICATION NAME] eye drops to the bedside. The nurse asked the resident if she wanted to take the eye drops that morning. The resident declined the eye drops, saying she did not need them at that time. The nurse did not ask the resident why she did not want to take the eye drops, nor did she advise the resident the purpose of the drops. (The resident also had orders for natural tears.) - Review of this [AGE] year old woman's medical record found she had [DIAGNOSES REDACTED]. 365.9 - Unspecified [MEDICAL CONDITION] 374.05 - Trichiasis of eyelid without entropion 375.15 - Unspecified tear film insufficiency 366.9 - Unspecified cataract - On 03/15/11 at approximately 3:30 p.m., review of the nursing entries (which reflected the reasons for medications not being administered noted on the electronic Medication Administration Record [REDACTED] - 03/14/11 at 08:52 - ""[MEDICATION NAME] - 1 drop both eyes q (every) day : Refused med."" - 03/13/11 at 09:46 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused med."" - 03/12/11 at 10:09 - ""Patient requested not to have eye drops in."" - 03/08/11 at 08:38 - ""[MEDICATION NAME] - 1 drop both eyes q day : Pt. (patient) refused eye drops states she does not need the right now."" - 03/07/11 at 08:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states it makes her eyes feel funny."" - 02/27/11 at 09:43 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused states 'I dont (sic) take them any more."" - 02/25/11 at 09:15 - ""[MEDICATION NAME] - 1 drop both eyes q day : resident refused [MEDICATION NAME] eye drops."" - 02/22/11 at 08:32 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refused eye drops states 'I quit taking those they make my eyes worse."" - 02/21/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused med this am (morning)."" - 02/20/11 at 09:42 - ""[MEDICATION NAME] - 1 drop both eyes q day : Resident refused eye drops today."" - 02/12/11 at 09:03 - ""[MEDICATION NAME] - 1 drop both eyes q day : refused [MEDICATION NAME] eye drops."" - 02/08/11 at 08:20 - ""[MEDICATION NAME] - 1 drop both eyes q day : Refuses [MEDICATION NAME] eye drops."" In January 2011, the [MEDICATION NAME] was held on 01/24/11, 01/23/11, 01/16/11, 01/10/11, and 01/09/11. - A ""Physician's Contact Note"", dated 12/28/11 at 18:25, noted: ""Complaints of eyes burning, refusing [MEDICATION NAME] dye drops, appetite decreased. Dr. ____ in to see resident today."" At that time, the resident was assessed as having [MEDICAL CONDITION] and antibiotic eye drops were ordered. No further evidence was found indicating the physician had been notified of the resident's continued intermittent refusal of the [MEDICATION NAME] eye drops. There was no indication the resident was told the drops were for her [MEDICAL CONDITION]. - Review of the resident's current care plan found no care planning relative to the resident's refusal of the [MEDICATION NAME] eye drops. - Review of information about [MEDICATION NAME] at http://www.[MEDICATION NAME].com/content/index.aspx found: ""[MEDICATION NAME] is indicated for the reduction of elevated intraocular pressure in patients with open-angle [MEDICAL CONDITION] or ocular hypertension ... [MEDICATION NAME] offers easy once-a-day use ... ""[MEDICATION NAME] is an eyedrop that lowers pressure in the eye. You don't usually feel eye pressure, but if it is too high, it can damage the optic nerve and cause vision loss. [MEDICATION NAME] is your partner in the fight against high eye pressure which can lead to [MEDICAL CONDITION]. ..."" - Notification of the physician when a resident refuses medications was discussed with Employee #78 (an RN) at 10:00 a.m. on 03/16/11. She said she thought the resident had to refuse three (3) days in a row before the physician was contacted. Employee #76 (the minimum data set coordinator) was in the room at this time. Employee #76 asked her if it had to be three (3) days before the physician was notified of a resident refusing medications, but Employee #78 said she did not know. -- b) Resident #11 Medical record review for Resident #11, conducted on 03/09/11, revealed Resident #11 received [MEDICAL TREATMENT] on an outpatient basis due to having [MEDICAL CONDITION]. A [MEDICAL TREATMENT] communication sheet, filled out by the [MEDICAL TREATMENT] center on 12/26/10, indicated the physician at the [MEDICAL TREATMENT] center had scheduled the resident to go out to a local hospital on [DATE] for a surgical procedure. A nursing note, dated 12/26/10 at 3:58 p.m., stated, ""Pre/Post [MEDICAL TREATMENT] Weight: Pere (sic) weight -85.1kg. Resident attended [MEDICAL TREATMENT], but they were unable to access her. She was sent back without receiving treatment. She is scheduled to meet with the Doctor in out patient at (name of hospital) to have her Quinton catheter checked. Will be NPO (nothing by mouth) after midnight and will be picked up by (name of ambulance company) at 5:00 a.m."" During an interview on 03/09/11 at approximately 1:00 p.m., the director of nursing (Employee #79) reported she felt the nursing staff at the facility needed to contact the responsible party even if the [MEDICAL TREATMENT] center made the appointment. Resident #11 did not have capacity to understand and make informed health care decisions, and her sorrugate decision-maker was not informed of the appointment. .",2014-07-01
11271,"LINCOLN NURSING AND REHABILITATION CENTER, LLC",515171,200 MONDAY DRIVE,HAMLIN,WV,25523,2010-10-22,157,D,1,0,LT0O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and interview with the treating physician, the facility failed to promptly notify the resident's physician and legal representative of a significant change in the physical condition and deterioration in health of one (1) of three (3) sampled residents. Resident identifier: #31. Facility census: 58. Findings include: a) Resident #31 Review of Resident #31's medical record found this [AGE] year old female resident suffered from dysphagia and required nectar consistency fluids. Further review found she had a [DIAGNOSES REDACTED]. The resident was determined to lack the capacity to understand and make medical decisions, and a legal representative (Family #1) was serving as her surrogate decision-makker for all medical decisions. On 09/14/10 at 3:23 p.m., a nurse recorded in the nursing notes that blood was observed in the resident's urine. The treating physician was notified, and a urinalysis with culture and sensitivity was ordered, and the resident was ordered Bactrim DS. The resident received her first dose of Bactrim DS at 9:00 p.m. on 09/14/10. A subsequent note nursing, dated 09/15/10 at 7:20 a.m., documented the resident had decreased level of consciousness (LOC). According to an interview with the director of nursing (DON - Employee #71) on 10/22/10 at 12:15 p.m., the resident's weight was 130#. At 30 cc per kg, the resident would require 1776 cc of fluid each day. Review of the intake and output records found the resident only consumed 1020 cc on 09/13/10, 1100 cc on 09/14/10, 890 cc on 09/15/10, and no (0) cc on 09/16/10. Review of the nursing notes found an entry by a registered nurse (RN - Employee #68), dated 09/16/10 at 8:35 a.m., documenting the resident had no urinary output on the night shift. In the section of the nursing note entitled ""Physician contact"" was documented ""N/A"" (not applicable). In the section entitled ""Responsible party notification"" was documented also ""N/A"". The next nursing note, dated 1:55 p.m. on 09/16/10, documented that the physician on-call was notified of the family's request to transport Resident #31 to the emergency room for further evaluation. An interview with Family #1 (Resident #31's legal representative), at 10:10 a.m. on 10/20/10, revealed the facility did not contact her concerning the decline in her mother's medical condition. Family #1 stated she did not become aware of her mother's critical condition until she was called by a relative who was visiting the resident on the afternoon of 09/16/10. She stated that, had the facility notified her at any time, she would have requested that her mother be sent to the hospital. An interview with the licensed practical nurse (LPN - Employee #61) who worked the day shift of 09/16/10 was conducted via telephone at 1:45 p.m. on 10/21/10. She verified that a family member came in close to lunch time and asked her how Resident #31 was doing. She stated she told this family member that the resident was not doing very ""good"" and she couldn't get her to eat or drink anything. Employee #61 stated this visiting family member called Family #1 (the resident's legal representative). She stated that the legal representative came into the facility and decided to send the resident to the hospital. An interview with the treating physician, on the afternoon of 10/21/10, revealed the physician expected to be notified of any resident displaying a decreased level of consciousness and no urinary output. The facility failed to assure prompt notification was made to the treating physician and the legal representative when this resident's health status declined. The failure to notify as required caused a delay in necessary medical treatment for [REDACTED].) .",2014-07-01
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
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
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
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
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
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
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
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
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
7455,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-06-13,158,B,0,1,TA7B11,"Based on resident interview and staff interview, the facility failed to ensure personal funds are available at all times. The facility does not provide access to resident funds in the evenings or on the weekends. This practice has the potential to affect more than a limited number of residents. Facility census: 113. Findings include: a) On 06/03/13 at 1:47 p.m., Resident #24 stated during a Stage 1 interview she did not have access to her personal funds on the weekends. On 06/11/13 at 4:00 p.m., during an interview with the Administrator, Employee #162, a Consultant, Employee #159, and the Director of Nursing Services, Employee #11, it was revealed resident funds are not available at all times. The Administrator verified resident funds are not available in the evenings or on the weekends unless there is a manager on duty in the facility.",2017-04-01
9548,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,158,C,0,1,5V2011,"Based on review of resident funds, staff interview, and the confidential resident group interview, the facility failed to assure residents had access to petty cash on an ongoing basis. This practice had the potential to affect all residents for whom the facility handled funds. At the time of the survey, the facility handled funds for one hundred-twelve (112) residents. Facility census: 157. Findings include: a) On 11/19/09 at 2:30 p.m., residents' accounts were reviewed with the office manager and the staff member who handled resident funds. At that time, it was revealed residents only had access to their personal funds during the facility's regular business hours and for four (4) hours each Saturday and Sunday. This was confirmed during the confidential resident group meeting held on 11/18/09.",2015-10-01
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
2189,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-03-31,159,B,0,1,YOOX11,"Based on staff interview and record review, the facility failed to offer a petty cash fund for residents to have ready access to monies when needed such as on weekends. This has the potential to affect the forty-six (46) residents who currently have the facility handle their funds. Facility census: 58. Findings include: a) Interview with Accounts Payable Employee #50, on 03/28/17 at 3:00 p.m., revealed the facility does not have a petty cash procedure to ensure residents have access to their funds when wanted or needed. Review of the admission policy information at the same time showed new residents are informed about how the facility will handle money for them, but does not explain how the process is for them to get money at different times such as when the business office is not open. There was also nothing posted to direct residents how to obtain money when the business office is closed.",2020-09-01
3912,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,159,E,0,1,VTNG11,"Based on record review and staff interview, the facility failed to safeguard, manage, and account for the residents' personal funds deposited with the facility in accordance with regulations. The facility failed to ensure the resident/responsible party received quarterly notices for two (2) of three (3) reviewed, and/or failed to ensure residents who received Medicaid were notified the account reached $200 less than the Social Security Income (SSI) resource limit for four (4) of five (5) resident accounts reviewed. Resident identifiers: #59, #8, #109, #21, and 119. Facility Census: 109. a) Residents #109, #8, #119, #59 A financial record review, on 11/03/6 at 11:27 a.m., with Business Office Manager (BOM) #84, revealed the above residents received Medicaid services and had greater than $1800 in the Resident Funds account. The BOM reviewed the financial records and stated the accounts contained amounts greater than $1,800. b) Resident #59 The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 08/08/16 noted a brief interview for mental status (BIMS) score of 14, which indicated Resident #59 was cognitively intact. The resident fund management statement noted account balances greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for thirty (30) of thirty (30) --August (YEAR) for thirty-one of thirty-one days --July (YEAR) for twenty-three (23) of thirty-one (31) days BOM #84 provided a copy of a letter, dated 10/20/16 related to notification of funds. Both the signature of the facility representative and resident acknowledgement were blank. The acknowledgement of receipt of resident trust, dated 10/20/16 was also contained no signatures. c) Resident 8 Resident #8 ' s financial record indicated the resident's account contained greater than $1,800 dollars for: --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for twenty-nine (29) of thirty (30) days d) Resident #109 The account of Resident #109 exceeded $1,800 as follows: --November (YEAR) for three (3) of three (3) days --October (YEAR) for twenty-two (22) of thirty-one (31) days --September (YEAR) for twenty-one (21) of thirty (30) days --August (YEAR) for fourteen (14) of thirty-one (31) days e) Resident #119's The account of Resident #119 exceeded $1,800 for --November (YEAR) for three (3) of three (3) days --October (YEAR) for thirty-one (31) of thirty-one (31) days --September (YEAR) for twenty (20) of thirty (30) days b) Resident #59 and #21 The BOM, interviewed on 11/03/16 between 11:27 a.m. and 11:50 a.m., reviewed the financial and medical records of Resident #59 and #21. She voiced she was unable to verify the resident and/or responsible party had received a quarterly statement. : BOM related Resident #21 had an account balance of zero dollars ($0.00) due to the money had been transferred into the facility's account.",2020-04-01
4071,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2015-09-30,159,D,0,1,FG3Z11,"Based on review of the facility's financial records for the residents' personal funds accounts and staff interview, the facility failed to ensure the resident or responsible party as applicable, for (1) of four (4) residents whose financial records were reviewed, was informed when the resident's personal fund account was within $200.00 of the Social Security resource limit for West Virginia. Resident identifier: #28. Facility census: 87. Findings include: a) Resident #28 During a review of the personal funds accounts managed by the facility, at 9:00 a.m. on 09/30/15, the account of Resident #28 revealed she had a total balance on 09/28/15 of $2028.78. Resident #28 was a Medicaid recipient and the allowed Social Security Income (SSI) resource limit amount in West Virginia is $2000.00. Staff member #34, who was identified as the person responsible for managing the personal funds accounts, was interviewed at 10:15 a.m. on 09/30/15. When asked if the responsible party for Resident #28 was notified of the resident's account balance, she stated she did not know, but, it was her practice to notify the Social Worker assigned to the resident when a personal funds account balance reached $1,500.00. She presented a copy of the form letter used. During an interview at 10:30 a.m. on 09/30/15,Social Worker #44, who was assigned to Resident #28, acknowledged she had not informed the DHHR (Department of Health and Human Resources) representative, who was responsible for the resident, of the balance which was approaching the Medicaid asset limit and was now over that limit. She stated she was, Planning to talk to him about starting a burial account since she knew the resident did not have one, but had not done so yet. She said she was sure, when contacted, the resident's representative would agree. She acknowledged she had been made aware of the balance, but could not say when. During an interview with the Administrator at 11:30 a.m. on 09/30/15, she agreed it would have taken months for the balance of the personal funds account to increase from $1500.00 to the present $2028.78 and the resident's responsible party should have been notified.",2020-02-01
4078,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-07-19,159,D,0,1,KKFY11,"Based on staff interview, resident interview, policy review, and record review, the facility failed to notify the responsible party and/or resident when the resident's personal funds were within $200.00 of the supplemental security income (SSI) limit of $2,000.00. This was true for one (1) of one (1) resident reviewed for the care area of personal funds. Resident identifier: #137. Facility census: 105. Findings include: a) Resident #137 Review of the care area of personal funds, during Stage 2 of the Quality Indicator Survey (QIS), revealed Resident #137's personal funds account, managed by the facility, totaled $1,887.48 on 07/13/16 at 3:00 p.m. At 3:20 p.m. on 07/13/16, when asked how the facility notified residents/responsible parties when personal funds were within $200.00 of the $2,000.00 limit, Business Office Manager (BOM) #57 stated she notified Social Worker (SW) #108. BOM #57 verified she had no proof of notification of the resident/responsible party when the resident's personal funds were within $200.00 of the allowable amount for a single person receiving Medicaid benefits. She confirmed the allowable amount is was $2,000.00. BOM #57 verified awareness the resident could lose eligibility for Medicaid funding if personal funds exceeded $2,000.00. At 3:30 p.m. on 07/13/16, SW #108 said she had no proof, but believed she told the resident's responsible party about the account. SW #108 said the facility had taken the resident out for shopping trips to spend her money. At 2:00 p.m. on 07/14/16, review of the facility's policy entitled Resident Funds, revised on 04/15/16 found the policy included: -- In accordance with state regulations, all medical Assistance residents must be notified monthly when the resident's account reaches $200.00 of the state's asset level for Medicaid eligibility. -- Prior to notifying the resident/responsible party, review the account to ensure that all activity has been properly recorded (e.g., care cost withdrawals and deposits). -- Maintain a copy of the notification letter in the resident's file. -- Provide a copy of the notification letter to the Social Services Department so that they may assist with the spend-down of excess funds (e.g., burial account). At 2:55 p.m. on 07/14/16, when asked about spending her personal funds, the resident began talking about the United States food stamp program. She did not appear to comprehend the nature of the attempted conversation about spending her money or the recent shopping trips out of the facility to spend her excess funds.",2020-02-01
4194,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,159,E,0,1,XDKG11,"Based on staff interview, family interview, and review of resident personal funds account balances, the facility failed to ensure residents who had a personal funds account at the facility had access to petty cash after business office hours. This practice had the potential to affect more than an isolated number of residents. In addition, the facility failed to ensure a quarterly statement of the balance of Resident #15's personal funds account was provided in writing to the resident's representative within 30 days after the end of the quarter. Resident identifier: #15. This was identified during a random opportunity for discovery. Resident identifier: #15. Facility census: 113. Findings include: a) Personal funds At 2:23 p.m. on 04/10/17, Business Office Manager (BOM) #13 verified the facility did not have a means to provide any petty cash to residents with personal funds accounts when the business office was closed, which included evenings and weekends. BOM #13 said residents could only get personal funds monies Monday through Friday during the daytime hours. b) Resident #15 During Stage 1 of the Quality Indicator Survey, at 9:28 a.m. on 04/04/17, the resident's responsible party (the resident's daughter) said she had never received any statements regarding Resident #15's personal funds account. The daughter said she received the resident's monthly check and wrote a personal check to the facility for the resident's monthly room and board. She also deposited money in the resident's account for, Things like a haircut at the beauty shop. She stated she did not know the exact amount in her mother's account. At 1:06 p.m. on 04/05/17, BOM #13 confirmed she did not mail a quarterly statement to the resident's daughter. She said she gave a copy of the quarterly statement to the resident. The BOM said she did not think she could send a statement to the daughter because the daughter did not have a durable power of attorney. BOM #13 did confirm the daughter paid the resident's monthly bill at the facility and deposited money in the resident's personal funds account. Review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/06/17 found the resident scored a 3 on her Brief Interview for Mental Status (BIMS), indicating severe cognitive impairment. A score of 3 indicated the resident would not be capable of understanding a personal funds account statement. These findings were discussed with the administrator at 8:12 a.m. on 04/11/17. As of the close of the survey on 04/11/17 at 2:45 p.m., the administrator had provided no further information.",2020-02-01
4377,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2016-11-17,159,D,0,1,7LQH11,"Based on resident interview, record review and staff interview the facility failed to ensure one (1) of five (5) residents had quarterly financial statements made available to them. Resident #6 expressed a desire to know how much money was in her resident trust account. She was not getting a quarterly financial statement. Resident identifier: #6. Facility census: 35. Findings include: a) Resident #6 On 11/15/16 at 9:17 a.m., Resident #6 stated she had never asked the facility how much money was in her account but she knew she had one because her son had set it up for her. During a resident interview, on 11/17/16 at 12:00 p.m., Resident #6 indicated she would like to know how much money she had in her account. She said she did not really want to buy anything but did want to know how much money was in her account. On 11/17/16 at 2:29 p.m., the accounts payable clerk said Resident #6 did not get a copy of her quarterly statement because her son pays her bill and they send the quarterly statement to him. A review of the account revealed the account had a balance of $40.00. At 2:30 p.m. on 11/17/16, the director of accounting was interviewed and stated the facility actually prepares the statements monthly instead of quarterly. She confirmed the facility was not giving a copy of the monthly statements to Resident #6. She said she would get together with the nursing staff to find the best way to determine who would deliver the statement to the resident.",2019-11-01
4404,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,159,E,0,1,BBQT11,"Based on a review of resident funds, confidential resident interviews, and staff interview, the facility failed to place funds in excess of $50.00 in an interest bearing account and failed to obtain written permission to handle these funds for seven (7) of seven (7) residents reviewed who had funds in excess of $50.00. The facility also failed to develop a procedure to make money available for residents upon request and outside of normal business hours. This practice had the potential to affect fifteen (15) residents for whom the facility managed funds. Facility Census: 58. Findings Include: a) Petty Cash A review of the facility petty cash logs revealed there were seven (7) residents currently residing at the facility who had money in the facility's petty cash account in excess of $50.00. These account balances were as follows: --Resident #18 - balance of $99.25 --Residents # 30 and #45 - Joint Petty Cash - balance of $969.00 --Resident #79 - balance of $98.00 --Resident #1 - balance of $578.82 --Resident #9- balance of $238.07 --Resident #7- Balance of $125.00 Interviews with Residents #30 and #45 revealed they did not want their money placed in an interest bearing account, but they want it at the facility. The residents said it was not safe to keep it in their room so the facility kept it for them and they can go to the office and get it when the office staff is in. During an interview on 08/03/16 at 2:00 p.m., Billing Clerk #7 confirmed the facility did not always place resident's funds in excess of $50.00 in an interest bearing account if the residents did not want them to. Billing Clerk # 7 also verified the facility did not have written policies or evidence it obtained authorization to keep the excess funds in the facility. b) Availability of Funds Confidential resident interviews on 07/26/16 and 07/27/16, identified the facility did not always have money available for the residents if the office was not open. An interview with the Billing Clerk #74 on 08/03/16 at 2:00 p.m., confirmed there was no petty cash made available when the office staff or the administrator were not in the facility.",2019-11-01
4533,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,159,E,0,1,OVQ111,"Based on record review, family interview, and staff interview, the facility failed to ensure each resident and/or responsible party who had a resident trust account with the facility was provided a financial record (statement) of the account on a quarterly basis and/or upon request. This was true for five (5) of five (5) resident reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #7, #20, #1, #17, and #6. Facility Census: 36. Findings Include: a) Resident #7 During a family interview at 12:50 p.m. on 04/18/16, Resident #7's responsible party indicated that he was the resident's representative for financial decisions. When asked if the facility maintained a resident trust account for Resident #7, he said they did have an account for her in case she wanted to get her hair done or should she need anything. He was then asked, Does the facility give you a statement of how much money is in the resident's account? He stated, I don't recall them ever giving me anything like that. In the afternoon on 04/19/16, the facility was asked to provide any statements sent to Resident #7's responsible party and/or to Resident #7. The facility did not provide any statement for Resident #7 as of 04/21/16 at 1:00 p.m. at which time the facility was asked to provide a complete accounting of Resident #7's trust fund. Review of this accounting found the first money deposited into Resident #7's account was deposited on 10/14/15, which was six (6) months prior to this review. During an interview at 12:35 p.m. on 04/21/16, the Chief Financial Officer (CFO) confirmed the facility had sent no statements to Resident #7 or her responsible party. The CFO said they had provided all that they had as far as statements were concerned, and none were found for Resident #7. b) Resident #20 The facility provided a list of all residents who currently had a resident trust fund with the facility. Resident #20 was chosen as a random sample for review. On the afternoon of 04/19/16, the facility was asked to provide the quarterly statements sent to Resident #20 and/or her responsible party regarding Resident #20's personal funds account for the previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received one (1) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15. She had not received a statement for 01/01/16 through 03/31/16, 10/01/15 through 12/31/15, or 04/01/15 through 06/30/15. c) Resident #1 Resident #1's name was on the list of residents with funds handled by the facility. The resident was chosen as a random sample for review. On the afternoon of 04/19/16, the facility was asked to provide the quarterly statements sent to Resident #1 and/or her responsible party regarding the resident's personal funds account for the previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m. found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. d) Resident #17 Resident #17 was chosen at random for review of funds from the list the facility provided. On the afternoon of 04/19/16, upon request, the facility provided the quarterly statements sent to Resident #17 and/or her responsible party in the last 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. e) Resident #6 Resident #6 was randomly selected for the list provided by the facility. On the afternoon of 04/19/16 the facility provided the quarterly statements sent to Resident #6 and/or her responsible party during previous 12 months. A review of the statements provided on 04/21/16 at 12:00 p.m., found the resident had only received two (2) quarterly statement in the last 12 months. She received a statement for the quarter of 07/01/15 through 09/30/15 and 04/01/15 through 06/30/15. She had not received a statement for 01/01/16 through 03/31/16, or 10/01/15 through 12/31/15. f) An interview with the CFO at 12:35 p.m. on 04/21/16 confirmed the facility had not sent the quarterly statements to these residents as required. He stated they had provided all the statements they were able to locate.",2019-10-01
4843,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2016-04-14,159,E,0,1,K3E211,"Based on resident trust fund account information and staff interview, the facility failed to provide the required quarterly financial statements to residents, nor responsible parties. Responsible parties stated they were receiving the statement until last (MONTH) when they stopped. This was evident for two of two residents who were reviewed for funds accounting. Resident identifiers: #67 and #21. Findings include: a) Resident #67 and #21 Interview with Business Office Staff #60, on 04/11/16 at 12:25 p.m., verified the facility did not distribute quarterly financial statements to responsible parties for which the facility was the representative payee. Business Office Staff #60 further revealed the facility would provide a copy as a courtesy, but they were not routinely provided. On 04/11/16 at 2:50 p.m., the administrator #61 provided statements of conversations with the responsible party for both Residents #67 and #21. These statements indicated the responsible party understood the checks came to the facility and if they have any questions regarding the trust fund account they could ask the office. However, the facility had not provided quarterly statements as required. Discussion with the power of attorney (POA) for Resident #67 on 4/12/16 at 10:35 a.m., revealed she had been receiving statement from the previous business office staff till last December, then they stopped. The new business office staff has not been sending them like before. Review of the corporate (YEAR) admission packet on 04/15/16 at 2:15 p.m., revealed on page 17, personal property and funds section 4 . the center will also provide a quarterly statement regarding your funds to you or your responsible party. This does indicate it is only to be given as a courtesy.",2019-07-01
4871,NELLA'S NURSING HOME,5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2016-03-16,159,E,0,1,6KMN11,"Based on personal funds review and staff interview, the facility failed to deposit resident's funds in excess of $50 in an interest bearing account. This had the potential to affect all residents fifteen (15) residents for which the facility maintained personal funds accounts. Facility census: 75. Findings include: a) Review of the personal funds account for the three (3) months prior to the Quality Indicator Survey revealed an ending balance on 12/03/15 of $4,374.31 with a total monthly deposit of $812.00, on 01/14/16 an ending balance of $4,198.50 with a monthly total deposit $812.00, and on 02/13/16 an ending balance of $2,549.55 with a monthly total deposit of $812.00. During an interview on 03/09/16 at 11:58 a.m., Employee #1, who worked with the facility finances, stated all resident personal funds went into one account and that account was not interest bearing. Each month's personal funds balance was greater than the total deposit which would require an interest bearing account.",2019-07-01
4998,STONE PEAR PAVILION,515130,125 FOX LANE,CHESTER,WV,26034,2015-10-01,159,E,0,1,GCQW11,"Based on records review, observation, staff interview, and review of the A Matter of Rights handbook, the facility failed to manage and account for the personal funds of five (5) of twenty (20) residents in accordance with accepted accounting practices. The facility did not obtain written authorization to manage the personal funds of three (3) of five (5) residents (Residents #8, #16, and #27) and did not have signed receipts for cash withdrawals for three (3) of five (5) residents (Residents #32, #51, and #8). Resident identifiers: #8, #16, #27, #32, and #51. Facility census: 55. Findings include: a) Review of the personal funds accounts with Office Personnel #89 beginning on 09/30/15 at 11:40 a.m., found the following: 1. Resident #32 -- A cash withdrawal of $45.00 on 08/13/15, for which there was no signed receipt. -- A cash withdrawal of $50.00 on 06/18/15, for which there was no signed receipt. 2. Resident #51 -- A cash withdrawal of $50.00 on 08/13/15, for which there was no signed receipt. -- A cash withdrawal of $20.00 on 08/18/15, for which there was no signed receipt. -- A cash withdrawal of $5.00, on 08/19/15, for which there was no signed receipt. Office Personnel #89 stated she did not always get a signature for cash withdrawals from a resident's personal funds account. 3. Resident #8 Review of the personal funds account with Office Personnel #89 for Resident #8, on 09/30/15, revealed the resident's sister was issued a check for $750.00 from the resident's personal funds account. This money was issued to the sister to spend down to maintain the resident's Medicaid status within the financial eligibility limits. A letter sent to the sister, dated 07/03/15, provided notification of the Medicaid eligibility requirements for the resident. The record did not contain any signed receipt for the cash withdrawal. In addition, the record did not contain any receipts for what the $750.00 was spent to purchase on behalf of the resident's needs within the Medicaid requirements. Office Personnel #89 verified the facility did not maintain this information. Additionally, the facility had no current consent authorizing the resident's sister to manage the resident's personal funds account. Office Personnel #89 stated the resident's brother, who previously managed the resident's account since admission on 01/17/12, had passed away. She stated the facility failed to get consent for the sister to manage the resident's account. 4. Resident #16 Review of Resident #16's personal funds account, on 09/30/15, revealed no consent for the facility to manage the resident's personal funds. 5. Resident #27 Review of Resident #27's personal funds account, on 09/30/15, revealed no consent for the facility to manage the resident's personal funds. b) Review of A Matter of Rights On 09/30/15 at 4:15 p.m., review of the handbook, A Matter of Rights, provided to residents upon admission, found on page 11, number 3, the handbook identified the facility would account for all residents funds according to generally accepted accounting principles.",2019-04-01
5035,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,159,D,0,1,IPN311,"Based on staff interviews and review of personal funds, the facility failed to obtain consents to manage personal funds for two (2) of five (5) residents whose funds were reviewed (Resident #46 and #68) In addition, the facility failed to deposit personal funds into Resident #46's account on two (2) separate occasions. Resident identifiers: #46 and #68. Facility census: 72. Findings include: a) Resident #46 and Resident #68 On 9/16/15 at 11:24 a.m., the personal funds for these residents were requested from Administrative Assistant (AA) #100. AA #100 stated she would locate the consent forms. On 09/17/2015 at 11:18 a.m., AA #100 provided the consents to manage personal funds from the admission packets of Residents #46 and #68. The forms completed at the time of admission for each of these residents indicated they did not want the facility to manage their personal funds. AA #100 verified the facility managed the personal funds for both residents, and confirmed the facility did not have a current consent form that authorized the facility to manage the residents' personal funds An interview with Administrator #97, on 09/17/15 at 10:22 a.m., revealed the social workers obtained permission to manage funds at the time of admission, from the resident or the responsible party. This documentation was included in the admission packet. If a resident or responsible party later decided they wanted the facility to manage the resident's personal funds, the social worker did not always obtain consent. Administrator #97 verified consents were not obtained from Resident #46 and #68 to manage their personal funds. b) Resident #46 A review of the personal funds for five (5) residents, with AA #100 on 09/16/15 at 11:24 a.m., revealed the personal fund account for Resident #46 did not show deposits of $50.00 for the months of (MONTH) (YEAR) and (MONTH) (YEAR). Interview with Billing Clerk #101, on 09/17/15 at 10:22 a.m., revealed Resident #46 changed payor sources from Medicare to private pay to Medicaid over the course of her stay at the facility. Resident #46's family handled her personal funds, then changed to the have the facility handle the resident's personal funds. Billing Clerk #101 stated the resident became eligible to receive $50.00 each month once she became eligible for Medicaid. Billing Clerk #101 stated the resident's billing was confusing with the different changes in payor sources. She verified the failure to deposit $50.00 into the resident's personal funds in (MONTH) (YEAR) and (MONTH) (YEAR).",2019-04-01
5144,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,159,D,0,1,PDA311,"Based on resident interview, staff interview, and personal funds record review, the facility failed to provide quarterly statements to two (2) of five (5) residents reviewed for personal funds. Resident identifiers: #50 and #33. Facility census: 55 Findings include: a) Resident #50 During a Stage 1 interview, on 06/16/15 at 12:13 p.m., Resident #50 related she had a personal funds account with the facility, but did not receive notification of the balance. The resident said the facility did not provide a quarterly statement. Review of the medical record, on 06/18/15 at 10:30 a.m., revealed a determination of capacity, completed by the physician, indicating the resident had health care decision making capacity. Additionally, review of the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 05/19/15, revealed a brief interview for mental status (BIMS) score of fifteen (15). The score, the highest possible score, indicated the resident was cognitively intact. b) Resident #33 An interview with Resident #33 on 06/16/15 at 2:38 p.m., revealed the resident had a personal funds account with the facility, but did not receive a quarterly financial statement. The resident related she had to ask if she wanted the information. c) An interview with the business office manager (BOM) on 06/18/15 at 9:49 a.m., revealed residents with a personal funds account received financial statements quarterly. The BOM indicated statements were provided to both the resident, and also the representative if indicated. She indicated the resident and/or representative signed the form, indicating the information was received. Review of personal funds records revealed there were quarterly statements signed by residents and/or representatives; however, the quarterly statements for Resident #50 and Resident #33 did not contain a signature. The BOM confirmed neither resident received their 03/31/15 quarterly statement. .",2019-03-01
5320,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2015-09-17,159,C,0,1,I3KW11,"Based on resident interview and staff interview, the facility failed to manage resident funds in a manner, which ensured residents had access to their funds seven (7) days per week, rather than just during normal banking hours. This had the potential to affect 19 of 19 residents whose accounts were managed by the facility. Resident identifiers: #5, and #20. Facility census: 25. Findings include: a) Resident #5 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 9:23 a.m., Resident #5 said residents could not get money from their accounts on weekends. b) Resident #20 During an interview in Stage I of the Quality Indicator Survey (QIS) on 09/15/15 at 4:33 p.m., Resident #20 said residents could not get money from their accounts on weekends. On 09/17/15 at 7:15 a.m., interviews conducted with Licensed Practical Nurse (LPN) #100, and Nurse I #87. Upon inquiry, both said they were unsure how residents would get money out of their accounts on weekends. They said they have no petty cash box in the medication carts or in the locked medication room. LPN #100 said, in the past six (6) years of her employment with the facility, she does not recall any resident requests for money out of their accounts on weekends. During an interview with Accounts Payable Representative #101, on 09/17/15 at 10:43 a.m., she said residents might only access their funds for cash during banking hours, Monday through Friday. She said there is no administrative staff available on weekends to obtain cash from (name of bank) on weekends. She was unsure if the (name of bank) was open on Saturdays. She acknowledged the facility does not keep cash on hand. She said if the residents wanted cash for use on the weekends, they needed to request those funds prior to bank closing on Fridays. She further explained residents must sign a check to obtain cash from his/her bank checking account, and two (2) administrative staff members must sign the check. Someone from the facility then travels to the bank to cash the check for the resident in the amount desired.",2019-01-01
5403,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2015-05-14,159,E,0,1,NX8Z11,"Based on review of residents' personal funds accounts and staff interview, the facility failed to manage the personal funds for four (4) of four (4) residents reviewed. The facility failed to ensure three (3) residents, Residents #1, #5, and #49, who received Medicaid benefits, received notice when the balance of their personal funds account was within $200.00 of the supplemental security income (SSI) allowable limit. In addition, the facility failed to provide a quarterly statement of the balance of Resident #63's personal funds to the financial representative within thirty (30) days after the end of each quarter. Resident identifiers: #1, #5, #49, and #63. Facility census: 127. Findings include: a) Resident #1 Review of the resident's personal funds account, on 05/13/15 at 10:45 a.m., found the resident had a balance of $1,853.64 on 04/30/15. b) Resident #5 Review of the resident's personal funds account, on 05/13/15 at 10:50 a.m., found the resident had a balance of $1,841.02 on 04/30/15. c) Resident #49 Review of the resident's personal funds account, on 05/13/15 at 11:00 a.m., found the resident had a balance of $1,884.30 on 04/30/15. d) At 11:04 a.m. on 05/13/15, Business Office Manager #166 verified she had not notified the residents, and/or the responsible parties, when Residents #1, #5, and #49's personal funds accounts were within $200.00 of the $2,000.00 allowable amount for Medicaid recipients. She verified the residents should have received notice when their accounts totaled $1,800.00. e) Resident #63 At 10:17 a.m. on 05/12/15, during Stage 1 of the survey, the resident's responsible party was interviewed. The family member identified herself as the resident's daughter and responsible financial party. She verified the resident had a personal funds account at the facility and said she had deposited $50.00 in the account several months ago. When asked if she received quarterly statements of the balance in the resident's personal account fund, she replied, No, but I guess I could always ask them. Review of the Resident #63's personal funds account on 05/13/15, found Resident #63 had a balance of $45.76 in her account on 04/30/15. At 11:04 a.m. on 05/13/15, Business Office Manager #166 verified the responsible family member had not been receiving quarterly statements. She stated the statements were going to the resident's husband, who was no longer in charge of the resident's personal funds. She stated the account was set up in 2009, when she was not employed at the facility. She said the account should have been updated with the resident's daughter's name when the husband was no longer the financial representative. Business Office Manager #166 said, I will fix that right now.",2019-01-01
5802,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2014-10-16,159,E,0,1,T8L111,"Based on facility record review and staff interview, the facility failed to ensure the resident personal funds accounts were deposited in an account separate from any of the facility's operating accounts. This had the potential to affect the fifty (50) residents, who had authorized the facility to manage their funds. Facility census: 111. Findings include: a) A review of the Trust Fund Balance Report, at 2:30 p.m. on 10/15/14, revealed a balance in the accounts of $17,156.64 as of 10/01/2014. The bank statement, dated 09/30/14, revealed a balance in the account of $29,228.77. This was an overage of $12,072.13. Employee #153, who stated she had been responsible for the residents' personal funds less than a year, said there was a surplus every month. She said she had been instructed to disregard the amount because the company's accountants were investigating the source of the overage and would take care of it. During an interview with the Administrator (NHA), the Director of Nurses, and the Assistant Director of Nurses, at 3:50 p.m. on 10/15/14, the Administrator acknowledged knowing there was additional money in the account. He stated he was sure the money belongs to the nursing home. The NHA said the money had been there since the previous accountant left, but the company accountants had not figured out the source and/or what to do about it. He stated the interest generated was being divided among the residents with accounts. When asked directly if he was aware none of the facility's operating funds were supposed to be in the resident's account, he replied that he did.",2018-07-01
6353,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,159,D,0,1,OMIN11,"Based on personal funds review and staff interview, the facility failed to provide a quarterly statement of personal funds managed by the facility, in writing and/or verbally, to the resident and/or the resident's representative within 30 days after the end of each quarter. This was true for three (3) of three (3) residents reviewed for personal funds. In addition, the facility failed to notify Resident #7 and/or his representative when the resident's personal funds account was $200.00 dollars less than the Supplemental Security Income (SSI) resource limit, which is $2,000.00 (dollars) in West Virginia. Resident identifiers: #7, #21, and #22. Facility census: 61. Findings include: a) Resident #7 A review of Resident #7's personal funds account, on 05/30/14 at 11:00 a.m., revealed Resident #7 received Medicaid benefits. The resident's account balance was greater than $2,000.00 in October, November, and December 2013. No evidence was found to indicate the facility notified the resident/responsible party when the account was 200.00 less than the SSI resource limit for one person. Further review revealed the quarterly statements (the accounting of the personal funds account managed by the facility), were received and signed by the nursing home administrator (NHA). The resident/responsible party had not been provided an individual financial record in writing and/or verbally of the account balance. An interview with Employee #70, Nursing Home Administrator (NHA), on 05/30/14 at 1:15 p.m., confirmed Resident #7 and/or the responsible party had not been given written and/or verbal notification when the account was 200.00 less than the SSI resource limit for one person. b) Resident #21 A review of Resident #21's personal funds account, on 05/30/14 at 11:30 a.m., revealed the quarterly statements were received and signed by the NHA. The resident had not been provided an individual financial accounting in writing and/or verbally of the account balance. c) Resident #22 Review of Resident #22's personal funds account, on 05/30/14 at 12:00 p.m., revealed the quarterly statements were received and signed by the NHA. The resident/responsible party had not been provided an individual financial statement in writing and/or verbally of the account balance. d) During an interview with the NHA, on 05/30/14 at 1:15 p.m., he verified he received the quarterly resident trust statements, and he had not informed the residents in writing and/or verbally of their account balances. The NHA voiced his concern of privacy/confidentiality if the residents left the personal account statements lying around and/or if others knew how much was in the residents' accounts.",2018-04-01
6484,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2014-03-27,159,D,0,1,TPO611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review, the facility failed to provide one resident (#16) with a quarterly statement of his personal funds account out of four residents with concerns regarding personal funds. Findings include: Resident #16 was admitted on [DATE] with [DIAGNOSES REDACTED]. A review of the clinical record for resident #16 revealed that he was assessed to be cognitively intact with a Brief Interview of Mental Status score of 12 on a quarterly MDS (Minimum Data Set) assessment dated [DATE]. Further review of the clinical record revealed that resident #16 did not have capacity to make his own decisions. During an interview with resident #16 on 3/25/14 at 9:01 AM, the resident stated that he is not given a quarterly statement of his personal funds account, though occasionally the facility does tell him how much money he has in his account. He further stated that he would like to receive a copy of his quarterly statement. During an interview conducted with Business Office Assistant staff #13 on 3/26/14 at 3:01 PM, staff produced the most recent quarterly statement of the resident's personal funds account. The statement had been signed by the facility's administrator. There was no evidence that the resident had also been provided a copy of his personal funds account statement. During an interview conducted with Nursing Home Administrator staff #94 on 3/26/14 at 3:18 PM, staff stated that as the facility is the Representative Payee for the resident's finances, the administrator signs the quarterly statement on behalf of the resident. Staff stated that they would in the future provide a copy to residents for whom the facility is Representative Payee, but that they do not currently do so.",2018-03-01
6674,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-10-01,159,D,0,1,KBHF11,"Based on resident interviews and staff interviews, the facility failed to ensure Residents #14, #58, #39, and #46 received a copy of their personal funds statements. The residents said they did not receive statements and the facility was unable to provide evidence they provided residents with personal funds statements. Resident identifiers: #14, #58, #39, and #46. Facility census: 87. Findings include: Residents #14, #58, #39, and #46 were interviewed on 09/22/14 and 09/23/14. These four (4) residents all stated that the facility does not let them know how much money they have in their personal funds account. -- Resident #14 - In an interview on 09/23/14 at 9:13 a.m., the resident stated, I have to ask, they do not tell me how much money I have in my account. -- Resident #58 - In an interview on 09/22/14 at 3:47 p.m., the resident said, They don't let me know how much. She said she did not receive a statement. -- Resident #39 - During an interview on 09/22/14 at 11:37 a.m., she said she had no idea how much money she had in her account. She said she gets chips and pop, but they never let her know how much money she has. -- Resident #46 - In an interview on 09/22/14 at 4:00 p.m., the resident said she did not receive a quarterly statement. She said they would tell her if she asked. In an interview with Psychology Assistant #13 on 09/30/14 at 12:35 p.m., he said there was a period of time when he helped pass out resident mail, but did not recall if the mail contained any resident statements. He stated that if he did pass out resident statements, he did not document the provision of the statements to the residents. During an interview on 09/30/14 at 12:39 p.m., the Recreation Assistant #129 stated there was one time in the last three (3) months where she passed out mail because they were short on staff. She stated she passed out resident personal funds account statements. The Recreation Assistant #129 stated she was informed she should not have passed out those statements and was instructed to collect as many of them as she could. RA #129 stated she complied with this request and collected as many of the resident personal funds account statements as she could. An interview was conducted with the Administrative Service Manager (ASM) #149 on 09/30/14 at 12:42 p.m. The ASM #149 stated she did not instruct staff to collect the statements from the residents and was not aware that had been done. She was not sure if the statements were again passed out to the residents. The ASM #149 stated she was unable to provide any documented evidence the statements were or were not delivered to the residents.",2017-12-01
6965,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2013-11-12,159,E,0,1,X5R211,"Based on staff interview and record review, the facility failed to ensure resident's funds in excess of $50.00 were deposited in an interest bearing account. Forty-three (43) of sixty-five (65) residents with funds handled by the facility had more than $50.00 in their accounts as of 11/04/13. Facility census: 95. Findings include: a) A review of the Trust - Current Account Balance as of 11/4/13 by Posting Date found sixty-five (65) residents had funds deposited in this account. Forty-three (43) residents had balances in excess of $50.00 according to this report. An interview was held at 9:00 a.m. on 11/06/13 with the Business Office Manager (Employee #6). She was asked to provide evidence showing the resident funds were in an interest bearing account. On 11/07/13 at 11:30 a.m., the Administrator provided a letter from the bank where the resident funds account was held. This letter stated on 11/06/13 the account had been changed to an interest bearing account. The Administrator acknowledged the resident funds had not been in an interest bearing account until 11/06/13, after the surveyor had requested documentation it was in an appropriate account.",2017-09-01
7047,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,159,D,0,1,GJXP11,"Based on a review of the facility's accounting records, medical records, and staff interview, the facility failed to ensure the authorization to handle personal funds was completed within legal state guidelines for two (2) of three (3) residents sampled for funds. Resident identifiers: #79 and #43. Facility census 61. Findings include: a) Resident #79 A review of the Trial Balance of the personal funds belonging to Resident #79 indicated he had a balance of $1245.39 in his account. The file did not have evidence of a valid authorization for the facility to act as fiduciary of the resident's funds. This resident, who was deemed by his physician to lack the capacity to form medical decisions, had a financial and medical power of attorney. There was an authorization form in his file dated 04/18/13, but it was unsigned. b) Resident #43 A review of the Trial Balance of the personal funds belonging to Resident #43 indicated he had a balance of $303.10 in his account. The resident was deemed by his physician to lack the capacity to form medical decisions. The only signature on the resident's authorization form was his own, and the form was not dated or witnessed. c) During an interview with Employee #58 (Business Office Manager) at 4:25 p.m. on 09/12/13, she acknowledged the authorizations found were the only ones on file for those residents. She could not state for certain the date of the authorization for Resident #43, who had been a resident since 10/05/12.",2017-09-01
7064,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2014-07-14,159,E,0,1,U25211,"Based on interview with staff and review of personal funds accounts, the facility failed to keep residents' personal funds in excess of $50.00 in an interest bearing account. The residents did not receive any interest on monies that were being held in this account. This practice affected twelve (12) of thirteen (13) residents for whom the facility handled money. Resident identifiers: #24, #59, #4, #47, #8, #44, #21, #18, #40, #16, #9, and #14. Facility census: 64. Findings include: a) Residents #24, #59, #4, #47, #8, #44, #21, #18, #40, #16, #9, and #14 Review of the residents' personal funds accounts on 07/09/14 at 10:00 a.m., revealed there was no interest being provided to residents who had requested the facility manage money for them. During an interview with the administrator (Employee #56) on 07/09/14 at 11:14 a.m., he indicated he did not have the money for the 12 residents deposited in an interest bearing account. He said he had been unable to find banks which would honor these types of individual accounts since 09/11/11.",2017-09-01
7712,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,159,B,0,1,Q01G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to provide a statement of account balances for 1 of 1 residents (Resident #89) with concerns related to personal fund account statements out of 20 residents interviewed. Findings include: Resident #89 was admitted on [DATE]. During an interview on 1/08/2013, Resident #89 reported that he was not given a statement of his facility managed trust fund account. On 1/10/2013 at 5:10 PM, an interview was completed with Bookkeeper #85. Bookkeeper #85 said that trust fund statements go out quarterly. Resident #89 has an account. I don't have have a statement for him for June or October. He did have one for the quarter ending in March (2012). If he didn't sign it and give it back, it won't be in the file. If they don't return the signed sheet, there isn't any way to show they got the statement, but everyone gets one. We provide the envelope with the statement in the daily mail. The residents bring them back up to me.",2017-02-01
7723,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2013-02-05,159,D,0,1,DTX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, financial record review, and staff interview, the facility failed to ensure that personal funds managed by the facility had a written authorization by the resident or the resident's legal representative for one (1) of three (3) sampled residents. Resident identifier: #70. Facility census: 100. Findings include: a) Resident #70 A review of the financial records, at 8:30 a.m. on 02/05/13, in the presence of Employee #131 (person responsible for handling resident funds) revealed Resident #70 had a personal funds account managed by the facility in the amount of $1170.56. Resident #70 was admitted to the facility on [DATE]. She had been deemed by her physician to lack the capacity to make her own health-care decisions on 07/04/10. The form used by the facility to obtain the authorization for the facility to manage the resident's personal funds was marked No and signed by the resident's daughter, who had completed the admission process. The resident's son who was, and continued to be, the Medical Power of Attorney (MPOA) was not available. During an interview with Employee #131, at 8:45 a.m. on 02/05/13, it was verified there was no authorization in the file allowing the facility to handle the resident's funds. During an interview with Employee #87 (Social Worker), at 10:45 a.m. on 02/05/13, she verified there was no authorization for the personal funds account.",2017-02-01
7810,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2012-06-08,159,E,0,1,U80L11,"Based on interviews and review of facility practice, the facility failed to ensure same-day access to personal funds for 5 (#s 56, 69, 75, 99, 124) of 10 residents interviewed who had a personal funds account with the facility. Findings include: Five residents (#s 56, 69, 75, 99, 124) interviewed on June 4, 2012, stated that they did not have access to their personal funds account when they need it, including on weekends. An interview was conducted with the Business Office Manager (staff #83) on June 8, 2012. Staff stated that residents have access to their personal funds Monday through Friday from 7:30 am to 5:00 pm. Residents can access their personal funds by requesting a withdrawl from the receptionist. If the receptionist has gone home for the day, residents would have to wait until 7:30 am the next morning. Residents have access to their personal funds on weekends through a manager with access to a petty cash locked box only 8 hours a day. An interview was conducted with the Administrator on June 8, 2012. The Administrator confirmed that the above procedures are currently in place and accurately described. The policy and procedure of the facility regarding personal funds was reviewed. The policy states that the facility should maintain a RPTF (Resident Personal Trust Fund) Petty Cash Fund to enable the facility to meet resident's request of a cash withdrawl.",2017-01-01
8000,PENDLETON MANOR INC,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2012-08-03,159,C,0,1,706T11,"Based on resident interview and staff interview, the facility failed to ensure that fifteen (15) residents with personal funds being managed by the facility, had access to petty cash on an ongoing basis. This practice had the potential to affect all of the fifteen (15) residents. Facility census: 81. Findings include: a) During an interview with the Resident Council President (Resident #63) during Stage I of the survey, this resident stated the facility manages personal funds for her/him and there was no access to the funds on weekends or at night. During an interview with Employees #3 and #4, who are responsible for handling resident funds within the facility, at 9:00 a.m. on 08/02/12, they stated there was a petty cash box maintained at the facility with $150.00 and an additional $50.00 kept in the Activity Department but, they confirmed this money was only available when one of them, or the activity personnel, were present. There was no one on site with access to petty cash at night, on holidays, or on weekends.",2016-11-01
8371,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2012-11-29,159,E,0,1,X70T11,"Based on record review, resident interview, and staff interview, the facility failed to ensure residents received quarterly statements notifying them of the balance in their resident trust (personal) account. Five (5) of five (5) residents reviewed were not provided quarterly statements. Resident identifiers: #23, #54, #6, #11, and #4. Facility census: 48. Findings include: a) Resident #23 and #54 On 11/27/12 at 9:28 a.m., during Stage 1 of the survey, Resident #23 indicated he had a personal funds account with the facility, but did not know how much money he had in the account. He said he thought the facility would tell him if he asked them. On 11/27/12 at approximately 1:00 p.m., Resident #54 indicated the facility also kept personal money for her, but she did not know how much money she had. b) Residents #6, #11, #4, #23, and #54 At 2:30 p.m. on 11/27/12, the account technician III (Employee #296) provided a list of residents who had requested the facility maintain a personal account for them. Five (5) residents were selected for review. Resident #6, #11, #4, #23, and #54 had personal accounts with the facility. Employee #296 indicated the five (5) residents did not have capacity. She said the residents' responsible parties received the quarterly fund balance report. She said the facility did not give quarterly statement balance reports to residents who were incapacitated. On 11/28/12, at approximately 2:00 p.m., the administrator (Employee #4) indicated the facility would evaluate incapacitated residents to determine their interest in receiving quarterly statements. He agreed the resident's incapacity status did not automatically make them unable to understand their quarterly trust account statements.",2016-07-01
8528,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2012-04-26,159,E,0,1,JZJM11,"Based on resident interview and staff interviews, the facility failed to make resident funds available on an on-going basis. This had the potential to affect more than an isolated number of residents. Resident identifiers: #98, #90, #97, #112. Findings include: a) During interviews with residents, on 4/23/12, residents were asked whether the monies in their personal funds accounts were available to them when they wanted, including weekends. Four (4) residents had negative responses to the question: During an interview with Resident #98, on 04/23/12 at 01:48 p.m., he stated, Have to follow their hours. During an interview with Resident #90, on 04/23/12 at 12:01 p.m., he stated, Only when someone is in the office they have certain hours to give out money. Two (2) other residents, #97 and #112, were interviewed at 12:07 p.m. They just stated, No, without elaboration. During an interview with the Nursing Home Administrator (NHA), on 04/25/12 at 2:00 p.m., he stated the residents had access to their funds, 7 days a week, 7 a.m. - 7:30 p.m. Monday thru Friday and 8 a.m. - 4:30 p.m. on weekends. He continued that all the residents were aware of the times. He elaborated further that the facility once had a petty cash fund because they did not have a receptionist. Now we have a receptionist that works until 7:30 M-F and 8 - 4:30 Sat and Sun. It is a better safe-guard for the money and the nurses can attend to their nursing responsibilities without having to safeguard the cash box too. The NHA was asked how the younger residents living in the building could get a pizza on Saturday if they wanted one. He responded, If there was some pre-planning, they could get a pizza at 9 p.m. on Sat night. They also have a lock-box in their room where they can keep money if they want to. The NHA stated that when he saw how this evolved, I thought I evolved with it. I thought I was accommodating the weekend and evening hours. The NHA concluded, After hours I felt better that nursing didn't have a cash box in medication room. When I made these changes I felt I made that accommodation. I thought the residents were OK with the 8 - 4:30 times. I will be glad to take a second look.",2016-05-01
8853,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2012-03-15,159,B,0,1,8YB611,"Based on interviews with six (6) residents in Stage I of the Quality Indicator Survey (QIS) and staff interview, the facility failed to ensure residents had access to personal funds after normal business hours. This was true for six (6) of thirty-two (32) Stage II sample residents. Resident identifiers: #22, #16, #29, #21, #4, and #26. Facility census: 59. Findings include: a) Residents #22, #16, #29, #21, #4, and #26 During stage I of the survey, these residents were interviewed and were asked, Can you get money when you need it, including on the weekends. Each of the residents stated money was not available when the business office was closed. Review of the resident funds accounts found all six (6) residents had a personal account at the facility. Employee #34, a licensed practical nurse, was interviewed, at approximately 10:00 a.m., on 03/14/12. Employee #34 stated money was not available after the business office was closed. Employee #36, a register nurse, was interviewed, at approximately 10:15 a.m., on 03/14/12. This employee stated if residents needed money after the business office closed, she would call the office staff and they could come into the facility and unlock the safe to get money.",2016-03-01
8916,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,159,E,0,1,NP7N11,"Based on resident interview and staff interview, the facility failed to ensure residents had access to their personal funds after the business office closed in the evenings and on weekends. This was true for four (4) of forty (40) residents interviewed in stage one of the survey. Resident identifiers: #52, #74, #1 and #36. Facility census: 90. Findings include: a) Residents #52, #74, #1 (the resident counsel president) and #36 These residents were all interviewed in stage one of the quality indicator survey (QIS). All of them expressed they only had access to their personal funds when the business office was open. They all stated they could not get any money in the evenings or on the weekends. On 12/05/11, starting at approximately 10:15 a.m., the following employees were interviewed and were asked if residents had access to their personal funds after business hours and on the weekends: -- Employee #122, the registered nurse (RN) supervisor on the first floor, stated, If they want money they have to get it before the weekend. -- Employee #170, a licensed practical nurse on first floor, stated residents could only get money when the business office was open. -- Employee #110, an RN working on the second floor, was unaware of how residents would receive money on the weekends. -- Employee #59, a unit manager on the second floor, and Employee #117, an RN unit manager for third floor, both stated residents could not get money on the weekends. ------------ An interview was conducted with Employee #93, the resident accounts manager, on the morning of 12/6/11. This employee verified Residents #52, #74, #1, and #36 all had personal funds accounts managed by the facility. She stated the guard on the weekends had a key to the business office and could get funds for the residents if needed. Interviews with residents on the stage I sample and staff verified that neither the residents, or the management staff, were aware of how to obtain residents' personal funds if the business office was closed.",2016-03-01
9010,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,159,D,0,1,EZVZ11,"Based on review of resident personal funds accounts and staff interview, the facility failed to ensure it had written authorization to handle personal funds for three (3) of eleven (11) residents. The facility handled personal funds for a total of eleven (11) residents. Resident identifiers: #53, #64, and #66. Facility census: 70. Findings include: a) A review of resident accounts with Employee #26 (admissions manager and long term accounts manager), on 01/26/12, at approximately 1:00 p.m., revealed she handled personal funds for eleven (11) residents on the long term care units (Nursing Care Unit I and Nursing Care Unit II). According to Employee #26, the facility handled funds for Resident #53, whose family had recently begun bringing in money for the resident. She said the facility also handled funds for Resident #64, whose son also brought in money for his mother and for Resident #66, who had received an overpayment from an income source. A review of residents' funds account balances revealed Resident #66 had a balance of $33.95 in his account. Resident #53 had a balance of $50.00 in her account and Resident #64 had a balance of $120.00 in her account. Employee #26 verified she did not have signed authorization from the resident or responsible party to handle personal funds for these three (3) residents",2016-02-01
9260,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,159,D,0,1,JZU011,"Based on record review and staff interview, the facility failed to obtain written authorization for the management of personal funds from the legal representative of one (1) of five (5) sampled residents. Resident identifier: #40. Facility census: 55. Findings include: a) Resident #40 Review of the financial records of five (5) sampled residents for whom the facility managed personal funds found an account was being managed by the facility for Resident #40. Further review found no evidence the resident or a legal representative with the authority to make financial decisions on the resident's behalf had provided written authorization permitting the facility to manage the resident's personal funds. This was verified by Employee #47 ( who was assisting with the review) at 2:00 p.m. on 10/04/11, and acknowledged by the director of nurses and the administrator at 2:30 p.m. on 10/04/11, after they had reviewed the records.",2016-01-01
10025,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,159,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to obtain valid written authorizations prior to handling the personal funds of two (2) of twelve (12) sampled residents, and failed to provide quarterly statements of account activity to one (1) of these residents, who was alert and oriented. Resident identifiers: #49 and #44. Facility census: 50. Findings include: a) Resident #49 A review of the financial records revealed the written authorization on file allowing the facility to manage the personal funds of this resident, who has been determined to lack the capacity to make health care decisions, was signed by her mother, who was the resident's health care surrogate (HCS) on admission to the facility. The WV Health Care Decisions Act does not convey to a HCS the authority to make decisions on behalf of an incapacitated individual other than those related to health care (e.g., financial decisions). b) Resident #44 A review of the clinical records for Resident #44 revealed she was alert and oriented to person, place, and time and had been determined by the physician to have the capacity to make her own healthcare decisions. Review of the resident's financial records found the resident's daughter signed the authorization for the facility to manage the resident's personal funds. Upon questioning at 11:30 a.m. on 02/09/10, the office manager (Employee #5) also stated the quarterly statements of account activity were mailed to the daughter. She verified she does not supply a statement to the resident, although she agreed the resident would understand the statement. During an interview with the administrator and the office manager at 2:15 p.m. on 02/10/10, they acknowledged the resident should have been informed of her financial status and given the option to make her own decisions about her personal funds. They related that this matter would be referred to the social worker next week, upon her return from vacation. Employee #5 also stated she would ensure the resident started receiving quarterly statements. .",2015-07-01
10119,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,159,D,0,1,9ELI11,"Based on review of residents' funds and staff interview, the facility failed to notify two (2) of two (2) residents who received Medicaid benefits when the amounts in their accounts reached $200 less than the SSI resource limit, as specified in section 1611(a)(3)(B) of the Act. Each of these residents were within less than $20 of the SSI limit before they were notified. Resident identifiers: #49 and #79. Facility census: 99. Findings include: a) Resident #49 On 10/21/09 at 2:00 p.m., this resident's funds were reviewed with the facility's accounting office manager (Employee #58). At that time, this resident had a balance of $1993.21. According to Employee #58, when a resident's funds reach $200 within the SSI limit, this information is provided to the social worker (SW), so the resident and/or family can be contacted. At 8:15 a.m. on 10/22/09, an interview was conducted with the SW (Employee #23). The SW stated she had received an e-mail from Employee #52 regarding the resident's funds. The SW produced the e-mail, which was dated 10/16/09. At that time, the resident was already within $6.79 of the SSI limit. Upon inquiry, the SW confirmed this was the first and only notice she had been provided regarding this resident's funds. b) Resident #79 On 10/21/09 at 2:00 p.m., this resident's funds were also reviewed with the facility's accounting office manager (Employee #58). At that time, this resident had a balance of $1982.36. At 8:15 a.m. on 10/22/09, during the interview with the SW, the SW confirmed the information regarding this resident's funds was provided in the same e-mail as Resident #49's, on 10/16/09. At that time, the resident was already within $17.64 of the SSI limit. Upon inquiry, the SW confirmed this was the first and only notice she had been provided regarding this resident's funds. .",2015-06-01
10173,MANSFIELD PLACE,515129,PO BOX 930,PHILIPPI,WV,26416,2009-09-10,159,D,0,1,N3OU11,"Based on record review and staff interview, the facility failed to obtain written authorization from the legally responsible person before handling the personal funds for one (1) random resident, and failed to ensure quarterly reports of financial activity were being provided to one (1) sampled resident with capacity and the legal representative of one (1) random resident. The financial records of five (5) residents were reviewed. Resident identifiers: #28 and #43. Facility census: 56. Findings include: a) Resident #28 A review of the clinical record of Resident #28 revealed an alert and oriented female who has been determined by her physician to have the capacity to make her own healthcare decisions. A review of her financial records revealed the quarterly statements of her personal fund account were sent to a family member, but not to the resident. This was confirmed by Employee #92 (the person responsible for handling resident funds) at 10:40 a.m. on 09/10/09. b) Resident #43 A review of the clinical record of Resident #43 revealed his physician determined he lacked the capacity to make healthcare decisions and appointed a health care surrogate to act on his behalf. The authorization for the facility to handle his personal funds was signed on 10/06/05 by a person who indicated he was the resident's ""conservator"", but there was no evidence of the conservatorship appointment in the files and no indication this person received quarterly statements of the resident's financial activity. During an interview with Employee #92 at 10:40 a.m. on 09/10/09, she stated that, to her knowledge, the person in question was no longer the conservator for the resident and did not want to be contacted, although she had no documentation to confirm this. She stated she signed the quarterly statements and filed them. She admitted that, at this time, there was no one legally responsible for Resident #43's finances and she knew of no actions in process to remedy the situation. This was confirmed by the social worker (Employee #83) at 11:30 a.m. on 09/10/09. This resident was a Medicaid recipient and also received benefits from the Veterans Administration, although his total personal account was not above the allowed amount at this time. In a follow-up interview with Employee #92 at 2:30 p.m. on 09/10/09, she stated made an inquiry at the bank and was told that a representative at the bank was the conservator and would be in touch with the facility. .",2015-06-01
10193,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2010-01-28,159,E,0,1,MFK411,"Based on financial record review and staff interview, the facility failed to implement a system to allow residents to obtain personal funds in amounts less than $50.00 at any time. This had the potential to affect all seventy-four (74) residents with monies held for them by the facility. Facility census: 100. Findings include: a) A review of the resident account information revealed the facility managed personal funds for seventy-four (74) residents. The facility maintained a petty cash box at the facility in the amount of $500.00. During an interview with the individual responsible for handling resident funds at the facility at 11:30 a.m. on 01/28/10, Employee #89 stated petty cash was available daily until 8:00 p.m.; after that time, they would have to call her at home. She also acknowledged there was no requirement for her to be available after hours. She stated she would rectify this as soon as possible. .",2015-06-01
10204,"CLARKSBURG NURSING AND REHABILITATION CENTER, LLC",515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2009-11-11,159,D,0,1,D6IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain written authorization, from a person with the legal authority to give such authorization, prior to managing the personal funds of two (2) of sixteen (16) sampled residents. Resident identifiers: #37 and #39. Facility census: 95. Findings include: a) Resident #37 A review of the facility's financial records found Resident #37 had a resident trust account that was being managed by the facility. The written authorization permitting the facility to handle the funds was signed by the resident's medical power of attorney representative (MPOA) to whom the resident, prior to loss of healthcare decision-making capacity, did not confer the authority to make financial decisions. The records indicated regular deposits to the account came from Black Lung benefits. The staff member responsible for handling the residents' funds (Employee #34) stated, at 11:00 a.m. on 11/10/09, that the Black Lung benefits first went to the resident's financial POA (not the same person as the MPOA), and he forwarded it the facility. Employee #34 stated the MPOA had signed the authorization, because she was present at admission, but quarterly account balance statements were sent to both the MPOA and the financial POA. It was noted that the facility could not produce a copy of the financial POA document. b) Resident #39 A review of the financial records of Resident #39 revealed this [AGE] year old female had been determined to lack the capacity to make healthcare decisions by her attending physician and had previously designated her brother as her Durable power of attorney (DPOA) and MPOA. At the time of her admission to the facility on [DATE], her DPOA indicated in writing he did not authorize the facility to handle the resident's personal funds. The facility was now handling the resident's funds, but there was no evidence of a signed authorization consenting to this. The staff member responsible for handling resident funds (Employee #34) stated, at 11:00 a.m. on 11/10/09, that she had reviewed the file and could not locate an authorization. .",2015-06-01
10243,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,159,D,0,1,5XSR11,". Based on family interview, staff interview, and medical record review, the facility had failed to ensure residents and/or their legally authorized representatives received quarterly statements informing them of the balance in their personal funds accounts, for one (1) of twenty-nine (29) Stage II sample residents. Resident identifier: #48. Facility census: 48. Findings include: a) Resident #48 During a telephone interview on 05/25/10 at approximately 7:00 p.m., Resident #48's daughter-in-law, who was her responsible party, reported she did not receive quarterly statements from the facility informing her of the balance in the resident's personal funds account. In an interview on 06/01/10 at approximately 3:00 p.m., the account collections technician III (Employee #156) reported she did not mail out quarterly statements to the responsible parties, nor did she give them out to residents who were capable of handling their own finance. She reported the facility's social worker (Employee #152) was responsible for these activities. In an interview on 6/02/10 at 11:08 a.m., the facility's social worker (Employee #152) reported Employee #156 comes over to the facility on a quarterly basis and reviews with her the residents' personal funds statements. In an interview on 06/02/10 at 11:30 a.m., the facility's administrator related he learned from an interview with the social worker (Employee #152) that she had reviewed Resident #48's quarterly statement with Employee #156 and signed off as having completed the review. However, Employee #152 indicated she had not given a copy of this statement to Resident #48 due to her inability to process the information. The social worker stated the resident might misunderstand the information and think someone had stolen money from her. Medical record review disclosed a power of attorney document dated 08/31/00. This document indicated the resident's son and/or daughter-in-law could act as the resident's lawful attorney, with the authority ""... to receive on my behalf all dividends, interest income arising from my personal estate, or any part thereof; and, upon receipt of any monies under these presents to deposit in said bank in my name, and to withdraw the same or any other funds that may be on deposit in said bank in my name. ..."" The facility failed to ensure the resident's legally authorized representative received a quarterly trust fund statement in the resident's stead. .",2015-06-01
10368,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-08-06,159,D,0,1,FGH911,"Based on record review and staff interview, the facility failed to obtained written authorization from the court-appointed conservator for one (1) of twenty (20) residents prior to handling the resident's personal funds. Resident identifier: #49. Facility census: 112. Findings include: a) Resident #49 A review of financial records revealed, on 11/13/07, the court appointed both a guardian (WV DHHR) and a conservator (Community Response Foundation, Inc.) to act on Resident #112's behalf. The facility's records indicated that, on 08/04/09, Resident #112 had a total of $1563.53 in personal funds deposited with the facility. Further review revealed the authorization for the facility to handle these funds was signed with an ""X"" by the resident on 01/08/09, but the resident's mark was not witnessed. A quarterly statement was given to Resident #112 on 04/17/09, and his mark was witnessed by two (2) employees (#111 and #200). During an interview at 10:30 a.m. on 08/05/09 with Employees #200 and E#201 (who were responsible for handling resident funds), they acknowledged they had never contacted the resident's court-appointed conservator, because it was ""hard to get through to anyone"". They also stated they would try to reach someone before the amount in the account reached $2000. .",2015-04-01
10453,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,159,D,0,1,924C11,"Based on record review and staff interview, the facility failed to obtain written authorization for two (2) of five (5) sampled residents prior to managing their personal funds accounts. Resident identifiers: #48 and #56. Facility census: 153. Findings include: a) Resident #48 Review of the financial records for this resident found the facility allowed the resident's health care surrogate to make financial decisions on behalf of the resident. The WV Health Care Decisions Act only allows a health care surrogate to make medical decisions on behalf of a resident who lacks capacity, not financial decisions. b) Resident #56 Review of this resident's financial records found an individual signed the authorization form to give the facility the right to handle the resident's personal funds, but there was no document giving this individual the legal authority to do so. This was discussed with the person in charge of handling resident funds on the afternoon of 08/11/09. .",2015-03-01
10487,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2009-08-20,159,D,0,1,D1B011,"Based on record review and staff interview, the facility disclosed information regarding a resident's personal funds account to an individual who did not have the legal authority to receive this information. This was evident for one (1) of five (5) residents whose personal funds were reviewed. Resident identifier: #21. Facility census: 60. Findings include: a) Resident #21 Financial records for this resident were reviewed as part of the resident funds accounting portion of the survey process. The review revealed this resident's quarterly financial statements were going to the individual designated as the resident's health care surrogate. (Under the WV Health Care Decisions Act, a health care surrogate only has the legal authority to make health care decisions on behalf on a resident lacking the capacity to do so; a health care surrogate does not have the legal authority to access a resident's finances or make financial decisions on behalf of a resident.) There was no document showing the resident's health care surrogate had the legal right to access this information. This was verified with the administrator and business office manager (Employee #69) on the afternoon of 08/19/09. .",2015-03-01
10622,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,159,B,0,1,GCMN11,". Based on resident and staff interview, the facility failed to assure residents had access to their funds on weekends and/or at other times the business office was closed. This practice had the potential to affect all residents for whom the facility managed funds. At the time of the survey, the facility maintained a trust fund for sixty-nine (69) residents. Facility census: 83. Findings include: a) During Stage I confidential resident interviews on 11/29/10 and 11/30/10, four (4) residents described that their personal funds were not available on weekends and/or at other times the business office was not open. On 12/08/10 at 2:00 p.m., an interview was conducted with the business office staff member who assists in resident funds. At that time, this staff member described that, prior to 11/30/10, residents had not been able to get funds except during business office hours. This person stated that, on that date, resident funds became available to residents at times the business office was closed, by means of a small amount of money provided to nursing personnel for this purpose. .",2015-01-01
10712,"GUARDIAN ELDER CARE AT WHEELING, LLC",515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2009-08-20,159,D,0,1,S2JZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review and staff interview, the facility failed to obtain written authorization from the legal representative for financial decisions for one (1) of twenty-one (21) sampled residents and one (1) resident of random opportunity, both of whom had been determined to lack the capacity to understand and make medical decisions and whose personal funds were held and managed by the facility. Resident identifiers: #106 and #5. Facility census: 138. Findings include: a) Resident #106 According to the medical record, Resident #106 was admitted to the facility on [DATE], and was determined to lack the capacity to understand and make medical decisions on 04/23/08. He signed his own admission information, which did not include an authorization for handling of personal funds. The resident had a durable power of attorney (DPOA), but there was no evidence the DPOA signed an authorization for the facility to handle the resident's personal funds. During an interview with the person responsible for handling resident funds at 10:00 a.m. on 08/19/09, she acknowledged there was no written authorization on file but stated that new forms had been developed and signatures had been obtained after the previous resurvey. She would look for them. At 08:30 a.m. on 08/20/09, the administrator presented the mislaid authorization form signed by the resident, but the date of the authorization was September 2008, which was after the resident had been determined to be incapacitated. b) Resident #5 Medical and financial records of Resident #5 revealed she had been determined to lack the capacity to make health care decisions, and her son had been named her health care surrogate (HCS). The HCS, who was not the legal power of attorney for financial decision-making, was permitted to sign the form authorizing the facility to deposit and handle the resident's personal funds, which included a pension not associated with the social security program. During an interview with the administrator and the three (3) social workers at 2:40 p.m. on 08/19/09, they acknowledged there was no evidence Resident #5 had a legal representative with the authority to make financial decisions on her behalf. --- Part II -- Based on record review and staff interview, the facility failed to ensure two (2) residents, whose stays were covered by Medicaid, were notified when the amounts in their personal funds accounts had reached $1800.00. Resident identifiers: #63 and #74. Facility census: 138. Findings include: a) Resident #63 Review of the financial record of Resident #63 revealed a personal account balance of $1937.72, but there was no evidence the resident's POA had been notified. b) Resident #74 Review of the financial record of Resident #74 revealed a personal account balance of $1914.46, but there was no evidence the resident's conservator had been notified. c) During an interview at 4:00 p.m. on 08/19/09, the administrator agreed there was no documentation of notification but maintained the office clerk did call them. .",2014-12-01
10879,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2009-12-10,159,D,0,1,4I6911,"Based on staff interview and record review, the facility failed to obtain written authorization from the appropriate party prior to handling the personal funds for two (2) of twenty (20) residents in the sample. Resident identifiers: #10 and #98. Facility census: 111. Findings include: a) Resident #10 Review of the financial records for this resident showed the resident's medical power of attorney (MPOA) representative signed the authorization form to allow the facility to manage Resident #10's personal funds. This individual was not granted power of attorney by the resident to make financial decisions. b) Resident #98 The resident's trust fund authorization form was signed, on 12/20/08, by a family member who was not granted power of attorney by the resident to make financial decisions; this family member had also not been appointed by the court to serve as the resident's conservator. c) Both of these issues were discussed with the business office manager (Employee #53) on 12/08/09 and again on 12/09/09, who verified these individual did not have the authority to make financial decisions on behalf of the residents. .",2014-11-01
10942,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2009-06-18,159,B,0,1,HO2T11,"Based on record review and staff interview, the facility failed to obtain written authorization from the legal representatives, of five (5) of six (6) sampled residents with lack capacity, prior to holding and managing personal funds for these residents. Resident identifiers: #15, #23, #26, #39, and #41. Facility census: 61. Findings include: a) Resident #15 Medical record review revealed Resident #15 lacked capacity, and a representative from West Virginia Department of Health and Human Resources (DHHR) had been appointed as health care surrogate (HCS) to make medical decisions, because both the resident's daughter and her sister declined this responsibility. Resident #15 had $1,860.39 in a personal funds account being held and managed by the facility based on the signature of her daughter, although there was no evidence the daughter had the legally authority to either grant this permission or determine how the money would be disbursed. During an interview with the social worker at 4:00 p.m. on 06/16/09, she stated the resident's daughter had told her she was the resident's power of attorney (POA), but the daughter had never produced the documentation to verify this claim. b) Resident #23 Medical record review revealed Resident #23 lacked capacity to make medical decision, and a HCS was appointed to make these decisions for him. Resident #23 had $1700.63 in a personal funds account being held and managed by the facility based on the signature of the HCS, although there was no evidence the HCS had the legally authority to either grant this permission or determine how the money would be disbursed. (State law does not authorize a HCS to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, who was responsible for managing the personal funds accounts, she stated she was aware of this and that part of this money was to be paid to the funeral home for a burial plan. c) Residents #26 and #39 Residents #26 and #39, both of whom had been determined to lack capacity, had designated medical power of attorney representatives (MPOAs) to make their medical decisions for them. In both cases, the MPOAs for Residents #26 and #39 gave signed authorization for the facility to manage the residents' personal funds accounts. However, a review of the documentation failed to produce any evidence of the MPOAs had the legal authority to make financial decisions on behalf of these residents. (State law does not authorize a MPOA to also make financial decisions on behalf of an incapacitated person.) During an interview with Employee #62, she stated she was aware that neither resident had designated a power of attorney to make financial decisions on their behalf.. d) Resident #41 Resident #41 had been adjudged incompetent and had a legal guardian appointed by the court to make medical decisions. This guardian gave signature authorization for the facility to manage the resident's personal funds. Review of the legal documents found no evidence that this guardian had also been appointed to serve as conservator, which would have given the guardian legal authority to make financial decisions for the resident. During an interview with Employee #62, she stated she was aware that Resident #41's legal representative was limited to guardianship only. .",2014-11-01
11023,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,159,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of facility records, and staff interview, the facility failed to notify the responsible party an incapacitated Medicaid recipient when the amount in the resident's account was within $200.00 of the SSI resource limit, for one (1) of eighty-nine (89) residents with personal trust fund accounts managed by the facility. Resident identifier: #28. Facility census: 121. Findings include: a) Resident #28 A review of the Resident #28's medical record revealed this [AGE] year old female who had been determined to lack capacity and who had previously designated her daughter to serve as both her medical and financial power of attorney. The primary payer for her nursing home stay was MCD - Medicaid (West Virginia). The resident's trust statement, dated 02/03/09, stated the balance of funds in her account was $2,590.40. The balance had reached the total of $1800.00 on 12/01/08, at which time the facility should have notified the responsible party that the resident's account was within $200.00 of the allowed SSI limit. There was no evidence in the file to indicate the resident's responsible party had been notified of the account balance and the possible repercussions of this total (loss of Medicaid eligibility), although quarterly statements had been posted in January 2009. During an interview with Employee #159, who was responsible for handling resident funds, at 2:00 p.m. on 02/04/09, she stated she was aware of the balance and explained that she supplied a list of resident balances to the business office manager (Employee #154) each month. The business office manager was to notify families of high balances. Employee #154, when interviewed at 2:15 p.m. on 02/04/09, stated he had tried to contact Resident #28's responsible party by phone but had gotten no answer. He explained the practice of the facility was to notify the family when the balance reached $1800.00, and when the total reached $2000.00, he was to notify DHHR; he stated that he had already done this. He also stated he was going to send a form to the responsible party to sign for permission for the facility to purchase something for the resident, but he was not sure what it would be, and he had not done so when asked at 11:00 a.m. on 02/05/09. The social worker (Employee #79), when interviewed at 2:30 p.m. on 02/04/09, was asked if she was aware of the resident's amount of available funds. She stated she was not, that she was usually not informed of the amounts in the resident accounts and was not involved in contacting the family, although, if asked, she could suggest items the resident might need. When told that a review of the nurses' notes revealed evidence of family notification of changes in condition, she verified the family member was very involved in her mother's care, that she had not had a problem reaching her by phone, and more than one (1) contact number was listed for the responsible party on the resident's medical record. .",2014-09-01
11149,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,159,B,0,1,OCKG11,"Based on a review of the resident trust account information and staff interview, the facility failed to ensure quarterly account balances / statements were being sent only to persons with the legal authority to access this information. The facility sent quarterly account balances / statements to unauthorized third parties for four (4) residents. Resident identifiers: #11, #36, #30, and #33. Facility census: 50. Findings include: a) Residents #11, #36, #30, and #33 Record review for Residents #11, #30, #33, and #36 found there was no authorization for anyone to handle financial matters for these residents. A review of the personal fund records, with the business office manager on 08/12/09 at 10:00 a.m., found quarterly financial statements were being sent to unauthorized representatives for all four (4) residents, two (2) of whom were alert and oriented and were entitled to this information themselves. .",2014-08-01
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
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
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
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
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
2252,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,160,D,0,1,DU6R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident account funds and staff interview, the facility failed to ensure that upon the death of a resident, the residents's funds were conveyed to the appropriate individual or probate within thirty (30) days. This was evident for three (3) of three deceased residents whose resident account funds were reviewed. Resident identifiers: #102, #3, #19. Facility census: 81. Findings include: a) Resident #102, #3 and #19 Review of the resident account funds on [DATE] at 2:00 p.m. found the following residents had expired with funds remaining in their accounts: --Resident #102 expired on [DATE]. She left $50.01 in her account. --Resident #3 expired on [DATE]. She left $408.81 in her account. --Resident #19 expired on [DATE]. $4.01 remained in the account. b) Staff interview During an interview with the business office representative, Employee #125 the time of this review, he said the former business office employee who took care of this task left employment very recently. He surmised the former employee most likely waited to complete the final accounting until she found out if there was an estate. He said this fell through the cracks, as they typically complete the final accounting within thirty (30) days of the resident's death. He said the check is ready to send. He added a newly hired employee for this position just began orientation on [DATE].",2020-09-01
2961,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2017-09-28,160,D,0,1,BKPR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey Resident #104 and Resident #17's funds to the appropriate person and/or jurisdiction within 30 days of discharge from the facility. This was true for two (2) of six(6) discharged residents whom the facility managed money for. Resident Identifiers: #104 and #17. Facility Census: 61. Findings Include: a) Resident #104 A review of the trial balance log for the Resident Trust Fund Accounts as of [DATE] at 10:30 a.m. on [DATE] found Resident #104's resident trust fund account had a current balance of $196.96. Review of Resident #104's medical record found Resident #104 was discharged to home on [DATE]. An interview with the Business office Manager (BOM) at 11:00 a.m. on [DATE] confirmed Resident #104 was discharged from the facility on [DATE] and that he has since passed away. The BOM stated that she is in the process of sending the money to unclaimed property since the resident died on [DATE]. She stated that they just recently had training on sending funds to unclaimed property because the process had changed. b) Resident #17 A review of the trial balance log for the Resident Trust Fund Accounts as of [DATE] at 10:30 a.m. on [DATE] found Resident #17's resident trust fund account had a current balance of $5.50. Review of Resident #17's medical record found Resident #17 was discharged to home on [DATE]. An interview with the BOM at 11:00 a.m. on [DATE] confirmed Resident #17 was discharged to home on [DATE] and that her resident trust fund had a current balance. She stated she would get her a check out as soon as possible.",2020-09-01
3017,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,160,E,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident funds and staff interviews, the facility failed to ensure personal funds deposited with the facility were conveyed to Resident #3 within 30 days of discharge, and failed to convey to the individual or probate jurisdiction the funds of three (3) residents (#1, #2, and #17) within 30 days of the resident's death. This was found for four (4) of four (4) residents reviewed for conveyance of funds. Facility Census: 52. Findings include: a) Resident #1 Resident #1 expired on [DATE]. The resident's funds ($1567.07) were not conveyed to the State of West Virginia until [DATE], 45 days after her demise. b) Resident #2 Resident #2 expired on [DATE]. The resident's funds ($0.59) were not conveyed to the state of West Virginia until [DATE], 43 days after her demise c) Resident #3 Resident #64 was discharged on [DATE]. The resident's funds ($1711.85) were not conveyed to the resident until [DATE] - 32 days after his discharge. d) Resident #17 A review of the facility's surety bond and resident funds bank balance receipt dated [DATE] on [DATE] at 4:15 p.m., discovered Resident #17 had an outstanding balance of $515.16. The resident had expired in the facility on [DATE]. Business Office Manager #49 reported on [DATE] at 4:20 p.m. that Resident #17 had expired on [DATE] and the facility's corporation had not responded at present to release the money to refund to the next of kin. She stated, I realize it is over 30 days as required, but a check request form was sent to the facility's corporation on [DATE]. They (the facility's corporate office) have not released the money to be refunded, so our hands are tied. During an interview with the Administrator on [DATE] at 8:00 a.m., she stated, I will be contacting the corporate office to see why it has taken over 30 days to release the money for refund to the next of kin or power of attorney and will rectify this matter.",2020-09-01
3841,HOLBROOK HEALTHCARE CENTER,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2016-11-10,160,D,0,1,6GKK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on financial record review and staff interview, the facility failed to convey funds, and/or a final accounting of funds, to the appropriate individual or probate jurisdiction within thirty (30) days of the residents' death for two (2) of four (4) residents reviewed. Resident identifiers: #114 and #115. Facility census: 92. Findings include: a) Resident #114 and #115 The Resident Ledger, dated [DATE] - [DATE], reviewed on [DATE] at 1:00 p.m., revealed Resident #114 expired on [DATE] and the resident ' s funds were conveyed to the individual who had been the resident ' s responsible party on [DATE]. Resident #115 expired on [DATE] and funds were conveyed to the individual who had been the resident ' s responsible party on [DATE]. c) Bookkeeper #62, interviewed on [DATE] at 1:06 p.m., stated the payments were late because the families had not provided proof of administration and the money could not be conveyed until that time. Upon request to see the proof of administration provided by the families, the bookkeeper provided the estate notice dated [DATE] for Resident #115 - which was after the funds were conveyed to the former responsible party on [DATE]. The bookkeeper said she could not provide clarification, and acknowledged Resident #114's funds were conveyed prior to the date of the administration notice, but not within the 30 day window required by State law. Additionally, Bookkeeper #62 said she did not have an estate notice for Resident #115, and that the funds were conveyed late.",2020-07-01
3855,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2017-01-19,160,D,0,1,DBHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to release the balance of two (2) deceased residents ' personal funds to the individual or probate jurisdiction administering the individual's estate as provided by State law. Resident identifiers: #96 and #32. Facility census: 62. Findings include: a) At 10:59 a.m. on [DATE], review of the care area of person funds review with the Accounts Payable (AP) Employee #9 found the following: 1. Resident #32 Resident #96 expired on [DATE]. At the time of death, the resident had $963.45 remaining in her personal funds account. On [DATE], a check for this amount was issued to a funeral home. 2. Resident #96 Resident #96 expired on [DATE]. The balance remaining in the personal funds account at the time of death was $158.10. On [DATE], a check was issued to a funeral home for this amount. b) Upon the death of a resident, the balance of the personal funds can only be released to the individual or probate jurisdiction administering the resident's estate. AP #9 confirmed the funeral home was not the probate jurisdiction administering the estates of Residents #32 and #96. c) At 8:40 a.m. on [DATE], these findings were discussed with the administrator, director of nursing, and Vice President of Operations #112. The administrator said the check issued to the funeral home for Resident #32 was still in the outgoing. She retrieved the check from the mail after surveyor intervention.",2020-04-01
3913,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,160,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based record and staff interview the facility failed to convey personal funds in accordance with regulations upon death. This practice affected three (3) residents but had the potential to affect all residents who had a personal funds account upon death. Facility census: 109 Resident identifiers: Facility census: 109. Resident identifiers: Resident #13, #58 and #112. Findings include: a) Resident #13, #58 and #112 A financial record review, with Business Office Manager (BOM) #84, on [DATE] at 11:31 a.m., revealed the above residents had a Resident Funds Account with the facility, and had expired within the previous three (3) to six (6) months. The residents' accounts, reviewed with the BOM revealed the facility had not conveyed the deceased residents' personal funds and a final accounting to the individual or probate jurisdiction administering the individual's estate, within 30 days, as provided by State law. b) Resident #58 expired on [DATE] and the account noted a pending amount of $1,131.49. c) Resident #13 expired on [DATE] and had an account balance of $865.58. d) Resident #112 expired on [DATE] and a check in the amount of $36.01 was made payable to the facility on [DATE]. e) The BOM reviewed the financial records and medical record and voiced no information was present to indicate each resident's responsible party had been notified of the account balance, and acknowledged the accounts had not been conveyed to the responsible parties within thirty (30) days as required.",2020-04-01
3947,WILLOW TREE HEALTHCARE CENTER,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2016-05-26,160,D,0,1,ULQ211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personal funds record review and staff interview, the facility failed to close the trust fund within 30 days after a resident expired for one (1) of one (1) fund account reviewed. Resident identifier: #62. Facility census: 99. Findings include: a) Resident #62 Review of records on [DATE] noted Resident #62 died on [DATE]. A check closing the resident's trust fund account was generated on [DATE]. During an interview on [DATE] at 1:12 p.m., the Business Office Manager #80 stated, I must have been looking at the date I closed the account, [DATE] instead of the date the resident died . The checks are supposed to go out within 30 days.",2020-04-01
4134,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,160,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the personal funds for two (2) of 21 (twenty-one) residents (who have personal accounts managed by the facility) had the balance of their personal funds conveyed to the individual administering the resident's estate or probate jurisdiction within 30 days of death. Resident identifiers: #34 and #35. Facility census: 29 Findings include: a) Resident #34 Review of the resident's Fund Balance Account at 8:54 a.m. on [DATE], found Resident #34 was discharged from the facility on [DATE]. The resident's remaining balance was $34.26 in a checking account and $108.79 in a savings account. b) Resident #35 Review of the resident's, Fund Balance Account at 8:54 a.m. on [DATE], found Resident #35 was discharged from the facility on [DATE]. A balance of $23.75 remained in the personal account. c) Interview with Employee #15, the manager of the resident's personal funds At 9:00 a.m. on [DATE], Employee #15, verified both Residents #34 and #35 were deceased . She stated no one had qualified to settle the resident's estate and the facility had a waiting period of 60 days to release the funds to the state's unclaimed property. Employee #15 said the facility has to send out a due diligence letter that gives the responsible party 60 days to come forward. She verified the facility had not conveyed the resident's personal funds within 30 days of the resident's death.",2020-02-01
4195,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,160,E,0,1,XDKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure five (5) of seven (7) residents reviewed for the care area of personal funds during Stage 2 of the Quality Indicator Survey (QIS), had his/her personal funds conveyed within 30 days of death to the individual or probate jurisdiction administering the resident's estate. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #136, #39, #73, #95, and #110. Facility census: 113. Findings include: a) Resident #136 Medical record review found Resident #136 expired on [DATE]. On [DATE], the resident's trust account contained a balance of $17.00. b) Resident #39 Medical record review found Resident #39 expired on [DATE]. On [DATE], the resident's trust account contained a balance of $189.19. c) Resident #73 Medical record review found Resident #73 expired on [DATE]. On [DATE], the resident's trust account contained a balance of $877.26. d) Resident #95 Medical record review found Resident #95 expired on [DATE]. On [DATE], the resident's trust account contained a balance of $942.43. e) Resident #110 Medical record review found Resident #110 expired on [DATE]. On [DATE], the resident's trust account contained a balance of $70.10. f) At 2:49 p.m. on [DATE], Business Office Manager (BOM) #13 confirmed the personal funds of Residents #136, #39, #73, #95, and #110 were not conveyed to the individual or probate jurisdiction administering the residents' estates within 30 days of the resident's death.",2020-02-01
4227,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2015-12-10,160,D,0,1,X38Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview, the facility failed to convey the personal funds to the individual or probate jurisdiction administering the resident's estate for one (1) of three (3) residents reviewed for personal funds of seventeen (17) Stage 2 residents. The facility did not provide a final accounting of funds within thirty (30) days of a resident's death. Resident Identifier: #28. Facility census: 89. Findings include: a) Resident #28 Personal funds, reviewed with Bookkeeper #89 on [DATE] at 4:40 p.m., revealed Resident #28 expired on [DATE]. The resident fund management service statement contained a note which indicated, Resident is deceased . A transaction description, noted an ending balance of $42.50. The resident statement, dated [DATE], also revealed a non-transferring account with an active status, and a balance of $42.50. Bookkeeper #89 related she was unsure of the timeframe required for a final accounting of the resident's funds. She acknowledged the account had not been conveyed to the individual or probate jurisdiction administering the resident's estate within 30 days of Resident #28's death.",2020-02-01
4257,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,160,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to dispense funds timely from trust accounts for two (2) of three (3) deceased residents reviewed. This failed practice had the potential to affect more than a limited number of residents. Resident identifiers: #69 and #166. Facility census: 69. Findings include: a) Resident #69 On [DATE] at 4:40 p.m., an interview was completed with the facility Bookkeeper #9 regarding the conveyance of residents' funds upon their death. Bookkeeper #9 stated, If they (residents) have an account and they die, we have so many days to turn the money over to unclaimed property or to have someone show they are executor of the estate. I think it's 30 days. Bookeeper #9 further stated Resident #69 passed away on [DATE], the facility closed the account on [DATE] and the check was sent out on [DATE]. Review of the Resident Statement for Resident #69 revealed Resident #69 died on [DATE] and the check to close her trust fund account was issued on [DATE]. b) Resident #166 Review of the Resident Statement for Resident #166 revealed Resident #166 died on [DATE]. The form noted a check to close out the trust fund account was issued on [DATE]. c) Interview with Business Office Manager On [DATE] at 9:18 a.m., an interview was completed with the Business Office Manager (BOM) who stated, We hold the checks for 30 days to let the family decide if they want to open an estate. After that, we send the check to the estate or if it is unclaimed property, we send it to our office in New Mexico. Then they send it to the State's unclaimed property.",2020-02-01
4644,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2015-12-18,160,D,0,1,5DCP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of residents' personal funds accounts and staff interview, the facility failed to convey personal funds managed by the facility, upon the death of the resident, to the appropriate individual or probate jurisdiction administering the estate for Resident #146. The facility failed to convey the personal funds of Resident #87 within the required thirty (30) day timeframe after the resident's death. This was true for two (2) of five (5) residents reviewed for conveyance of personal funds upon death. Resident Identifiers: #146 and #87. Facility Census: 91. Findings include: a) Resident #146 Record review of personal funds accounting, at 3:00 p.m. on [DATE], found Resident #146 expired on [DATE]. At the time of her death, her personal fund account had a balance of $1,961.12. Further review of the record found on [DATE], a check was issued to (name of local funeral home) for $1,961.12 to close her account. An interview with the Business Office Manager (BOM), at 3:35 p.m. on [DATE], confirmed the remaining balance of Resident #146's personal fund account was paid to the funeral home managing her funeral arrangements. She indicated she did not have knowledge that the check could not be issued directly to the funeral home. b) Resident #87 Record review of personal funds accounting, at 3:15 p.m. on [DATE], found Resident #87 expired on [DATE]. At that time, his personal funds account had a balance of $186.03. Further review of the record found on [DATE], the facility issued a check for $186.05 to close his account. The amounts varied between the time of his death and [DATE], because the account received two (2) cents in interest. An interview with the BOM at 3:40 p.m. on [DATE], she confirmed Resident #87's personal funds were not conveyed within 30 days of his death. She indicated the check should have been issued prior to [DATE], and was not issued until [DATE].",2019-08-01
5102,RALEIGH CENTER,515088,1631 RITTER DRIVE,DANIELS,WV,25832,2015-04-10,160,D,0,1,CRGX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the funds for two (2) of three (3) residents reviewed for the conveyance of personal funds upon death were conveyed, and a final accounting of the funds, were sent to the individual administering the resident's estate or probate jurisdiction within thirty (30) days of the resident's death. Resident identifiers: #16 and #13. Facility census: 66.Findings include:a) At 11:30 a.m., on [DATE], a review of the facility's records for residents who expired within the past year, and for whom the facility managed funds, was conducted. 1. Resident #16 This resident expired on [DATE]. The facility had a check made out to the daughter of Resident #16 for $657.97, dated [DATE]. This was the balance of the remaining funds which should have been conveyed to the resident's estate or probate jurisdiction. An interview with Employee #8, the office manager, on [DATE] at 11:15 a.m., revealed Resident #16's funds of $657.97 were released to the daughter instead of the resident's estate or probate jurisdiction as required. 2. Resident #13This resident expired on [DATE] at 1:08 a.m. The facility had a check made out to the son of Resident #13 for $2,336.86, dated [DATE]. This was the balance of the remaining funds which should have been conveyed to the resident's estate or probate jurisdiction. An interview with Employee #8, the office manager, on [DATE] at 11:15 a.m., confirmed Resident #13's funds of $2,336.86 were released to the son instead of the resident's estate or probate jurisdiction as required.",2019-03-01
5145,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,160,D,0,1,PDA311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed transaction report records and staff interview, the facility failed to convey a final accounting of a resident's funds to the individual or probate jurisdiction administering the resident's estate within thirty (30) days of death for one (1) of three (3) residents whose closed accounts were reviewed. Resident identifier: #88. Facility census: 55. Findings include: a) An interview with the business office manager (BOM) on [DATE] at 1:38 p.m., revealed closed records were maintained in binders in the business office. She indicated funds should be conveyed to the individual or probate jurisdiction administering the resident's estate within thirty (30) days of a resident's death. Record reviews revealed the following: 1. Resident #88 This resident's resident fund management service (RFMS) status change form indicated the resident expired on [DATE]. The resident statement indicated the account was closed on [DATE] with a debit of $637.42. A facility RFMS petty cash account check made payable to the State treasury was dated [DATE], with a notation the money was for unclaimed property of Resident #88. The BOM confirmed the date of the transaction was [DATE]. The business office manager confirmed the facility did not convey the deceased resident's personal funds and a final accounting of funds to the probate jurisdiction or the resident's estate within thirty (30) days of death.",2019-03-01
5186,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2016-03-03,160,E,1,0,MTOL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to convey within 30 days of death, the resident's funds, and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate. This was evident for two (2) of three (3) residents' closed records reviewed. Resident identifiers: #6 and #11. Facility census: 125. Findings include: a) Resident #6 Review of residents' personal funds accounts, on [DATE] at 11:05 a.m., found the current balance of Resident #6's funds totaled $1118.60. Resident #6 expired on [DATE]. b) Resident #11 Review of residents' personal funds, on [DATE] at 11:05 a.m., found the current balance of Resident 11's funds totaled $35.84. Resident #11 expired on [DATE]. c) During an interview with Assistant Administrator #164, on [DATE] at 11:05 a.m., she said typically, resident funds were conveyed to the individual or probate jurisdiction administering the resident's estate within thirty (30) days of a resident's death. She said she just spoke with the corporate office, who informed her the checks for $1118.60 and for $35.84 would be mailed to those residents' estates that very day.",2019-03-01
5328,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2015-06-18,160,D,0,1,6BSN11,"Based on record review and staff interview, the facility failed to ensure the funds for one (1) of three (3) residents reviewed for the conveyance of personal funds, were sent to the individual administering the resident's estate or probate jurisdiction after the resident's death. Resident identifier: #80. Facility census: 94. Findings include: a) Resident #80 On 06/17/15 at 11:30 a.m., the facility's closed account summary report revealed Resident #80's account was closed on 03/12/15 with a final balance of $1,007.84. During an interview with Office Manager #77 on 06/17/15 at 11:45 a.m., the office manager stated the facility had sent a check for $1,007.84 on 03/13/15 to Resident #80's husband. She verified the facility had issued the check to the resident's husband without evidence he was the executor of the resident's estate.",2019-01-01
5538,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2015-06-04,160,E,0,1,EDOZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey the personal funds and a final accounting to the individual or probate jurisdiction administering the individual's estate within thirty (30) days of the resident's death. This was found for ten (10) residents who expired more than 30 days ago. Resident identifiers: #20, #34, #57, #134, #158, #159, #133, #23, #95, and #160. Facility census: 97. Findings include: a) During a review of the facility's Resident Ledger dated [DATE] - [DATE], at 9:30 a.m. on [DATE], it was determined there were ten (10) residents with a positive balance in their accounts who had expired over 30 days prior to this review. The following residents had balances in a personal funds account managed by the facility, thirty (30) days or more after the resident expired: # 20 expired [DATE] $ 4.00 # 34 expired [DATE] $36.00 # 57 expired [DATE] $ 2.50 #134 expired [DATE] $20.00 #158 expired [DATE] $90.91 #159 expired [DATE] $34.71 #133 expired [DATE] $29.00 # 23 expired [DATE] $19.00 # 95 expired [DATE] $23.23 #160 expired [DATE] $54.00 Employee #144 was the person identified as responsible for handling the Resident Fund Accounts, and was present during the review. When asked why expired residents still showed a positive monetary balance, she stated the family for each resident was notified, and the facility continued to keep the money in the account until it was claimed. She stated she had never transferred money to the State and was not sure how to proceed. During an interview with the Administrator and Employee #144, at 1:30 p.m. on [DATE], the Administrator said they would rectify this as soon as possible.",2018-10-01
5560,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2015-02-12,160,D,0,1,7Y3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of West Virginia State Code, the facility failed to convey an expired resident's unclaimed funds as provided by State law. This was found for one (1) resident during a random opportunity for discovery while reviewing the facility's management of residents' personal funds. Resident identifier: # 2. Facility census 57. Findings include: a) Resident # 2 On [DATE], a review of the records for the Facility Management of Personal Funds revealed an active account for Resident # 2 in the amount of $711.75. The account record revealed interest was still being paid to the account. Further review revealed Resident # 2 expired on [DATE]. During an interview with Employee #22, at 12:30 p.m. on [DATE], she verified the account was still active. She stated letters had been sent to the responsible party for that resident, but there had been no response. She indicated she was aware the State required unclaimed funds be forwarded to the West Virginia (WV) State Treasurer's office. Employee #22 had no comment why it had not been done. These findings were presented to the Administrator immediately following that interview. b) According to the WV State Code ,[DATE]C-18: . upon the death of a resident, any funds remaining in his or her personal account shall be made payable to the person or probate jurisdiction administering the estate of said resident: Provided, That if after thirty days there has been no qualification over the decedent resident's estate, those funds are presumed abandoned and are reportable to the State Treasurer pursuant to the West Virginia Uniform Unclaimed Property Act, section one, article eight, chapter thirty-six of this code, et sequella.",2018-10-01
5634,MEADOWVIEW MANOR,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2015-04-16,160,E,0,1,CDOG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to ensure resident funds were conveyed to the individual or probate jurisdiction administering the resident's estate according to State law. The deceased resident funds were distributed to individuals without appropriate authorization of individual or probate jurisdiction to administer the residents' estate for five (5) of five (5) residents reviewed for whom the facility managed funds. Resident identifiers: #2, #12, #81, #82, #83. Facility census: 55. Findings include: a) During resident fund review, Bookkeeper #21 reported five (5) residents whose funds were distributed after the death of the resident from (MONTH) of 2014 through (MONTH) of (YEAR). 1. Resident #2 had $31.50, which was distributed by check to an individual known by the resident. 2. Resident #12 had $5.00, which was distributed in cash to an individual known by the resident. 3. Resident #81 had $732.60, which was distributed by check to the resident's spouse. 4. Resident #82 had $20.00, which was distributed by check to an individual known by the resident. 5. Resident #83 had $113.56, which was distributed by check to an individual known by the resident. On [DATE] at 3:35 p.m., Bookkeeper #21 stated she was not aware regulations required deceased resident funds be distributed to an appropriate authorized individual or the probate jurisdiction administering the residents' estate.",2018-09-01
5803,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2014-10-16,160,D,0,1,T8L111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview, the facility failed to ensure a deceased resident's personal funds, and a final accounting of those funds was conveyed to the state probate jurisdiction within 30 days of death. Resident identifier: #142. Facility census: 111. Findings include: a) Resident #142 During an interview with Employee #153 (person identified as responsible for personal funds), at 2:30 p.m. on [DATE], when asked if any of the accounts identified with a current clinical status of discharged or deceased had been retained for more than 30 days, she answered, Yes and identified the account of Resident #142. A review of the Trust Fund Balance Report as of [DATE], revealed a balance of $365.52 in the account of Resident #142. Further review revealed Resident #142 was admitted to the facility on [DATE] and expired on [DATE]. Employee #153 stated the resident's account had been active since she assumed her position within the last year. She said she had been informed by administration that this account was being handled by the corporation accounts and no further action was necessary. During an interview with the Administrator (NHA), the Director of Nurses, and the Assistant Director of Nurses, at 3:50 p.m. on [DATE], the NHA acknowledged knowing there was a remaining amount in the account for Resident #142, who had expired in 2005. He said he had notified the corporate office the money needed to be turned over to the State, but no action had been taken.",2018-07-01
5915,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2014-10-15,160,D,0,1,8R4I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to properly convey a resident's personal funds upon death for one (1) of three (3) residents reviewed for personal funds. The day before Resident #153 expired, a staff member transferred Resident #153's funds to another resident without any authorization to make the transfer. Resident identifier: #153. Facility census: 142. Findings include: a) Resident #153 This resident had a personal funds account managed by the facility. The resident expired on [DATE]. A review of Resident #153's Trust Transaction History report, indicated a cash withdrawal on [DATE] in the amount of $520.88. During an interview and record review with the Director of Finance (DOF), on [DATE] at 9:40 a.m., she stated Resident #153 expired on [DATE]. She further stated the resident's personal funds had been withdrawn on [DATE]. The DOF stated Resident #153 was a ward of the State, and did not have family. She indicated the resident had a close friend, who was also a resident at the facility (Resident #154), and she transferred Resident #153's personal funds into Resident #154's personal funds account one day before Resident #153's death. The DOF stated she did not receive any instructions from the facility's Administration or from Resident #153 on how the personal funds should be conveyed. The DOF made the transfer herself, and stated she thought of the money as a gift to Resident #154 from Resident #153 since they were so close to each other. She stated the residents used to live together, were always sharing their things, and called each other sisters. A review of Resident #154's Trust Transaction History report indicated a deposit on [DATE], in the amount of $520.88. There was no check written to the personal funds account of Resident #154 for the deposit. The DOF stated she made the transfer in the facility's accounting system from Resident #153's account to Resident #154's account. The DOF stated she was not aware of any written policy on the conveyance of funds after death. She stated if a resident had a personal funds account with a balance, they would make any remaining payment on the resident's liability. After paying the balance owed to the facility, they find out from the family if an estate had been created. If no estate had been created, the money was then sent to a state recovery fund. A review of the facility's policy and procedure for Resident Trust Accounts, with an implementation date of [DATE], and last revised on [DATE], indicated the policy did not include instructions on the conveyance of resident's funds after death. During an interview with the Director of Operations on [DATE] at 2:30 p.m., she stated the resident's personal funds should be transferred to the estate of the resident after death. If the check had not been cashed or if no estate had been created, then the funds would be transferred to the West Virginia Unclaimed Property Fund.",2018-05-01
6354,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,160,D,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the funds for one (1) of one (1) resident reviewed for the conveyance of personal funds upon death were conveyed, and a final accounting of the funds were sent, to the individual administering the resident's estate or probate jurisdiction within thirty (30) days of the resident's death. Resident identifier: #79. Facility census: 61. Findings include: a) Resident #79 At 9:30 a.m. on [DATE], a review of the facility's records for residents who expired within the past year, and for whom the facility managed funds, was conducted. Resident #79 expired on [DATE]. The facility had a check made out to the estate of (resident's name) for $696.69, dated [DATE]. This was the balance of the remaining funds which should have been conveyed to the resident's estate or probate jurisdiction within thirty (30) days of the resident's death. An interview with Employee #70, the nursing home administrator, on [DATE] at 11:15 a.m., revealed the administrator had no information regarding why the facility still had not sent the check for $696.69 to the resident's estate or probate jurisdiction.",2018-04-01
6461,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2014-05-15,160,D,0,1,8VLA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to convey within 30 days the residents' personal funds to the individual or probate jurisdiction administering the residents' estate for three (3) of three (3) residents who had expired with personal funds remaining. Resident identifiers: #124, #125, and #129. Facility census: 90. Findings include: a) Resident #124 The personal funds review conducted on [DATE] at 10:00 a.m. revealed Resident #124 expired on [DATE] with a personal funds account balance of $1,160.35. The facility issued a check for $1,160.35 to the resident's son on [DATE]. During an interview conducted with accounting Staff (Employee #126) on [DATE] at 10:13 a.m., staff stated the son's wife had communicated to Employee #126 on the phone that the son was the executor of resident #124's estate and promised to send paperwork stating such. The facility issued the check more than 30 days following the resident's death and without evidence Resident #124's son was the executor of the resident's estate. b) Resident #125 Resident #125 expired on [DATE] with a personal funds balance of $22.43. During an interview with Employee #126 (accounting staff) on [DATE] employee stated the resident's personal fund balance of $22.43 had not yet been conveyed to the individual or probate jurisdiction administering the resident's estate. c) Resident #29 Resident #29 was discharged to the hospital on [DATE]. The resident expired at the hospital. Resident #29 expired with a personal funds balance of $233.17. During an interview with Employee #126 on [DATE], the employee stated the facility had not conveyed to the individual probate or jurisdiction administering the resident's estate the resident's personal fund balance of $233.17. A review of facility policy and procedures regarding resident trust accounts stated, Upon death, if a resident has a personal fund deposited with the facility, the facility must resolve the disposition of any personal funds remaining in the resident trust fund within 30 days . The remaining resident funds and a final accounting of those funds will be disbursed to the individual or probate jurisdiction administering the resident's estate. A check request will be completed and submitted to Administration for refund to the estate. During an interview on [DATE] with Employee #126, the employee stated in the absence of an executor, any remaining funds are sent to the state as unclaimed funds.",2018-03-01
6828,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2013-10-31,160,E,0,1,PWUW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to convey the personal funds and provide a final accounting of the funds of a deceased resident to the individual or probate jurisdiction administering the resident's estate within thirty (30) days as provided by State law (,[DATE]C-18). Resident identifier: #66. Facility census 97. Findings include: a) Resident #66 A review of the facility's [DATE] accounting records, at 03:00 p.m. on [DATE], revealed Resident #66, who expired on [DATE], continued to show a balance in a personal account of $124.68. This was acknowledged by Employee #72 (identified as the employee handling personal accounts) in an interview at 3:00 p.m. on [DATE]. She stated they had sent two (2) letters to the family and were waiting for them to contact the facility with instructions. There was no evidence of this in the record. Employee #72 denied knowledge that the funds were to be forwarded to the West Virginia State Treasurer after 30 days. During an interview with the Administrator, at 2:00 p.m. on [DATE], he acknowledged the funds had not been dispersed and stated they would be forwarded to the State Treasurer's Office as soon as possible.",2017-11-01
6852,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2014-02-14,160,D,0,1,U18411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personal funds review and staff interview, the facility failed to ensure one (1) of two (2) residents reviewed had personal funds conveyed, and a final accounting of those funds sent to the individual or probate jurisdiction administering the resident's estate, within 30 days of the resident's death. The facility disbursed funds from the deceased resident's account to a funeral home instead of to the resident's estate. In addition, the facility did not return a social security check received for the resident after his death to the social security administration. Resident identifier: #59. Facility census: 70. Findings include: a) Resident #59 A review of the personal funds, on [DATE] at 4:00 p.m., revealed Resident #58 expired on [DATE]. The facility wrote a check for $250.08 to the funeral home on [DATE]. The administrator (Employee #80) confirmed the facility had sent the final accounting of resident's funds which totaled $250.08 to a funeral home instead of to the resident's estate. The administrator said he knew he had not acted appropriately when he sent the resident's money to a funeral home instead of to the resident's estate. He indicated the resident's family did not have the financial ability to apply to become executor of his estate; therefore, he elected to send the money in the resident's trust account to the funeral home to assist with burial expenses. On [DATE] at 4:27 p.m., the administrator (Employee #80) and the business office manager (Employee #82) said a social security check was deposited into the resident's facility trust account on [DATE]. The check remained in the resident's account on [DATE]. The business office manager said she had a conference call with her company representative on [DATE]. During that call Employee #82 had to look at the facility's closed resident trust accounts. At that point she discovered the social security check for Resident #58 remained in the resident's closed account. The office manager said she thought the money would automatically revert back to social security, so she never went into the resident's account after it closed to make sure this check had been returned. She said her company would assist her in getting this money returned to social security, but that process might take a couple days.",2017-11-01
6861,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2014-03-07,160,E,0,1,JZ4X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the funds for six (6) of six (6) residents, reviewed for the conveyance of personal funds, were conveyed and a final accounting of the funds were sent to the individual administering the resident's estate or probate jurisdiction within thirty (30) days of each resident's death. Resident Identifiers: #56, #59, #8, #45, #22 and #93. Facility Census: 62. Findings Include: a) Resident #56 At 8:00 a.m. on [DATE], the facility's trial balance report with the date of [DATE] revealed Resident #56 expired on [DATE]. There was a balance of $15.25 in the resident's account at the time of the review. b) Resident #59 At 8:00 a.m. on [DATE], the facility's trial balance report with the date of [DATE] revealed Resident #59 expired on [DATE]. At the time of the review, the resident had a balance of $523.25 in her resident trust account. c) Resident #8 At 8:00 a.m. on [DATE], the facility's trial balance report with the date of [DATE] was reviewed. This report revealed Resident #8 expired on [DATE]. The resident's balance at the time of the review was $152.13. d) Resident #45 At 8:00 a.m. on [DATE], the facility's trial balance report with the date of [DATE] was reviewed. This report revealed Resident #45 expired on [DATE]. The resident's balance as of [DATE] was $404.26. e) Resident #22 At 8:00 a.m. on [DATE], the facility's trial balance report with the date of [DATE] revealed Resident #22 expired on [DATE]. At the time of the review, the resident still had a balance of $6.23 in the resident trust account. f) Resident #93 At 8:00 a.m. on [DATE], a review of the facility's trial balance report revealed Resident #93 had a balance of $763.35. The report revealed the resident expired on [DATE]. g) An interview with Employee #5, the business office manager, at 9:30 a.m. on [DATE], confirmed Residents #56, #59, #8, #45, #22 and #93 had the aforementioned funds in their account, even though the residents expired in September, November or December of 2013. Employee #5 stated she had only been in her current position since November and was still in the learning process. She confirmed she had not dispersed the funds for Residents #56, #59, #8, #45, #93, or #22 to the appropriate probate jurisdiction or individual administering the residents' estates within 30 days of each resident's death.",2017-11-01
7048,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,160,B,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's accounting records and staff interview, the facility failed to convey the personal funds for two (2) deceased residents,and provide a final accounting of the funds to the individual or probate jurisdiction administering the individual's estate within 30 days as provided by State law. This was found for two (2) of 21 account holders. Resident identifiers: #18 and #68. Findings include: a) Resident #18 A review of the accounting records dated [DATE] on [DATE], revealed Resident #18, who expired on [DATE], continued to show a balance in a personal account of $1123.96. This was acknowledged by Employee #58 (Business office manager) in an interview at 4:25 p.m. on [DATE]. She stated they had notified the family and were waiting for them to contact the facility with instructions. There was no evidence of this in the record. b) Resident #68 A review of the accounting records dated [DATE] on [DATE], revealed Resident #68, who expired on [DATE], continued to show a balance in a personal account of $245.82. During an interview with Employee #58 at 4:25 p.m. on [DATE], she acknowledged the funds had been there until yesterday, [DATE], when she contacted the family and was directed to issue a check made out to the executer of the estate and forward it to the funeral home.",2017-09-01
7095,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,160,D,0,1,1ZMG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the facility's accounting records and staff interviews, the facility failed to ensure resident funds were conveyed to the individual or probate jurisdiction administering the resident's estate according to State law. deceased resident funds were distributed to funeral homes without appropriate authorization of the individual or probate jurisdiction administering the residents' estates for two (2) of three (3) residents for whom the facility managed funds. Resident identifiers: #5 and #175. Facility census: 118. Findings include: a) Resident #5 A review of Resident #5's accounting records, on [DATE] at 10:30 a.m., revealed the balance of the account showed a check written to an area funeral home on [DATE]. In an interview with the bookkeeper (Employee #35), on [DATE] at 11:25 a.m., she stated verbal permission was given by the power of attorney (POA). Employee #35 stated there was no evidence to support verbal permission was given to give the funds to the funeral home. When Employee #35 was asked if she was aware the POA was not valid after death, she stated No. In addition, she stated corporate had given a directive that it was okay to obtain verbal consent and send funds to the funeral home. b) Resident #175 A review of Resident #175's accounting records, on [DATE] at 10:40 a.m., revealed the balance of the account showed a check written to an area funeral home on [DATE]. Another check was written to the estate of Resident #175. In an interview with the bookkeeper on [DATE] at 11:30 a.m., she stated verbal permission was given by the power of attorney (POA). Employee #35 stated there was no evidence to support verbal permission was given to give the funds to the funeral home. She further confirmed there was no legal documentation which indicated the individual or probate jurisdiction who was appointed to administer this resident's estate, yet the funds were released to the POA. c) On [DATE] at 12:00 p.m., the administrator was informed of the findings. He stated he was trying to find more information from corporate headquarters regarding the disbursement of funds after a resident died . No further information was provided by exit on [DATE].",2017-08-01
7128,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,160,D,0,1,XBZ111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to convey Resident #82's personal account funds to a legally qualified entity within thirty (30) days of the resident's death. This was found for one (1) of three (3) sampled residents reviewed for conveyance of funds upon death. Resident identifier: #83. Facility census: 53. Findings include: a) Resident #83 A review of the financial records and closed medical records [REDACTED]. He authorized the facility to manage the resident's personal funds at the time of admission. Further review of the financial and closed medical records [REDACTED]. A letter of administration for the estate of Resident #83 was completed on [DATE]. A check was not issued until [DATE], which was seventy-nine (79) days after the resident's death. During an interview with Employee #47, the business office supervisor (BOS), and Employee #89, vice-president of operations, at 1:45 p.m. on [DATE], it was stated that when the resident expired, the HCS had been having surgery so the facility thought they would hold it for him. They both verified the funds should have been released to the estate of the deceased resident within thirty (30) days of death as required by regulation.",2017-08-01
7318,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2013-04-18,160,D,0,1,KPNE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds, and/or a final accounting of those funds, after the resident's death, to the individual or probate jurisdiction administering the individual's estate as provided by State law. This was found for one (1) of four (4) records reviewed for residents with personal funds deposited with the facility. Resident identifier: #66. Facility census: 51. Findings include: a) Resident #66 A review of the facility's financial records showing the balance in the resident trust accounts at the end of [DATE] revealed an account for one (1) resident who had expired on [DATE]. During an interview with Employee #74, the Billing Clerk, at 1:50 p.m. on [DATE], she stated Resident #66 had expired on [DATE], and a check for the balance of her account ($200.59) had been issued to the funeral home on [DATE], and another check for ($20.02 ) was sent to the funeral home on [DATE]. There was no evidence to reflect the probate jurisdiction administering the individual's estate had been issued a final accounting of the resident's personal funds or had approved the payments made by the facility from the resident's account.",2017-06-01
7424,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2013-07-12,160,D,0,1,WFVL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, financial record review, and staff interview, the facility failed to convey the personal account funds of a deceased resident to a legally qualified entity for one (1) of five (5) residents who no longer resided in the facility. The facility issued a check for the balance of the personal funds, after the death of a resident, to the funeral director. The resident had no one appointed to legally handle his finances and/or to make the decision for the disbursement of the resident's funds. Resident identifier: #99. Facility census: 141. Findings include: a) Resident #99 During a review of the records of the personal funds belonging to the residents of the facility, at 11:30 a.m. on [DATE], accompanied by Employees #9 (Finance Director) and #72 (Business Office Manager), Employee #9 was asked to explain the dispersal of funds for Resident #99, after his death. She stated the balance of his account ($1572.35) was paid to the funeral home on [DATE], on the verbal instructions of his family. Both employees acknowledged, after reviewing the records, that Resident #99 had a Health Care Surrogate (HCS), but had made no appointment of a Power of Attorney prior to his death. They affirmed the resident's account included monthly deposits from both Social Security and a private pension. They acknowledged that neither the HCS nor the funeral director had presented documentation which allowed legal acceptance of these funds. An interview was conducted with Employee #121 (Social Service Supervisor) at 3:30 p.m. on [DATE]. She verified Resident #99 had been deemed by his physician to be unable to form his own health care decisions and a HCS (his niece) had been appointed. She stated the niece was advised of the rising balance of the resident's personal fund account and the effect it would have on his Medicaid status. Employee #121 said she was unsure of any final decisions made. Employee #121 verified the resident had only a HCS, and no conservator or financial power of attorney was assigned. There was no evidence the HCS was advised of the financial limitations of being a HCS. When questioned, Employee #121 stated she did not discuss the need for a financial Power of Attorney (POA) with family members, because she had never been asked to do so and assumed the business office people did this. During an interview with Employees #144 (Administrator), #65 (Director of Nurses), and #216 (Corporate Consultant), at 5:00 p.m. on [DATE], this situation was discussed. At 10:30 a.m. on [DATE], the Administrator presented information that the resident's HCS was informed, on [DATE], that the resident had no pre-burial arrangements, but there was no evidence the HCS had proceeded with this, and there had been no deductions from the resident's account. The administrator stated it was her understanding that West Virginia did not require a legal financial representative if the family was in agreement.",2017-04-01
7747,CLAY HEALTH CARE CENTER,515142,1053 CLINIC DRIVE,IVYDALE,WV,25113,2013-04-16,160,D,0,1,KUG911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on financial record review and staff interview, the facility held funds longer than 30 days after Resident #77 expired. These funds had not been dispersed to the individual or agency with probate jurisdiction over the resident's estate. This practice was evident for one (1) of one (1) resident who still had funds in the trust fund account at the facility. Facility census: 57. Findings include: a) Resident #77 A review of financial accounts for residents who have monies in the trust fund account revealed Resident #77 still had a balance of $50.14 which was there since his death in [DATE]. This money was still in the facility accounts as of [DATE] when the survey began. Discussion with Employee #14, the bookkeeper, on the afternoon of [DATE] mid morning, revealed she had not returned any funds to the estate as there were still hearings being held to determine settlement of the estate. The funds were remaining in the account until this was decided. She confirmed the funds had not been dispersed to the estate of the individual nor the probate jurisdiction administering the estate.",2017-02-01
7860,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,160,D,0,1,ZN3T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of resident fund accounts, review of the facility's resident funds policy, and staff interview, the facility failed to convey a resident's personal fund to the individual administering the resident's estate within thirty (30) days of death. One (1) of five (5) resident fund accounts reviewed contained this error. Resident identifier: #64. Facility Census: 124. Findings include: a) Resident # 64 An interview was conducted with Employee # 93, the office manager, at 1:00 p.m. on [DATE]. She stated when a resident expired the money in their account was disbursed to the appropriate person within thirty (30) days of death. Final accounting for Resident #64's resident fund account was reviewed at 2:00 p.m. on [DATE]. The review revealed Resident #64 expired on [DATE]. The balance of Resident #64's personal fund account on [DATE] was $2793.07. The facility's resident funds policy states, Disbursement of monies will be done in accordance with state regulations. An interview was conducted with Employee #19, the facility bookkeeper, at 9:00 a.m. on [DATE]. Employee #19 reported they had missed this and had not sent the disbursement of the money to Resident #64's son. She reported they were in the process of doing it, but she was aware it had been longer than thirty (30) days since the resident's death.",2017-01-01
8218,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,160,D,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of discharged residents' financial account balances, medical record review, and staff interview, the facility failed to provide a final accounting and a refund of the balance of a resident's personal funds to the individual or probate administering the individual's estate within thirty (30) days of death. This was true for one (1) of three (3) discharged records reviewed for personal funds. Resident identifier: #122. Facility census: 112. Findings include: a) Resident #122 Medical record review found the resident expired at the facility on [DATE]. The resident's financial account was reviewed with Employee #59, the business office assistant, at 3:35 p.m. on [DATE]. Employee #59 verified a check was not issued for the balance of the resident's funds ($1,065.13) until [DATE]. At 5:00 p.m. on [DATE], the administrator stated the facility had to wait until the account was settled before issuing the funds and this was not always possible to refund a residents money within 30 days of death.",2016-07-01
8662,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-01-11,160,B,0,1,46GB11,"Based on review of residents' personal funds and staff interview, the facility failed to convey residents' funds, and to provide a final accounting of those funds, to the individual or probate jurisdiction administering the residents' estates. Instead, the facility paid the residents' funds to the funeral home and did not provide a final accounting of the residents' funds to a legally authorized individual or probate jurisdiction administering the estate. This practice affected three (3) of three (3) sampled residents. Resident identifiers: #2, #9, and #100. Facility census: 76. Findings include: a) Residents #2, #9, and #100 Review of the facility's personal funds accounting records found these three (3) residents' final accounts were paid directly to a funeral home. During an interview, on the afternoon of 01/11/12, a business office manager, Employee #63, confirmed when a resident passed away the facility did provide a final accounting of the residents' funds, and did not send the funds to the individual or probate jurisdiction administering the resident's estate. Employee #63 stated, All funds go directly to the funeral home.",2016-04-01
8829,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,160,B,0,1,5Y7411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility document reviews, staff interviews, and review of the facility's policy, the facility failed to convey personal funds within thirty (30) days after death for seven (7) deceased residents. Resident identifiers: #19, #22, #70, #66, #91, #96, and #97. Facility census: 100. Findings include: a) Residents #19, #22, #70, #66, #91, #96, and #97 Review of facility documentation. on [DATE] at 2:00 p.m., revealed that the facility failed to convey residents' personal funds within thirty (30) days of death. The documentation contained the following information: - Resident #19 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred-five (105) days after death. - Resident #22 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - seventy-nine (79) days after death. - Resident #66 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - fifty-two (52) days after death. - Resident #70 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - one hundred fifty-seven (157) days after death. - Resident #91 - date of death was recorded as [DATE] and funds conveyed by check on [DATE] - sixty-nine (69) days after death. - Resident #96 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - thirty-nine (39) days after death. - Resident #97 - date of death recorded as [DATE] and conveyance of funds by check not sent as of [DATE] - fifty (50) days after death. - During an interview on [DATE] at 2:15 p.m., the bookkeeper (Employee #83) stated she was new to the position since [DATE] and did not realize the facility was not in compliance with conveyance of resident personal funds within thirty (30) days of death, until a few days ago. During an interview on [DATE] at 9:00 a.m., Employee #120 (the interim director of nursing) and Employee #119 (the interim administrator) indicated they were aware of the facility's non-compliance with conveyance of funds and that Employee #83 was new to the position. - Review of the facility policy titled Distributions / Refunds and dated [DATE] indicates in the Procedure section, the following: discharged or deceased residents must be issued refund checks from the 'Trust Fund'. The Business Office Manager must ensure compliance with these regulations by quickly processing the request so that a check is issued according to state guidelines, but no longer than 30 days after discharge or death.",2016-03-01
9322,CRESTVIEW MANOR NURSING & REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2011-09-20,160,B,0,1,GVDH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of financial records and staff interview, the facility failed to convey the resident's funds and/or a final accounting of those funds within 30 days after the death of the resident for two (2) of eighteen (18) sampled residents with personal funds as required by State law. Resident identifiers: #3 and #150. Facility census: 62. Findings include: a) Residents #3 and #150 A review of the facility's financial records showing the balances in the resident trust accounts at the end of [DATE] revealed accounts for two (2) residents who had expired over thirty (30) days prior. During an interview with Employee #26 at 11:50 a.m. on [DATE], she stated Resident #3 had expired on [DATE], and a check for the balance of his account ($606.17) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence to reflect the resident's power of attorney (POA) had been issued a final accounting of the resident's personal funds. In a follow-up interview with Employee #26 with Employee #1 (the facility's office manager) at 3:00 p.m. on [DATE], they stated Resident #150 had expired on [DATE], and a check for the balance of his personal fund account ($414.61) had been issued to the facility for payment of outstanding room charges on [DATE]. There was no evidence this resident's POA had been issued a final accounting of the resident's personal funds.",2015-12-01
9607,HEARTLAND OF RAINELLE,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2010-03-05,160,D,0,1,I2AU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to convey, within thirty (30) days, personal funds for a resident who had expired. This was noted for one (1) of five (5) residents reviewed for this aspect of personal funds. The resident expired on [DATE]. As of [DATE], the funds had not been conveyed to the resident's estate. Resident identifier: A. Facility census: 55. Findings include: a) Resident A On [DATE], review of the resident funds, with the administrator, found an account balance of $831.68 for this expired resident, who expired on [DATE]. At 2:00 p.m. on [DATE], the administrator confirmed these funds had not yet been conveyed to the resident's estate.",2015-10-01
10440,"NELLA'S NURSING HOME, INC.",5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2011-03-16,160,E,0,1,JSOV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility had failed to convey the funds and a final accounting of those funds within thirty (30) days after the deaths of eight (8) residents. Resident identifiers: #86, #87, #88, #89, #90, #91, #92, and #93. Facility census: 66. Findings include: a) Residents #86, #87, #88, #89, #90, #91, #92, and #93 A review of resident trust fund records, in the presence of Employees #18 and #61 (business office employees who were responsible for the resident's personal fund accounts) at 2:30 p.m. on [DATE], revealed a discrepancy when attempting to reconcile the facility's records with the bank records. During an interview with Employee #61 at 3:45 p.m. on [DATE], she presented a list of residents, which she said had been furnished by the auditors employed by the facility, revealing account balances for eight (8) former residents who had died . She stated that, upon each resident's death, a check was mailed to the person listed in their record as their responsible party, but this check had never been acknowledged by return or by being cashed. There had been no follow-up to the initial check mailing. Employee #61 stated that she had not realized that these accounts still existed. The residents, the dates they expired, and the account balances were as follows: Resident #86 - [DATE] - $40.00 Resident #87 - [DATE] - $259.46 Resident #88 - [DATE] - $0.01 Resident #89 - [DATE] - $148.26 Resident #90 - [DATE] - $40.00 Resident #91 - [DATE] - $113.78 Resident #92 - [DATE] - $1.00 Resident #93 - [DATE] - $80.00 The total amount of funds that had not been conveyed was $682.51. The administrator, who arrived during the interview, stated she was not aware of these funds. She stated she was aware of the State law that unclaimed funds were to be forwarded to the Office of Unclaimed Properties after thirty (30) days. Additionally, there were nineteen (19) residents who had been discharged (but had not expired) between 2001 and [DATE], who continued to have monies in the facility-managed personal account fund. This amount totaled $3477.92. .",2015-04-01
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
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
2190,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-03-31,161,B,0,1,YOOX11,"Based on review of the surety bond, bank statements from the resident trust fund account and staff interview, the facility failed to ensure a surety bond was in place to cover the highest daily balance of the resident trust fund account. This failed practice has the potential to affect at least forty-six (46) residents who allow the facility to handle funds for them. Facility census: 58 Findings include: a) Interview with the Accounts Payable Employee #50, on 03/28/17 at 3:00 p m., revealed the surety bond was in the amount of $30,000. Bank statements from the resident trust fund account for the most recent quarter showed the highest daily balance from the account on (MONTH) 13, (YEAR) was for $30,343.05 which was above the surety bond amount. This was discussed with the Administrator, on 03/28/17 at 3:45 p.m. She was not aware the bond had not been sufficient and would check with financial services division of the facility to see if it had been increased. She returned shortly afterward and stated there had been no increase in the surety bond amount above $30,000 and verified the bond was not enough to cover that highest daily balance.",2020-09-01
3842,HOLBROOK HEALTHCARE CENTER,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2016-11-10,161,E,0,1,6GKK11,"Based on financial record review, review of the facility ' s Surety bond, and staff interview, the facility failed to maintain a Surety bond to ensure the security of all personal funds of residents deposited with the facility. This practice had the potential to affect more than a limited number of residents. Facility census: 92 Findings include: a) Resident Funds The Surety bond, reviewed on 11/07/16, revealed the facility had a bond for forty thousand dollars ($40,000.) Financial records, reviewed from 07/01/16 through 10/31/16 revealed the bond exceeded $40,000 as follows: $40,335.10 on 07/06/16 $41,182.72 on 07/07/16, $41,186.24 on 07/08/16, 07/09/16, 07/10/16, $41,174.24 on 07/11/16, 07/12/16 and 07/13/16 $43,084.03 on 08/03/16, $42,609.02 on 08/04/16, $43,294.02 on 08/05/16, 08/06/16, 08/07/16, $43,724.02 on 08/08/16, $41,498.81 on 09/02/16, 09/03/16, 09/04/16, 09/05/16, $42,668.34 on 09/06/16, $41,388.33 on 09/07/16, $40,331.50 on 10/05/16 and 10/06/16 The bookkeeper, interviewed on 11/07/16 at 5:30 p.m., said the facility had fifteen percent overage coverage on the Surety bond to cover over $40,000. On 11/08/16 at 9:30 a.m., upon request to provide confirmation of the overage coverage, the bookkeeper said she would have to check the front office. The administrator reviewed the Surety bond and bank statements and confirmed the facility did not have coverage for an amount over $40,000. The administrator related the bond had been changed, and verified the Surety bond was not sufficient to cover the Resident Trust funds.",2020-07-01
3914,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,161,E,0,1,VTNG11,"Based on financial record review and staff interview, the facility failed to purchase a Surety bond to ensure the security of all personal funds of residents deposited with the facility. Resident Funds accounts exceeded the amount of the surety bond. This practice had the potential to affect more than a limited number of residents. Facility census: 109. Findings include: a) The Surety bond, reviewed on 11/02/16, revealed a bond in the amount of one hundred twenty thousand dollars ($120,000). The bank statement daily balances, dated 07/01/16 through 10/31/16, reviewed on 11/03/16 at 8:55 a.m., noted balances in excess of the bond as follows: --$144,052.14 on 09/12/16 --$139,836.84 on 09/11/16, 09/10/16, and 09/09/16 --$140,068.84 on 09/08/16 --$140,168.84 on 09/07/16 --$141,794.92 on 09/06/16, 09/05/16, 09/04/16, 09/03/16, and 09/02/16 --$140,115.42 on 08/09/16 --$140,220.42 on 08/08/16 --$140,310.42 on 08/07/16, 08/06/16 and 08/05/16 --$139,880.50 on 08/04/16 and 08/03/16 --$128,339.92 on 07/06/16 --$128,150.22 on 07/05/16 --$126,230.47 on 07/04/16, 07/03/16, 07/02/16 and 07/01/16 The administrator acknowledged during an interview at about 10:30 a.m., the daily funds exceed the amount of the Surety bond.",2020-04-01
3965,FAIRMONT HEALTHCARE AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2017-06-30,161,E,0,1,25Q611,"Based upon review of facility documents and staff interview, the facility failed to have an approved surety bond to ensure the security of the residents' personal funds. This failed practice had the potential to affect one-hundred-six (106) residents having personal funds deposited in the care of the facility, and so had the potential to affect more than a limited number of residents. Facility census: 115. Findings include: a) The review of the facility's surety bond began on 06/28/17 at 9:30 a.m. A copy of the surety bond had been requested upon entrance. The facility provided a certificate listing the names of persons appointed as attorneys-in-fact to act to provide surety up to an amount of $2,000,000.00. There was no mention of the facility or its relationship to all or any portion of the amount specified. Clarification was requested from the Administrator on 06/28/17 at 10:00 a.m. She provided a second document entitled continuation certificate which stated a bond was in force in the amount of $76,000.00 for the facility's resident funds account for the period from 07/01/17 to 07/01/18. An approval of the bond, or a continuation approval of the facility's bond, by the West Virginia Attorney General was requested from the Administrator. She said the facility did not have such a document. She offered to contact the Office of Health Facility Licensure and Certification, the agency which facilitates the process of obtaining the required approval documentation of West Virginia nursing facilities from the Attorney General's office to find out the status of the facility's surety bond. She reported there was no approved surety bond in effect as required by statute due to the fact the bond was not submitted by the parent corporation in accordance with the provisions of the law.",2020-04-01
4164,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2016-02-05,161,E,0,1,5SB711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on facility record review and staff interview, the facility failed to ensure the security of all residents' personal funds deposited with the facility. The surety bond had not been continued and the rider for an increase in the amount of the surety bond had been denied by the Attorney General's office. This practice had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) Residents' Funds Review of the surety bond on [DATE] at 8:00 a.m., found no evidence of a current surety bond and continuation certificate, stamped as approved by the West Virginia Office of the Attorney General. An interview with the administrator on [DATE] at 8:46 a.m., confirmed the facility did not have an approved surety bond. The administrator related a rider had been requested for the amount of forty-five thousand dollars ($45,000.00), but had not been approved. She related the form was being returned due to it required an original signature and did not have one. A signature was required for acknowledgement by the principal if it was a corporation or limited liability company. Upon inquiry, the administrator indicated the original amount of the certificate was thirty-three thousand dollars ($33,000.00). When requested to see the approved certificate, the administrator related she did not have one. An interview with the Department of Health and Human Resources Specialist, Sr, with the Office of Inspector General, Office of Health Facility Licensure and Certification, on [DATE] at 10:57 a.m., revealed the continuation certificate had not yet been approved, and the certificate had expired on [DATE]. The expiration date was also noted in a letter to the facility dated [DATE]. Additionally, the residents' funds checking account bank statement for the previous quarter, reviewed on [DATE] at 9:00 a.m., revealed funds exceeded the amount of $33,000.00 on the dates of [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE].",2020-02-01
4794,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2015-11-04,161,E,0,1,KC5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's surety bond, interview with staff at the Office of Health Facility Licensure and Certification (OHFLAC), and staff interview, the facility failed to maintain an approved surety bond, or otherwise assure the security of all personal funds of residents deposited with the facility. This had the potential to affect the sixty-eight (68) residents for whom the facility managed a personal funds account. Facility census: 87. Findings include: a) During the survey in (MONTH) (YEAR), the facility provided a copy of its surety bond for resident trust funds. The policy term was from [DATE] to [DATE]. b) The facility did not have an approval letter from the Office of Health Facility Licensure and Certification (OHFLAC), and a copy of the surety bond as approved by the Attorney General's office. Each facility is required by State law to send their original bond to the Office of Health Facility Licensure and Certification, the holder of the bonds. OHFLAC, in turn, sends the original bonds to the Attorney General's office for review and approval each year. The Attorney General's office will stamp the bond once approved and return the original bond to OHFLAC. c) Upon request for the status of the bond on [DATE] at 3:41 p.m., confirmation was received from OHFLAC that the bond submitted by the facility expired on [DATE]. d) In an interview with the administrator, on [DATE] at 3:45 p.m., she said the bond was submitted today to OHFLAC via Fedex, but it would not arrive at OHFLAC, nor would it be approved by the Attorney General's office, prior to survey exit.",2019-07-01
5609,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2015-03-04,161,E,0,1,KF9N11,"Based on a review of the facility's surety bond, review of resident trust fund bank statements, and interview with the director of nursing, the facility failed to ensure its surety bond was sufficient to safeguard all personal funds residents had deposited with the facility. This had the potential to affect ten (10) of ten (10) residents for whom the facility handled funds. Facility census: 38. Findings include: a) Review of the resident trust fund bank statements for October, November, and (MONTH) 2014, on 03/03/15 at 10:15 a.m., revealed the highest daily balance for the most recent completed quarter was $18,505.67 on 12/02/14. The bond held by the facility to cover the trust fund account was for $10,000.00. This amount did not ensure sufficient coverage of the highest daily balance in the account. In an interview with the director of nursing (DON), on 03/04/15 at 12:45 p.m., the DON verified $10,000.00 was the correct amount of the surety bond.",2018-09-01
5804,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2014-10-16,161,E,0,1,T8L111,"Based on facility record review and staff interview, the facility failed to guarantee they could pay the residents for losses occurring from any failure by the facility to hold, safeguard, manage, and account for the residents' funds. The facility failed to secure a surety bond in an amount which covered all the funds held in the Resident Trust Fund account. This had the potential to affect any and/or all fifty (50) residents with personal funds deposited in the account. Facility census: 111. Findings include: a) A review of the bank statement for the Resident Trust Fund account, dated 09/30/14, revealed a balance in the account of $29,228.77. Further review revealed balances of $29,458.94 on 08/29/14, $28,441.19 on 07/31/14, and $31,042.00 on 06/30/14. The Surety Bond provided by Administration for review on 10/09/14, which was approved by the Attorney General of West Virginia, was for the amount of $18,000.00. During an interview with the Administrator (NHA), the Director of Nurses, and the Assistant Director of Nurses at 3:50 p.m. on 10/15/14, the NHA acknowledged the amount of the surety bond was not equal to the highest amount recorded in the account. He stated he would act on this immediately.",2018-07-01
5812,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2014-10-21,161,E,0,1,VUH711,"Based on review of facility records and staff interview, the facility failed to obtain a surety bond for an amount sufficient to guarantee payment for any loss of resident funds held, safeguarded, and/or managed by the facility. This had the potential to affect ninety-one (91) residents for whom the facility managed personal funds. Facility census: 115. Findings include: a) A review of the financial records of the facility revealed it had a surety bond in the amount of $75,000.00. At 12:10 p.m. on 10/15/14, a review of the bank statements for the last quarter (July, (MONTH) and (MONTH) 2014) revealed the residents' funds were deposited in a pooled account. This review revealed the following dates and balances which exceeded the surety bond amount of $75,000.00 (the balances listed are the highest balance for the day listed): -- 07/03/14- $91,533.72 -- 07/15/14- $76,295.74 -- 07/16/14- $78,879.64 -- 07/17/14- $76,205.74 -- 08/01/14- $99,767.53 -- 08/04/14- $75,560.63 -- 08/05/14- $75,974.76 -- 09/03/14- $86,666.09 An interview, with Business Office Manager #59 at 1:40 p.m. on 10/15/14, confirmed the facility's surety bond was for $75,000. She then reviewed the bank statements for the dates indicated and confirmed the balance of the resident trust fund account was greater than the surety bond on those dates She stated, We will have to get a new surety bond.",2018-07-01
6042,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-03-27,161,E,0,1,R3PM11,"Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the highest daily balance of the resident trust fund for February 2014. This had the potential to affect all 117 residents with a resident trust fund account. Facility census: 135. Findings include: a) On 03/24/14 at 3:00 p.m., review of the resident funds on deposit found the highest daily balance, according to the Account Summary for February 2014, balance was $69,988.73 on 02/07/14. The facility's current surety bond was for $60,000.00. The bond was insufficient to cover the resident trust fund accounts of the one hundred seventeen (117) residents who had a trust account with the facility. b) On 03/24/14 at 3:30 p.m., an interview was completed with Employee #152 (Business Office Manager), she acknowledged the daily balance on 02/07/14 of $69,988.73 had exceeded the amount of the current surety bond.",2018-05-01
6238,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2014-08-14,161,E,0,1,EXXT11,"Based on financial record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover the total amount of residents' funds as of the most recent quarter. This had the potential to affect all residents with a resident trust fund account with the facility. Fifty (50)residents had a personal funds account with the facility. Facility census: 50. Findings include: a) On 08/12/14 at 10:00 a.m. a review of the resident funds on deposit revealed the most recent quarterly balance, according to the Account Summary, was April 2014: $16,595.24; May 2014: $15,030.23; and June 2014: $16,655.19. The facility's current surety bond was for $10,000.00. The bond was insufficient to cover the resident trust fund accounts of the fifty (50) residents who had a trust fund account with the facility. b) On 08/12/14 at 10:30 a.m., an interview was conducted with Employee #100 (Business Office staff). Employee #100 acknowledged the account summary balances for the most recent quarter had exceeded the amount of the current surety bond.",2018-04-01
6332,DAWN VIEW CENTER,515163,PO BOX 686,FORT ASHBY,WV,26719,2014-07-09,161,D,0,1,2M0C11,"Based on facility record review and staff interview, the facility failed to ensure the security of the personal funds accounts of the thirty-nine (39) residents with funds held by the facility. The facility failed to secure a surety bond of an amount large enough to cover losses occurring from any failure by the facility to safeguard the residents' funds. Facility census: 66. Findings include: a) A copy of the facility's surety bond, approved by the State in the amount of $50,000.00, was provided for review on 06/26/14. A review of the bank statement, for the period of May 1, 2014 - May 31, 2014, which contained the personal funds of 39 residents of the facility, was completed at 9:45 a.m. on 07/03/14 in the presence of Employee #50 (person designated as responsible for the resident funds) and the Administrator. The bank statement indicated the account balance exceeded the amount of the surety bond on 05/02/14, with a posted balance of $50,851.52, and on 05/05/14 with a posted balance of $51,093.76. The Administrator acknowledged the accuracy of the figures after reviewing the statement and stated she would arrange for an increase in the bond amount as soon as possible.",2018-04-01
6350,E.A. HAWSE NURSING AND REHABILITATION CENTER,515173,18086 STATE ROUTE 55,BAKER,WV,26801,2014-04-15,161,E,0,1,D8L411,"Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover all of the funds. This had the potential to affect all 57 residents with a resident trust fund account. Facility census: 70. Findings Include: a) A review of resident funds on deposit with the facility at 10:30 a.m., on 04/15/14, found the facility's current surety bond was for a sum of $19,000.00 with the term beginning 07/26/13 and ending 07/26/14. Review of the resident fund accounts beginning 07/26/13 and ending 03/31/14 revealed the following months beginning balance being greater than the $19,000.00 surety bond: September 2013 with a beginning balance of $22,229.82, November 2013 with a beginning balance of $23,432.96, February 2014 with a beginning balance of $20,943.12, and March 2014 beginning balance of $22,306.25. On 04/15/14 at 11:50 a.m. during an interview with the business office supervisor, (Employee #33), she acknowledged the amount of money in the resident trust account was higher than the surety bond's coverage.",2018-04-01
6355,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,161,E,0,1,OMIN11,"Based on review of facility records and staff interview, the facility failed to obtain a surety bond for an amount sufficient to guarantee payment for any loss of resident funds held, safeguarded, and/or managed by the facility. This had the potential to affect fifty-five (55) residents for whom the facility managed personal funds. Facility census: 61. Findings include: a) A review of the financial records of the facility revealed it had a surety bond in the amount of $25,000.00. At 3:45 p.m. on 05/22/14, a review of the bank statements for the last quarter (January, February, and March 2014) revealed the residents' funds were deposited in a pooled account. The bank was unable to provide the facility with a statement that revealed the daily balance. A review of the monthly statements revealed the facility had balances that were greater than $25,000.00, the amount of the survey bond, on at least two (2) days. On 02/03/14 there was a balance of $26,989.80, and on 03/07/14 there was a balance of $27,634.80. On these dates, the account balance exceeded the total coverage afforded by the surety bond. An interview was conducted, at 11:15 a.m. on 05/29/14, with Employee #70, the nursing home administrator. He was informed of the two (2) days in which the total account balance in the residents' funds account exceeded the amount of the surety bond. No other information was provided by the end of the survey on 06/02/14.",2018-04-01
6540,MAIN STREET CARE,5.1e+155,"189 SUMMERS HOSPITAL ROAD, SUITE 300",HINTON,WV,25951,2013-10-18,161,E,0,1,XUI411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the resident funds ledger and staff interview, the facility failed to purchase a surety bond, or otherwise provide assurance satisfactory to the Secretary, to assure the security of all personal funds of residents deposited with the facility. The facility managed the funds for twenty-five (25) residents. Twenty-three (23) of the twenty-five (25) residents were current residents of the facility and two (2) had recently expired. The facility still had money in the accounts of the expired residents. The failure to secure a surety bond had to the potential to affect the funds of all the twenty-five (25) resident fund account holders. Resident Identifiers: #18, #17, #21, #16, #23, #20, #29, #27, #33, #25, #10, #22, #2, #30, #11, #31, #8, #5, #9, #14, #7, #26, #15, #19, and #4. Facility Census: 25. Findings Include: a) Resident #18 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #18 had a resident account managed by the facility with a balance of $78.81. b) Resident #17 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #17 had a resident account managed by the facility with a balance of $50.00. c) Resident #21 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #21 had a resident account managed by the facility with a balance of $31.31 d) Resident #16 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #16 had a resident account managed by the facility with a balance of $78.31. e) Resident #23 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #23 had a resident account managed by the facility with a balance of $461.25. f) Resident #20 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #20 had a resident account managed by the facility with a balance of $212.55. g) Resident #29 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #29 had a resident account managed by the facility with a balance of $57.86. h) Resident #27 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #27 had a resident account managed by the facility with a balance of $110.35. This resident expired at the facility on [DATE]. i) Resident #33 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #33 had a resident account managed by the facility with a balance of $39.80. j) Resident #25 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #25 had a resident account managed by the facility with a balance of $86.51. k) Resident #10 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #10 had a resident account managed by the facility with a balance of $100.00. l) Resident #22 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #22 had a resident account managed by the facility with a balance of $924.88. m) Resident #2 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #2 had a resident account managed by the facility with a balance of $444.79. n) Resident #30 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #30 had a resident account managed by the facility with a balance of $57.50. o) Resident #11 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #11 had a resident account managed by the facility with a balance of $3.00. This resident expired at the facility on [DATE]. p) Resident #31 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #31 had a resident account managed by the facility with a balance of $669.06. q) Resident #8 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #8 had a resident account managed by the facility with a balance of $59.00. r) Resident #5 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #5 had a resident account managed by the facility with a balance of $296.14. s) Resident #9 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #9 had a resident account managed by the facility with a balance of $663.17. t) Resident #14 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #14 had a resident account managed by the facility with a balance of $7.00. u) Resident #7 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #7 had a resident account managed by the facility with a balance of $456.27. v) Resident #26 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #26 had a resident account managed by the facility with a balance of $69.40. w) Resident #15 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #15 had a resident account managed by the facility with a balance of $85.45. X) Resident #19 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #19 had a resident account managed by the facility with a balance of $573.74. y) Resident #4 The facility's resident fund ledger was reviewed at 2:00 p.m. on [DATE]. This review revealed Resident #4 had a resident account managed by the facility with a balance of $18.00. z) An interview with Employee #20, the business office manager, at 9:15 a.m. on [DATE], revealed the facility did not have a surety bond in place. She stated they had applied for one, but the company had requested additional information which they were working on getting together. She stated it was an ongoing process which had not yet been completed.",2018-02-01
6595,SPRINGFIELD CENTER,515188,10797 SENECA TRAIL SOUTH,LINDSIDE,WV,24951,2014-04-24,161,E,0,1,LCKP11,"Based on review of residents' funds accounts, review of the facility's current surety bond, and staff interview, the facility failed to ensure the amount of the surety bond was sufficient to cover the residents' funds. This had the potential to affect each of the 28 residents for whom the facility managed personal funds. Facility census: 51. Findings include: a) Review of the surety bond, at 11:00 a.m. on 04/23/14, revealed it was in the amount of $35,000.00. b) On 04/23/14, the business office manager, Employee #59, provided the daily balances of the 28 residents for whom the facility managed funds. Review of this information revealed a balance of $36,032.40 on 02/03/14. On 03/03/14 the resident funds balance was $36,456.57. c) On 04/23/14 at 1:03 p.m., an interview was conducted with the administrator, Employee #1, regarding the surety bond. She was shown the surety bond did not cover the full amount of residents' personal funds managed by the facility for the dates of 02/03/14 and 03/03/14. The administrator said, Okay.",2018-01-01
6812,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-02-20,161,E,0,1,SDOD11,"Based on record review and staff interview, the facility failed to guarantee the security of all personal funds deposited with the facility. The facility did not have a surety bond of sufficient value to cover all of the funds. This had the potential to affect all fifty-one (51) residents with a resident trust fund account. Facility Census: 85. Findings include: a) A review of resident funds on deposit with the facility, at 2:00 p.m. on 02/18/14, found the facility's current surety bond (# 9358) was for a sum of $30,000.00. An account summary for January 2014 had an average ledger balance of $33,310.60 and an average available balance of $32,775.69. Further review, on 01/06/14, noted the account balance was $50,309.40. In a discussion with the Administrator and Employee #112, Bookkeeper, on 02/18/14 at 4:00 p.m., they both acknowledged the amount of money in the resident trust account was higher than the surety bond's coverage and stated they would apply for an increase in surety bond.",2017-11-01
6915,WORTHINGTON NURSING AND REHABILITATION CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2014-02-06,161,E,0,1,WX3211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to maintain a surety bond to protect resident funds managed by the facility for ninety-six (96) of one hundred (100) residents. The facility's surety bond expired; however, the facility had not made arrangements for a new one. This practice had the potential to affect all residents for whom the facility handled funds. Facility census: 100. Findings include: a) An interview was conducted with the administrator on [DATE] at 4:45 p.m. When asked, she said the facility's surety bond had expired. She said generally the surety bond was automatically renewed the first of January annually, but for some reason this did not happen this year (2014). At 3:30 p.m. on [DATE], an interview was completed with Employee #5, who works in the facility's accounting division. She produced a reconciliation of accounts. Employee #5 said the facility manages personal funds for ninety-six (96) residents. The amount of the individual resident accounts totaled $18,914.03 at this time. She agreed the surety bond expired on [DATE]. The amount of the expired surety bond was $30,000. On [DATE] at 3:30 p.m., the administrator said the facility was beginning the process this week of obtaining a current surety bond.",2017-10-01
6966,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2013-11-12,161,E,0,1,X5R211,"Based on staff interview and record review, the facility failed to ensure the security of resident personal funds. The amount of the surety bond was not sufficient to cover the highest account balance of the resident funds account. This was true for sixty-five (65) of sixty-five (65) residents whose funds were handled by the facility. Facility census: 95 Findings include: a) The current surety bond provided by the facility, dated 12/26/12, was for $35,000.00. A review of the transaction history for the resident funds account was completed on 11/06/13. There were multiple days over the past six (6) months with a daily balance exceeding the surety bond amount. On 10/07/13 the daily balance of the account was $63,183.93. This was discussed with the Administrator at 11:00 a.m. on 11/07/13. She acknowledged the current surety bond amount was not sufficient. She stated the facility had applied to increase the amount. She provided a copy of the new bond at that time for an amount of $62,500.00. This was still not sufficient to cover the highest single daily account balance.",2017-09-01
7065,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2014-07-14,161,E,0,1,U25211,"Based on review of facility records, surety bond review, and staff interview, the facility failed to obtain a surety bond for an amount sufficient to guarantee payment for any loss of resident funds held, safeguarded, and/or managed by the facility. The amount of the facility's surety bond was not sufficient to cover the highest daily balance during the most recent quarter. This had the potential to affect thirteen (13) residents for whom the facility managed personal funds. Resident identifiers: #5, #24, #59, #4, #47, #8, #44, #21, #18, #40, #16, #9, and #14. Facility census: 64. Findings include: a) Residents #5, #24, #59, #4, #47, #8, #44, #21, #18, #40, #16, #9, and #14. A review of the financial records of the facility on 07/09/14 at 8:45 a.m., revealed the facility had a surety bond in the amount of $20,000.00. The surety bond was listed as effective until 06/18/16. At 9:00 a.m. on 07/09/14, a review of the bank statements for the last quarter revealed the residents' funds were deposited in a pooled account. A review of the monthly statements revealed the account had a balance greater than $20,000.00, the amount of the surety bond, on one (1) day. On 04/04/14, there was a balance of $26,874.46. On that date, the account balance exceeded the total coverage afforded by the surety bond. An interview was conducted on 07/09/14 at 9:00 a.m. with the billing office clerk (Employee #78) and at 11:14 a.m. on 07/09/14 with the administrator. At these times the administrator and billing office clerk were informed of the insufficient amount of the surety bond. No further information was provided by the end of the survey on 07/14/14.",2017-09-01
7129,WYOMING NURSING AND REHABILITATION CENTER,515164,236 WARRIOR WAY,NEW RICHMOND,WV,24867,2014-01-10,161,E,0,1,XBZ111,"Based on facility record review and staff interview, the facility failed to obtain a surety bond of a sufficient amount to guarantee payment for any loss of residents' funds held, safeguarded, and/or managed by the facility. This had the potential to affect fifty-one (51) residents who had personal funds managed by the facility. Facility census: 53. Findings include: a) A review of the financial records of the facility revealed it had a surety bond in the amount of $28,000.00. A review of the fifty-one (51) residents' accounts (which were active on 01/09/14) revealed a cumulative total account balance of $27,063.75. At 1:45 p.m. on 01/09/14, this amount was verified by Employees #59 (Business office assistant) and #47 (Business office supervisor), the employees responsible for overseeing the accounts. A review of the bank statements, for the months ending on 10/31/13 and 11/30/13, revealed the residents' funds were deposited in a pooled account. The Daily Balance Summary revealed the following daily balance amounts: -- 10/31/13 - the amount was $41,418.54 -- 11/04/13 - the amount was $39,408.54 On these dates, the account balance exceeded the total coverage afforded by the surety bond. During an interview at 2:45 p.m. on 01/09/14, with Employees #47, business office supervisor, and #89, vice-president of operations (responsible for overseeing the accounts), and Employee #140 (assistant administrator), Employee #141, explained that all of the residents' incoming funds were deposited into this floating account and held there for up to several days before the facility withdrew the portion of funds required to pay the monthly bills. She stated this was done this way to ensure maximum interest accumulation. She verified these daily balances were typical for each month. Employees #140, and Employee #141 acknowledged that on these four (4) days, the total account balance exceeded the amount of the surety bond.",2017-08-01
7304,WAYNE NURSING AND REHABILITATION CENTER,515168,6999 ROUTE 152,WAYNE,WV,25570,2013-09-27,161,E,0,1,M85T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to maintain an approved surety bond, or otherwise assure the security of all personal funds of residents deposited with the facility. This was found for the eighteen (18) residents for whom the facility managed a personal funds account. Facility census: 58. Findings include: a) During the survey, the facility provided a copy of their surety bond for resident trust funds in the amount of $20,000.00. The policy term was from [DATE] to [DATE]. b) The facility did not have an approval letter from the Office of Health Facility Licensure and Certification and a copy of the surety bond as approved by the Attorney General's office. Each facility is required by State law to send their original bond to the Office of Health Facility Licensure and Certification (OHFLAC), the holder of the bonds. OHFLAC, in turn, sends the original bonds to the Attorney General's office for review and approval each year. The Attorney General's office stamps the bond once approved and returns the original bond to OHFLAC. c) Upon request for the status of the bond on [DATE] at 2:00 p.m., confirmation was received from OHFLAC that the bond was submitted by the facility on [DATE], but that corrections to the original documents were required for approval by the Attorney General. OHFLAC reported the corrected documents or the original surety bond had not been received from the facility so it could be submitted to the Attorney General's Office for approval. The approved bond expired on [DATE]. d) An interview was conducted with administrator, Employee #76, on [DATE] at 2:59 p.m. She confirmed the required corrected documents had not yet been submitted.",2017-06-01
7312,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2013-08-22,161,B,0,1,E42711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, communication with the state agency office, and review of the surety bond information, it was determined the facility does not have a currently approved surety bond to cover resident funds being held by the facility. This practice has the potential to affect each of the twenty-eight (28) residents who have funds managed by the facility. Facility census: 54. Findings include: a) Interview with Employee #71, the office manager, on [DATE] at 10:00 a.m., revealed the facility had a continuation certification letter from the insurance company who issued the surety bond for the facility. Review of the letter indicated the bond, for a specified amount, was in effect from [DATE] until [DATE]. This continuation notice did not contain a seal or letter from as required from the necessary state agencies to indicate it was approved and effective. Contact with the state survey agency office revealed the most current information on file showed the facility's bond expired in 2012. No other surety bond or evidence of a continuation had been submitted and approved by the state agency or the attorney general's office. Further discussion with Employee #71 indicated the facility had not submitted the most recent continuation certificate letter to the necessary agencies for proper approval.",2017-06-01
8296,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,161,F,0,1,TTVD11,"Based on facility record review and staff interview, the facility failed to provide a surety bond approved by the appropriate state agency, as required by West Virginia (WV) State Law, to ensure compensation of the resident for any loss of residents' funds managed by the facility. This had the potential to affect all residents (36) with funds managed by the facility. Facility census 52. Findings include: a) Review of facility records, at 1:30 p.m. on 07/17/12, failed to show evidence that the $37,000.00 surety bond on file, for protection of the residents' funds being managed by the facility, had been submitted and approved by the WV Attorney General's Office. The Trial Balance of the Resident Fund account, provided by Employee #22 (Office Manager), indicated, Balances as of: 07/16/12 shows a balance in the account of: $11,220.08. An inquiry to the State office was made. An email, received at 2:15 p.m. on 07/17/12, stated the agency had no surety bond issued for this facility since 2010. It is required annually. During an interview with Employee #37 (Administrator) and Employee #22 who is responsible for handling residents' funds, at 9:15 a.m. on 07/18/12, they acknowledged the statement was correct. Employee #37 stated he had already informed the corporate office and this would be rectified as soon as possible.",2016-07-01
8729,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY STREET,HARRISVILLE,WV,26362,2012-04-12,161,E,0,1,QOYO11,"Based on review of facility documents and staff interview, the facility failed to provide a surety bond sufficient to ensure compensation of the resident for any loss of residents' funds managed by the facility. This had the potential to affect all residents with funds managed by the facility. Facility census: 54. Findings include: a) A review of facility documents, at 1:00 p.m. on 04/11/12, revealed the surety bond on file for protection of the residents' funds being managed by the facility was in the amount of $5000.00. The trial balance of the resident fund account, provided by Employee #31, reflected a balance of $5830.66 as of 04/09/12. The administrator (Employee #1) and Employee #31, who was responsible for handling the residents' funds, were interviewed at 3:00 p.m. on 04/11/12. They acknowledged the statement was correct. The administrator agreed the total account balance exceeded the coverage amount of the current surety bond.",2016-04-01
8805,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2012-03-08,161,D,0,1,SUZB11,"Based on facility record review and staff interview, the facility failed to provide adequate surety, as required by West Virginia state law, to ensure compensation of the resident for any loss of the resident's funds that were managed by the facility. This had the potential to affect more than a limited number of residents with funds managed by the facility. Facility census: 106. Findings include: a) Review of facility records, at 10:00 a.m. on 03/07/12, revealed the Surety Bond on file for protection of the residents' funds being managed by the facility was in the amount of $50,000.00. The trial balance of the Resident Fund account, provided by Employee #24, indicated: Balances as of: 03/05/12 reflected a balance in the account of: $59,080.41. During an interview with the administrator, at 10:15 a.m. on 03/07/12, she acknowledged the statement was correct and reflected the total early in the month prior to the disbursement of the monthly room charges. The administrator agreed the total exceeded the coverage amount in the current Surety Bond. The administrator stated she would contact the corporate office immediately.",2016-03-01
9468,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-02-02,161,B,0,1,U0V411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's continuation certificate and staff interview, the facility failed to provide evidence that the facility's surety bond had been reviewed (for sufficiency of form and amount) and approved by the Attorney General's Office for the funds of eleven (11) residents that were being managed by the facility. Review of the continuation certificate found it had not been submitted for review and approval by the Attorney General's Office; therefore, this facility was managing residents' personal funds without an approved surety bond. Facility census: 63. Findings include: a) Review of the facility's surety bond continuation certificate revealed a lack of evidence that it had been reviewed, for sufficiency of form and amount, by the West Virginia Attorney General's Office. Review of the facility's surety bond, held by the Office of Health Facility Licensure and Certification (OHFLAC), found the last surety bond that had been approved through the Attorney General's Office (#B 895) had expired on [DATE]. During a telephone interview on [DATE] at 2:00 p.m., the facility's office manager (Employee #31) confirmed the facility had not submitted the continuation certificate to OHFLAC for review and approval by the Attorney General's Office. Facility records revealed the facility managed funds for eleven (11) residents, and their current high balance for the month of January, 2011 was $1,300.00. Review of the continuation certificate noted the amount of the bond was for $20,000.00.",2015-11-01
9496,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-06-22,161,E,0,1,DLX411,"Based on a review of the facility's surety bond and staff interview, the facility failed to provide a surety bond in amount sufficient to assure the security of all personal funds of residents deposited with the facility. During a review of the surety bond, with an effective date of 05 August 2010 to 05 August 2011, it was discovered the bond was in the amount of three thousand ($3,000.00) dollars. During a review of the Resident Trust Trial Balance Report dated 05/01/2011 thru 06/22/2011, it was discovered the current ending balance was $3,245.43, which is above the amount of the surety bond. This practice fails to assure the security of all personal funds of residents deposited with the facility as required and has the potential to affect fourteen (14) residents who have deposited funds with this facility. Facility census:47. Findings include: a) Review of the facility's surety bond, with an effective date of 08/05/10 to 08/05/11, revealed the bond was in the amount of three thousand ($3,000.00) dollars. Review of the Resident Trust Trial Balance Report, dated 05/01/2011 thru 06/22/2011, found the current ending balance was $3,245.43, which exceeded the amount of the surety bond. An interview with the facility's office manager (Employee #55), on 06/22/11 at 10:50 a.m., confirmed the amount of the surety bond was not sufficient to cover the balance of the resident funds for the fourteen (14) residents who have deposited funds with the facility.",2015-11-01
9527,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2011-05-24,161,E,0,1,OXPS11,"Based on facility record review and staff interview, the facility failed to obtain a surety bond of an amount sufficient to guarantee payment for any loss of residents' funds held, safeguarded, and/or managed by the facility. This has the potential to affect sixty-four (64) residents who have personal funds managed by the facility. Facility census: 103. Findings include: a) A review of the financial records of the facility reveal that they have a surety bond in the amount of $40,000.00. A review of the sixty-four (64) residents' accounts (which were active on 04/30/11) revealed a cumulative total account balance of $17,164.12. At 3:45 p.m. on 05/18/11, this amount was verified by Employees #141 and #142, who were responsible for overseeing the accounts. A review of the bank statement for the month ending on 04/30/11 revealed the residents' funds were deposited in a pooled account. The Daily Balance Summary revealed the following daily balance amounts: - 04/26/11 - $53,278.93 - 04/27/11 - $53,244.37 - 04/29/11 - $53,384.24 - 04/30/11 - $53,389.06 On these dates, the account balance exceeded the total coverage afforded by the surety bond. During an interview at 3:45 p.m. on 05/18/11 with Employees #141 and #142 (responsible for overseeing the accounts) and Employee #140 (assistant administrator), Employee #141 explained that all of the residents' incoming funds were deposited into this floating account and held there usually for several days before the facility withdrew the portion of funds required to pay the monthly bills. She stated this was done this way to ensure maximum interest accumulation and verified these daily balances were typical for each month. Employees #140, #141, and #142 acknowledged that, on these four (4) days, the total account balance exceeded the amount of the surety bond.",2015-10-01
9637,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,161,E,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and interview with a representative of the State licensure agency (agency designated to as holder of surety bonds for State-licensed nursing homes), the facility failed to assure the security of all personal funds of residents deposited with the facility. This was true for sixty-five (65) residents whose accounts were reviewed. Facility census: 105. Findings include: a) When reviewed on [DATE] at 1:00 p.m., the surety bond submitted by the facility (bond # 6703) was found to have no stamp or signature indicating approval by the State Attorney General's Office for sufficiency of form and amount. When asked for a letter indicating the bond had been approved by the Office of Health Facility Licensure and Certification (OHFLAC), the facility's administrator (Employee #1) indicated the facility had recently sent the original bond to the State Attorney General's Office. The administrator provided an e-mail from the Genesis Health Care corporate office, which was sent to him on [DATE], stating the original bond was just sent to the state. A telephone call was made to OHFLAC on [DATE] at 2:00 p.m., inquiring as to whether the bond had been received in OHFLAC and approved by the State Attorney General's Office. A return e-mail, on [DATE] at 4:00 p.m., stated, Surety bond number 6703 was set to expire on [DATE]. The facility has submitted a renewal bond which was stamped as received in the office on [DATE]. This renewal bond has not yet been approved by the Attorney General's Office. The facility did not have a surety bond in effect at the time of the survey, and the renewal certificate had not been requested until after the original bond had expired. This information was shared with the facility's administrator at 9:00 a.m. on [DATE], and her voiced understanding.",2015-10-01
9669,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-12-03,161,E,0,1,U6B111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and interview with a representative of the State survey agency (the holder of all surety bonds), the facility failed to procure a surety bond approved by the State Attorney General as required by State law, to assure the security of all personal funds of residents deposited with the facility. This has the potential to affect all forty-nine (49) residents with funds deposited with the facility. Facility census: 102. Findings include: a) When reviewed on [DATE] at 1:00 p.m., the surety bond provided by the facility (bond # 7886) was found to have no stamp or signature indicating review and approval by the State Attorney General. When asked for evidence the bond had been approved, the administrator (Employee #128) related that the facility had no approval letter. This surveyor conducted a telephone interview with a representative of the State survey agency (the holder of all surety bonds for resident trust funds in WV nursing facilities) at 2:00 p.m. on [DATE], at which time the representative asked that a copy of the facility';s surety bond be faxed for review. A return telephone call, on [DATE] at 2:40 p.m., revealed the only bond on file with the State survey agency was bond # 7407, which expired on [DATE]. Bond # 7886 had not been reviewed, for sufficiency of form and amount, and approved by the State Attorney General as required.",2015-10-01
10084,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,161,E,0,1,FFCS11,". Based on record review and staff interview, the facility failed to obtain a current surety bond to protect all personal funds of residents deposited with the facility. This had the potential to affect all residents who elected to have their funds managed by the facility. Facility census: 112. Findings include: a) Shortly after entrance to the facility, facility staff provided requested information regarding the surety bond. Review of the surety bond revealed an accompanying letter from the Office of Health Facility Licensure and Certification (OHFLAC - the State agency designated to serve as the holder of such bonds for nursing homes in WV) dated 01/11/10, relaying a request from the Attorney General's Office to make necessary corrections and return the surety bond to the OHFLAC. Furthermore, the letter instructed the facility to contact the Attorney General's Office for any further questions regarding the corrections. Interview with the business office director (Employee #3), on 03/04/10 at 9:30 a.m., revealed the surety bond was signed by the representative authorized by the corporation to do so, although he was neither the president or vice-president of the corporation nor owner or general partner of the company as specified by the Attorney General's office. She said the corporate office takes care of this, not the facility, and they were in the process of trying to clarify this. On 03/04/10 at 10:15 a.m., a representative from OHFLAC, when interviewed, reported that, as of this date, the facility's surety bond covering the period of 08/15/09 through 08/15/10 had not been approved by the Attorney General's Office. .",2015-07-01
10760,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2009-06-25,161,E,0,1,667112,"Based on a review of the facility's surety bond and staff interview, the facility failed to obtain an approval by the WV Office of Attorney General (AG) for the surety bond after the amount of the bond was increased. This practice has the potential to affect at least fifty-one (51) residents. Facility census: 77. Findings include: a) A review of the facility's surety bond revealed the facility had increased the amount of the bond from $20,000 to $40,000 to assure the security of the residents' personal funds. There was no evidence this new surety bond had been approved by the AG for sufficiency of form and amount, as required. The administrator verified, at 09/07/09 at 4:00 p.m., the bond with the new amount had not been approved by the AG's office. .",2014-12-01
11150,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,161,E,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to obtain a surety bond in sufficient amount to assure the security of all personal funds of residents deposited with the facility. This had the potential to affect any residents who utilized the facility to keep their personal account funds. Facility census: 50. Findings included: a) A review of information provided by the administrator, on [DATE], found the facility did not have a current surety bond to assure the security of all personal funds of residents deposited with the facility. This was verified via e-mail communication on [DATE] with the Office of Health Facility and Certification, the State agency designated as holder of surety bonds for nursing facilities. A surety bond in the amount of $2500.00 (Bond # SU,[DATE]) expired on [DATE], and it was not renewed. The total of resident funds deposited at the facility was $1474.51. On [DATE] at 5:30 p.m., the administrator reported the facility had $100,000 liability insurance, he but could not find any other information regarding this prior to exit at 7:00 p.m. on [DATE]. --- NOTE: Commercial insurance may only be used to secure resident funds when specific conditions outlined in W.V. Code are met. For example, according to W.V.C. ,[DATE]C-7, ""This insurance policy shall specifically designate the resident as the beneficiary or payee (sic) reimbursement of lost funds."" .",2014-08-01
11205,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2009-12-03,161,E,0,1,TDS111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain a surety bond to assure the security of all personal funds deposited with the facility; the current surety bond expired on [DATE]. This has the potential to affect all forty-five (45) residents for whom the facility currently handles personal funds. Facility census: 116. Findings include: a) A review of the facility's current surety bond found it had expired on [DATE]. The survey began on [DATE]. There was no evidence that a certificate of continuation had been submitted to the State survey agency or approved by the State attorney general's office as required by State law. Discussion with the administrator, on the afternoon of [DATE], confirmed the surety bond had not been renewed as of this date. The facility handles the personal funds of forty-five (45) current residents. .",2014-07-01
3896,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2016-09-23,163,D,0,1,0MB311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to ensure Resident #170 was afforded the right to choose her personal physician upon admission to the facility. This was true for one (1) of four (4) residents reviewed for the care area of [MEDICAL TREATMENT]. Resident Identifier: #170. Facility Census: 178. Findings Include: a) Resident #170 A review of Resident #170's medical record at 4:00 p.m. on 09/23/16, found she had two (2) recent admissions to the facility. She was admitted on [DATE], discharged to the hospital 08/12/16 and was readmitted on [DATE]. Review of the admission orders [REDACTED]#272). Resident #170's record contained a history and physical completed by DO #272 which on 08/23/16. This History and Physical contained the following statement, Patient admitted to my services but requests to be changed to (Name of attending Medical Doctor (MD) #273 as he is her regular provider. Review of the nursing progress notes found a note dated 08/27/16 at 9:42 a.m. stating, (Name of MD #273) arrived at facility identifying patient as a long time patient of his, he requested patient be switched from (Name of DO #272) to his care in facility. Also contained in Resident #170's medical record was a form titled, Consent for Treatment and Release of Information. This form indicated that Resident #170 had designated MD #273 as her attending physician, however his name was marked out and replaced with DO #272's name. This form was signed by the resident on 08/12/16. The name of the physician was changed by the nurse completing the form and it was unknown if it was done prior to or after the resident signed the form. An interview with Resident #170 at 4:15 p.m. on 09/23/16, confirmed she was not given a choice of physician upon admission to the facility. She stated, I had one Doctor when I first got here because I did not know (Name of MD #273) came here. When I found out he came here I told them I wanted to be switched and they switched me. She stated, He has been my Doctor for a long time and he knows all about me and I really like him. An interview with the Director of Nursing (DON) at 4:44 p.m. on 09/23/16, confirmed Resident #170 was admitted to the services of DO #272 upon her admission on 08/12/16 and 08/22/16. She stated that the nurses are to list the names of all three physician's and let the resident choose which physician they want. She confirmed Resident #170 was not switched to MD #273's services until 08/27/16 when MD #273 visited the facility and requested she be changed to his services.",2020-04-01
7748,CLAY HEALTH CARE CENTER,515142,1053 CLINIC DRIVE,IVYDALE,WV,25113,2013-04-16,163,F,0,1,KUG911,"**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 had the right to choose a personal attending physician. The facility's physician changed. None of the residents were given sufficient notice to make a choice regarding whether or not they wanted to use the physician chosen by the facility, attempt to find one on their own, and/or transfer to a facility in which a physician of their choice practiced. This practice affected all residents residing in the facility. Facility census: 57 Findings include: a) Interview with Employee #47, the social services supervisor, the afternoon of 04/09/13, revealed the facility had a new physician as of Monday 04/08/13. Upon inquiry about notification of residents, families, and/or responsible parties, Employee #47 stated the facility notified them by mail on Friday 04/05/13 (three (3) days prior to the change). Further interview revealed the previous physician gave the facility a 30 day notice he/she would no longer be [MEDICATION NAME] at the facility. This short notice was not sufficient notice for each resident, family, and/or responsible to make a choice regarding whether or not they wanted to use the physician chosen by the facility, attempt to find one on their own, and/or transfer to a facility in which their physician of choice practiced.",2017-02-01
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
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
402,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2017-08-08,164,D,1,1,FUQO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to offer privacy during a medical treatment and ensure medication packets with pharmacy labels were disposed of in a manner that protected personal, medical, and health information. Personal identifiers including a resident's name, physician, diagnosis, and medication were listed on the pharmacy labels. These were random observations. Resident identifiers: #74, #89, and #108. Facility census: 98. Findings include: a) Medication Packets A random observation of the West Hall on 08/01/17 at 12:20 p.m. revealed three (3) visible empty medication cards/packets in the trash can of the medication cart. The following medication cards contained the resident's full name, physician, diagnosis, and medication orders [REDACTED] -Resident #89-Entacapone 200 mg-1 tablet four times a day for [MEDICAL CONDITION] -Resident #89-[MEDICATION NAME]/[MEDICATION NAME] 25 mg-250 mg-1 Tablet by mouth four times a day for [MEDICAL CONDITION] -Resident #108-[MEDICATION NAME]-[MEDICATION NAME] 5 mg-325 mg An interview with the Director of Nursing (DON) on 08/01/17 at 12:25 p.m. revealed the nursing staff is supposed to take a black marker and cover all resident information before discarding the medication packets. b) Blood Draw A random observation of the West Hall on 08/07/17 at 9:00 a.m. revealed Resident #74 having his blood drawn by Phlebotomist #222 in the hall beside the West Wing Nurses Station. An interview with the Director of Nursing (DON) on 08/07/17 at 9:05 a.m. revealed blood draws should be done in the resident's room or a private location.",2020-09-01
787,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2017-05-03,164,E,1,0,W9H111,"> Based on observation, staff interview and record review, the facility failed to maintain secure and confidential medical records. This failed practice had the potential to affect more than a limited number of residents. The electronic Medication Administration Record [REDACTED]. Resident identifiers: All residents residing on the rehabilitation wing. Facility census: 92. Findings include: a) Rehabilitation wing On 05/02/17 at 12:50 p.m., an observation of the EMAR was made in the rehabilitation wing. This EMAR was sitting open on a medication cart with the screen displaying the names, faces, and location of several residents. A mouse was also on top of the cart, creating a situation where any bystander could have access to resident information, if desired. The cart was observed, and no nursing staff came in sight. There were residents, visitors and non nursing employees in the hall. The Assistant Director of Nursing, was called upon for questioning, and she locked the screen of the EMAR at 1:08 p.m. She said it was not supposed to be unlocked, but she had locked it. The facility training form regarding Patient Confidentiality (HIPAA) defines the wide variety of information that should be kept confidential. Guidelines for protecting patient confidentiality, according to the facility training information, includes: Protect all records. and Do not leave patient information displayed on computer screens.",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
1360,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2017-06-29,164,E,0,1,PAQV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the personal privacy of residents including medical and health information. A nurse report sheet was left unattended on a medication cart in the hallway. Information including the resident's names, room numbers, medications, treatments, and other medical interventions were viewable on the document. This practice affected twenty-one (21) residents. This was a random observation. Resident identifiers: #3, #5, #12, #14, #19, #43, #57, #73, #80, #87, #88, #100, #102, #108, #111, #113, #125, #128, #138, #156, and #158. Facility census: 115. Findings include: a) Nurse Report Sheet A random observation, on 06/26/17 at 10:50 a.m., on the North Hall, revealed a Nurse Report Sheet on top of the medication cart. The Nurse Report Sheet contained the following information: --Resident #3-Resident's first name, room number, and [MEDICATION NAME] at 2 am --Resident #5-Resident's first name, room number, and PRN [MEDICATION NAME] --Resident #12-Resident's first name, room number, and Foley, ABT ear gtts to lt ear, JanCare 7 am --Resident #14-Resident's first name, room number, and [MEDICATION NAME]-URI --Resident #19-Resident's first name, room number, and PRN [MEDICATION NAME] at 2 am --Resident #43-Resident's first name, room number, and Poor eat/drink, Hospice, Nectar thick liquids --Resident #57-Resident's first name, room number, and [MEDICATION NAME]-URI, was [MEDICAL CONDITION], neb tx. --Resident #73-Resident's first name, room number, and [MEDICATION NAME] TID, Gent oint to eye, PRN [MEDICATION NAME] at 6 am --Resident #80-Resident's first name, room number, and [MEDICATION NAME] 4.5 mg --Resident #87-Resident's first name, room number, and PRN [MEDICATION NAME] 6 am --Resident #88-Resident's first name, room number, and Trach, [DEVICE] feeding off at 6 am on at 10 am, S/P cath --Resident #100-Resident's first name, room number, and Hospice --Resident #102-Resident's first name, room number, and PRN [MEDICATION NAME] 6 am --Resident #108-Resident's first name, room number, and Nicotine Patch 21 mg qd --Resident #111-Resident's first name, room number, and Need stool for fit test --Resident #113-Resident's first name, room number, and [MEDICATION NAME] Patch --Resident #125-Resident's first name, room number, and PRN Neb tx, Cough syrup --Resident #128-Resident's first name, room number, and Nectar thick liquids --Resident #138-Resident's first name, room number, and [MEDICATION NAME], Foley --Resident #156-Resident's first name, room number, and PRN [MEDICATION NAME], Assist x1 --Resident #158-Resident's first name, room number, and Tube Feeding, Foley An interview with Registered Nurse (RN) #90 on 06/26/17 at 10:55 a.m. revealed she should not have left the Nurse Report Sheet unattended on the medication cart. The RN stated she usually turns the Nurse Report Sheet over when she is not at the medication cart but forgot to on this occasion.",2020-09-01
1433,EASTBROOK CENTER,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2017-02-07,164,D,0,1,JRR311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the personal privacy regarding personal health information and medical treatment of [REDACTED]. This failed practice had the potential to affect more than an isolated number of residents who were under the care of medical school resident #117. Resident identifier: #158. Facility census: 133. Findings include: a) Resident #158 A dining observation was conducted on 01/30/17 at 12:00 p.m. There were seventeen (17) residents in the dining room at that time awaiting lunch while staff passed drinks out to them. On 01/30/17 at 12:03 p.m., a raised voice was heard from across the dining which was clearly heard from the other side of the room. A female with a stethoscope around her neck, later identified as medical school resident #177, was loudly speaking to Resident #158 about his personal health and medical treatment. Her discussion was about his respiratory symptoms and included comments such as, No need for a chest x-ray right now, it is most likely a [MEDICAL CONDITION] infection. She also made medical treatment recommendations including, Stay away from soda and, If your symptoms get worse, let me know. Resident #158 was interviewed after medical school resident #177 left the dining room on 01/30/17 at 12:10 p.m. and he stated I don't know who she was. A second attempt was made to interview resident #158 when he was alone in his room [ROOM NUMBER]/02/17 at 10:50 a.m. and he was unable to answer questions appropriately. During an interview with assistant administrator #162 on 02/01/17 at 1:45 p.m., she was able to verify the identity of medical school resident #177. She stated the medical students were under the supervision of the medical director and the requirements of resident privacy were the same as for all facility employees. She provided a copy of the Business Associate Agreement the facility had with the medical director, effective (MONTH) 1, (YEAR). On page one (1), paragraph five (5) this document states the purpose of the agreement is, ensuring compliance with the requirements of the Health Insurance Portability and Accountability Act (HIPAA) law and relevant state law. Assistant administrator #162 said that medical school student #177 would be expected to uphold the same agreement as the medical director who was overseeing her. An interview conducted with patient liaison #128 on 02/02/17 at 10:52 a.m., she verified she meets with all residents and families to review their admission packet, which includes the HIPA[NAME] She said she goes over the information and has the resident or responsible party sign a consent to release information, which designates who has permission to each resident's health information. She provided a copy of the signed consent, dated 04/15/16, for Resident #158. None of the other sixteen (16) residents who were in the dining room on 01/30/17 at 12:03 p.m. were listed on that consent to receive, information about the health status, treatment received and response to treatment for [REDACTED]. Patient liaison #128 was asked if she felt staff speaking loudly in the dining room about a resident's health condition where several other residents were able to hear was a HIPAA violation. She said, Yes, I think that is a HIPAA violation.",2020-09-01
1986,WELLSBURG CENTER,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2017-09-14,164,E,0,1,7HYJ11,". Based on observation, staff interview, and resident interview, the facility failed to ensure the right to personal privacy for two (2) of two (2) residents reviewed for the care area of privacy. The facility provided no means to prevent wandering confused residents from entering the rooms of other residents. This practice affected two (2) residents, but had the potential to affect more than an isolated number of additional residents. Resident identifiers: #24 and #74. Facility census: 55. Findings include: a) Resident #24 During an interview with Resident #24 on 09/13/17 at 8:50 a.m., a male resident (later identified as Resident #42) entered the room and wheeled himself in his wheelchair past bed A before he was taken out of the room by a staff member. Resident #24 stated, This happens all the time day or night and it is really annoying and sometimes it scares me with different men coming in here. They are confused and not right in the head and I tell the staff to keep them out of here but nothing has been done. Upon inquiry, Resident #24 said the facility had not offered her any means to deter the roaming confused residents from entering her room. b) Resident #74 Resident #74 reported during an interview on 09/13/17 at 9:15 a.m., The only problem I have here is male residents coming into my room all the time. (Resident #20's first name) will go into other people's rooms and yesterday when he was in my room; I kept yelling at him to get out when he was at the foot of my roommates' bed but he just kept coming in the room. I put my call light on and was yelling for the nurse, because sometimes he hits people but it took a good five minutes before anyone came to help me. Another male resident (first name of Resident #9) comes into other resident rooms too. I have seen (first name of resident #66) in other rooms too. All three (3) of them have come in here at different times too. I have seen (first name of resident #66) in action. He (Resident #66) has punched a nurse on night shift and on day shift also punched another female resident. Upon further inquiry she said I am very afraid of them. I don't sleep at night because you don't know what they will do. I have told everyone about this happening and that I am afraid including nurses aides, nurses but nobody does anything. Resident #74 further said the facility had not offered her any means to deter the roaming confused residents from entering her room. Regional Nurse Consultant #26 reported on 09/13/17 at 3:58 p.m., Originally the facility had stop signs that Velcro on the door frames to deter wandering residents from going into other residents rooms on every resident doorway but those were removed a while back. The Director of Nursing (DON) present during the interview interjected, We don't' have any residents here that wander and don't use them. The DON did not respond when inquired about the four male residents observed and named in interviews wandering into resident rooms. On 09/13/17 at 4:50 p.m., the Administrator reported that Resident #74 had been given a Velcro stop sign for her room after staff had spoken with her. At no time during the interviews had Resident #74 been named as having a concern of residents entering her room",2020-09-01
2050,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2017-05-05,164,D,0,1,NNC911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to protect the resident's privacy regarding personal health information and medical treatment. Resident #49 was examined by a physician in the activity room in the presence of six (6) other residents. This failed practice has the potential to affect more than an isolated number of residents. Resident identifier: #49. Facility census: 49. Findings include: a) Resident #49 A random observation, on 05/03/17 at 9:25 a.m., revealed seven (7) residents sitting the the activity room awaiting a bible study activity. Resident #49 was pulling her pants leg up to display her ankles and legs to a male with a stethoscope around his neck, later identified as Physician #109. Physician #109 was speaking to Resident #49 about her personal health and medical treatment. He could be overheard through out the room. His discussion covered leg [MEDICAL CONDITION], pain control, and medications changes. Physician #109 then proceeded to listen to her lungs with a stethoscope. Upon inquiry of the Director of Nursing (DON), on 05/03/17 at 9:28 a.m., she was able to provide the identity of Physician #109 as Resident #49's attending physician. She looked into the activity room through the window and stated, Yes he ( Physician #109) is performing a physician visit/examination of Resident #49. The DON immediately entered the activity room and asked Resident #49 if she would like to go to her room and Resident #49 continued to speak with Physician #109. Immediately following the observation, an interview was conducted with Physician #109. He stated, this is not something unusual to examine a resident in various areas of the facility wherever they are at the time and I do it almost all the time. Not something that I do for an annual exam of course. I don't really see any difference than doing it in her room with a roommate. After further inquiry, he stated, Yes I see where that could be a privacy and dignity issue in the activity room, because in her room I could at least pull the privacy curtain. I did not think of this being a dignity or privacy issue but see that it certainly is and will certainly discontinue seeing residents in the facility in public areas. The DON reported during a follow-up interview on 05/03/17 at 9:53:a.m., All the physicians here do that type of thing of examining residents in various public areas all the time. During an interview, on 05/03/17 at 10:13 a.m., Resident #49 stated, yes he (Physician #109) did visit me and examine my legs and lungs in the activity room. They visit you anywhere you are, be it the activity room, hallway, dining room or your room. When inquired how she felt about being examined in a public area, she replied, I thought that was just the way it was and I did not have a choice if I wanted to see the physician. It is not very private and it is a little strange to have everyone hear what you are telling your doctor and what is wrong with you. Since you have asked me and I have thought about it, No I don't think it is right. From now on I will ask them to take me somewhere private where I can talk about me without everyone hearing my problems, I deserve to have privacy and to be treated with respect from now on.",2020-09-01
2351,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2017-02-28,164,D,0,1,MNKY11,"Based on observation and staff interview, the facility failed to provide privacy during medication administration for Resident #93. On 02/22/17 at 10:50 a.m., facility staff failed to provide privacy during administration of insulin; staff failed to close the resident's door, window blinds and/or privacy curtain when administering an injection of insulin in Resident #93's abdomen. This was a random opportunity for discovery. Resident identifier: #93. Facility census: 89. Findings include: a) Resident #93 On 02/22/17 at 10:50 a.m., during medication administration observation Resident #93 had a glucometer blood glucose test completed by Registered Nurse (RN) #102. The results of the glucometer blood glucose reading was 296; which resulted in Resident #93 receiving insulin as prescribed. RN #102 entered Resident #93's room and found the resident sitting in his wheelchair. RN #102 proceeded to give the insulin injection in Resident #93's abdomen. RN #102, failed to close the resident's door, window blinds and the privacy curtain. Interview with the Director of Nursing (DON) on 02/22/17 at 1:45 p.m., found the expectation when providing care in which requires the resident's body to be exposed, the staff should close the resident's door, close the window blinds and/or use the resident's privacy curtain.",2020-09-01
3018,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,164,D,0,1,CPO811,"Based on a random observation, staff interview, and policy review, the facility failed to secure confidential information for Resident #2. The nurse left the Medication Administration Record [REDACTED]. Facility census: 52. Findings include: a) Resident #2 During a random observation on 07/11/14 at 4:10 p.m., Registered Nurse (RN) #1 pushed the medication cart up the hall toward the office. The nurse left the medication cart to answer the telephone, leaving the Medication Administration Record [REDACTED]. After returning, the nurse pushed the cart down the hallway, said he forgot something and walked up the hallway. The nurse again left the Medication Administration Record [REDACTED]. Upon inquiry, the nurse confirmed the record should have been covered to maintain privacy/confidentiality of the medical record. An interview with the Center Nurse Executive (CNE) at 5:30 p.m. on 07/11/17, confirmed the nurse failed to maintain confidentiality of the medical record when the resident's medication record was left open and unattended. The facility's Notice of Privacy Practices policy noted, This location is required by law to maintain the privacy of your medical information",2020-09-01
3121,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2017-07-27,164,E,0,1,QOSP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed to ensure a medication packet with a pharmacy label was disposed of in a manner that protected personal, medical, and health information. Personal identifiers including a resident's name, physician, and medication were listed on the pharmacy label. This was a random observation. Resident identifier: #31. Facility census: 65. Findings include: a) Resident #31 A random observation of the 100 Hall, on 07/24/17 at 11:15 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, physician, and medication order ([MEDICATION NAME] 40 milligrams) on the pharmacy label. An interview with Registered Nurse (RN) #5, on 07/24/17 at 11:20 a.m., revealed the empty medication packets containing pharmacy labels are always discarded in the trash. The RN stated all resident information should be protected. A review of the facility policy, on 07/26/17 at 12:00 p.m., titled Protected Health Information (PHI), Management and Protection with a revision date of (MONTH) 2014 stated, It is the responsibility of all personnel who have access to resident and facility information to ensure that such information is managed and protected to prevent unauthorized release or disclosure.",2020-09-01
3272,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2017-02-09,164,D,0,1,UXFJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility provided confidential medical information to an entity who was not the resident's responsible party. This was true for one (1) of seventeen (17) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #86. Facility census: 58. Findings include: a) Resident #86 Record review found the resident was admitted to the facility on [DATE]. The medical record contained a copy of a guardian/conservation court appointment dated 08/21/08. The resident's facility physician deemed the resident to lack capacity to make medical decisions on 11/01/16. Review of the nurses notes found the resident had a fall on 02/04/17. The nursing note dated 02/04/17 at 4:07 p.m. revealed she, Heard resident calling for help, when entering room saw resident in floor sitting on buttocks beside w/c (wheelchair) able to move all extremities, unwitnessed and Neuro checks started. Assisted via 2 assist back to w/c. A nursing note dated 02/04/17 at 7:10 p.m. read, Notified DHHR (Department of Health and Human Services) via voice mail. A nursing note dated 02/06/17 read, d/c (discontinue) potassium 20 meq, (milliequivalent) BID (twice a day) PO (by mouth), start potassium 20 meq daily PO, DX (diagnosis), potassium 5.3. DHHR made aware via voice mail. (A normal potassium level is 3.6 to 5.2). The facility social worker (SW) #62, verified at 1:00 p.m. on 02/07/17, the resident's guardian/ conservation, was the resident's brother. She stated, the appointment of the brother in 2008 continues to be in effect and the DHHR is not the resident's responsible party. At 1:29 p.m. on 02/07/17, the director of nursing said, she did not know why the nurse would have contacted DHHR and not the legal representative. She also confirmed the DHHR is not the resident's medical decision maker and should not have been notified of changes in condition. .",2020-09-01
3641,MINNIE HAMILTON HEALTH CARE,51A013,186 HOSPITAL DRIVE,GRANTSVILLE,WV,26147,2017-11-01,164,E,0,1,0.0,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure the privacy of medical records was maintained during medication administration observation for five (5) of seven (7) opportunities observed. This failed practice had the potential to affect more than a limited number of residents who received medications administered by facility staff. Resident identifiers: #15, #7, #19, and #1. Facility census: 22. Findings include: a) Resident #15 At 8:59 a.m. on 10/31/17 licensed practical nurse (LPN) #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. At 2:13 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #15. After LPN #2 entered the room for Resident #15 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. b) Resident #7 At 2:05 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #7. After LPN #2 entered the room for Resident #7 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. c) Resident #19 At 2:09 p.m. on 10/31/17 LPN #2 was observed administering medication to Resident #19. After LPN #2 entered the room for Resident #19 with the cup of medications, it was noted that the Medication Administration Record [REDACTED]. d) Resident #1 At 2:19 p.m. on 10/31/17 LPN #9 was observed administering medication to Resident #1. Resident #1 was in the hallway, past the water fountain near the nursing station. LPN #2 left her medication cart outside of the room for Resident #15, she went to the end of the hall and entered the room of Resident #1. She then walked back up the hall, passing her medication cart, and walked towards the nursing station to give Resident #1 his medication. She left the MAR indicated [REDACTED]. A medical record review was conducted 10/31/17 and it revealed the MARs may include health information such as: Resident name, physician, date of birth, account number, room number, diet, allergies [REDACTED]. This matter was discussed with the DON and LPN #2 on 10/31/17 at 3:37 p.m. The DON stated that leaving the MAR indicated [REDACTED].",2020-09-01
3758,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2017-11-02,164,D,0,1,1EPD11,"Based on a random observation and staff interview, the facility failed to provide personal privacy for a resident in a resident community bathroom. Resident #5 was on the toilet and visible to other residents and anyone walking in the hallway which is the main thoroughfare on the A-1 unit. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #5. Facility census: 57. Findings include: a) Resident #5 During a random observation on 10/31/17 at 3:48 p.m. while walking down the main hallway on the A-1 unit observed a male resident in the community bathroom with the entrance door open and the privacy curtain pushed open to the far end. The resident on the toilet is visible to anyone in or walking up the hallway which is the main thoroughfare for the unit. Two (2) female residents were seated in wheelchairs in the hallway and two (2) male residents were walking in the hallway within sight of the resident community bathroom. Four (4) staff members were within the enclosed nurses' station and upon inquiry Health Service Worker (HSW) #93 stated, The community bathroom is used for all the residents on the unit. She further explained that some of the residents require assistance to use the community bathroom and some of the residents can go on their own not requiring assistance. The privacy curtain is always pulled for all residents, we just observe the residents not requiring assistance and pull the curtain for them, so privacy is maintained for all residents. Upon walking up the hallway HSW #93 observed Resident #5 on the toilet without the privacy curtain pulled. She stated, No _______(first name of Resident #5) was not provided privacy and anyone can see him from the hallway. He (Resident #5) can go to the bathroom by himself and we should have made sure the privacy curtain was pulled. She then proceeded to pull the privacy curtain.",2020-09-01
4017,WEIRTON MEDICAL CENTER,515077,601 COLLIERS WAY,WEIRTON,WV,26062,2017-03-22,164,D,1,0,88RJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview and observation, the facility failed to ensure a computer monitor located on the medication cart in the hallway was covered in a manner that protected personal, medical, and health information. Personal identifiers including the resident's name, physician, date of birth, and medication orders were visible on the screen. This was a random observation. Resident identifier: #3. Facility census: 20. Findings include: a) Resident #3 A random observation in the hallway outside room [ROOM NUMBER], on 03/22/17 at 8:40 a.m., revealed a computer screen fully visible to anyone in the hallway on the medication cart. The computer screen contained the resident's full name, date of birth, physician, and medication orders. An interview with Licensed Practical Nurse (LPN) #17, on 03/22/17 at 8:45 a.m., revealed the computer screen should always be turned off before walking away from the medication cart. The LPN stated she was asked to assist a resident and forgot to turn the monitor off. The LPN stated all resident information should always be kept confidential. An interview with Registered Nurse-Charge Nurse(RN-CN) #13, on 03/22/17 at 8:55 a.m., revealed all resident information should be safeguarded while not in use by the clinical staff.",2020-03-01
4079,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-07-19,164,D,0,1,KKFY11,"Based on a random observation and staff interviews, the facility failed to provide privacy to Resident #39 when staff failed to close the privacy curtain and/or door to the resident's room when providing care. Resident identifier: #39. Facility census: 105. a) Resident #39 On 07/13/16 at 9:34 a.m., Nurse Aide (NA) #156 assisted Resident #39 with the resident's privacy curtain open. The resident's gown was inside her brief. NA #156 assisted the resident to pull up her brief and adjust her clothes. After this observation NA #156 said, Let's pull the curtain. On 07/14/16 at 11:58 a.m., when informed of what had happened with Resident #39's being exposed during personal care, Licensed Practical Nurse (LPN) #149 she had informed the director of nursing (DON). The director of nursing, when informed of the incident on 07/18/16 at 3:00 p.m., agreed the nurse aide should have pulled the privacy curtain before she began assisting the resident with pulling up her brief.",2020-02-01
4129,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2017-01-05,164,E,0,1,NRK511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and observation, the facility failed to ensure medication and pharmacy labels were disposed of in a manner that protected personal medical and health information. Personal identifiers including resident name, medication and [DIAGNOSES REDACTED]. This was a random observation. Resident identifiers: #143 and #82. Census 85. a) Resident #143 On 01/04/17 at 7:55 a.m. during a random observation, an intravenous medication bag including resident name, medication and [DIAGNOSES REDACTED]. The labeled resident identifiers were visible from the hallway. On 01/04/17 at 8:02 a.m., an interview occurred with Licensed Practical Nurse (LPN) #2 regarding facility protocol on handling of resident identifiers and personal medical information including medication labels. LPN #2 stated personal identifiers and personal medical information including resident names and [DIAGNOSES REDACTED]. LPN #2 removed items with the Resident #143 identifiers from the wastebasket. On 01/04/17 at 8:05 a.m. an interview with LPN #76 who acknowledged the facility expects nurses to remove resident name, [DIAGNOSES REDACTED]. On 01/04/17 at 9:41 a.m., an interview with the Staff Educator stated nursing knows to remove resident identifiers and personal medical information before discarding. The Staff Educator stated that the facility was putting together an education regarding managing health protected information. b) Resident #82 On 01/05/17 at 7:43 a.m., LPN #55 was observed to have a medication package with resident identifiers including resident name and [DIAGNOSES REDACTED]. An interview with LPN #55 revealed the facility had a protocol for discarding narcotic packaging with resident identifiers. LPN was unable to state protocol of discarding non-narcotic medication labels containing protected health information. On 01/05/17 at 8:00 a.m., an interview with the Director of Nursing revealed the facility had a protocol for discarding narcotic packaging with protected health information but will add a protocol for discarding all packaging with resident identifiers including resident name and diagnosis.",2020-02-01
4196,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,164,D,0,1,XDKG11,"Based on observation and staff interview, the facility failed to maintain personal privacy for a resident receiving an enteral feeding. This affected one (1) resident observed at random during the survey while her enteral feeding was infusing. Resident identifier: #17. Facility census: 113. Findings include: a) Resident #17 An observation on 04/04/17 at 8:32 a.m. noted Resident #17 self-propelling her wheelchair in the hallway near her room. Her enteral feeding, attached to a pole, was infusing. The exposed feeding bottle identified the type of nutrition infusing, the resident's name and room number, the infusion rate, the time it was started, and the time it was due to be stopped. Licensed Practical Nurse (LPN) #24 was also in the hall. When interviewed on 04/04/17 at 8:35 a.m., she said the enteral feedings were not covered. A second observation on 04/05/17 at 10:30 a.m., again found Resident #17 up in the hall with the personal information on her enteral feeding exposed. During an interview with LPN #17 on 04/05/17 at 10:35 a.m., said they did not typically cover feeding tube bottles when a resident was out of his or her room. When discussed with the director of nursing on 04/10/17 at 12:47 p.m., she had no comment.",2020-02-01
4356,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2016-06-21,164,E,0,1,2UNV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure the confidentiality of personal and clinical information for residents. Resident #31's personal and clinical information was attached to a lab specimen in an unlocked refrigerator in an unlocked room. This room was accessible to anyone in the facility. This practice had the potential to affect more than a limited number of residents. Resident identifier: #31. Facility census: 98. Findings include: a) A random observation on 06/21/16 at 9:00 a.m. revealed the Soiled Utility Room on the West Hall was unlocked. The room contained an unlocked refrigerator labeled Specimen Fridge and Biohazards. Inside the refrigerator was a vial of blood inside a plastic bag. Attached to outside of the bag was a Laboratory Testing Information Sheet and a Face Sheet for Resident #31. The resident's first and last name, Social Security Number, Physician's name, Medicare number, [DIAGNOSES REDACTED]. An interview with Licensed Practical Nurse (LPN) #50 on 06/21/16 at 9:45 a.m. revealed the soiled utility room on the West Hall was the designated location for all laboratory (lab) specimens within the facility to be stored until picked up by the lab. LPN #50 stated the soiled utility room and the refrigerator, where the specimens were stored, were never locked. LPN #50 stated all lab specimens contain a Laboratory Testing Information Sheet and a Resident Face Sheet which contained personal and clinical information. In an interviewed on 06/21/16 at 10:00 a.m., the Director of Nursing (DON) stated lab specimens awaiting pick up had never been locked up in the facility. The DON stated all lab specimens contained resident identifiers and personal information that should be safeguarded from people not involved in their care. The DON stated all lab specimens should be secured and would ensure this happened immediately.",2019-11-01
4552,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2016-11-22,164,E,0,1,EZR311,"Based on observation and staff interview, the facility failed to provide privacy for a resident during a wound care treatment by not closing the door to the room or pulling the privacy curtain between residents. This practice was found for one (1) of two (2) Stage 2 sample residents observed for wound care. Resident identifier: #69. Facility census: 55. Findings include: a) Resident #69 During an observation of wound care treatment, on 11/16/16 at 9:21 a.m., provided by Registered Nurse (RN) #54, privacy was not provided to Resident #69. RN #54 did not close the door to the resident room preventing visitors, staff or other residents from viewing the treatment to his right heel wound and/or pull the privacy curtain between Resident #69 and his roommate, allowing his roommate to view the entire wound treatment. Immediately following the observation during an interview with RN #54, she agreed she did not provide privacy during the residents' treatment by closing the resident's room door or pulling the privacy curtain between Resident #69 and his roommate.",2019-09-01
4597,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2016-02-29,164,D,0,1,7MOP11,"Based on a random observation, resident interview, and staff interview, the facility failed to provide personal privacy during activities of daily living (ADL) care. Resident #87 was observed brushing his teeth in the ADA (Americans with Disabilities Act) restroom with the door open and in view of other residents and staff in the hallway. This had the potential to affect a limited number of residents residing in the facility. Resident identifier: #87. Facility census: 64. Findings include: a) Resident #87 On 02/24/16 at 2:56 p.m., a random observation found Resident #87 brushing his teeth in the ADA (Americans with Disabilities Act) restroom with Nurse Assistant (NA) #32 holding the door open. The ADA restroom was located in the hallway, between the nurses' station and the dining/activity room. This resident was in full view of the residents and staff walking in the hallway. The interim nursing home administrator (INHA), on 02/24/16 at 3:05 p.m., stated Resident #87 did not have his teeth brushed that day and staff were assisting the resident at that time. The INHA was informed Resident #87 was observed brushing his teeth in the ADA restroom in full view of residents and staff. The INHA stated she would take care of this immediately. In an interview on 02/24/16 at 3:22 p.m., when asked if he had his teeth brushed that day, Resident #87 stated, Yes and everyone got to watch. I didn't exactly like that, but at least my teeth were brushed.",2019-09-01
4688,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2016-03-24,164,D,0,1,4ZOC11,"Based on observation, resident interview, review of facility policy and procedure, and staff interview, the facility failed to maintain protect the private space for two (2) of two (2) residents reviewed for dignity and respect. The facility failed to prevent a wandering resident (#39) from entering uninvited into the rooms of Residents #49 and #30. This affected two (2) residents, but had the potential to affect more than an isolated number of additional residents. Resident identifiers: #49, #30, and #39. Facility census: 51. Findings include: a) Resident #49 During an interview on 03/23/16 at 12:47 p.m., Resident #49 stated he was upset about a resident wandering into his room by the name of (Resident #39). He stated two (2) weeks ago, Resident #39 came into his room uninvited, had a bowel movement on the floor, and used his tissues to try and clean herself. Resident #39 then proceeded to go through his personal belongings with her soiled hands. In addition, he stated he turned on his call light when she entered the room. He stated he thought it took about thirty (30) minutes for the staff to respond and clean his room and remove Resident #39. He stated my legs are paralyzed and I can not get her out of my room. Although Resident #49 could not give a more specific date, he stated he talked with the nursing home administrator (NHA) and was told they could not shut the door because his roommate was at risk for falls and Resident #39 could not be restrained. Resident #49 stated a Velcro barrier was put on the door, but Resident #39 just removed it and came in and took things out of his room. On 03/23/16 at 12:15 p.m., the Social Worker (SW) was asked if she was aware of the incident regarding Resident #39 entering Resident #49's room uninvited and she stated Yes. On 03/23/16 at 3:00 p.m., during an interview with the NHA he stated he had talked with Resident #49 the morning after the incident with Resident #39. He stated he explained to Resident #49 that the door barrier was in place and staff were made aware to monitor the wandering of Resident #39 more closely. He further stated when Resident #49 requested the door to his room be closed, he explained that the door had to remain open for the benefit of staff being able to monitor his roommate for falls. The NHA was asked for facility's policy and procedure regarding wandering residents, and the NHA stated there was no facility policy and procedure regarding wandering residents. b) Resident #30 On 03/24/16 at 2:37 p.m., after explaining the reason for the interview was to inquire about the door barrier across her doorway, Resident #30 stated, Oh yes, that is to keep another resident from coming into my room. When asked if she knew the resident's name, she stated it was (Resident #39's name). Resident #30 explained she had several craft items in her room and Resident #39 would come into her room uninvited and start going through her things. She further stated she would yell at Resident #39 to leave. An additional interview with the SW on 03/24/16 at 2:43 p.m., regarding Resident #30 stating a resident was coming into her room uninvited, the SW explained they had put the door barriers up if a resident complained. In addition, the SW stated staff could request a door barrier be put up.",2019-08-01
4795,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2015-11-04,164,E,0,1,KC5S11,"Based on observation, staff interview, and resident interview, the facility failed to ensure the right to personal privacy for four (4) of four (4) residents reviewed for the care area of privacy. The facility provided no means to prevent wandering confused residents from entering their rooms. This practice affected four (4) residents, but had the potential to affect more than an isolated number of additional residents. Resident identifiers: #23, #120, #128, and #53. Facility census: 87. Findings include: a) Resident #23 Observation on 10/26/15 at 2:30 p.m., revealed a female resident walked into Resident #23's room and climbed into his bed. He immediately screamed at her and she got up and walked out of the room. At 2:45 p.m., observation revealed a second resident, Resident #73, entered the room and attempted to sit on the resident's bed. After Resident #73 was assisted out of the room, Resident #23 said the residents who lived on the Solana unit, previously a locked Alzheimer's unit, repeatedly entered his room. Upon inquiry, Resident #23 said the facility had not offered him any means to deter the roaming confused residents from entering his room. b) Resident #120 During a Stage 1 resident interview, on 10/26/15 at 2:30 p.m., two (2) female residents entered Resident #120's room between 2:30 p.m. and 2:45 p.m. The first resident climbed into the roommate's bed and exited after Resident #120 and the roommate yelled at her. The second non-communicating resident was assisted from the room by the surveyor. Resident #120 reported this was a continuous occurrence. He said the residents who resided on the Solana unit, previously a locked Alzheimer's unit, entered his room from either the bathroom door or the hallway door. He stated they often climbed into their beds, carried items out of the room, and sometimes attempted to take food off of their meal trays while they were eating in their room. Resident #120 reported he and his roommate requested a slide lock to at least keep the bathroom door closed, but the request was denied. He said he was never offered a means to deter the wandering confused residents from entering the room. c) Resident #128 During an interview, on 10/27/15 at 8:40 a.m., Resident #128 reported the residents who resided on the Solana unit, previously a locked Alzheimer's unit, often wandered into his private room and walked around making muttering sounds. He said once a male resident entered his room and sat down in the chair for a while. Resident #128 said he also woke up one (1) night and found a resident standing over him looking at his face. He stated he reported these incidents to the nursing assistants. Upon inquiry, he said he was never offered a means to deter the wandering, confused residents from entering his private room. d) Observation on Hilltop Wing revealed three (3) wooden swing gates were installed on residents' doorways to deter wanderers from entering the rooms. No such gates were located on Woodside hall where Residents #23, #120, and #128 resided. e) Resident #53 Resident #53 was interviewed on 10/29/15 at 10:45 a.m. He reported several residents in the facility voiced concerns when they were informed the new ownership/management had decided to unlock the doors to the Solana unit, an Alzheimer's unit. He said the residents from the Solana unit began roaming throughout the facility, entering other residents' rooms and taking personal belongings. Resident #53 said these concerns were discussed at resident council. He said staff told them nothing could be done. Resident #53 reported a confused resident entered his room and climbed into his bed when he was not in the room. The resident said his roommate told him the resident defecated in his bed on that occasion. Resident #53 said he asked for a wooden triangular swing gate for his door, but was told he would have to wait until maintenance could make more. f) Observations during the survey found three (3) wooden swing gates on the doors on the Hilltop wing. There were no swing gates on the Woodside hall, where Residents #23, #120, and #128 resided. g) Maintenance Supervisor #27 was interviewed on 11/04/15 at 8:20 a.m. He was unaware of any resident's request for the triangular wooden swing gates used to deter the wandering residents from entering other residents' rooms. He said he made the wooden gates as they were needed, and did not currently have any to hang on the residents' doors. h) Licensed practical nurse (LPN) #54 was interviewed on 10/27/15 at 9:45 a.m. She confirmed the residents with dementia wandered throughout the facility now that the Solana unit was no longer locked. She confirmed some of the residents entered other residents' rooms, climbed into their beds, and took their belongings. i) During the survey, observation revealed residents, who resided on the Solana unit, previously a locked Alzheimer's unit, wandered freely throughout the facility all day long. They were not provided activities to keep them busy, as they were provided when they resided in a setting designed for residents with dementia.",2019-07-01
4895,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2016-01-28,164,D,0,1,SPJZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to maintain personal privacy of a resident during wound care. Resident #169 was uncovered from her chest to her ankles, exposing unnecessary frontal body parts while staff provided treatment to her coccyx. This was found for one (1) of twenty-eight (28) Stage II residents observed during the annual Quality Indicator Survey. Resident identifier: #169. Facility census: 99. Findings include: a) During an observation of wound care, on 01/28/16 at 12:15 p.m., Licensed Practical Nurse (LPN) #146 pulled the blankets off of Resident #169, exposing all body parts that were not covered by her shirt and socks. The resident was positioned on her side for treatment of [REDACTED]. In an interview immediately after the 12:25 p.m. on 01/28/16 observation, LPN #146 confirmed she had left Resident #169 overly exposed while providing treatment to her coccyx. During an interview on 01/28/16 at 12:27 p.m., Resident #169 reported feeling very uncomfortable being left uncovered from her chest to her ankles while LPN #146 provided wound care to her bottom.",2019-05-01
4996,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-04-28,164,D,1,0,47EZ11,"> Based on observation and interview, the facility failed to provide visual privacy to one (1) of six (6) residents on the sample. The resident was not provided privacy during an observation of a dressing change and personal care. Resident identifier: #5. Facility census: 94. Findings include: a) Resident #5 During an observation of Resident #5 on 04/27/16 at 10:45 a.m., Licensed Practical Nurse (LPN) #73, completed a dressing change on the resident's right ankle and applied cream to the resident's feet and back. The LPN raised the resident's pants up to her knees as well as the back of her shirt up to her neck. Neither the resident's bedside curtain, nor the door to the room were closed during the care. The resident was in full view of anyone passing in the hallway. In an interview on 04/27/16 at 11:00 a.m., LPN #73 stated she was nervous and forgot to close the door to Resident #5's room. The LPN stated the resident's curtain or door should always be closed when providing care.",2019-04-01
5176,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2015-05-15,164,D,0,1,EP0S11,"Based on medical record review, resident interview, and staff interview, the facility failed to ensure each resident's privacy for one (1) of one (1) residents reviewed. Resident #36 resided in a room with two (2) roommates (Residents #75 and #23.) The facility did not ensure the resident received accommodations for private visits with her spouse. Resident identifier: #36. Facility census: 95. Findings include: a) Resident #36 During an interview with Resident #36 on 05/12/15 at 9:17 a.m., the resident related she had requested a private room because her husband visited daily. The resident related she was told, That was not likely to happen, insurance makes a difference. Resident #36 said, So many rooms are set aside for skilled nursing - short term stay, and she was informed she could not utilize those rooms. The resident also related, Some staff have spoken on my behalf, and related they would like for her husband to be able to stay. Resident #36 further added her two (2) roommates could, not do for themselves. She said the nursing assistants disrupted her privacy when caring for her roommates. Review of the care plan revealed Resident #36 was unable to return home, and staff were to encourage family visits. The resident's spouse visited daily, but the facility had not addressed the resident's psychosocial status related to intimacy. Interviews with the director of nursing (DON) and social worker (SW) on 05/14/2015 4:15 p.m., revealed they were unaware the husband had stayed in the room with the resident and her two (2) roommates. The DON related staff had not informed her of the resident's spouse having overnight visitation, and was not aware Resident #36 wanted private visitation. The director of nursing and social worker related they would have accommodated the resident's needs. During another interview with Resident #36, the DON and SW, on 05/14/15 at 4:30 p.m., the resident informed the DON and SW of her husband's overnight stay. She again related they slept in the room with her two (2) roommates. Resident #36 indicated her husband stayed Friday to Monday. The resident related her spouse tried to stay again, but just couldn't do it, because he was too uncomfortable with the situation. Resident #36 confirmed she wanted privacy for intimacy with her spouse, but she did not have full visual and auditory privacy. The DON and SW assured the resident they would try to find a room to accommodate her needs.",2019-03-01
5839,ST. MARY'S HOSPITAL,515113,2900 FIRST STREET,HUNTINGTON,WV,25702,2015-01-09,164,D,0,1,RXZ911,"Based on observation and staff interview, the facility failed to ensure residents' personal privacy was maintained during medication administration and during a dressing change. The privacy curtains were not pulled, and the door to the resident's room was open allowing full view of Resident #42 when the nurse administered an insulin injection. For Resident #52, the privacy curtains were not long enough to ensure visitors, visiting with the roommate, could not view a wound treatment. This was true for two (2) resident's discovered during random observations of resident care. Resident identifiers: #42 and #52. Facility census: 15. Findings include: a) Resident #42 At 1:14 p.m. on 01/05/14, the resident was being interviewed during Stage I of the Quality Indicator Survey. During the interview, Employee #11, a registered nurse, knocked on the resident's door and stated she needed to give the resident her insulin shot. The surveyor left the resident's room and stood in the hallway. Employee #11 raised the bottom of the residents shirt, exposing her stomach, and administered the insulin without pulling the curtain or closing the resident's door. The registered nurse clinical manager, Employee #39, was advised of the above occurrence at 9:27 a.m. on 01/08/15. Employee #39 stated she would have expected the nurse to ensure privacy by closing the door to the room or pulling the privacy curtain before administering the insulin. . b) Resident #52 The wound treatments for Resident #52 were observed on 01/07/15 at 2:17 p.m. Employee #52 was a male resident. Employee #39, licensed practical nurse (LPN) performed the wound treatments in the resident's room. Two (2) females were visiting Resident #52's roommate and were present in the room during the treatment. Employee #39 did not ask Resident #52 if it was okay for the visitors to stay in the room; resulting in the lack of auditory privacy. Furthermore, during this observation, the privacy curtain was too short to provide full visual privacy when entering the door. Interview with Employee #39, clinical manager, on 01/07/15 at 3:15 p.m., confirmed the nurse should have asked the resident if it was okay with him if the visitors remained in the room during the treatment. If the resident did not want the visitors to be present, the nurse should have asked them to leave while she was providing care. Employee #39 also confirmed the privacy curtain was too short to provide full visual privacy.",2018-07-01
6068,GLASGOW HEALTH AND REHABILITATION CENTER,515118,"120 MELROSE DRIVE, BOX 350",GLASGOW,WV,25086,2014-09-12,164,D,0,1,3Q4T11,"Based on observation and staff interview, the facility failed to ensure personal privacy during a medical treatment for one (1) of seventeen (17) sample residents and for one (1) randomly observed resident during medication pass. A licensed practical nurse failed to provide privacy for Resident #32 while performing a fingerstick and administering insulin in the resident's abdomen. Resident #84 was provided fingerstick blood sugar and a respiratory treatment, in the presence of a roommate and two (2) visitors without the privacy curtains being pulled. Resident identifiers: #32 and #84. Facility census: 93. Findings include: a) Resident #32 On 09/11/14 at 11:30 a.m., a licensed practical nurse (LPN #44) was observed doing a blood sugar fingerstick and administering a nebulizer treatment to Resident #32 without pulling the privacy curtains. This resident's roommate and two (2) visitors were present and in full view of the procedures. In an interview with the director of nursing, on 09/11/14 at 4:30 p.m., she agreed Resident #32 should have been provided privacy during the blood sugar fingerstick and nebulizer treatment. b) Resident #84 On 09/11/14 at 4:04 p.m., a licensed nurse (RN #33) was observed doing a blood sugar fingerstick and administering insulin in Resident #84's abdomen without pulling privacy curtains and/or closing the door. The resident was visible to any person walking down the hallway and the resident's roommate was present in the room. In an interview with RN #33, at that time, she was in agreement the privacy curtains should have been pulled.",2018-05-01
6126,STONE PEAR PAVILION,515130,125 FOX LANE,CHESTER,WV,26034,2014-07-18,164,F,0,1,XYGH11,"Based on observation, staff interview, and policy review, the facility failed to maintain confidentiality of medical records. The electronic Medication Administration Record [REDACTED]. This practice had the potential to affect all residents as the eMAR allowed access to information about all residents residing in the facility. Facility census: 56. Findings include: a) At 5:45 p.m. on 07/17/14, a medication cart was observed on the West hall unattended. The eMAR was open on top of the cart and logged in with resident health information clearly visible. Three (3) residents were in the hallway near the cart at that time. Registered Nurse, Employee #33, approached the cart at 5:47 p.m. from the east hall. Employee #33 was interviewed and stated she was responsible for the West hall medication cart. When questioned regarding the eMAR being open, she stated I never do that, I was helping a resident. This matter was discussed with the Assistant Director of Nursing, Employee #5, on 07/18/14 at 9:00 a.m. She said it was against policy to leave health information of residents visible to others. She provided a policy for Electronic Medical Records dated May 2014. The policy included, Computer screen is to be closed or functionally locked when not in attendance by licensed nurse or in use.",2018-05-01
6202,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2015-05-14,164,D,0,1,5FNV11,"Based on observation and staff interview, the facility failed to ensure full visual privacy for one (1) resident identified during a random opportunity for discovery. The resident was not provided privacy while staff provided personal care. Resident identifier: #88. Facility census: 111. Findings include: a) Resident #88 On 04/23/15 at 7:55 p.m., Resident #88 was heard yelling out in the hallway of the 400 hall. Upon entering the room, Resident #88 was sitting in a geri-chair. Four (4) nurse aides (NAs), NAs #51, #104, #101, and #110, were present in the room. The resident was dressed only in an adult brief. The privacy curtains were not pulled around the resident, whose bed was located beside the door. The resident's roommate (Resident #53) was sitting in a chair in full view of Resident #88. When asked about providing privacy for Resident #88, the NAs nodded their heads in the affirmative, as they continued attempting to dress Resident #88. NA #104 then made an effort to pull the privacy curtain and Resident #88 grabbed the curtain and yelled, I got to go.",2018-05-01
6356,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,164,D,0,1,OMIN11,"Based on record review and staff interview, the facility failed to ensure one (1) resident, identified through a random opportunity for discovery, was treated in a manner that maintained the visual privacy of the resident's body during personal care. A male housekeeper was present in the resident's room and witnessed the provision of personal care for a female resident. Resident identifier: #52. Facility Census: 61. Findings Include: a) Resident #52 Employee #29, a housekeeper, was interviewed at 8:17 a.m. on 05/22/14. He stated that about three (3) of four (4) months ago he had reported and incident of physical abuse involving Resident #52. He said he was in the resident's room putting clothes in Resident #52's closet. He stated Employee #27 had picked up Resident #52 off the bed while changing her clothes and then allowed her to drop back down to the bed. The reportable incident for Resident #52 dated 02/25/14 and the 5 (five) day follow-up regarding the allegation of the abuse of Resident #52, dated 02/25/14, were reviewed. The report included in the description of abuse, information which should have been, but was not, addressed regarding the resident's privacy. The report indicated Employee #67, the social service supervisor (SSS), had spoken with multiple employees and had unsubstantiated the allegation of abuse; however, the facility did not address the fact a male housekeeper (Employee #29) was able to witness Employee #27 changing a female resident's clothing. Employee #67, the SSS, was interviewed at 12:00 p.m. on 05/23/14. She stated she did not even think about Resident #52's dignity/privacy. She stated she did not investigate anything as it pertained to the resident being seen by a male housekeeper during a garment change. The SSS said she also did not investigate the situation to determine if Employee #27 had maintained the privacy of Resident #52 from the other residents residing in the four (4) bed ward.",2018-04-01
6875,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2013-05-22,164,D,0,1,M57P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident observation, staff interview, and review of the facility's policy regarding treatment of [REDACTED]. Staff failed to close the blind while the resident's body was exposed during the provision of care. Resident identifier: #1. Facility census: 61. Findings include: a) Resident #1 On 05/14/13, a random observation found Employee #32, a nursing assistant (NA), providing care to Resident #1. The resident was lying on her right side and the backside of her body was exposed from head to toe. The window blind was open and looked out onto a yard with a sidewalk. When questioned, the nursing assistant said the window blind should have been drawn. During an interview with the DON on 05/15/13 at 8:00 a.m., she said Employee #32 had spoken with her. The DON said she informed the nursing assistant the blinds should have been drawn to promote privacy. The DON said she used lawn service as an example of the potential for exposure, to help the NA understand the relevance of closing the blind. Review of the facility policy 1.95 Treatment: Considerate and Respectful, on 05/21/13 at 10:53 a.m., revealed staff would show respect and dignity when caring for a resident. It noted to maintain resident privacy of body, including keeping the resident sufficiently covered. Employee #47, the assistant director of nursing (ADON), provided evidence Employee #32 had been previously educated on 04/12/12, and therefore was knowledgeable, concerning the resident's right to dignity and privacy.",2017-11-01
6948,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2013-06-25,164,D,0,1,WVZU11,"Based on a random observation, review of facility policies, and staff interview, the facility failed to provide personal privacy for a medical treatment. A resident received a breathing treatment in the dining room. The treatment continued into the serving and eating of lunch. Resident identifier: #22. Facility census: 59. Findings include: a) Resident #22 During the initial tour of the facility, shortly after entrance at 11:30 a.m. on 06/17/13, Resident #22 was observed in the dining room by two (2) surveyors. He was reclined in a geri-chair and had on oxygen (O2). A staff member approached him and initiated a nebulizer treatment in front of numerous other residents who were awaiting lunch, including a resident who was sitting at Resident #22's table. This treatment was still taking place as lunch was served and as the other resident at the table was served his lunch. On 06/20/12 at 10:10 a.m., the DON was interviewed about breathing treatments. She said it should not happen during meals and it was a daily occurrence. An interview was attempted with Resident #22 on 06/20/13 at 10:30 a.m. He was cognitively unable to complete the interview. A second interview with the DON was held on 06/24/13. She discussed giving nebulizers in dining room and said it was a dignity issue. She provided the facility's medication administration policy which did not include information about giving medications in public. A policy and procedure on aerosol treatments was provided by the Director of Respiratory Therapy at 3:30 on 06/24/13. It did not include information about giving treatments in public areas. The facility practice was discussed and he said they have been doing it for a couple of years, not for the therapist's convenience, but for the resident. He felt it decreased confusion by not dragging residents back to their rooms for a treatment, and then dragging them back. He did not acknowledge a violation of privacy by giving breathing treatments in public.",2017-09-01
6972,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2014-01-16,164,F,0,1,ONOL11,"Based on observation and staff interview, the facility failed to provide confidentiality of medical records. During random observations, the medication administration records of two (2) residents were exposed while placed on top of medication carts in the hallways. This practice had the potential to affect all facility residents who received medications. Resident identifiers: #44 and #129. Facility census: 87. Findings include: a) A random observation was conducted on the Two West Unit on 01/13/2014 at 12:35 p.m. During this observation, the Medication Administration Record [REDACTED]. The medication cart was unattended. An interview was conducted with Employee #76 (Licensed Practical Nurse-LPN) on 01/13/14 at 12:40 p.m. The LPN stated she ran off quickly to assist a resident and forgot to cover the medication administration record. She said the Medication Administration Record [REDACTED]. b) A random observation was conducted on 01/15/14 at 9:45 a.m. on the One East Unit. The Medication Administration Record [REDACTED]. The medication cart was unattended. An interview with Employee #100 (Licensed Practical Nurse-LPN) was conducted on 01/15/14 at 9:48 a.m. The LPN stated she was giving a resident his/her medication and forgot to cover the medication administration record. She stated the Medication Administration Record [REDACTED]",2017-09-01
7236,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2014-07-23,164,D,1,0,R9GB11,"Based on observation and staff interview, the facility failed to ensure one (1) resident identified through random observation was treated in a manner that maintained the resident's privacy during toileting. Resident #34 was being assisted in the bathroom by a health service worker (HSW). The HSW failed to ensure the bathroom door was closed, leaving the resident exposed below the waist. Resident identifier: #34. Facility census: 94. Findings include: a) Resident #34 During random observations in the C North Area Day Room at 4:08 p.m. on 07/22/14, a resident pointed to the bathroom door. Resident #34 was standing in the bathroom facing the bathroom door which opened into the C North Day Room. The resident was unclothed from the waist down. A licensed practical nurse (LPN) #107 was nearby and was asked to look into the bathroom at 4:09 p.m. on 07/22/14. She immediately went into the bathroom and closed the door. When she returned from the bathroom she was asked whether Resident #34 had gone into the bathroom alone. She stated, No, a health service worker (HSW) was in there with him. She indicated Resident #34 needed assistance toileting. When asked if the HSW should have assisted the resident with his toileting needs with the door open she replied, No, absolutely not.",2017-07-01
7340,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2014-05-29,164,D,1,0,MSKF11,"Based on observation, review of facility policy and procedure, and staff interview, the facility failed to provide personal privacy for a resident during an observation of a pressure ulcer on the resident's coccyx. When observing Resident #59 ' s pressure ulcer, the nursing staff did not close the blinds to the window in the resident ' s room or pull the privacy curtains completely around the resident's bed. This was true for one (1) of five (5) residents whose pressure ulcers were observed. Resident identifier: #59. Facility census: 117. Findings include: a) Resident #59 On 05/29/14 at 11:10 a.m., during an observation of Resident #59's Stage II pressure ulcer located on the coccyx, Employee #43, a registered nurse (RN), did not close the blinds to an outside window. A parking lot was located outside the window where random observations revealed people walked down the sidewalk to their cars. In addition, the privacy curtain was pulled the length of Resident #59's bed, but was not pulled around the foot of the bed. Two (2) visitors and a roommate were also in the room during the observation. A review of the facility ' s policy and procedure titled Wound Dressings: Aseptic, on 05/29/14 at 1:45 p.m., revealed Section 7. included, Explain the procedure and provide privacy. The nursing home administrator (NHA) and the director of nursing (DON) were present during this policy and procedure review. When asked whether she agreed there was a problem with providing privacy during the observation of Resident #59's pressure ulcer, the NHA smiled and shrugged her shoulders.",2017-05-01
7456,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-06-13,164,D,0,1,TA7B11,"Based on observation and staff interview, the facility failed to ensure the personal privacy of a resident during a physician's visit. During a physician's visit a resident was examined in the hallway and a progress note was dictated at the nurses' station in front of staff and other residents. This was a random observation. Facility census: 113. Findings include: a) Resident #127 On 06/04/13 at 08:30 a.m., Resident #127 was examined in the hallway by a physician (Employee #160). After examining Resident #127, the physician then proceeded to dictate a progress note on a recording device at the nurses' station in front of several other residents and staff. At 9:30 a.m. on 06/04/13, Employee#28, who was present when the physician examined the resident and dictated the progress note, was interviewed regarding the observations. She verified the physician's actions",2017-04-01
7685,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2013-03-22,164,E,0,1,B0M411,"Based on observations and staff interview, the facility failed to use privacy curtains that provide full visual privacy. This affected residents who resided in rooms 2, 3, 7, 9, 14 and 27. Findings include: Multiple semi-private rooms were observed during the survey from 03/18/2013 through 3/20/2013 including rooms 14, 27, 9, 7, 3 and 2. Curtains that separated the beds in those rooms were not long enough to provide visual privacy to the resident in the bed furthest from the door. On 03/19/2013 at 9:15 AM, an interview was conducted with maintenance staff #75. Staff #75 was shown the curtains and responded, I hadn't thought about it before, but the curtains don't cover the residents. This would be the same in all of our semi-private rooms.",2017-02-01
7713,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,164,E,0,1,Q01G11,"Based on observations and staff interview, the facility failed to provide privacy curtains to adequately maintain resident privacy through out the home in semi-private rooms. Findings include: During observations of resident rooms during the survey, resident rooms were noted to have a curtain track that went the width of the room across the foot of the beds in rooms that can house two residents. The curtains hanging in those tracks were only long enough to cover one bed at a time. A dividing curtain between the beds was long enough to go from the wall at the head of the bed to the track that covered the width of the room at the foot of the bed. The curtains could only be pulled to provide privacy for one resident at a time. Rooms observed on the D Hall were 2,4,6,8 and 12. On the C hall rooms observed were 8 and 14. All rooms in the facility were not observed for adequate privacy curtains. During a tour with Maintenance Supervisor #65. Maintenance Supervisor #65 acknowledged that with the existing curtains both beds are not private. We will have to get another curtain to cover the other bed.",2017-02-01
7886,"WEIRTON MEDICAL CENTER, D/P",515077,601 COLLIERS WAY,WEIRTON,WV,26062,2012-12-13,164,D,0,1,3VUY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy, and staff interview, it was determined the facility failed to ensure the right to personal privacy for three (3) of twenty-nine (29) sample residents. The facility took photographs of pressure areas and other [MEDICAL CONDITION] on areas of their bodies, without covering the private areas which did not need photographed. Additionally, the facility failed to obtain written informed consent prior to taking these photographs of private areas of the residents' bodies. There was no written consent from either the residents or the residents' responsible party. Resident identifiers: #20, #196, and #85. Facility census: 25. Findings include: a) Resident #20 During the medical record review it was discovered the facility had taken color pictures of pressure ulcers on this resident's buttocks. Review of the pictures revealed the resident was not draped to prevent exposure of areas of the peri-anal area which did not require a photograph. There were four (4) such pictures within the resident's medical record. The medical record is used by disciplines who would have no need to view these pictures. While reviewing the medical record it was also discovered there was no written informed consent for these photographs from this resident or a legal surrogate. During a review of the facility policy regarding photography, titled Patient Care Manual category 200.00, reference number 209.00, dated January, 2001, it was found on page 5 of 4: If the individual's genital or rectal area is photographed the individual or the individual's legal surrogate must give written consent. During an interview with the director of nursing (DON), Employee #5291, on 12/13/12 at 2:15 p.m., it was confirmed that written consent was not obtained prior to the photographs. b) Resident #196 A medical record review, on 12/11/12 at 2:35 p.m., indicated the resident was admitted to the facility on [DATE] with [MEDICAL CONDITION] varying degrees to his lower body. During the record review it was found the facility had obtained four (4) eight (8) by ten (10) inch color photographs of the resident's legs, inner thighs, and genital areas. No consent by the resident for the photographs could be located during the medical record review. A review of the facility policy labeled Patient Care Manual, category 200.00, reference number 209.00, dated January 2001 was conducted on 12/13/12 at 12:30 p.m. The policy revealed written permission should be obtained prior to taking photographs, if it was necessary to photograph the individual's genital area. The policy also stated the individual (resident) must give written consent for the facility to take the photographs. During an interview with the DON, on 12/13/12 at 2:15 p.m., it was confirmed there was no consent obtained for the photographs. c) Resident # 85 A medical record review, on 12/12/12 at 11:33 a.m., found Resident #85 was admitted to the facility on [DATE] with two (2) stage II pressure ulcers and one (1) suspected deep tissue injury on his buttocks. During the record review it was found the facility had taken three (3) eight (8) by ten (10) inch colored photographs of these areas. No consent for these pictures could be found in the medical records. Additionally, there was no drape placed on the resident to prevent exposure of the peri-anal area which was not required to be photographed. During an interview with the DON, on 12/13/12 at 2:15 p.m., it was confirmed that no consent was obtained prior to taking the photographs.",2016-12-01
7889,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2012-08-17,164,E,0,1,INBY11,"Based on observations and staff interview, the facility failed to provide privacy equipment in semiprivate rooms. Findings include: On 8/13/2012 and 8/14/2012, observations of resident rooms were made multiple times. Semi-private resident rooms including rooms F12, F16, B11, G14 and B4 were noted to have privacy curtains that would not enclose, and ensure the privacy of, residents in the bed closest to the door (Bed 1). The curtain left an approximately 18 inch gap that would allow anyone passing from the door to the bed closest to the window (Bed 2), or from Bed 2 to the bathroom or the door to the hall, to see a resident in Bed 1. On 8/15/2012 at 9:15 AM, an interview was completed with the Maintenance Director. The Director said that he had not heard any complaints about the privacy curtains. He acknowledged that the curtains could not enclose Bed 1. He added, 'We can extend the track and make the curtain reach.",2016-12-01
8468,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2012-05-11,164,D,0,1,HIO211,"Based on observation and staff interview, the facility failed to treat 1 of 19 sampled residents (R66) in a manner that maintained the privacy of his body. The facility failed for 19 of 19 sampled residents and 73 additional residents (to equal all residents who resided in the facility) to keep confidential each resident's medical information. Findings include: 1. On 05/08/12 during initial tour, a Licensed Practical Nurse 59 (LPN) exposed the genitals of R66 in the presence of a visitor, with the privacy curtain open, and the door to the common hallway open. During an interview with LPN59 at 10:12am, she stated It just took a second, no one saw him. 2. Observation on 05/08/12, 05/09/12, 05/10/12 and 05/11/12 revealed the facility labeled the outside of each clinical record with the resident's name and end of life status on large brightly colored labels. Each resident was identified as either Resuscitate on a large bright green label or No Code on a large bright pink label. All of the binders were easily read from the common hallway on both the A and B units. An interview with LPN59 on 05/08/12 at 11:00am revealed the facility always labeled the outside of the clinical record so staff can easily find it. LPN59 said she did not consider a resident's code status, was anything personal.",2016-06-01
8529,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2012-04-26,164,E,0,1,JZJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interview, the facility failed to provide privacy curtains that ensured full visual privacy for residents in 23 rooms. Room #s 6, 7, 9, 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, and 64. Findings include: a) During tour of the South Unit of the facility, the following rooms were observed to have a privacy curtain hanging for bed A of each room that did not provide full visual privacy for the residents residing in rooms 36, 37, 38, 39, 40, 41, 42, 43, 44, 45, 48, 49, 53, 54, 56, 57, 59, 61, 62, 64. These observations were verified by the maintenance director at 12:30 p.m. on 04/26/12. b) Observation of room [ROOM NUMBER] bed A, on 04/23/12 at 2:50 p.m., and on 04/26/12 at 1:24 p.m., revealed the privacy curtain was not long enough to go entirely around the resident's bed to provide full visual privacy. c) Observation of room [ROOM NUMBER] bed A, on 04/23/2102 at 10:53 a.m., and on 4/26/12 at 1:24 p.m., and also room # 9 bed A, observed on 04/23/12 at 3:53 p.m. and 4/26/12 at 1:25 p.m., revealed these privacy curtains were also not long enough to go entirely around the resident's bed to provide full visual privacy. This was verified by maintenance director on 04/26/12 at 11:30 a.m",2016-05-01
8642,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2011-08-17,164,D,0,1,5VE911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of the facility policy, the facility's staff failed to maintain the confidentiality of clinical records for one (1) of forty-seven (47) Stage II sample residents. Resident identifier: #136. Facility census: 89. Findings include: a) Resident #136 Observation, during medication administration on 08/09/11 at 8:35 a.m., revealed that Employee #86 (a registered nurse - RN) entered room [ROOM NUMBER], leaving the medication cart unattended, in the hallway and out of the employee's line of sight. The Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. During an interview at the time of the observation, Employee #86 stated the MAR indicated [REDACTED] Review of the facility policy titled 6.0 General Dose Preparation and Medication Administration revealed: 5. During medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: . 5.6 Observe each resident's privacy and rights in accordance with Applicable Law. During interviews conducted with the director of nursing (DON) and assistant director of nursing (ADON) on 08/11/11 at 7:50 a.m., the DON voiced the expectation that the nurse was to cover the MAR indicated [REDACTED]. The ADON also stated the MAR indicated [REDACTED]",2016-04-01
8830,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-08-31,164,E,0,1,5Y7411,"Based on observations and staff interview, the facility failed to protect the privacy and confidentiality of twenty (20) of one hundred (100) residents who reside in this facility. Observations during the course of the survey on Woodside Hall, with a capacity of twenty (20) residents, found the nursing station was located in a large room which was also being utilized as a day room for residents. Nurses who were assigned to work on Woodside Hall were observed discussing residents' personal medical information on the telephone, with other disciplines, among each other, and with a nurse practitioner while alert, oriented residents were seated in the room. This practice had the potential to affect all twenty (20) residents who reside on this hall. Facility census: 100. Findings include: a) Observations on Woodside Hall, during the course of the survey from 08/21/11 to 08/31/11, found the nursing station was located in a large room which was also being utilized as a day room for residents. Nurses who were assigned to work on Woodside Hall was observed discussing residents' personal medical information on the telephone, with other disciplines, among each other, and with a nurse practitioner, while alert, oriented residents were seated in the room. Family members were also observed in this room, either conversing with nursing staff or with residents who were seated in the room. In an interview on the afternoon of 08/31/11, the interim administrator (Employee #119) agreed these open discussions of resident-specified information at the nursing station constituted a breech of resident personal privacy and confidentiality of personal and clinical records information.",2016-03-01
8939,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,164,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to provide privacy curtains in a resident's room that were of sufficient width to provide the resident with privacy when drawn around the bed. Resident identifiers: Resident #20. Facility census: 50 Findings include: a) Resident #20 During an interview with Resident #20, on 09/18/12 at 3:56 p.m., it was observed the privacy curtain only covered the bed from the top of the bed to within two (2) feet of the end of the bed. When asked about the curtain coverage, Resident #20 responded with a laugh and stated it had always been like that. Resident #20 was admitted to the facility on [DATE]. Random observations made throughout the survey revealed no staff member recognized the privacy curtain was not providing Resident #20 with privacy. On 9/26/12 at 3:55 p.m., an interview with the housekeeping/laundry director, revealed this employee was not aware of the problem with the privacy curtain. On 09/27/12 at 9:30 a.m., an interview was conducted with the administrator regarding the privacy curtain. The administrator stated she was not aware of the problem and a tour was conducted with the administrator and the housekeeping/laundry director. Although there were now two (2) privacy curtains, the administrator and housekeeping/laundry director agreed this did not provide privacy for Resident #20.",2016-03-01
9011,GRAFTON CITY HOSPITAL,515057,1 HOSPITAL PLAZA,GRAFTON,WV,26354,2012-01-31,164,E,0,1,EZVZ11,"Based on observation and staff interview, the facility failed to provide privacy for residents taking a shower or using the tub in the main shower room on Unit 1. This shower room had no shower curtain in place to provide privacy. The shower curtain rod was on the floor. This had the potential to affect all residents on Unit 1. Facility census: 70. Findings include: On 01/23/12 at 12:30 p.m., observation of the main shower room on Unit 1, found the shower curtain rod on the floor of the shower room and no shower curtain in place. On a tour with the administrator (Employee #150), on 01/25/12 at 12:30 p.m., the administrator observed the shower curtain rod on the floor and no hanging shower curtain. This employee agreed if a resident was receiving a shower or tub bath, no privacy would be provided. Observation of the shower room, on 01/26/12 at 2:00 p.m., found the shower curtain and rod were in place in the Unit 1 main shower room.",2016-02-01
9479,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2011-02-02,164,D,0,1,SJCY11,"Based on observation and staff interview, the facility failed to ensure each resident has the right to confidentiality of his or her clinical records, as evidenced by staff leaving confidential clinical records unattended / open to public view during medication administration. This affected two (2) residents of random observation. Facility census: 84. Findings include: a) An observation made during medication administration, on 01/25/11 at 8:40 a.m., found a registered nurse (RN - Employee #2) left the medication cart unattended in the hallway with the Medication Administration Record [REDACTED]. An observation made during medication administration, on 02/02/11 at 7:40 a.m., found Employee #2 again left the medication cart unattended in the hallway with the MAR indicated [REDACTED]. On 02/02/11 at 1:00 p.m., an interview with the director of nursing (DON - Employee #1) revealed it was a violation of a resident's privacy for the MAR indicated [REDACTED].",2015-11-01
9538,"WEIRTON MEDICAL CENTER, D/P",515077,601 COLLIERS WAY,WEIRTON,WV,26062,2011-02-15,164,D,0,1,PL2X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide privacy to one (1) of eighteen (18) sampled residents during a medical treatment. Employee # was doing a medical treatment to the elbows of Resident #194. During the treatment observation, the resident's room door to the public hallway was not closed, and the privacy curtain was not pulled to ensure personal privacy and confidentiality. Resident identifier: #194. Facility census: 27. Findings include: a) Resident #194 During a treatment observation on 02/08/11, at 11:15 a.m., a licensed practical nurse (LPN - Employee # ) applied treatments to [MEDICAL CONDITION] on the elbows of Resident #194, prior to which the LPN failed to provide privacy and confidentially by failing to close the door to the public hallway or pull the privacy curtain. Also during this observation, other residents were noted to be ambulated in the hall way by physical therapy, and visitors were passing the resident's room door. During an interview on 02/09/11 at 1:30 p.m., the director of geriatric services (Employee #5291) confirmed the nurse should have provided privacy for the resident when doing these treatments.",2015-10-01
9703,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,164,D,0,1,RDGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation, the facility failed to protect the privacy of one (1) of thirty-five (35) Stage II sample residents while care was being rendered. Resident identifier: #67. Facility census: 65. Findings include: a) Resident #67 Observation, on 08/10/10 at 1:05 p.m., found Employee #77 (a respiratory therapist) placing a suctioning catheter into the resident's [MEDICAL CONDITION] and applying suction. The resident coughed and flopped her arms and legs about in the bed. The corridor door was open, and a male visitor was observed to stop in the hallway and watch the employee during the procedure.",2015-10-01
9783,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,164,E,0,1,2XEX11,". Based on observation and staff interview, the facility failed to ensure resident privacy was maintained during the evening meal on 05/24/10. The physician's assistant was observed examining and discussing medical issues with residents and family members openly in the dining room during the meal with other residents AND their family members present and within hearing distance. This occurred for one (1) of thirty three (33) Stage II sample residents and three (3) randomly observed residents. Resident identifiers: #154, #170, #171, and #172. Facility census: 57. Findings include: a) Residents #154, #170, #171, and #172 During the evening meal on 05/24/10, observation found the certified physician's assistant (PA-C) in the dining room talking to residents and their family members. There were other residents and family members present in the dining room who were able to hear the PA-C discuss the residents' medical conditions. The PA-C also examined two (2) of the residents while they were eating their meals (Resident #150 and #171), using a stethoscope and listening to their chests. During an interview on 05/27/10 at 10:00 a.m., the administrator acknowledged these residents should be removed from the dining room to a private area for discussion of their medical conditions and examination by the PA-C. .",2015-09-01
10073,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2012-03-01,164,D,1,0,0TSC11,". Based on observation, the facility failed to ensure personal privacy was maintained during a nursing procedure for one (1) of nine (9) sampled residents. Resident identifier: #33. Facility census: 71. Findings include: a) Resident #33 During random observations, conducted on 02/29/12 at 11:15 a.m., a registered nurse (RN), Employee #31, was observed flushing Resident #33's gastrostomy tube. It was noted the roommate and two (2) visitors were in the room and were watching the procedure. The nurse exposed the resident's abdomen and failed to pull the curtain between the beds or close the door to the hallway. The resident's gastrostomy tube and abdomen were clearly visible from the hallway, as was the procedure performed by the RN. .",2015-07-01
10116,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2009-10-23,164,D,0,1,9ELI11,"Based on random observations, the facility failed to ensure privacy was provided during care and treatment. A dressing change to a resident's leg wound was being provided without the door to the room or the cubicle curtains being drawn. Another resident was given an insulin injection in the abdomen without privacy being provided. Resident identifiers: #22 and #42. Facility census: 99. Findings include: a) Resident #22 On 10/21/09 at 2:35 p.m., while passing by Resident #22's room, observation found a nurse (Employee #39) performing a dressing change to the resident's right lower leg. The resident was sitting up in a chair near the foot of her bed. The door to the hall was open, the resident's roommate was also sitting up in a chair and could view the dressing change, the cubicle curtains had not been drawn, and the window blinds had not been closed. A nursing assistant came into assist the nurse as she prepared to change the dressing on the resident's left leg. The nursing assistant closed the door, pulled the cubicle curtain, and closed the blind on the window. b) Resident #42 On 10/22/09 at 11:32 a.m., Employee #39 was observed checking residents' blood sugars. Resident #42's blood sugar reading was 202. This required insulin coverage. The nurse drew up the insulin and gave the injection in the resident's abdomen. The resident was sitting in a chair near the door to the hall. Her roommate was also present. The door open was open, and the nurse did not draw the cubicle curtain to provide privacy for the resident. .",2015-06-01
10347,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,164,D,0,1,5TIO11,"Based on observation and staff interview, the facility failed to protect the privacy of one (1) of thirteen (13) sampled residents by leaving confidential resident information observable in a hallway unattended. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 When entering the room of Resident #30 for an observation of wound care at 11:10 a.m. on 10/06/09, the surveyor observed the treatment administration record lying open on top of the treatment cart located in the hallway outside the room. The resident's name, wound status, and treatment information were accessible to anyone who stopped in the hallway. Both of the treatment nurses (Employees #74 and #34) had already entered the room. The door was left open throughout the treatment, and the record was still open when the room was exited approximately fifteen (15) minutes later. During an interview with the assistant director of nursing (Employee #74) and the wound care nurse (Employee #62) at 10:30 a.m. on 10/07/09, they were informed of the observation. .",2015-05-01
10578,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-09-20,164,D,1,0,KU2H11,". Based on observation and staff interview, the facility did not ensure the confidentiality of medical records when a nurse left a binder of residents' medication administration records (MARs) on unattended and open to view in the hallway during a medication pass. Facility census: 119. Findings include: a) A random observation, on 09/19/11 at 7:30 p.m., found an unattended medication cart on top of which was a binder of MARs open to view. The MAR indicated [REDACTED]. At that time, a visitor was walking in the hallway and would have been able to view the contents of that resident's MAR. Shortly thereafter, the nurse (Employee #136) arrived at the medication cart and closed the binder, after the situation was brought to her attention. In an interview on 09/19/11 at 7:35 p.m., Employee #136 stated she knew the MAR indicated [REDACTED]. .",2015-01-01
10806,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,164,D,0,1,7F5X11,"Based on observations, the facility failed to ensure privacy during medical treatment for one (1) of three (3) residents for whom a treatment was observed. The resident's body was exposed more than was necessary during a treatment to her coccyx. Resident identifier: #30. Facility census: 86. Findings include: a) Resident #30 On the mid-afternoon of 09/22/09, a dressing change for this resident was observed. The resident was in bed and was turned onto her right side by a nursing assistant (Employee #35), so a licensed practical nurse (LPN - Employee #103) could do the treatment to the resident's coccyx area. The resident had on a hospital-type gown that was not tied in the back. The resident was exposed posteriorly from head to toe, although only the area of the coccyx needed to be uncovered. .",2014-12-01
11020,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,164,D,0,1,53ZE11,"Based on an observation and staff interview, the facility did not ensure one (1) resident of random selection (#120) was afforded the right to confidentiality of clinical records. Facility census: 121. Findings include: a) Resident #120 An observation, on 02/03/09 at 9:25 a.m., revealed Resident #120's Medication Administration Record [REDACTED]. The medication cart was in the hallway and visible to anyone walking in the area. An interview with the nurse (Employee #139) revealed she forgot to close the medication binder after she dispensed the prescribed medications and walked into the room to administer the medications to the resident. .",2014-09-01
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
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
5005,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-04-20,165,D,1,0,06GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, medical record review, and facility record review, the facility failed to ensure the rights of one (1) of six (6) sample residents to voice grievances without reprisal. Resident #33 related a Licensed Practical Nurse (LPN) and a Nurse Aide (NA) retaliated against the resident after a complaint was initiated over the administration of a medication. The nurse confronted the resident and the nurse aide did not assist with a transfer from chair to bed, and required the resident remain in his chair for over two (2) hours after dinner. Resident identifier: #33. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife on 04/18/16 from 4:04 p.m. to 4:45 p.m., Resident #33's wife said a complaint had been initiated about the administration of [MEDICATION NAME], but it was a misunderstanding. According to the resident's wife, the resident thought he received Tylenol instead of [MEDICATION NAME]. Resident #33 agreed with his wife's statement. Resident #33's wife related Licensed Practical Nurse (LPN) #20 came to the resident's room, and said they needed to talk. The nurse told Resident #33 She did not appreciate him reporting her to the administrator. The resident's wife indicated the nurse had said they had gotten her in trouble. Resident #33 and his wife also related LPN #20 had said to him that she had her medication cart at his door every day at 4:00 p.m. They also stated she asked him, Do you know what this is? and he had answered, Tylenol?, and the nurse had responded, No, it's (it is) your [MEDICATION NAME]. Resident #33's wife related the Center Nurse Executive (CNE) had entered the room and spoken with LPN #20, and they exited the room. Resident #33 related she had apologized to the nurse for the misunderstanding, and had called the facility and offered her apologies. Resident #33 related the day after the incident, he was in his chair for dinner and requested to return to bed. He said NA #82 (LPN #20's spouse) walked up and down the hallway assisting the other NA, looked in his room and glared, but did not attempt to assist with a transfer to bed. NA #82 was assigned to 100 hallway, but was helping the NAs on the 200 hall where the resident resided. According to the resident, he was left in his chair for two (2) hours and 20 minutes after dinner. The medical record, reviewed on 04/18/16 at 3:00 p.m., found a 90 day minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/09/16, identified the resident scored 13 of a possible 15 for the Brief Interview for Mental Status (BIMS) - indicating the resident was cognitively intact. The assessment also identified Resident #33 required the extensive assistance of two (2) persons for transfers. [DIAGNOSES REDACTED]. The pain assessment indicated he received scheduled pain medication, and received as needed (PRN) medication and/or was offered medication and received non-medication interventions for pain. The care plan, reviewed on 04/18/16 at 3:08 p.m., revealed he was dependent upon staff for transfers and locomotion due to left sided [MEDICAL CONDITION]. Progress notes, reviewed from the date of admission on 01/05/16, indicated a lift-transfer assessment was completed on 01/05/16. The assessment indicated the resident required a total lift for transfers. An interview with the social worker (SW) on 04/19/16 at 3:35 p.m., revealed she had no additional concerns and/or grievances other than what was provided on 04/18/16. The SW related the facility took allegations Very seriously. Resident #33 and his wife, interviewed on 04/19/16 at 3:45 p.m., related it was okay to speak with the Center Nurse Executive (CNE) and social worker, related to the incident involving LPN #20 and NA #82. During an interview on 04/19/16 at 4:30 p.m., CNE revealed she was aware of the concern related to the allegations Resident #33 and his wife had reported during the interview. She also said a concern had been filed with the corporate compliance line. Concern/grievance/complaint forms, reviewed with the CNE, found no evidence the complaint had been initiated. She related the information may have been placed in another file and exited the room. She returned with a complaint filed with the compliance line. She related it was a mixture of things which were misinterpreted. The CNE said she was standing three (3) doors down on the 200 hallway when the interaction with LPN #20 and Resident #33 occurred. When she heard the conversation, she went to the room and intervened. The CNE stated she instructed the LPN to allow the facility to handle the situation. She also confirmed NA #82 assisted on the hallway, and had spoken with him and LPN #20. The CNE indicated the staff informed her the resident had remained up in his chair for over two (2) hours 'because they were preparing him for discharge to home. The CNE confirmed she had not interviewed other staff working with NA #82, the date of the incident and could not provide evidence the facility had investigated thoroughly to refute the allegation of retaliation.",2019-04-01
5275,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2016-02-29,165,D,1,0,HFVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, and resident interview, the facility failed to ensure that grievances voiced by a resident were investigated, a resolution sought, and the resident notified and kept informed of the progress toward resolution. This was found for one (1) of four (4) residents in the sample. Resident identifier: #2828. Facility census: 60. Findings include: a) Resident # 2828 1. A review of the resident's clinical record revealed Resident #2828 was a [AGE] year-old male admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. He had been determined by a psychological evaluation on 08/18/14, to have the capacity to form his own health-care decisions. The resident was observed at 2:50 p.m. on 02/24/16, being pushed in a wheelchair by an aide to the beauty shop for a haircut. He was clean, groomed, and dressed appropriately. He was alert and greeted the surveyors pleasantly. During an interview with Resident #2828 at 12:30 p.m. on 02/29/16, the resident alleged he did not receive enough food to eat and had to supplement his diet by purchasing food from outside the facility. The resident was a vegetarian and was allergic to peanuts. The resident's untouched lunch tray was present in the room and contained a salad, a small bowl of soup, and a peanut butter sandwich, although his tray card identified the resident was allergic to peanuts. He said this was not unusual and that he often received peanut butter crackers as a snack item. He said he had complained about the food and told them his preferences, but They didn't listen. The sandwich and the menu card were taken to the kitchen and presented to Dietary Manger (DM) #3 at 1:15 p.m. on 02/29/16. The DM acknowledged the resident had received the sandwich in error and she would rectify this. She stated the resident often complained about the food and staff were aware he went to local stores to buy food. She said she had met with the resident many times since his admission here and tried to provide foods he would eat. She agreed he had lost weight. There was no evidence in the clinical record of those interviews or of any changes to the resident's diet. The care plan, initiated on 07/28/14, listed the problem as, DIET I - Requires an NCS (no concentrated sweets) 2000 calorie Vegetarian Diet. A goal for this problem was, Tolerate diet which was updated on 12/30/15 with a goal stating, Dietary will attempt to meet resident's food choices to the best of the facility's ability. The only intervention pertaining to food choice was that the resident would mark the menu with his choices each week. In an interview with RN #19 (DON) at 1:45 pm on 02/29/16, she acknowledged the resident complained about his diet often. She said he usually ate most of it and hid anything left to eat later. When asked if there were any records of these complaints, which would include the actions taken, she said she would have to review the record. There had been no written complaint forms provided at the time of exit. 2. The final complaint the resident had was that he had purchased a new computer and it had disappeared when his room was searched. When asked when this had happened, he said it was last week, but later in the conversation, he said it was last month. He did say that he had tried to get the facility to call the police to report the stolen computer and he had reported it to the Ombudsman. During an interview with Interim Administrator #33 at 2:00 p.m. on 02/23/16, he said he knew we (the surveyors) were there to investigate the resident's missing computer. The Interim Administrator said the resident had been claiming the loss of the computer since the room search that was done on 02/03/16, while the resident was out of the facility for an appointment with an outside physician. He stated there had been several items confiscated, but they did not include a computer. RN #150, interviewed at 1:30 p.m. on 02/29/16, said the resident had told her his computer was missing after the room search on 02/03/16, but when she contacted Interim Administrator #33, he told her the computer was seen under the bed and she relayed this to the resident. b) The requested complaint/grievance reports, incident reports, and allegations reported to the State were provided to the surveyors by Assistant Administrator #10 at 3:00 p.m. on 02/23/16. Review of the documents found no documented forms related to Resident #2828 contained in these records. At 9:30 a.m. on 02/24/16, when Interim Administrator #33 and Assistant Administrator #10 were asked why there was no evidence of complaints/grievances or allegations of missing items in the supplied documents, Assistant Administrator #10 said the resident had complained ever since his admission and staff probably quit writing it down. Interim Administrator #33 said he thought there was a report for the missing computer and he would look for it. c) On reentry to the facility at 10:00 a.m. on 02/29/16, a copy of an Immediate Fax Reporting of Allegations - Nursing Home Program and the Five-day Follow-up were provided. The Immediate report read as follows, (Resident #2828) feels personal items have been stolen and nothing done. (Resident) says he is not properly nourished and has lost weight. Just learned of this on 2 pm 2/22/16. This report was dated 02/23/16 and signed by Assistant Administrator #10. There was a one-page handwritten unsigned statement attached, which did not address the computer at all. The 5-day follow-up, completed and signed by Social Worker #107 (SW) stated, Upon thoroughly investigation unsanitary items have been removed from his room but his personal belongings has been put in a separate room with lock/key as he has too many items, suitcases, and duffle bags to put in his room. There was no evidence provided during the survey to indicate the resident's complaints and/or allegations had been addressed formally or that an attempt had been made to resolve the complaints and the resident informed of the resolution.",2019-02-01
5468,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2015-03-27,165,D,0,1,HEH611,"Based on observation, resident interview, record review and staff interview, there was no evidence the facility supported a resident's right to voice grievances and/or actively sought a resolution to the grievance for one (1) resident identified through a random opportunity for discovery. There was no evidence the facility addressed the resident's complaint that her roommate's television was too loud. Resident identifier: #23. Facility census: 64. Findings include: a) Resident #23 During Stage 1 of the survey, on 03/23/15 at 2:39 p.m., Resident #23 commented she had a new roommate, who played her television (TV) very loud during all hours of the day and night. Resident #23 stated, I just have to watch the pictures on my television, because I can't hear the shows and this usually continues until 3:00 in the morning. Resident #23 further stated, I have told the nurses, the social worker and anyone who will listen to me, because this is disturbing to me and causing me not to get any sleep. During the interview with the resident, the roommate's television volume was very loud, making it difficult to hear the resident's responses during the interview. A review of the facility grievance/complaint forms, on 03/26/15 at 12:30 a.m., revealed no evidence of a complaint from Resident #23 regarding her roommate's television being loud and affecting her comfort. Licensed Practical Nurse (LPN) #24 commented in an interview, on 03/26/15 at 1:20 p.m., she was aware Resident #23 complained about her roommate's TV being too loud. LPN #24 said she spoke with Resident #23 and her roommate regarding the loud TV. The roommate said all Resident #23 needed to do was tell her to turn it down if it was too loud. LPN #24 stated, I told them both because they are roommates, they need to compromise with each other, because they have been roommates for a month now. In an interview, on 03/26/15 at 1:30 p.m., with the Director of Nursing (DON), she stated, I am unaware of any complaint about Resident #23's roommate with a loud TV. During an interview with Social Worker (SW) #27, on 03/26/15 at 1:40 p.m., she stated, I have spoken with Resident #23 and her roommate concerning the TV being too loud. We are in the process of purchasing new headphones for the roommate, so her TV volume will not disturb Resident #23. On 03/2615 at 2:40 p.m., SW #27 stated, I did not complete a grievance/complaint form regarding the loud TV, and I should have completed one for the complaint.",2019-01-01
8402,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2013-06-12,165,D,1,0,NZCN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, family interview, medical record review, concern report review, and staff interview, the facility failed to ensure residents/families had the right to file grievances and have the staff investigate and respond to those grievances. One (1) of six (6) residents/families had concerns that had not been documented or investigated. Three (3) of three (3) months of resident council minutes, also had grievances voiced by residents, which the facility had not documented or addressed. Resident identifier: #123. Facility census: 120. Findings include: a) On 06/11/13 at 11:00 a.m., a review of the resident council minutes for March, April, and May 2013 was completed. Each month's minutes noted the resident council had voiced concerns. In March, they had issues with ice pass, call lights, and missing clothing. In April, they had issues with ice pass and call lights. In May, they had issues with call lights, water pass, and dusting. There were no notes regarding resolution of these issues. On 06/11/13 at 1:10 p.m., the activity director (Employee #84) stated she forwarded the resident council's concerns to the departments responsible for correcting them. She said she never received any correspondence back from the departments. The activity director said she had a lot of trouble getting the departments to respond to any concerns voiced by the council. On 06/11/13 at 7:00 p.m., during a family interview, Resident #123's family member stated he/she had voiced complaints at the facility several times, but the facility never put the complaint in writing or gave him/her a response. They stated on one occasion the facility presented an action plan on a plain typed sheet of paper, but the plan did not contain a signature and did not address the fact the family wanted their concerns filed as a formal complaint/grievance. On 06/11/13 at 4:00 p.m., Employee #44 (licensed practical nurse) said she had taken care of Resident #123 while she lived at the facility. She said the resident's daughter often complained to her about her mother not getting showers or her clothes changed. She said she would tell the daughter this was because her mother resisted care and preferred to make her own choices regarding clothes, but the daughter did not accept this. Employee #44 and the director of nursing both stated the family had received information about their mother's [DIAGNOSES REDACTED]. The LPN and director of nursing said the facility had ever filled out a concern/complaint form documenting the family's concern or the facility's investigation into their concerns. On 06/12/13 at 1:20 p.m., the social worker (Employee #59) provided the facility's policy on grievances/concerns. The policy, revised on 06/10/13, stated the facility would provide a description of the procedure for voicing grievances/concerns on each unit in a prominent location. The policy also stated formal concerns may be registered by telephone, mail, office visit, or direct outreach to staff. Upon receipt of the grievance/concern, the facility policy stated the grievance/concern form would be initiated by the staff member receiving the concern and documented on the grievance/concern log. The policy went on to state that when the formal grievance/concern was logged, the administrator and appropriate department manager would be notified. The policy stated the department manager would contact the person filing the grievance to acknowledge receipt; investigate the grievance; engage the support of the ombudsman if warranted and notify the person filing the grievance of resolution within 72 hours. The social worker said she attends the morning meeting where the facility discusses grievances/complaints. She said the clinical staff normally stays after the meeting concludes to discuss the concerns/grievances. At that time, the social worker gives the complaints to the departments responsible for resolving them. She said the social workers were responsible for ensuring the appropriate department managers completed the complaint forms. She indicated there were issues with getting these forms returned. In the past, the facility used a tracking tool to write down who had filed a concern, which department it was assigned to and the date it was to be resolved. She said they would need to utilize this tracking tool again to ensure they logged, tracked and investigated. The social worker said the nursing staff had never informed her of any issues with the family of Resident #123. On 06/12/13 at 4:00 p.m. observations on each of the facility's three (3) units found they did not have information regarding the process for filing a complaint posted in a prominent location. The information was not posted anywhere on the units. The director of nursing (Employee #123) verified the facility did not have this information posted. The director of nursing also said she did not know why the facility did not log a complaint containing the family's concerns for Resident #123.",2016-06-01
11017,HEARTLAND OF KEYSER,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2009-02-05,165,D,0,1,53ZE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, record review, and staff interview, the facility failed to address grievances in a timely manner. Resident #109 had resided in the facility for over seven (7) years, and the facility failed to adequately address his repeated requests to have a cool sleeping environment at night. This was evident for one (1) of twenty-one (21) sampled residents. Resident identifier: #109. Facility census: 121. Findings include: a) Resident #109 Record review revealed Resident #109 was an alert, oriented [AGE] year old male who resided in the facility for nearly eight (8) years. His physician had determined he had the capacity to understand and make his own informed healthcare decisions. Due to [DIAGNOSES REDACTED], he required total assistance from staff with the performance of activities of daily living. He was unable to leave his bed unless lifted out with a mechanical or other total lift, was unable to walk, and used a motorized wheelchair. During an interview on 02/04/09 at approximately 10:00 a.m., he stated his desire to keep his room warm by day and cool at night. Per the resident, he gets up in his scooter by day and feels cold. At night, he likes to cover up in bed with his warm blanket to keep his trunk and extremities warm, but he needs to have cooler air during sleep to facilitate breathing, feeling like he smothers if the air is too hot. He stated staff has known of these needs for years. He stated the heat last night was so unbearable he could not breathe, but staff refused to turn down the heat as he requested. He said he awoke drenched in sweat and had to get up at 2:30 a.m. to sit in his scooter for the remainder of the night, so he could breathe. He said he would like to have his room at 66 degrees Fahrenheit (F) while sleeping at night, although this was an estimated number as there was no thermometer in the room to measure the exact temperature. He was considering moving to another facility, but he stated his preference would be to stay where he was, since this was his home, if only the heat could be turned down at night. Interview with a social worker (Employee #119), on 02/04/09 at 2:15 p.m., revealed she was aware of his desire for coolness at night during sleep, and she admitted this had been an ongoing problem resulting in numerous roommate changes over the years. She said his current roommate, who had dementia, was placed there in the past week or so, and he was unable to speak for himself and say if he felt warm or cold. Interview with Resident #109's former roommate (Resident #9), on 02/04/09 at 2:45 p.m., revealed Resident #9 (aged 95) recently moved out of that room because it was too cold at night. He transferred to another room down the hall but, due to the television being too loud, he transferred again to the private room where he currently resides. At this time, Resident #9 was fully dressed and wore a heavy jacket over his street clothes and his room felt very warm, yet he stated he just felt comfortable at the moment. This resident had resided in the facility since 01/23/09. An attempt was made to interview Resident #109's current roommate on 02/04/09 a 3:15 p.m., but he was not interviewable due to his [DIAGNOSES REDACTED]. Interview with the assistant director of nursing (Employee #65), on 02/04/09 at approximately 3:00 p.m., revealed she, too, was aware of his desire for a cool room at night. She stated the water pipes in that room froze once about a year ago. She agreed the resident's stated desire for a 66 degree F temperature at night was not too cold for her, but there was no thermometer to objectively gauge the actual room temperature. She reported that, once, a nurse arrived to work at 7:00 a.m. and said she could see her breath in that room. Resident #109's unresolved desire for a cool sleeping environment was relayed to the administrator, the director of nursing, and other staff present on 02/04/09 at approximately 4:00 p.m., and they acknowledged this has been a recurring problem throughout the years trying to suit him with compatible roommates. On 02/05/09 at 8:45 a.m., the social worker (Employee #119) reported the facility obtained a thermometer for the resident's room and planned to keep the room between 72 degrees F and 81 degrees F, and she asked if the State regulation stipulated a room temperature between these two (2) parameters, as there was a roommate to consider who could not speak for himself. She stated that to her knowledge there had never been a thermometer in his room before. When asked if the facility was abiding by Resident #109's wishes for his comfort zone (citing his comfort as the right temperature for him), and about the facility's inability to find a suitable roommate in the seven (7) years Resident #109 had resided there, Employee #119 offered no further information at this time. On 02/05/09 at 9:45 a.m., observation found Resident #109 lying in his bed. When interviewed, he reported feeling ""completely beat"" due to two (2) nights in a row without good sleep due to the heat. He stated, ""I woke up and couldn't get my breath and was wringing wet."" He stated the nurse told him, at 3:00 a.m., that it was 78 degrees F and informed him the room temperature had to be at least 72 degrees F and she would not lower the heat for him. Review of nursing notes, dated 02/05/09 at 3:00 a.m., found, ""Heat on set @ (at) 78 degrees per thermometer in room."" A subsequent note, at 5:00 a.m., recorded the room temperature at 74 degrees, documented his complaint of sweating and not breathing well due to the heat, and documented verbal exchanges for the preceding twenty (20) minutes that acknowledged ""he is miserable"" but contained no documentation of comfort measures nor reassurances being offered. Clinical record review revealed a social services progress note, dated 01/29/09, documenting Resident #109 being upset about the food and reporting he could move to another facility, followed by staff advisement ""that we only wanted to keep both he and his roommate comfortable"". Another social services progress note, dated 02/03/09, documented a meeting with Resident #109, during which the author ""completed an assessment for possible transfer. . . . (Resident) has been unhappy with HOK (Heartland of Keyser) regarding room temperatures"". The note further indicated a plan to contact another facility when a bed becomes available. .",2014-09-01
11251,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2010-03-18,165,D,1,0,8Q6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, record review, and staff interview, the facility failed to assure one (1) of four (4) sampled residents was afforded the right to voice grievances via their legal representative without reprisal. Resident identifier: #2 Facility census: 118. Findings include: a) Resident #2 During an interview with Resident #2's legal representative / family member conducted on 03/17/10 at 12:00 p.m., the legal representative stated that, when she had previously expressed concern to the facility about Resident #2's care, she was told that if she was not happy with the care the resident received, the facility would assist her in finding alternate placement. The legal representative stated she no longer brings complaints or concerns to the attention of the facility out of fear the resident would be forced to move to another facility. A review of the facility's grievance / complaint reports found Resident #2's family met with staff members on 02/03/10 at 3:10 p.m., related to concerns that the resident received a double dose of [MEDICATION NAME]. The hand-written record of the meeting contained the following: ""Family has been given option of replacement if they are not satisfy (sic) w/ (with) resident's care & there (sic) response was we don' t want him replaced it is to (sic) convienced (sic) for their mother to visit."" In ann interview was conducted with the administrator (Employee #1) on the morning of 03/18/10, he stated he attended the 02/03/10 meeting and did offer to assist the family in finding alternate placement if they were not satisfied with the care provided by the facility.",2014-07-01
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
733,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2017-09-19,166,D,1,1,4U3U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, resident interview, policy review, and review of grievance concern forms, the facilty failed to provide prompt response to grievances regarding personal property. This was true for two (2) of five (5) residents reviewed for personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #136 and #79. Facility census: 119. Findings include: a) Resident #136 On 09/11/17 at 2:14 p.m., a review of the medical record revealed Resident #136 was admitted to the facility on [DATE]. A Brief Interview for Mental Status (BIMS) on admission revealed a score of 15 which indicates intact cognition. During a Stage 1 interview with Resident #136 on 09/11/17 at 3:50 p.m., when asked the question: Have you had any missing personal items? She stated, Yes. When asked Did you tell staff about the missing item(s)? She stated, Yes. When asked Has staff told you they are looking for your missing item(s)? She stated, (Yes). Resident #136 stated she usually keeps her personal items put away but there's not alot of room. She stated her tablet and (DVD) Digital Versatile Disc player went missing on (MONTH) 16, (YEAR). She stated that her son bought her a lockbox and maintenance secured it to the top of her dresser. She further stated the facility was going to replace the tablet but her sister bought her a new one. Review of a Grievance Form dated 10/27/16, Resident #136 reported she was missing a 10 portable DVD player and RCA laptop charger and wall adapter to her cell phone charger. Resident #136 stated in the grievance form they have been missing since 10/26/16. The Social Services Department was assigned to investigate this concern on 10/27/16. According to the documentation on the grievance form, they were unable to locate the missing items and would continue to look and Resident #136 was notified. Social Worker (SW #51) initiated the grievance form. Review of Grievance Form #2 dated 01/27/17, Resident #136 reported her RCA tablet and portable DVD player were missing. Documentation revealed that the facility was searched, items were not found and Resident #136 bought a new portable DVD player. Documented resolution stated the facility replaced the RCA player and Resident #136 was educated about risks of leaving items unattended. Resident is agreeable to having DVD player and tablet locked up when not in use. Resident educated that facility is not liable for any missing or lost items. DVD player replaced by facility. Social Worker (SW #51) stated during an interview on 09/18/17 at 3:00 p.m., when asked Can you describe the process when a resident files a grievance? SW #51 stated the resident fills out a grievance form and social services conducts the investigation. A missing items notice is sent to housekeeping, laundry, the Director of Nursing (DON), and the Nursing Home Administrator (NHA). She stated that once they look for it, they can do the actual investigation within 72 hours. When asked about the delay in replacing the DVD player for Resident #136, she stated she requested a receipt for the missing item and that the resident did not have it but later found it after several months and once they received the original receipt, the business office began the paperwork and the facility replaced the DVD player on 09/11/17. This was eleven (11) months after the items were reported missing. A review of the facility Grievance/Concern Policy and Procedure with a revision date of 02/13/17 was reviewed on 09/18/17 at 3:10 p.m. The Grievance Concern policy stated the facility is to assure prompt receipt and resolution of patient/representative grievance/concern within a reasonable expected time frame for completing the review of the grievance. The department manager will notify the person filing the grievance of resolution within 72 hours by providing a copy of the Grievance/Concern Form to the resident/resident representative. The NHA #96 stated during an interview on 09/19/17 at 9:34 a.m., he is the Grievance Officer. Discussed the grievance forms of Resident #136 indicating tablet and DVD player in which the tablet and DVD player were reported missing on 10/16/16. NHA states facility replaced both. Record review revealed a DVD purchase receipt 09/29/16. On 09/11/17, a medical record review and resident interview revealed the DVD player had not been replaced. Resident #136 reports her family bought her a Kindle to replace the missing tablet. Record review revealed a purchase receipt on 09/11/17 for a DVD player that the facility purchased and was given to the resident on 9/12/17. NHA stated he can't remember a year ago, went through several social workers, is trying to clean things up. I'm not going to lie to you. It should not be. It should not have aken so long to replace. Audit of missing resident property began at beginning of the month. b) Resident #79 During a Stage 2 interview on 09/18/17 at 2:00 p.m., SW #15 stated the resident reported her missing laptop on 01/27/17 and completed a Grievance Concern Form. When asked what happened after the five (5) day follow up? She stated APS said there was no harm when the process was initiated and her receipt was reimbursed. When asked how is follow through to resolution documented and why is the section titled Corrective Action by Facility blank? The SW stated that they are not permitted to write on the form once it has been faxed to OHFLAC, APS, and the Ombudsman. When asked Is this sufficient documentation to show that the concern was followed through to resolution. The SW stated No. On 09/18/2017 at 2:30 p.m., a medical record review revealed Resident #79 was admitted to the facility on [DATE], Dx:[MEDICAL CONDITIONS], wheelchair confined, A Brief Interview of Mental Status (BIMS) on admission revealed a score of 15 which indicates intact cognition.",2020-09-01
791,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2017-07-19,166,D,1,1,HITB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview, resident interview, family interview and review of the facility's grievance concern forms, the facility failed to follow up on Resident #119's representative's grievance and concern regarding a particular nurse aide(NA)assigned to care for her legally blind husband. This was true for one(1) of one(1) resident reviewed for the care area of social services. This practice had the potential to affect an isolated number of residents. Resident identifiers: #119. Facility census: 100. Findings include: a) Resident #119 Resident #119's interview during stage one (1) of the Quality Indicator Survey (QIS), on 07/10/17 at 3:48 p.m., revealed the resident has severely impaired vision and was allegedly told by a staff member to go find the bathroom himself when the resident had requested assistance. Resident #119 said he tripped and fell when he went alone to the bathroom and hurt his left hip. The resident who says he is legally blind cannot see well enough to distinguish the nurses from the Nurse Aides (NA), and is not sure who told him to go to the bathroom on his own. The resident said he was not sure who did it and could not recognize staff by their voice. The resident stated the facility had, raised hell because it was not reported, and was trying to find out who it was. He said he was told they would be disciplined. However, Resident #119 could not tell the surveyor who told him they were trying to find out about the incident. Review of a fall report dated 07/02/17, on 07/12/17 at 9:27 a.m., revealed (typed as written), Noted discolored area on left hip; resident asked what happened he stated, I got up trying to use the bathroom myself and tripped. He is unable to state that date or time of incident. He denied any allegations of abuse, denies any feelings of being threatened. Area does not appear suspicious. No abnormality noted; able to move all extremities; no increase in pain noted. Interview with Social Worker (SW# 102), on 07/12/17 at 4:25 p.m., revealed SW #102 was unaware the resident had reported any staff had told the resident to go find the bathroom himself when the resident had requested assistance. SW #102 said the resident's wife, as she was leaving the building one day, asked that a certain NA no longer be assigned to her husband, and mention something about a phone. When asked why the request had been made, SW #102 said he was not sure and would have to look at the concern and comment report he completed. A copy of the report was requested. Review of Employee concern and comment report dated 07/03/17, on 07/12/17 at 4:35 p.m., revealed Resident's Guardian identified a NA that she no longer wished to be assigned to care for Resident #119. The NA was removed off Resident #119's assignment as requested. There was no other documentation as to why or what might have caused the request to be made, or any follow up regarding the request. On 07/13/17 at 9:52 a.m., a phone interview with Resident #119's wife (MPOA)and this surveyor was conducted. When asked why she had requested a certain NA no longer be assigned to her husband, she replied, Because the NA had told her husband to find the bathroom on his own. She stated the NA said, Find it on his damn own. My husband is legally blind, he fell while trying to go to the bathroom on his own and got a nasty bruise on his hip. When asked if she had told anyone at the facility, she said she discussed it with SW #102 and told him why she did not want the NA to be assigned her husband. On 07/13/17 at 10:01a.m., review of records revealed MPOA was notified, after a nurse discovered the bruise on the resident's hip, on 07/02/17. Neuro checks were completed for the resident. A phone conference was conducted, on 07/13/17 at 10:27 a.m., with the Administrator, SW #102, Surveyor # , this surveyor, and the resident's wife (guardian/Medical Power of Attorney. The wife said she visited her husband on 07/03/17 and spoke with SW #102 and told him about the NA's actions and about some missing items. The wife was assured by the administrator it would be investigated. After the phone call SW #102 said, the NA was moved from the assignment because the wife did request it, but not because any of what the wife had just said on the phone. SW #102 stated it was the first he had heard of the wife's concerns and issues. The administrator stated he was unaware that any of this had occurred, he stated he knew the resident did have auditory hallucinations because he had been in the room with the resident when he has had them. He also stated that if a resident or family member requested a NA not be assigned to them they tried to accommodate them. SW #102 agreed with the administrator they try to accommodate the request. When asked how the facility would know why the request was made, or if there were any issues concerning the care or treatment of [REDACTED]. SW #102 stated, I will investigate it today as an unknown. Review of records, on 07/13/17 at 11:53 a.m., of the last quarterly minimum data set (MDS) with an assessment reference date of 06/15/17, revealed the following. Resident #119 has a Brief Interview for Mental Status (BIMS) reveals Cognitive status score of 10, indicating resident is moderately impaired. The resident usually is understood and usually can understand others. Resident #119 has severely impaired vision with corrective lenses. The resident needs extensive assist for activities of daily living(ADLs), and is not steady but able to stabilize his self with staff assistance, with range of motion he has an impairment on one side of his lower extremity. Resident #119 is frequently incontinent of bladder and bowel and is on a training program. The resident is on scheduled pain medication, insulin injections, antipsychotic, antianxiety, and antidepressant medications. Pertinent [DIAGNOSES REDACTED]. The medical record also revealed the resident had episodes of auditory hallucinations.",2020-09-01
1562,WHITE SULPHUR SPRINGS CENTER,515100,345 POCAHONTAS TRAIL,WHITE SULPHUR SPRING,WV,24986,2016-12-15,166,E,0,1,32NE11,"Based on resident interviews, family interview, review of resident council minutes, review of facility policy, and staff interviews, the facility failed to resolve grievances in a prompt manner. Six (6) of seventeen (17) residents who were asked whether they received assistance in a timely manner, and one (1) resident's family member, expressed complaints about staff answering call bells timely. The resident council minutes for eight (8) of nine (9) months in (YEAR) documented grievances concerning the timely answering of call lights. According to current resident/family member's comments, and the resident council minutes since at least (MONTH) (YEAR), the issue of the timely answering of call lights was not resolved. This practice had the potential to affect residents who were able to request assistance for care by utilizing the call light, and/or whose family members utilized call lights on behalf of residents. Census: 63. Findings include: a) During Stage 1 of the Quality Indicator Survey, when asked, Do you feel there is enough staff available to make sure you get the care and assistance you need without having to wait a long time? the following responses were received. 1. Resident #34 said during an interview on 12/06/16 at 11:04 a.m. that she had to wait a long time at night and had waited over an hour at times. 2. Resident #77, in an interview on 12/06/16 at 10:29 a.m., said staff was spread thin. The longest I have waited is 45 minutes, but mostly on whole, 5 minutes. 3. Resident #51 complained about not having enough nursing staff in order to help her get to bed during an interview on 12/07/16 at 1:09 p.m. 4. Resident #63, on 12/06/16 at 3:47 p.m., said, It does take a while when you put on the bell, they are busy. It can take 25 to 50 minutes to get off the bedpan. 5. Resident #126, on 12/05/16 at 3:33 p.m., said evening shift, could use another person - that evening shift was where the lacking was. She said one time she had waited 22 minutes and she, .had to go, unplugged myself and walked around to the bathroom. Couldn't wait. Twenty-two (22) minutes is the most. 6. Resident #124 said, I know they're terribly busy, but I have waited a long time to be changed. They come I guess whenever they can get here. I put on my call bell (to be changed), during an interview of 12/06/16 at 2:09 p.m. 7. Resident #44' s family member, in an interview on 12/06/16 at 2:37 p.m., said he pushed the call light and waited 25 minutes after the resident told him that she wet herself. b) Review of the resident council minutes on 12/12/16 and 12/13/16 revealed the resident council members had expressed concern with call light issues. The council minutes for the following months had documentation showing there was a problem with call light assistance (Residents voicing complaints were not identified in the minutes): -- (MONTH) (YEAR) - Call lights are not being answered in a timely manner, -- (MONTH) (YEAR) - Certified nursing assistants (CNAs) are answering call lights, turning them off and say I will be right back, but they don't come back , -- (MONTH) (YEAR) - not answering call lights in a timely manner, turning off call lights and not returning to assist residents, -- (MONTH) (YEAR) - residents said that CNAs continue to turn call lights off and say they will be back and not return, -- (MONTH) (YEAR) - council members state there is still a problem with CNAs answering call lights on 200 and 300 hallways, -- (MONTH) (YEAR) - staff not answering call lights in a timely manner turning lights off and saying they will be right back, -- (MONTH) (YEAR) - call light issues are ongoing, not being answered in timely manner and turning then off and not returning, -- (MONTH) (YEAR) - call lights not being answered timely, DON (director of nursing) attended and discussed concerns with call lights, -- (MONTH) (YEAR)- concerns are ongoing - CNAs turn lights off and do not return to assist residents. b) Review of the facility grievance/concern file and corresponding policy with a revision date of 11/28/16, found the purpose was to assure prompt receipt and resolution of patient/representative grievances/concerns. Upon receipt of the grievance/concern, the grievance form was to be initiated by the staff member receiving the form and documented on the concern log. This had not always been done. Grievances from the resident council members were to be recorded on the form and addressed. Several months of the resident council minutes that had issues regarding call light responses had not been put through the process of completing a grievance form and were not documented on the complaint log. c) During a meeting on 4:38 p.m. on 12/14/16 p.m. with the director of nursing (DON), administrator, and social worker (SW), they were in agreement they had not had a monitoring system in place to ensure follow up of grievances. The Administrator said he reviewed them, but they needed to go back and do more follow up. Staff did not complete a grievance report after each resident council meeting, nor were reports completed for each individual who expressed concern with call bells, which needed done.",2020-09-01
2537,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-08-08,166,D,0,1,0QX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, resident interview and staff interview, the facility failed to make prompt efforts to resolve grievances. Resident #26 was concerned he was not receiving Passive Range of Motion (PROM) services from Nursing. This concern was not resolved for sixteen (16) days. This was found for one (1) of ninety-seven (97) grievances reviewed. Resident identifier: #26. Facility census: 88. Findings include: a) Resident #26 is [AGE] years of age. He was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was determined by a physician to possess the capacity to make informed medical decisions. Review of his record began on 8/7/17 at 11:47 a.m. b) Review of complaints/grievances for (YEAR) to date on 8/7/17 at 11:47 a.m. found a complaint filed by resident #26 on 6/21/17. His concern was expressed to a Physical Therapist and he said he only received range of motion services (ROM) once. The complaint form documented the Therapist gave the concern to the administrator, the social services director, the director of nursing, and the nurse supervisor. There was a note dated 6/26/17 that the administrator told him We are working on his ROM program and will update him soon. There was a memorandum from the Director of Nursing dated 7/6/17 that she had spoken with resident #26 on 7/5/17. She also spoke with Nursing Assistants and his nurse. She wrote All parties were receptive to the plan moving forward. The administrator had a note that said she spoke with resident #26 on 7/26/17 and he said he began receiving his range of motion on 7/6/17. c) Review of therapy notes found he was receiving therapy from 5/5/17 to 6/1/17. He was discharged on [DATE] after he met short term goals. He was discharged to a passive range of motion program with nursing staff (PROM) to prevent any decline in function after discharge. Nursing documentation provided showed he first started receiving the PROM on 7/6/17. d) Resident #26 was interviewed on 8/7/16 at 2:42 p.m. He said he is now getting his PROM daily. He agreed that it took sixteen days after he expressed his concern to the therapist for him to start getting the PROM as recommended by the therapist to prevent decline. He said it helps him with pain and keeps his hips and legs more limber. He was asked why it took so long to resolve the concern and he said he had no idea, they told him they had to investigate and figure out why the aides weren't doing it. e) Facility administrator #111 was interviewed on 8/7/17 at 3:00 p.m. after review of the documentation, he agreed there was not prompt resolution of the concern and that resident #26 should have received the PROM as recommended by therapy without interruption.",2020-09-01
3434,FAIRMONT HEALTHCARE AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2017-06-30,166,E,1,0,25Q611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation, record review, concern/grievance form review, policy review, family interview and staff interview, the facility failed to ensure prompt efforts to address and resolve concerns/grievances from residents and their families in a timely manner. The facility did not resolve expressed concerns about hydration and a clean comfortable homelike environment for Resident #1, as documented in the Resident Council's group meeting minutes, and expressed concerns regarding missing glasses for Resident #52. Resident identifiers: #1 and #52. Facility census: 115. Findings include: a) Resident #1 The review of Resident #1's record began on 06/21/17 at 10:04 a.m. Resident #1 is [AGE] years of age. She was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions. A family member was acting as her responsible party. Resident #1 had a care plan in place for nutrition, hydration, elimination related to weight loss, and consistency of food and liquids. She had a care plan for multiple signs in her room as reminders for resident/staff per the family's request. One of the reminders was for two (2) large insulated cups of ice and water to be within her reach at all times. On 06/22/17 at 11:38 a.m., the resident's responsible party was interviewed in the resident's room. She was surprised her mother was still in bed. She had the two large cups for the resident's water, which were not filled. She was taking the cups to the administrator to make a complaint. Updated complaint/grievance forms were requested regularly as the survey progressed. As of the final day of the survey on 06/30/17, there was no complaint form regarding the lack of water for hydration. On 06/27/17 at 9:10 a.m., a visit was again made to Resident #1's room. Nurse Aide #64 was in the room cleaning an area of the floor between the bed and the bathroom door. She said she had been called to the room by the responsible party. She said there was feces on the washcloth and the floor. She said she was not the one who had left it there, but she was cleaning it up. The responsible party entered the room and said she had found the mess on the floor when she arrived for her visit and since there was no one around, she had gone in search of someone to clean it up. On 06/29/17 at 10:00 a.m., Resident #1's responsible party was interviewed in the resident's room. She said she had gone to interrupt the management morning meeting on 06/27/17 to make a complaint about the feces filled washcloth on the floor. Updated complaint/grievance forms were requested regularly as the survey progressed. As of the final day of the survey on 06/30/17, there was no complaint form regarding the feces on the washcloth on the floor. She held the large cups in her hands. They had some ice in them but no water. She said she had complained about the water just a few days ago but it does no good. b) Resident council meeting minutes for the previous six (6) months were reviewed, on 06/21/17 at 4:00 p.m. The record of the meetings began with a form called Resident Council Quality of Life Assessment - Group Interview. Some of the months, the form had two pages, and for others, there were three. Not all the questions had responses noted. For those that did, some negative responses were found as follows: --For the 06/05/17 meeting, for the question Does the group have input into the rules of the facility? the response was No, because they always give you reason for the rules. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered Not really, need more places. --For the 05/05/17 meeting, for the question Does the group have input into the rules of the facility? the response was No. The question Does the facility listen to your suggestions? was answered Sometimes. The question Are there places you can go when you want to be with other residents? was answered No. The question Are the temperatures of your foods ok? was answered Sometimes. The question How did staff react? (to a voiced grievance/concern) was answered They listened, but it depends on who it is. --For the (MONTH) meeting (no specific date was on the minutes), for the question Does the group have input into the rules of the facility? the response was No. The question Are meals generally on time? was answered No. --For the 03/01/17 meeting, the question Is there enough staff to take care of everyone? the answer was No. There was no list of attendees for the May, June, or (MONTH) meetings. For the January, February, and (MONTH) meetings, the average attendance was twenty-two (22) residents. There was no evidence of any attempts by the facility to address these negative responses. There was no follow up noted in the meeting minutes, and there were no complaint/grievance forms corresponding to the dates the concerns were stated by the council. An interview was conducted with the Activity Director, on 06/29/17 at 10:00 a.m. She agreed there was no record of any resolution or any attempt to address the concerns attributed to the council. On the afternoon of 06/28/17, the Administrator said the facility had a Concierge Program to compliment the complaint/grievance policy and procedure. She said residents and families were told about the program upon admission. She said management staff were assigned a group of resident rooms, and were charged with completing rounds at least weekly which were to be documented on a form entitled Concierge Program Rounds. Review of the policy and procedure found the concierge was charged with assisting the resident to complete a complaint/grievance form if needed. Review of some of the completed rounds found a form dated 06/12/17 in which an assigned management person for room [ROOM NUMBER]-1 checked the box on the form Concern Completed: Resident is making a statement which indicates his/her needs are not met. As of the final day of the survey, there was no completed complaint/grievance form found to document the concern. The responsible party for Resident #1 was asked about the concierge program as a possible means of resolving grievances on 06/29/17 at 9:30 a.m. She said she had never heard of it. c) Resident #52 On 06/26/17 at 12:16 p.m., during a Stage 1 family interview Resident #52's daughter was asked the question, Has (resident's name) had any missing personal items? the daughter answered Yes, they have lost my Mother's glasses months ago. A review of the concern/grievance reports, on 06//28/17 at 2:30 p.m., found a concern/grievance report dated 04/04/17 by Resident #52's daughter was reported to Referral Manager/Social Worker (RW/SW). Under title of Documentation of Grievance/Complaint, the concern was described as (typed as written): Said her mothers glasses have been missing and no one followed up with her about this. Also (first name of Resident #52) hair was dirty and a dirty blanket on dresser and teeth not clean, commode not flushed. Under the title of Documentation of Facility Follow-up, with Individual designated to take action on this concern: (name of Assistant Director of Nursing (ADON), and a date resolved by of 04/06/17. Under the title of (typed as written), Involved staff members were in-serviced on above concern. Follow-up reveals compliance with care concerns. Under the title of Resolution of Grievance/complaint, was grievance/complaint a check mark was placed before yes was written documentation states (typed as written), NHA (Nursing Home Administrator) on porch discussing with daughter and when staff came to get her to clean her up better and do her teeth, the daughter refused and said not now. Staff did complete after daughter left. This form was signed by the NHA on 04/24/17. During an interview and after reviewing the concern/grievance form for Resident #52, on 06/28/17 at 3:38 p.m., with RM/SW, she explained, I just took the concern and the NHA follows up on that and determines whether it is resolved or not. On 06/28/17 at 3:42 p.m., after reviewing the concern/grievance form for Resident #52 the NHA agreed that it was not resolved. She stated, I just spoke with the daughter about this and she said her mother has not had her glasses for over 2 months but I told her I thought they were found because I just put a pair of glasses on her last week. I remember because I had to fix her bangs when I put the glasses on. When inquired about the time frame for resolution of concerns--she stated it takes more than 1 or 2 days because we look through laundry and everything. When further inquired if it should take more than two (2) and a half (1/2) months to resolve a concern since this concern was voiced on 04/04/17 and Resident #52's glasses are still missing, she stated, Well they might be in the nurses cart. On 06/28/17 at 3:52 p.m., the NHA showed a glasses case containing a pair of glasses. She reported, These are the glasses that were in the drawer at the nurses station that she (Resident #52) wore last week but they aren't hers (Resident #52). The daughter described hers (Resident #52) as black with gold squiggly things at the temple and these are just plain brown. So we will have to just keep looking. Again inquired about a time frame for resolution of a resident or family member concern/grievance and the NHA did not reply.",2020-09-01
3808,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-04-21,166,F,1,0,0AC711,"> Based on a review of the Resident Council minutes, confidential resident interviews, confidential staff interviews, and grievance policy review, the facility failed to act promptly to resolved resident grievances. Confidential resident interviews revealed issues voiced in Resident Council from (MONTH) (YEAR) to the meeting (MONTH) (YEAR) included issues such as insufficient supplies of washcloths and towels to meet resident needs, over-bed tables that would not move or moved with difficulty, and staff not answering call lights timely. These findings had the potential to affect all residents residing in the facility. Facility census: 97. Findings include: a) Resident Council Minutes Review of the Resident Council minutes on 04/18/17 at 1:04 p.m., revealed the following information: - 12/22/16 - The minutes stated staff not answering call lights timely continued to be an issue. Resident Council President #51 stated she observed staff sitting at the Nurses' Station while three (3) call lights were active and staff did not respond to the call lights. The Department Response (Nursing) was to remind the residents to notify the nurse and staff were in-serviced regarding answering lights timely. - 01/18/17 - The minutes included, All resident's in attendance stated that call lights are still a problem. Takes a long time for them to be answered and some staff just walk by the call light and don't respond. The Department Response by the Director of Nursing (DON) stated a continuation to re-educate and monitor staff on a daily basis and reminding staff that everyone was responsible for answering call lights. - 02/15/17 - The minutes stated staff answering call lights was still a problem. The residents stated it took a long time for lights to be answered when assigned nurse aides (NA) were on lunch break. In addition, the residents stated NAs assigned to cover for NAs on lunch break did not answer call lights. The minutes included, That staff give them attitude all the time when they ask for something to be done. The minutes reflected that the DON would be informed of the concern. - 03/28/17 - The minutes stated, All resident's in attendance stated that call lights are still a problem. Residents did state that it has shown some improvement. Takes a long time for them to be answered and staff don't cover others lights when they are on breaks. A resident asked if all staff are to respond to the call lights, cause a nurse walked by a light? A resident stated that she had to wait for a very long time for a CNA to help her. The CNA came in turned off the light and stated she would be back, but didn't come back for a very long time. The Department Response stated, This is an ongoing issue. Re-educate and monitoring continues. Call lights are everyone's responsibility. The only time it's appropriate for a nurse to walk past is if she is giving medication. This is an issue that requires on going monitoring. Resident was unable to identify NA or state when this occurred. Residents reminded to notify supervisor immediately when this happens. The DON completed the department response. Confidential Interviewee (CI) #3 stated calls lights, .really sucks. They come in, turn off the call light, and say they will be back in a minute, and then don't come back. Sometimes they say they will get your aide and no one comes back. Cl #2 was present during this interview. Cl #2 agreed with the comments of Cl #3. When asked if they had seen any improvement since (MONTH) (YEAR), both agreed answering call lights had not improved. Cl #2 said, We are always wanting and never receiving. In an interview on 04/20/17 at 10:01 a.m., the Center Executive Director (CED) stated the facility had conducted in-services with staff and had a special corporate in-service for Nurse Managers regarding supervising staff and monitoring of call lights on 08/24-26/16. Monitoring sheets were developed, but only two (2) were available for review, as the other monitoring sheets (walking rounds) were shredded. c) Washcloths and Towels A continuing review of the Resident Council minutes revealed on 01/24/17 and 02/28/17 residents stated there were not enough towels and washcloths. During confidential resident interviews, Cl #2 and CI #3 agreed there were never enough washcloths and towels to take a shower, or in the mornings. Confidential interviews with staff (Cl #4 and #6) found they agreed that staff did not have enough washcloths and towels to meet the needs of the residents. Cl #6 stated this has been a long-standing problem. In an interview on 04/20/17 at 10:01 a.m., Center Executive Director (CED) stated normally the facility received linens daily at 10:30 a.m. When the grievance was noted at the 02/28/17 meeting, an additional par level of 50-70 washcloths and towels were added for 7:00 a.m. daily delivery. The CED thought this had resolved the issue. The 03/28/17 Resident Council minutes revealed this was a continuing grievance. When asked how the grievance was monitored for resolution, the CED said she had not heard any complaints from staff and/or residents about the washcloths and towels and assumed the grievance was not an issue. When asked what was the current census, the CED responded 98. When asked if she thought the par level of 50-70 washcloths and towels were sufficient to meet the morning needs of the residents, she did not respond. d) Over-bed Tables The residents complained in the Resident Council meetings of (MONTH) (YEAR) through (MONTH) (YEAR) the over-bed tables would not move or were very difficult to move. The residents felt this was due to the wheels being dirty. Cl #2 and CI #3 stated the over-bed tables were still an issue. Cl #2 attempted to move the over-bed table and could not get the table to move. Cl #5 stated he/she was not aware of an issue with the over-bed tables. According to Cl #5, the facility cleaned the over-bed tables on a rotating basis, and denied knowing anything about a grievance concerning the over-bed tables not moving or the wheels needing cleaned. The CED stated the over-bed tables were cleaned on a rotating schedule basis in an interview on 04/19/17 at 2:18 p.m. She stated she was unaware of a continuing problem with the over-bed tables. She stated she ordered approximately fourteen (14) new over-bed tables, but had not received them yet. e) Grievance Policy Review A Special Resident Council meeting was held on 01/24/17 at 2:00 p.m. The purpose of the meeting was to introduce the new Grievance Policy. The CED presented a copy of the new policy to the Resident Council President and stated copies would be available to the other residents upon request. The CED would be the Grievance Officer. The policy stated residents had a right to voice grievances orally (meaning spoken) or in writing, and to file grievances anonymously. In addition, the policy stated a review of the grievance would be completed and a written decision provided within 72 hours of the filing of the grievance. f) An interview with the CED on 04/20/17 at 10:01 a.m., the CED stated she was not aware the grievances regarding the washcloths and towels and over-bed tables were not resolved. She further stated the call lights were an ongoing grievance. The CED agreed she did review the Resident Council minutes and needed to pay closer attention to those minutes.",2020-08-01
3996,MAIN STREET CARE,5.1e+155,"189 SUMMERS HOSPITAL ROAD, SUITE 300",HINTON,WV,25951,2016-02-26,166,D,0,1,RR1211,"Based on record review, resident interview, and staff interview, the facility failed to ensure prompt efforts were made to resolve grievances, including those with respect to the behavior of other residents. This was true for two (2) of three (3) residents reviewed for the care area of social services during Stage 2 of the Quality Indicator Survey (QIS). Residents #30 and #9 (roommates) voiced they did not like being roommates. The facility had not taken steps to resolve the conflict. Resident identifiers: #30 and #9. Facility census: 30. Findings include: a) Resident #30 At 3:17 p.m. on 02/23/16, during a Stage 1 interview, the resident was asked if he had any concerns or problems with a roommate or any other resident. The resident said he did not like his roommate and his concerns had not been addressed by the staff. He said the roommate talked all the time and talked bad about him. Record review at 11:00 a.m. on 02/24/16 found the following nursing notes: -- 01/01/16, Paranoia and delusions noted once, talking about his crazy roommate and what he was going to do to him. Nurse deterred these thoughts and no more paranoia was noticed. -- 01/24/16, Increased paranoia and agitation noted two times. Stated he was going to whip his damn ass, in regards to his roommate. Nurse tried to direct his attention elsewhere but he repeated what he said earlier again. Resting in bed with eyes closed at this time. Call light within reach. At 1:59 p.m. on 02/24/16, the social worker said he was unaware Resident #30 did not like his roommate. He said he was unaware of the nursing notes recorded in the medical record. If I knew about it, I would have investigated to see what needed to be done. The social worker stated, Resident #30 has never actually hit anyone. At 12:12 p.m. on 02/25/16, the social worker said he had offered Resident #30 another room and the resident had accepted the offer and would be moving today. After surveyor intervention, the social worker made the following entry in the electronic medical record on 02/25/16, During conversations with (name of resident) he has indicated he is unhappy with his current roommate. He pointed out issues in the past and maintains that he would prefer to move. Roommate options were reviewed with (name of resident) and it was determined he would move to room b) Resident #9 At 1:18 p.m. on 02/23/16, an interview with the resident during Stage 1 of the QIS, found the resident did not like his roommate. Resident #9 stated, I can't stand my roommate, which is why I keep the curtain pulled. Record review at 11:30 a.m. on 02/24/16 found the following nurses' notes: -- 12/08/15, Staff reported some yelling at roommate. Nurse observed him yelling shut up followed by some laughter. Nurse asked him to please stop talking to resident in which he listened and nothing more was heard from either of them -- 08/07/15, Resident got into altercation with roommate yelling at him to shut the damn light off. He was very angry when nurse went in to assess the situation. Stated that he did not need the light on to use the bathroom Screaming heard two more times after this by staff. Staff assisted in resolving the matter. Will report to on coming shift. Will also inform social services of this incident. No other complaints voiced At 10:48 a.m. on 02/25/16, the social worker said he did not recall being told about the 08/07/15 nurse's note. After surveyor intervention, the social worker made the following note on 02/25/16, During survey interview (name of resident) expressed his dislike for his current roommate and indicated that he would be happy if he moved. As a result of discussion and dislike expressed-roommate relocated leaving the second bed in the room - bed (room and bed number) vacant at this time.",2020-04-01
4080,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-07-19,166,D,0,1,KKFY11,"Based on family interview and staff interview, the facility failed to actively seek resolution to a complaint of missing personal items and keep the family apprised of the progress towards resolution. This was true for one (1) of one (1) resident who triggered the care area of personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #74. Facility census: 105. Findings include: a) Resident #74 An interview with the resident's responsible party during Stage 1 of the Quality Indicator Survey revealed the responsible party reported some missing clothing to facility staff. The family member reported, during a visit in (MONTH) (YEAR), clothing was missing. A staff member in laundry told the family member to look in the lost and found. The family member reported she did and she found some of the missing items, but not all of them. She said the resident's name was marked in her clothing. When asked if the facility told her they would look for the missing items, she stated, No, they didn't do anything, I was the one who looked for the items. The family member stated she told the staff member working in laundry she had not found the resident's clothing. During an interview at 8:17 a.m. on 07/13/16 regarding the family member's concern Housekeeping Supervisor (HS) #169 said she remembered the following, About a couple of months ago (name of resident) told me a pair of blue pants were missing. The resident described the pants, and she found the pants in the lost and found. She returned the pants to the resident. She said, According to my evening shift girl, the daughter had also looked in lost and found and found some stuff but she (the daughter) didn't find everything when she looked. HS #169 said the staff member who talked to the daughter would be at work this evening and I could interview the staff member for more information. HS #169 identified Laundry Worker #164 as the staff member who talked with the daughter. HS #169 said the facility policy when family members reported missing clothing, and the clothing was not located, was to report it to social services and write it down. She said, I will look to see if someone wrote it down. Interview with Laundry Worker #164 at 3:01 p.m. on 07/13/16 revealed, I don't remember anything about any missing clothes. HS #169 said that maybe she had the wrong laundry worker. When asked what other workers could have spoken with the daughter, HS #169 said only one other employee could have spoken to the daughter and that employee no longer worked at the facility. At 1:37 p.m. on 07/14/16, Social Worker (SW) #108 said she never received a prior complaint from the laundry staff, the resident, or the daughter about any missing clothing for Resident #74. She said, I will call her (the daughter) and see if the items are still missing. At 9:30 a.m. on 07/19/16, SW #108 provided a copy of a grievance concern form dated 07/13/16. SW #108 called the resident's daughter who reported several items of clothing and a blanket missing. SW #108 said she was investigating the grievance and she would be following up with the daughter on the resolution of the grievance.",2020-02-01
4219,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,166,E,0,1,1GMW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview the facility failed to ensure social services addressed all grievances to the residents' satisfaction for three (3) of three (3) residents reviewed. This failed practice had the potential to affect more than a limited number of people and over repeated occurrences. Resident identifiers: # 93, #85 and #83. Facility census: 84. Findings include: a) Resident #93 During an interview with Maintenance Supervisor #72, on 08/10/16 at 8:25 a.m., he stated the resident had light bulbs for daylight and/or soft light. He was aware the resident was concerned with the lighting and would check with Resident #93 to see which he preferred. Resident had expressed concern to the surveyor during Stage I interviews the light was too bright in his eyes when he was lying in bed. He indicated he had informed the social worker (SW) and maintenance staff but it had not been corrected. Spoke with Maintenance Personnel #78, at 1:10 p.m. on 08/10/16, he stated the resident expressed concern with the light being too bright above his bed but was unsure of how long ago it was brought up. Maintenance Personnel #78 said they were going to try to get 40 watt bulbs or order new hospital type lights that go at the head of the bed so the brightest part of the light does not shine in the residents' eyes. According to the SW #40 at 2:50 p.m. the resident had not informed her of the light issue in his room. She stated the maintenance director had talked to him and he would address it. During an interview with Resident #83 on 08/10/16 at 3:40 p.m., he stated he had told several people about the lights being too bright in his eyes. Resident #83 said it had been an ongoing issue for months. He said he had told told everybody. He also said the maintenance staff came in today and changed out the lightbulbs. He said it did make a difference. b) Resident #85 1. Grievance #1 Review of the concern/grievance forms, completed during the past year, at 10:00 a.m. on 08/10/16, found Resident #85 voiced a concern on 04/12/16. The resident stated she was not assisted to the bathroom. The concern/grievance form had the following description of the action(s) taken to investigate, Spoke with resident regarding her allegations and she related it may have seemed like a long time and she stated it was O.K. Attached to the grievance/concern form were three (3) statements from staff: --Statement #1 written by a licensed practical nurse who wrote, On Tuesday 04/12/16 on night shift (name of resident) was assisted to bathroom via Hoyer lift 3 times by staff. --Statement #2 written by a nurse aide who wrote she did not assist the resident on 04/12/16. --Statement #3, dated 04/13/16, completed by a restorative licensed practical nurse (LPN) who wrote: At 6:50 a.m. resident observed lying in bed with lift pad under her. She was crying and saying help me dear lord please. Dressed in gown with brief on and wet with urine. Complained of lying on back and not being able to get up. This nurse and restorative CNA (certified nursing assistant) transferred resident to shower chair then proceeded to complete shower, dressed and transported to dining room via wheelchair no voiced complaints of pain discomfort and no further mention of morning care before restorative arrived. At 2:15 p.m. on 08/10/16, Social Worker (SW) #40 was interviewed regarding Resident #85's concern/grievance form. When asked why the form did not contain when the alleged incident occurred, SW #40 stated the resident did not know, then she said the incident occurred on 04/12/16. SW #40 was asked why she did not interview the resident's nurse aides who provided care on 04/12/16. She confirmed the Hoyer lift required two (2) staff members when used; therefore, two staff members must have assisted the resident to the bathroom if she went to the bathroom [ROOM NUMBER] times during the night shift of 04/12/16. According to statement #3, the resident was found to be wet at 6:50 a.m. SW #40 confirmed the statement was dated 04/13/16 but the writer was referring to 04/12/16. SW #40 said she was going to do a better job in the future when completing the concern/grievance forms and she would be more thorough when investigating. 2. Grievance #2 During Stage 1 of the Quality Indicator Survey (QIS), at 1:41 p.m. on 08/08/16, the resident stated someone had taken $20.00 from her. She said she had two (2) $20.00 bills which she thought she were well hidden in her room, but she guessed she didn't hide it good enough. This was about six months ago. She stated she told many staff members but the social worker told her the facility, Is not responsible for missing items. Review of the grievance/concern forms on 08/10/16, at 10:00 a.m., found no evidence the facility had investigated the resident's allegation of missing money. At 2:49 p.m. on 08/10/16, the Social Worker (SW) #40 said the facility usually doesn't write anything down concerning missing items. She said, It seems like I remember something about missing money and I told her she needed to keep her money up front. We don't replace missing money. Review of the resident's most recent minimum data set (MDS), a quarterly MDS, with an assessment reference date (ARD) of 06/20/16, found the resident's brief interview for mental status (BIMS) score was 15, indicating the resident was cognitively intact. c) Resident # 83 During Stage 1 of the Quality Indicator Survey (QIS) interview with Resident #83, at 2:12 p.m. on 08/08/16, found he had some missing money and clothes. When asked if he had told staff about the missing items he indicated he had, but it did not do any good and they basically said, sorry about your luck. During Stage 2 of the QIS interview with Resident #83, at 1:51 p.m. on 08/10/16, revealed he was missing eight (8) to ten (10) shirts and pairs of pants. He stated, They say they will tell (name of Social Worker (SW) #40), but nothing is ever found. He further stated around this time of the year that he always has money come up missing. Resident #83 stated, When it is fair (state fair) time they know my parents send me extra cash and when I go to the shower and come back someone has taken my money. He stated that last year they took $40.00. When asked if the staff ever addressed the concern related to his missing money he stated, you tell them but it does not do any good nothing ever changes. Resident #83 stated, the only time I have ever got anything back was last week when I had four (4) pairs of pants missing and the new girl (referring to SW #112) found them for me. He stated, she found them because she looked for them no one else has ever looked for anything that has been missing. d) Staff interviews An interview with SW # 40 and SW # 112, at 12:53 p.m. on 08/10/16, revealed they had no knowledge of Resident #83's complaints of missing money and/or clothes. SW # 112 indicated that last week he had reported four (4) pairs of pants were missing, but she found those in laundry and returned them to him. SW #40 and SW #112 had no other knowledge of any missing items for Resident #83. When asked what the process was for missing items, SW #40 indicated they will just look for the item and if they find it they will return it. If they don't find it they will replace it. She stated, We will replace anything except money and jewelry. When asked if they keep a written record of what has been reported missing and the results of the investigation and/or search for the item, they both indicated that was something that they needed to work on. SW #40 stated, we will usually just talk about it and we have not been writing it down. She continued, That is a process we are changing and will improve our record keeping. SW #40 stated, I do have a paper and it has a few things wrote down that we either found or replaced. She was asked to provide a copy of this paper. When provided the form was reviewed and had five entries none of which were dated. The residents were identified by number on the form. When SW #40 was asked to identify each resident by name she did so, but none of the missing items belonged to Resident #83. She again stated, Our record keeping on missing items has been lacking. SW #40 and SW #112 indicated that the facility provides information to each resident or responsible party about what is and is not replaced when missing upon admission to the facility. An interview with the Nursing Home Administrator (NHA) and Director of Nursing (DON), at 10:12 a.m. on 08/11/16, confirmed they did not have any knowledge about Resident #83's missing money or clothing. When asked about the process for missing items they both indicated that missing items were discussed daily during stand up meeting and they never really wrote anything down about them. When asked what kinds of things that do or do not replace they indicated it was really just dependent on the circumstances. The NHA stated, I know we replace items I can show you some receipts for things we have replaced. They both indicated that usually what they talk about is found and no follow up is needed. Later in the afternoon the NHA provided four (4) receipts which showed items replaced since (MONTH) of (YEAR). The items included socks, hair products, shampoo, and toothpaste. When asked about the admission paperwork and the facility's policy the NHA agreed they did not read the same. When asked which the facility follows he stated, We pretty much just follow the admissions information. He stated, If we replace something or not really just depends on the investigation and what we find out during the investigation. However; he was unable to provide any evidence that missing items including clothes and/or money were ever investigated by the facility. e) Review of Admission Booklet and Facility Policy Review of the Admission Booklet on 08/10/16 at 4:30 p.m. found the following noted under the heading, Personal Property: --Resident, and not the center, shall be responsible for the provision of all personal comfort items, including footwear, clothing, and petty cash to be utilized for the Resident's incidental expenses. --All clothing and other personal items shall be clearly marked by the Resident or the Representative to indicate ownership by Resident. --The center strongly discourages the keeping within the center valuable jewelry, papers, electronic equipment, large sums of money or other items considered of value. Should the resident choose to bring the aforementioned items, i.e. items of great value, the center shall not be responsible for loss, theft or destruction. Review of the facility's policy titled, Resident and Visitor Incident Policy and Procedure found the following for missing items greater than or equal to $50.00 (clothing, dentures, glasses, etc.): --The employee will immediately report the incident to the immediate Supervisor, DON, or Administrator. --The Supervisor, DON or administrator will conduct a timely investigation of the incident and complete the Incident Report Form. --If the company is found to be at fault, the item reported missing will be replaced with a duplicate item or a similar item of the same approximate function and value. --The Supervisor, DON or Administrator will continue communication with the resident and/or family throughout the investigation up to and including replacement of the missing item. --Follow up after receipt of the replacement is essential to resident satisfaction and company quality assurance and will be documented on the Incident report form, as appropriate. --If the company is not found to be at fault, an investigation will pursue in order to identify the root cause and attempt prevention of future occurrence. Actions taken will be documented on the Incident Report Form, as applicable.",2020-02-01
4405,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,166,D,0,1,BBQT11,"Based on family interview and staff interview, the facility failed to provide evidence a concern expressed by Resident #56's family was addressed and a prompt resolution to the concern was provided to the family. This was true for one (1) of three (3) family members interviewed. Resident identifier: #56. Facility census: 58. Findings include: a) Resident #56 During an interview during Stage 1 of the Quality Indicator Survey (QIS) at 4:09 p.m. on 07/26/16, Resident #56's family member said the family member had voiced a concern to the Director of Nursing (DON) regarding the care provided by Licensed Practical Nurse (LPN) #54. The family had alleged LPN #54 did not know how to provide proper incontinence care. LPN #54 did not wipe from front to back after an episode of bowel incontinence. LPN #54 did not change her gloves properly. LPN #54 continued to provide other care while wearing the same pair of gloves. When the family confronted LPN #54 issues, LPN #54 became upset and flung the resident's catheter bag. The alleged incident occurred sometime within the past month. When the family member told the Director of Nursing (DON) about the observations, the DON told her there were other nursing homes in the area and insinuated they could go somewhere else for care. The family member requested LPN #54 not be allowed to provide hands on care to the resident. At 2:17 p.m. on 07/27/16, LPN #17, who also worked on the same unit as LPN #54, said she was aware of a conflict between LPN #54 and the resident's family. This employee did not know exactly what had happened to cause the problems. LPN #17 said LPN #54 was timid and easily taken advantage of. During an interview at 2:36 p.m. on 07/27/16, LPN #54 said she was unaware of any problems with the family member of Resident #56. She said, Oh, I never have any problems with them. At 3:10 on 07/27/16, Nurse Aide (NA) #79 said she was aware there were issues between the family of Resident #56 and LPN #54. They think she (referring to LPN #54) is incompetent to do her job. I have actually seen the family member come into the facility to visit and get out her cell phone and call the facility to ask for another nurse to change the Resident's catheter. NA #79 said she did not know everything that had happened. On 08/01/16 at 11:40 a.m., when interviewed, the DON said she was aware the family did not, care for, LPN #54. She said, I feel it is more personal than specific. When asked if the family member had discussed concerns regarding incontinence care and infection control issues, she replied, Yes, and I talked to LPN #54 about it. When advised that LPN #54 said she did not know the family member had any problems with her care, the DON then said that maybe she did not specifically discuss incontinence care with LPN #54. The DON confirmed she did not document any of the concerns related to her by the family member of Resident #54 and did not document her follow up after the concerns were expressed. At 2:54 p.m. on 08/02/16, the Social Worker (SW) confirmed the facility did have a grievance/concern form and any concerns could be documented on that form. The SW said she was usually the person responsible for following up on any concerns. She said she was unaware of any compliant made by the family member of Resident #54. She verified the facility had only two (2) written complaints documented on the grievance/concern form in the past year and neither complaint referenced Resident #56.",2019-11-01
4498,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-10-13,166,D,1,0,HHR811,"> Based on staff interview, resident interview and medical record review, the facilty failed to ensure resident grievances were resolved for one (1) of eight (8) residents who had expressed concern with loud noises in the facility. A resident had expressed concern the roommate would play the television too loud at times which disturbed her. There was no evidence the staff had followed up and resolved this issue. This failed practice had the potential to affect a limited number of people. Resident identifier: #12. Census: 80. Findings include: a) Resident #12 (re: #73 roommate #73) A review of concern files revealed resident #12 expressed concern the roommate played the television too loud at times which disturbed her. The concern form, dated 09/13/16, said the roommate's (Resident #73) television was too loud. The concern form further stated the resolution to obtain ear phones for the roommate to use with her TV by 09/21/16 . Interview with resident #12, on 10/12/16 at 9:45 a.m., revealed she was under the impression the facility was going to get the roommate ear phones back in (MONTH) (2016), but they have not been purchased for the resident's use. Interview with the administrator and social worker, on 10/12/16 at 1:45 p.m., verified they had not obtained any type of headphone device for the roommate as yet. They had checked at several locations for ear phones but it was still not decided where to get them and who would pay to get them, the facility or the individual. On 10/16/16 at 2:00 p.m., the administrator after discussion with the surveyor, instructed the social worker to speak with Resident #73 about the headphones immediately. The social worker returned later that day and said at this time the resident did not wish to get them. The social worker said in September, Resident #73 had been agreeable to purchase and use headphones, but now had changed her mind. The facility staff had not followed up with either resident to ultimately get the issue resolved after it had been expressed about a month ago.",2019-10-01
4507,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2015-11-12,166,D,0,1,YR5K11,"Based on record review, family interview, resident interview, staff interview, and review of the facility's grievance policy, the facility failed to make prompt efforts to resolve a grievance concerning dentures for one (1) of three (3) residents reviewed for the care area of dental status and services. Resident identifier: #33. Facility census: 45. Findings include:a) Resident #33 During the Stage I interview with Resident #33 on 11/09/15 at 3:41 p.m., she stated, Somebody took my teeth. Doctor said next time he sees me, he would give me new teeth, can't imagine why anyone would take them. A review of Resident #33's inventory of personal effects on 11/11/15 at 9:00 a.m., revealed the resident had an upper denture plate, and a lower partial denture. On 11/11/15 at 9:05 a.m., a review of the nurse's documentation for Resident #33's quarterly minimum data set (MDS), revealed the resident's oral cavity was observed on 10/31/15 at 8:38 a.m. by Registered Nurse (RN) #88. RN #88's assessment revealed Resident #33 had no natural teeth or tooth fragment(s) (edentulous). The oral cavity assessment stated, The resident lost her dentures, family aware and will replace. Under dentures the section was marked resident does not have dentures. A progress note, dated 08/26/15, written by Licensed Practical Nurse (LPN) #31 on 11/11/2015 at 9:10 a.m., stated, Resident complains of dental pain at this time. Also her dentures are missing at this time. In an interview with Social Worker #34 on 11/11/15 at 10:55 a.m., Social Worker #34 was asked whether she was informed by the staff that Resident #33's upper denture plate and her lower partial were missing. She stated she was not informed by the staff. The social worker said she had a telephone log that indicated the resident's daughter left a message on 09/08/15 concerning Resident #33's missing her upper denture and lower partial. Social Worker #34 said when she called the resident's daughter back the next day, the daughter told the SW she had visited, and she thought someone had thrown away her mother's dentures. Social Worker #34 said she informed the resident's daughter the facility would pay two-hundred dollars ($200.00) to help her with the cost of replacing the dentures. Social Worker #34 said the cost would be around $457.00. The social worker said the daughter was going to arrange the services, but she never did. The facility had never called the daughter back what she had decided to do about the resident's dentures. The social worker was asked whether she had filled out a grievance form. She stated, I did not think this was a complaint. She confirmed that she did not complete a grievance form, but said she would complete one for the concerns regarding the missing dentures. In an interview with the resident's medical power of attorney (MPOA) on 11/11/15 at 12:45 p.m., when asked if her mother's upper dentures and lower partial were lost, she stated, I came into the facility to see my mother at the end of (MONTH) and mother was not wearing her dentures. The MPOA stated, She would not take her teeth out. My mother had pain in her lower gum line around the end of August. The daughter confirmed that she had called the facility and left a voice message about her mother's missing dentures. Observation of Resident #33's teeth on 11/11/15 at 1:03 p.m., found the resident had no upper teeth. She had one tooth on the right bottom side and there were three (3) small worn teeth in the left bottom gum. A review of the grievance policy on 11/11/2015 2:44 p.m., revealed the policy included, If the (facility's name) receives an oral complaint from residents, visitors, or family members, but they (the complainant) do not fill out a complaint form, the staff will fill out a complaint form and start the investigation. The grievance policy stated staff would try to solve the situation immediately, if able. If this could not be solved immediately, an investigation would be started to address the complaint, and it would be done as quickly as possible, by no later than five (5) days from the date of a complaint. Written notification would be given to the person lodging the complaint after a telephone call. A review of the (YEAR) grievance/complaint log, on 11/12/15 at 9:00 a.m., revealed the facility staff would write on the form the date of the complaint, resident name, summary of the complaint, and the date the complaint was resolved. The log did not contain Resident #33's complaint information. As of the time of the survey, there was no evidence of further efforts to resolve the resident's dental issue. There was no evidence of any follow up with the resident's daughter regarding the resident's dentures.",2019-10-01
4772,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2016-01-14,166,D,0,1,D0ID11,"Based on family interview, staff interview, policy review, and review of facility records, the facility failed to ensure prompt efforts were made to a grievance concerning lost clothing. The facility failed to promptly initiate an investigation into the lost item when first notified. This was found for one (1) of three (3) investigations into residents' lost personal possessions. Resident identifier: #96. Facility census: 159. Findings include: a) Resident #96 During an interview with a family member of non-interviewable sample Resident #96, on 01/11/16 at 5:00 p.m., the family member stated that a recent Christmas gift of a new pair of pajamas belonging to the resident was missing. While the family usually did the resident's laundry, she was concerned the new pajamas had gone into the facility laundry and not been returned. She stated she had reported the missing pajamas to the nurse aide (NA) caring for her family member, NA #7, and believed that a search for the pink flowered fleece pajamas with the resident's name on the pajamas was underway. On 01/13/16, the Unit Manager of the resident's unit, Unit Manager #19, was interviewed regarding the missing pajamas and the status of the investigation that the family member believed was underway. The Unit Manager was unfamiliar with the situation and reported that she had no knowledge of the missing pajamas. She added the usual procedure would be for the staff member who learned of the missing item to complete a lost property form or verbally report the missing item to either the charge nurse or directly to the Unit Manager. When the Unit Manager learned of the missing item, she would complete a Grievance/Concern form. In this case, because she had not learned of the missing item, no investigation was underway. After learning of the missing clothing, the Unit Manager promptly initiated an investigation by telephoning the family member and learning the details of the missing pajamas. The Unit Manager went to the facility laundry and described the missing item to the laundry staff, who immediately made an unsuccessful search for the pajamas. Additionally, the Unit Manager sought permission from a resident with a similar name to search that room for the pajamas in case they had been returned to the wrong resident. At 1:15 p.m. on 01/13/16, the Unit Manager provided a copy of the completed Grievance/Complaint form and the relevant policies. A resolution date of 01/16/16 had been set. If at that time the pajamas were not located the facility would replace or reimburse the family for the missing pajamas.",2019-07-01
4938,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,166,E,1,0,1MMH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the resident council minutes, review of grievance concern forms, and staff interview, the facility failed to make prompt efforts to resolve grievances. Residents attending the council meetings complained about staffs' failure to answer call lights in a timely manner. In addition to the council meetings, review of the grievance concern forms found two (2) residents complained, on separate occasions, regarding answering call lights in a timely manner. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #48 and #73. Facility census: 72. Findings include: a) Resident council minutes Review of the resident council minutes from the 11/02/15 meeting found 10 members, (whose names were not listed) attended the meeting. The council meeting minutes addressed a concern expressed at the meeting, .Call lights not being answered timely during meals and shift change The Director of Nursing (DON) addressed the facility's response to the complaint. The date the concern was addressed by the DON was not documented on the grievance form. The DON's response to the concern was, Nursing will randomly monitor and document timely of call lights to include monitoring during meal times and shift change. During the 01/26/16, resident council meeting, the resident's again complained about call lights not being answered timely. The response form, completed by the DON on 01/26/16, was, Nursing will randomly monitor call lights and nurse will validate on all shifts. At 12:18 p.m. on 05/16/16, Activity Directory #36, who completed the minutes of the resident council meetings, confirmed she never received the copies of the audits of the call lights that were to be completed by the DON. At 12:26 p.m. on 05/16/16, the DON confirmed the only call light audits completed, were those he completed on 02/09/16 and 02/18/16. The audit for 02/09/16 noted observation of call lights activated from 2:17 p.m. to 2:40 p.m. The audit for 02/18/16 noted observation of call lights activated from 1:10 p.m. through 1:41 p.m. The DON confirmed the call light audits were not completed on all three shifts, at shift change and during meal times as indicated in the resident council minutes. b) Resident #73 Record review on 05/10/16 at 11:30 a.m., found the resident was admitted to the facility on [DATE]. Review of the Grievance/Concern forms found Resident #73's spouse voiced a concern on 01/18/16 stating call lights were not answered timely on evening shift after dinner, between 6:00 p.m. and 8:00 p.m. The action taken to investigate the grievance concern was, Evening shift staff re-educated on call light timeliness and evening shift supervisor to monitor call lights. The grievance/concern form noted the facility's corrective action was, SW (social worker) followed up with (name of resident) on 01/21/16 and she reports call lights are better. c) Resident #48 Record review found the resident was admitted to the facility on [DATE]. Review of the grievance concern forms found Resident #48 voiced a concern on 04/22/16 stating call lights were not answered timely on evening shift after dinner, a few nights ago. The action taken to investigate the grievance concern was, Evening shift supervisor to monitor call lights. The grievance/concern form noted the facility's corrective action was, SW (social worker) followed up with (name of resident) on 04/25/16 and 04/26/16, he reports everything is much better. d) At 3:25 p.m. on 05/10/16, the administrator provided a copy of the nursing supervisors working on evening shift from 01/18/16 through 01/23/16. RN #50 was listed as the evening shift supervisor working on 01/19/16, 01/20/16, and 01/21/16 (the period of the resident's grievance). An interview with RN #50 at 3:30 p.m. on 05/11/16, found he was unaware Residents #48 and #73 had made any complaints about the timeliness of the call lights being answered. RN #50 said he did not complete any written audits regarding call lights during that period. He did acknowledge his job required keeping an eye on the care provided to residents and a part of this assignment included ensuring call lights were answered. An interview with Social Worker #93 at 5:45 p.m. on 05/12/16, found she did not have any evidence the evening shift supervisor monitored the call lights. She stated the director of nursing (DON) would have taken care of this issue. At 12:26 p.m. on 05/16/16, the DON confirmed he did not have any audits of call light monitoring for Resident #73 during the period of 01/18/16 through 01/23/16. e) Although the response on the form for Resident #72 identified staff were educated about call lights in (MONTH) (YEAR), the facility failed to monitor the effectiveness of the education. The facility also failed to complete monitoring on evening shift as the identified on the grievance forms for Residents #48 and #73 to ensure staff continued to answer call lights in a timely manner.",2019-05-01
5103,RALEIGH CENTER,515088,1631 RITTER DRIVE,DANIELS,WV,25832,2015-04-10,166,D,0,1,CRGX11,"Based on resident interview, staff interview, facility policy review, and review of the facility's grievance concern forms, the facility failed to identify and seek prompt resolutions to resident grievances, of which they were or should have been aware, for two (2) of five (5) residents reviewed for the care area of social services. Resident identifiers: #66 and #83. Facility census: 66. Findings include: a) Resident #66 At 11:06 a.m. on 04/06/15, an interview with the resident found she complained to staff that she was unable to sleep at nights. She stated her current roommate talked and made noises all night. Upon inquiry, the resident said she had complained to various staff members and nothing had been done. Observation, at 3:45 p.m. on 04/07/15, revealed Social Worker (SW) #59 entered the resident's room to discuss the resident's concerns. Upon entrance to the room, the resident looked up and called the social worker by her first name. The resident told her she could not get any sleep at night because of her roommate. Resident #66 stated, I'm going to crack if I don't get some rest. Employee #59 told the resident she would look into her concerns. The resident replied, That's what you told me the last time, but you never get back to me. At 8:15 a.m. on 04/08/15, Licensed Practical Nurse #22 stated she was aware the resident had complained about the noise at nights. At 9:38 a.m. on 04/08/15, the resident's nursing assistant (NA), Employee #57, stated she was aware the resident had complained about the noise at nights. She stated the resident's roommate mumbles all night and several other residents down the hall yell out during the night. She said the nurses were all aware of the problem. At 10:00 a.m. on 04/08/15, another nursing assistant, Employee #50, stated she was aware of the resident's concerns about the noise level at night. She stated the roommate sings and makes noise during the night. Medical record review found Resident #66 and her roommate had occupied the same room since the roommate's admission on 11/24/14. A significant change minimum data set (MDS), with an assessment reference date (ARD) of 02/05/15, found the resident scored a fifteen (15) on the brief interview for mental status (BIMS), indicating she was cognitively intact. Review of the completed grievance/concern forms for the past year, on 04/08/15, found no evidence the resident's complaints regarding her roommate were addressed. At 1:00 p.m. on 04/08/15, the admissions coordinator, Employee #42, and SW #59 confirmed they had no evidence the resident's concerns were addressed. b) Resident #83 An interview with Resident #83, at 9:51 a.m. on 04/07/15, revealed about four (4) weeks ago he went to an appointment in [NAME]ton. He reported he left for the appointment before lunch time and returned to the facility about 2:15 p.m He stated when he returned, he had to wait over an hour to get his clothes changed and to get a blanket. He also stated he asked for something to eat when he returned because he had missed lunch. He said it was 4:30 p.m. before they gave him something to eat. When asked if he told staff about his concerns, he stated, I asked to see the social worker that day. Then I asked to see her again the following day so that I could make a compliant, and to this day she has still not come to see me to take my compliant. I just quit asking for her to come. Review of Resident #83's medical record, at 9:14 a.m. on 04/08/15, found Resident #83 went to a doctor's appointment in [NAME]ton on 03/09/15. His appointment time was 11:00 a.m Review of the complaints and concerns for the previous six (6) months found no mention of Resident #83's concerns. An interview with the Social Service Director (SSD) #59, at 12:51 p.m. on 04/08/15, revealed no evidence the SSD had documented, investigated, or satisfactorily resolved Resident #83's concerns. She stated, I spoke with him about it but I must of not documented anything about my conversation with him. When asked what she did to resolve Resident #83's concern, she was unable to answer. An interview between the the SSD and Resident #83, at 3:00 p.m. on 04/08/15, was observed. During this interview, the SSD took down the resident's concern. She completed a concern form. At the time of exit, the SSD was still working to resolve Resident #83's concern. c) Review of the Grievance/Concern policy, which was revised on 06/10/13, found: All patients and/or their representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance/concern process . 1. Upon admission, the patient and/or patient representative are informed of their right to voice grievances/concerns and the process for doing so. 2. A description of the procedure for voicing grievances/concerns will be on each unit in a prominent location. 3. Formal concerns may be registered by telephone, mail, office visit, or direct outreach to staff. 4. Upon receipt of the grievance/concern, the Grievance/Concern Form will be initiated by the staff member receiving the concerns and documented on the grievance/concern log. 4.1 When the formal grievance/concern is logged, the Administrator and appropriate department manager will be notified. 4.1.1 If the grievance/concern is related to discrimination on the basis of disability, notify the Section 504 Coordinator (Administrator). Refer to Section 504 grievance policy. 4.1.2 For reports of abuse, follow the state-specific abuse policy for management of the incident and documentation requirements. 5. The department manager will: 5.1 Contact the person filing the grievance to acknowledge receipt; 5.2 Investigate the grievance; 5.3 Engage the support of the Ombudsman, if warranted; and 5.4 Notify the person filing the grievance of resolution within 72 hours. 6. Completed grievance/concern forms will be reviewed and retained by the administrator to assure the patient's interests have been addressed. 7. If the grievance/concern is unable to be resolved satisfactorily, refer to the patient/representative to the Regional Vice President of Operations and/or Manager of Clinical Operations for assistance. 8. Review grievance/concerns at the Quality Improvement committee meeting to identify trends.",2019-03-01
5457,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2015-06-22,166,D,0,1,N2E611,"Based on resident interview, medical record review, review of grievances and concerns forms, observation, facility policy and procedure, and staff interview, the facility failed to ensure prompt efforts were made to resolve grievances for one (1) of three (3) residents reviewed for the care area of social services. The resident reported concerns involving the behavior of other residents and missing personal items which were not addressed by the facility. Resident identifier: #76. Facility census: 62. Findings include: a) Resident #76 1. On 06/15/15 at 3:37 p.m., during Stage 1 of the Quality Indicator Survey (QIS), Resident #76 reported she had concerns and problems with other residents wandering into her room, taking her personal possessions and hitting her. The resident named Residents #15 and #58 as the problem residents. She stated Resident #15 had entered her room on several occasions and had eaten her food. She said he also hit you if he felt like it, and he had hit her. Resident #76 said Resident #58 had wandered into her room and had taken the remote control for her television and her glasses. She said staff were aware of her concerns, and she had reported these residents to the social worker. Review of the nursing notes, on 06/17/15 at 8:00 a.m., found a note dated 06/08/15, CNA (certified nursing assistant) reported to nurse that another resident was in the resident's room in his merry walker standing at the end of her bed hitting her left leg with his fists. Resident was saying, Quit hitting me to other resident. Immediately separated residents. Calmed and redirected resident. No signs of injury noted to left leg The facility's grievance/concern forms, reviewed at 8:15 a.m. on 06/17/15, found a grievance/concern reported by the resident on 02/19/15. Resident #76 stated Resident #15, . Deliberately hits people with his walker and she is fearful that he is going to cause a fall or hurt someone. She thinks he understands what he is doing because he smiles and laughs when bumping people. The resolution on 02/24/15, for the 02/19/15 grievance, was, The treatment team did discuss the other resident and his behaviors and some possible interventions, including re-direction and consistency of this re-direction by all staff, were identified. The grievance/concern forms contained no evidence indicating the facility addressed Resident #76's concern with Resident #15 when he hit her on 06/08/15. At 8:29 a.m. on 06/17/15, the administrator was asked how the facility addressed Resident #76's concerns regarding the behavior of other residents. She stated the facility addressed the issue on 02/19/15. The administrator presented no evidence the facility addressed the incident with Resident #15 on 06/08/15, when he hit Resident #76. There was also no evidence the facility addressed Resident #76's concerns about Resident #58. At 10:30 a.m. on 06/17/15, Resident #15 was observed in his Merry Walker in the television lounge across from the nurses' station. Resident #15 rolled his Merry Walker into the wheelchair of Resident #37. Staff were summoned to the lounge, by the surveyor, because the Merry Walker caught the wheel of Resident #37's wheelchair and Resident #15 was moving Resident #37 around in the lounge area. 2. On 06/15/15 at 3:37 p.m., Resident #76 also reported she had several missing CDs containing music from the 1960's. She said her son purchased a packaged set for her Christmas present. Resident #76 said she reported the missing CDs to activity staff members (she gave their names). She said she had not heard anything about her report and no one had returned the CDs to her. At 2:17 p.m. on 06/16/15, Activity Director (AD) #54, verified Resident #76 reported the missing CDs to her about one (1) or two (2) months ago. AD #54 stated the activity assistant might know because she accompanied Resident #76 to the social worker's office to report the missing CDs. At 2:25 p.m. on 06/16/15, Activity Assistant (AA) #55 verified she personally accompanied the resident to the social worker's office to report the missing CDs. AA #55 said she thought this was, about two (2) months ago. At 2:30 p.m. on 06/16/15, review of the grievance/concern logs found nothing related to the missing CDs. At 2:45 p.m. on 06/16/15, Social Services Director (SSD) #49 was asked how the facility investigated missing items when reported by residents. The SSD stated a grievance concern form was completed and the facility looked for the missing item. If the missing item was not located, the facility reimbursed the resident for the item. When asked if she knew anything about Resident #76's report of missing CDs, she replied, No. At 4:10 p.m. on 06/16/15, the administrator and the director of nursing were notified of the interviews with the resident, activity staff, and the social worker. The administrator stated she would complete a grievance/concern form and would investigate the allegation. Review of the resident's most recent minimum data set (MDS), a quarterly MDS with an assessment reference date (ARD) of 03/15/15, found the resident scored a fifteen (15), the highest score possible, on her brief assessment for mental status (BIMS), indicating she was cognitively intact. The resident was also deemed to have capacity to make medical decisions. Review of the facility's policy for grievances/concerns, revised on 06/01/15 found, All patients and/or their representatives may voice grievances/concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance/concern process.",2019-01-01
5575,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2014-12-12,166,D,0,1,VNJW11,"Based on review of the facility's grievance/complaint forms, staff interview, policy and procedure review, and resident interview, the facility failed to ensure prompts efforts were made to resolve grievance/complaints. In addition, the facility failed to keep the resident apprised of its progress toward resolution. This was true for three (3) of thirty-five (35) complaints/grievances reviewed. Resident identifiers: #63, #143 and #43. Facility census: 154. Findings include: a) Resident #63 On 12/04/14, review of the facility's grievance/complaint reports found on 10/13/14, Resident #63 reported, she was unable to get up for Saturday activities because a lift pad could not be found. Employee #52, the social services director, completed the complaint form. On 10/13/14 the compliant was assigned to the second floor unit manager, the administrator, and the director of nursing. The complaint was to be resolved by 10/18/14. Review of the facility's policy entitled, Grievance/Concern, revised on 06/10/13 found, . Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative, Social Services personnel will serve as patient advocates in the grievance/concern process . Section 5.4, Notify the person filing the grievance of resolution within 72 hours. The resolution for the grievance/complaint filed on 10/13/14 was: New lift pads to be ordered and an area made in each shower room to keep the lift pads. The documentation was not completed by the social services director until 11/24/14 and not within 72 hours as required by the facility policy. In addition, the form contained no evidence the information was communicated to the resident who made the complaint. At the bottom of the form was an area to indicate how and when the resident received the facility's resolution. This portion of the form contained no documentation. Employee #52 was interviewed, at 12:05 p.m. on 12/04/14. She was asked why the resolution of the grievance was not discussed with the resident, and why the response to the report was over 30 days. She said she followed up with the resident. The resident was interviewed at 2:00 p.m. on 12/04/14. She stated the incident had happened once again since her initial report, but she did not recall the date or if she reported the incident. She said she has her own lift pad now and she keeps the pad in her room. b) Resident #143 On 10/06/14 the family member of Resident #143 reported to staff the family did not feel she got changed quick enough after a bowel movement and was possibly having diarrhea. Attached to the grievance form was an e-mail dated 10/06/14, from the social services director to the director of nursing: (typed as written) I talked with (Name of resident) daughter (name of daughter) . She (daughter) state her sister was here Friday from 1-2. She (the sister) had to leave at 2 to pick up her grandkids. There were two nurses at the nurses station and her sister told them that (name of Resident) needed to be changed. There (their) reply to her was that they would have to find her C.N. A. Her sister then called her (the nurse) and asked her (the nurse) to make sure she (the resident) had been changed. (Name of Daughter) said she got here between 5:30 - 6. (Name of resident) was in the dining room on second (floor). She (daughter) said she thought she got a whiff of something then but wasn't sure. She (the resident) finished dinner and (Name of daughter) took her to her room. She (daughter) got a wash cloth to wipe off her (resident) hands and that is when she really smelled it. She (daughter) said she (the resident) was full and had to have her clothes changed, She said she (daughter) was here on Sunday to visit (name of resident) was sitting by the nurses station. Her brief was full at that time. She (daughter) doesn't know how long it had been that way. They got her cleaned up and (name of daughter) took her downstairs for a bit and when they returned upstairs she was full again. She (daughter) is wondering if she (resident) is having diarrhea because she (daughter) said that is what it looked like Friday. If she is having diarrhea she (daughter) would like to know. I told her we were looking into it and if we discovered she (resident) is having diarrhea we would let her know. The director of nursing (DON) responded to the social worker's e-mail on 10/6/14 at 4:04 p.m I talked with (name of nurse), she looked at BM (bowel movement)documentation 10/1 1 XL 10/2 2 smalls x 2 10/3 LG and small 10/4 4 small So the episodes over weekend isn't documented in BM book will have aides chart after I speak with them. (name of nurse) states no one reported diarrhea she does seem to go everyday, she takes stool softer at bedtime every night, so let me look into it more it may be she doesn't need the stool softner as frequently. The response to the daughter, on 10/14/14, was not timely as directed by the facility's grievance policy which states, Section 5.4 Notify the person filing the grievance of resolution within 72 hours. There was no evidence the facility responded to the family's concern regarding the resident being left soiled or if the resident had diarrhea. The findings were discussed with the administrator and the social worker at 10:19 a.m. on 12/09/14. No further information was provided. c) Resident #43 Review of the grievance concern forms, on 12/04/14, found the resident reported his cell phone was missing on 10/02/14. Resolution of the grievance/complaint form found the following, Spoke w/ (with) resident's son. He stated it had a tracking device and he was going to track it but never did. Set up an old one he had for him. The resolution was signed by Employee #52, the social services director, on 10/17/14. There was no evidence the facility searched for the telephone and no evidence the resident, who made the complaint, received any follow up after reporting the missing cell phone. The grievance/complaint form noted the resident was out to the hospital from 10/04/14 and returned on 10/14/14. The grievance was dated as resolved on 10/17/14, but there was no indication the resident received any follow up after returning from the hospital.",2018-09-01
5646,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2015-07-29,166,D,0,1,DSPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, and family interview, the facility failed to make prompt efforts to resolve grievances a resident and/or representative may have. A family member reported she voiced multiple complaints and concerns regarding her family member's care and said, Nothing gets done. A resident reported he had voiced complaints about another resident for the past two and a half (2.5) years and said, It falls on deaf ears and, No one does anything. Resident identifiers: #90 and #18. Facility census: 99. Findings include: a) Resident #90 A medical record review on 07/27/15 at 10:55 a.m., found this resident was admitted to the facility 07/01/11 with [DIAGNOSES REDACTED]. A physician's progress note dated 07/06/15 stated, She is no longer verbal with the exception of a few occasional words, and, She has fallen due to her trying to get in or out of bed/chair without assistance but is unable to call or ask for assistance. The most recent recreation assessment completed on 07/15/15 asked, What are the most important parts of your typical daily routine at home? for which the response by the resident representative was, lay down and take naps after her meals. The current care plan stated Resident is to be offered to be laid down after breakfast and dinner, if she says no, offer again a little later. The most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 04/23/15 coded resident under Section G, Item G0110, as being totally dependent for transfers and needing two (2) staff members for assistance. During an interview with the resident's responsible party, on 07/23/15 at 10:30 a.m., she voiced concern regarding staff not following the care plan she agreed to in the care plan meeting. The staff at the meeting agreed her mother would be out of bed at certain times, and returned to bed at certain times. She said staff were not doing that. She also said she came in frequently and found her family member wet. She said she had always reported concerns and there should be records of them. In an interview on 07/27/15 at 2:45 p.m., Social Worker #40 said Resident #90's responsible party had not voiced a complaint in a long time. Upon review the past six months complaints, performed on 07/27/15 at 3:30 p.m., there was a complaint dated 01/19/15 regarding Resident #90's bed sheets being brown ringed, a condition where the sheets had a dried brown circular area, presumably of old urine. There was a second complaint dated 07/01/15, which described two (2) occasions of Resident #90 not being laid down after breakfast. One occurrence was 06/29/15 and the other 07/01/15. The facility administrator documented this concern and part of the resolution was to educate staff regarding laying Resident down at key times. During an interview with the Administrator, on 07/28/15 at 10:00 a.m., this education had still not taken place yet. During an interview with the Director of Nursing, (DON) on 07/27/15 at 4:00 p.m., he said Resident #90's responsible party had come to him in the past about laying Resident down because she was tired and he had staff immediately lay her down each time. He said other than the 07/01/15 concern handled by the Administrator, it had been a long time since anything was written up formally. A second interview was held with the DON on 07/28/15 at 10:03 a.m. about the concern filed 07/01/15 that had still not had the education piece completed. He stated that is not a typical length of time to resolve a grievance and said, I'm not sure what happened there. A second interview was held with the responsible party of Resident #90 on 07/28/15 at 11:00 a.m. She reiterated she had complained many times in the past about Resident #90's bed being wet at various times and about Resident #90 being up in a wheelchair when she was care planned to be in bed. She said she did not attend the care plan meetings anymore, because it was not followed. She said she had complained to Nurse Manager #202 and to the DON and felt like nothing gets done. She said from now on she will go to the Administrator because at least the Administrator wrote down her concerns, although, she still does not feel the Administrator acted upon her concerns timely. b) Resident #18 On 07/27/15 at 11:00 a.m., Resident #18 requested to speak with a surveyor regarding problems he had with Resident #44. An incident report review performed on 07/28/15 at 8:45 a.m. for the past three (3) months found no reports of incidents regarding both residents. Review of grievance and concerns forms for the past six (6) months performed 07/27/15 at 3:30 p.m., found no concerns or grievances regarding disagreements between both residents. An interview was held with Resident #18 on 07/28/15 at 2:00 p.m. and he said Resident #44 had bullied him since he (Resident #18) was admitted two and a half (2.5) years ago. He denied being afraid of Resident #44, but he did say if Resident #44 did not leave the facility, then he (Resident #18) would have to go live somewhere else. He said he had complained multiple times to Nurse Manager #202, the DON, Social Worker #154, and the Administrator. He said, It falls on deaf ears, and, No one does anything. An interview was held with the DON on 07/27/15 at 3:45 p.m. and he said both Resident #18 and #44 instigate problems with each other and he and the staff frequently have to redirect both men. He said, You know how men are. An interview with Social Worker #154 was held on 07/27/15 at 2:45 p.m. and she said they do not fill out complaints for Resident #18's concerns; they document issues on his progress notes.",2018-09-01
5739,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2015-10-20,166,D,0,1,30IW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of complaints and grievances, the facility failed to make prompt efforts to resolve grievances/concerns voiced by one (1) of twenty-five (25) residents and/or families whose concerns were reviewed. The resident's family voiced several concerns during a care plan meeting. There was no evidence the facility addressed and/or implemented interventions to resolve each of the concerns. Resident identifiers: #111. Facility Census: 117.Findings include: a) Resident #111 A review of medical records, on 10/14/15 at 9:15 a.m., found Resident #111 was admitted to the facility on [DATE]. This ninety (90) year-old female's [DIAGNOSES REDACTED]. A review of the facility's Grievance/Concern Forms, on 10/14/15 at 10:00 a.m., found a Documentation of Grievance/Concern Form received on 05/26/15 for Resident #111 The concern reported was, Resident received wrong diet and liquids on meal tray on 05/23/15 and 05/24/15. Under Investigation, the date assigned for the investigation was 05/26/15. This concern was assigned to the administrator, dietary manager, and the director of social services for investigation of the grievance/concern. The action taken to investigate the grievance/concern was interviews with all dietary staff and nurse aides (NA). The Resolution of Grievance/Concern was, Did reeducation with all dietary staff and nursing assistants concerning trays and diets. Family notified on 05/27/15 in a face-to-face conversation. Further review of the medical records on 10/14/15 at 11:30 a.m., found a progress note written on 05/26/15 labeled Care Plan Meeting. Those in attendance were Registered Nurse (RN) #8, Certified Occupational Therapy Assistant (COTA) #107, and (2) two daughters, as well as Social Worker (SW) #98. SW #98 was the author of the progress note written on 05/26/15. Concerns voiced by Resident #111's family during the care plan meeting were: -- left wrist splint usage and education and the positioning of the splint, -- The practice of consistency of care (assigning the same staff to care for the resident) as this provided the resident with the most consistent and best care, -- concerns of the previous wheelchair used by the resident that was damaged by staff on 02/26/15, -- improper diet and regular liquids served on the resident's meal tray the last weekend (05/23/15 and 05/24/15), -- the family not being consistently informed of issues in relation to resident care, incidents, and order changes, -- request for the staff to use the white board in resident's room to communicate, -- dental concerns and request the facility to contact the dentist, and -- facility to educate the staff concerning oral care. In an interview at 11:30 p.m. on 10/15/15, SW #98 stated she remembered Resident #111's family voiced several concerns during the 05/26/15 care plan meeting. When asked why the facility only addressed one (1) concern, related to improper diet and liquids served on 05/23/15 and 05/24/15, and not the other concerns, SW #98 said, I should have followed up on all of the concerns, but I just didn't. SW #98 also could not provide evidence regarding which staff members were provided the education and/or what the content of the education provided.",2018-08-01
5861,HILLCREST HEALTH CARE CENTER,515117,462 KENMORE DRIVE,DANVILLE,WV,25053,2014-11-17,166,D,0,1,LO0C11,"Based on record review, policy review, staff interview, and family interview, the facility failed to resolve a grievance and failed to communicate the progress toward resolution to the grievant for one (1) of three (3) residents reviewed for the care area of abuse. Resident identifier: #56. Facility census: 87. Findings include: a) Resident #56 During a Stage 1 interview with Resident #56's daughter (health care surrogate) on 11/11/14 at 8:56 a.m., the daughter was asked, Has staff, a resident or anyone else here abused (resident's name) this includes verbal, physical or sexual abuse? The daughter revealed that on 11/04/14, she came to see her mother and when she was walking down the hall, she could hear her mother screaming. She stated she knocked on the door and then went on into the room. She stated two (2) nursing assistants (NAs), #37 and #65, had her mother on the side of the bed with their hands under her mother's arms. The daughter stated that the NAs were transferring her mother into a chair that was in front of them. The resident's daughter stated her mother required a mechanical lift and the assistance of two (2) to be transferred into her chair. When asked if she talked to someone about what had happened, she stated, Yes. She said she had made a grievance the very next day, which was 11/05/14, to the social worker (Employee #109.) When asked if staff informed her of their progress toward resolution for this grievance, she stated, No, no one ever came back and told me anything. I had to request my mother to be moved to the other side so the two (2) nursing assistants would not be caring for my mother. A review of the concerns and grievances, on 11/13/14 at 10:25 a.m., revealed the facility had no evidence they were actively seeking a resolution and/or keeping Resident #56's health care surrogate appropriately apprised of its progress toward resolution for her grievance. A review of the Kardex (a tool to inform nursing assistants what care a resident requires), on 11/13/14 at 11:00 p.m., confirmed Resident #56 required two (2) person physical assist with a mechanical lift for a transfer from bed to chair. An interview was conducted, on 11/13/14 at 2:20 p.m., with the social services supervisor (SSS) #109. SSS #109 stated Resident #56's daughter voiced a grievance regarding when she entered her mother's room, NAs #37 and #65 had her mother on the side of the bed with their hands under her arms. The daughter stated the NAs were transferring her mother into a chair in front of them. SSS #109 stated she went to Clinical Care Supervisor (CCS) #98 and discussed this with her because she felt it was a nursing problem. When asked whether the concern or grievance form was filled out, she stated, No. She said she did not fill out the grievance form because she gave the information to the clinical care supervisor. In an interview with CCS #98, on 11/13/14 at 2:29 p.m., she was asked whether she was actively working toward resolution of a grievance Resident #56's daughter made to the social worker. She said she had talked to NAs #37 and #65, and they stated the resident had her leg hanging off the left side of the bed. CCS stated the NAs told her they were trying to lay the resident down when the resident's daughter came in the room. The NAs informed the CCS the daughter thought they were transferring her to the chair. She stated the staff were not transferring the resident without a mechanical lift. She stated she had interviewed the nurse working that day, and verified the NAs were not transferring Resident #56 without a lift. The CCS was asked who the nurse was who was working that day. The CCS stated that she could not remember. The CCS stated she did not write anything on a concern/grievance form and/or inform Resident#56's daughter of what she found. She stated she did not know it was a grievance, so she did not go and talk with the resident's daughter or discuss the outcome with her. The CCS stated she did not have any evidence she had attempted to resolve the resident's daughter's grievance. Review of the facility's grievance policy, on 11/13/14 at 3:00 p.m., revealed the following: Social services director is responsible for accepting any complaints voiced by resident, family members or legally responsible parties. In the absence of the social services director, the executive director, director of nursing services/designee shall be responsible for accepting any complaints voiced by those mentioned above. A report of the findings and the actions taken if any will then be explained to the resident and/or the legally responsible party. The appropriate designee shall be notified of all efforts made to resolve complaints within forty-eight hours. All complaints/results, and follow-up of the investigation results will be documented and kept on file in the social services director office.",2018-07-01
5989,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2014-09-18,166,D,0,1,7HHJ11,"Based on resident interview, staff interview, and record review, the facility failed to actively work toward a resolution of a grievance for one (1) of two (2) sample residents reviewed for the care area of personal property during Stage 2 of the survey. The resident had a missing cell phone which the facility indicated they would replace if the resident's lost cell phone was not located. The facility replaced the cell phone with a cell phone which quit functioning soon after it was provided. The facility took no further action regarding the cell phone. Resident identifier: #90. Facility census: 98. Findings Include: a) Resident #90 In an interview with Resident #90, at 10:09 a.m. on 09/15/14, the resident said someone had stolen his cell phone. He said staff told him they were going to replace it, but they never did. The social worker (SW), at 8:25 a.m. on 09/17/14, confirmed the resident had a missing cell phone some time ago. She stated they searched for the phone and were unable to locate it. The SW said she provided the resident with a phone which had been unclaimed in the facility's lost and found for about six (6) months. A review of this reportable incident was completed at 10:30 a.m. on 09/17/14. The five-day follow up form, dated 05/24/13, was reviewed. The date of incident was noted as 05/22/13. The corrective action by facility was, Family was notified of missing cell phone(NAME)Co. (county) Sheriff's Dept.(department) also was notified of the alleged incident. Also, staff continues to monitor for cell phone. Encouraged resident not to keep things of value in room but in locked safe as well as will monitor when visitors are in room. Will replace cell phone if unable to locate phone. In an additional interview with Resident #90, at 10:45 a.m. on 09/17/14, he again stated he had not had a cell phone since his came up missing. When asked if the facility had given him a new phone he stated, No I don't have one. A follow-up interview with the SW, at 11:33 a.m. on 09/17/14, confirmed the facility gave the resident a phone which was in lost and found; however, at this time, the SW revealed the phone did not function for the resident. She stated the activities department took the phone and tried to get it to work, but were unable to do so. The SW said that was why Resident #90 did not remember getting a replacement phone, because it did not function very long after they gave it to him. She confirmed they did not get the phone to work and they did not replace it with a functioning phone. In an interview with the Activity Director (AD), at 11:50 a.m. on 09/17/14, she said she was not given the phone directly. She stated an activity assistant took the phone to work on it, but never got it working. The AD stated the phone had been in a cabinet in her office. When asked if the activity assistant was working that day, she stated, She does not work here anymore, she quit about six (6) months ago.",2018-05-01
6010,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2014-08-14,166,D,0,1,K1XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, resident interview, and family interview, the facility failed to ensure prompt efforts were made to resolve issues residents had, and also failed to keep resident and family members informed of progress toward resolution. This was found for two (2) of forty-six (46) residents reviewed and one (1) randomly reviewed resident. Resident identifiers: #103, #25, and #105. Facility census: 94. Findings include: a) Resident #103 Record review, beginning on 08/06/14 at 10:14 a.m., found this [AGE] year-old woman was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She was sent out to an out of state behavioral health unit on 07/25/14 due to escalating behaviors. During investigation of the facility's care for the maintenance of her nutritional status, it was discovered staff identified she had lost her dentures. The review found an inventory of personal items completed upon admission, 03/21/14, documented Resident #103 had both upper and lower dentures. The registered dietitian's medical nutrition therapy assessment, dated 06/24/14, included the statement, (typed as written): CNA (certified nursing assistant) believes resident does wear upper dentures but her lower dentures are lost. The resident was receiving a regular diet for both nutrients and texture. The nursing assessment completed upon admission (on 03/21/14) documented Resident #103 had both upper and lower dentures. The nursing assessment completed 06/24/14 documented Resident #103 had no dentures. On 08/06/14 at 11:57 a.m., information was requested from the director of nursing (DON), Employee #17, regarding any staff awareness of the missing dentures prior to 06/24/14, and any documented attempts to locate them or inform anyone of the loss. On 08/06/14 at 2:47 p.m., the DON confirmed that the exact date the dentures went missing could not be determined, but was documented as at least as far back as 06/24/14. He presented a Grievance/Concern Form designed to document, investigate, and resolve the loss. The form was initiated on 8/06/14. He said he was unable to find evidence of any previous attempts to locate the dentures. He acknowledged the loss could affect the resident's ability to chew the regular texture diet. b) Resident #105 This [AGE] year-old man was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. He was currently a Hospice resident. On 07/11/14, he was determined by a physician to possess the capacity to make informed medical decisions. His Brief Interview for Mental Status (BIMS) score, as assessed on 07/21/14, was 15 , indicating he was cognitively intact. The resident filed a complaint with the facility on 05/30/14, which said he reported several items missing from his closet, including paperwork, gel pens, pads of paper, change, cologne, a bracelet/necklace, and a watch. The Resolution of grievance/concern section of the complaint form was marked Yes indicating the issue had been resolved and the narrative said by facility search. Offer to replace items if determined facility at fault. The section Identify the method(s) used to notify the patient and/or patient representative of the resolution was blank. In an interview on 08/13/14 at 10:58 a.m., he was asked about the complaint he filed on 05/30/14. He recalled the complaint. When asked if the facility had notified him of any resolution or of attempts of resolution regarding the missing items, he said he had heard absolutely nothing from anyone since he made the complaint. He said the items were never returned to him. Social Worker #61 said, during an interview on 8/13/14 at 3:14 p.m., she had spoken to Resident #105 about his complaint, but acknowledged there was no documentation to support that, nor any description of what the final result of the attempt to resolve the complaint had been. c) Resident #25 This [AGE] year-old resident was admitted to the facility on [DATE] for rehabilitation. Her [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions upon admission. Her Brief Interview for Mental Status (BIMS) score, as assessed on 07/22/14, was 15 , indicating she was cognitively intact. Her husband filed a complaint with the facility on 06/29/14, which said there was not enough staff, the resident had to wait a long time for her call bell to be answered, and ice was not passed timely. The Resolution of grievance/concern section was marked Yes indicating it had been resolved. The narrative said by Re-education of staff. The section Identify the method(s) used to notify the patient and/or patient representative of the resolution was blank. The husband of Resident #25 was interviewed on 08/13/14 at 10:07 a.m. He was asked about the complaint he filed on 06/29/14. He recalled the complaint. He was asked if the facility had notified him of any resolution or at least attempts of resolution regarding the issues of concern. He said he had heard nothing from anyone since he had filed the complaint and things were no better now than they were then. Social Worker #61 said, during an interview on 08/13/14 at 3:14 p.m., she had not spoken to the husband regarding the complaint, but had instead addressed it with Resident #25 herself since she had capacity and acted as her own responsible party. She acknowledged there was no documentation to support that, nor any description of what the final result of the attempt to resolve the complaint had been. Resident #25 was interviewed on 08/13/14 at 4:00 p.m. She also recalled the complaint of 06/29/14. She said she had never heard anything from the facility since the complaint was made and that things were no better than they had been then.",2018-05-01
6080,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,166,E,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, observations, review of snack-related forms provided by the dietitian, review of resident council minutes, resident interviews, and staff interviews, the facility failed to actively seek a resolution to grievances and/or to keep the resident informed of the progress being made. Residents had voiced reoccurring concerns regarding the availability and/or the variety of snacks available when the kitchen was closed; and/or the extended length of time required for care needs to be met for fifteen (15) of thirty (30) residents interviewed. Resident identifiers: #62, #64, #7, #70, #15, #133, #115, #84, #88, #58, #19, #65, #141, #210 and #78. Facility census: 100. Findings include: a) Grievance: Snacks are not available and/or there was no variety of snacks when the kitchen was closed: 1) Resident #62 During an interview with Resident #62 at 3:30 p.m. on 01/07/14, during Stage 1 of the survey, she said there were few or no snacks kept on the care unit and if you requested something when the kitchen was not open you could not get it. She stated this was true for both food and/or drinks. The resident said she had stated this concern during resident council meetings, to the dietitian, at food club meetings, and to the nursing care staff, but nothing had been done. The only answer she received was from a nursing assistant, who said the kitchen would not stock snacks on the unit. 2) Resident #78 An interview with Resident #78 at 2:00 p.m. on 01/08/14, revealed she agreed there were few, if any, snacks available. She stated, If you want a snack they have to go to the kitchen to get it and you can't get anything when the kitchen is closed in the evening. She added, If you wanted something you should have the physician order [REDACTED]. According to the resident, there was usually juice or tea and crackers kept on the unit, but nothing more. She added that this had been brought up at resident council and she had voiced it to nursing staff and the kitchen staff, but she was told there was nothing they could do. 3) As a result of these interviews, the following observations were made during the survey: Observations of the nourishment kitchen serving the 300/400 halls were made at 8:30 a.m. on 01/08/14; 9:30 a.m. on 01/09/14; 3:00 p.m. on 01/13/14; and 8:15 a.m. on 01/14/14 (on 01/14/14 Employee #87 (Maintenance Director) was present). On each of these observations, there were only graham crackers, soda crackers, and individual containers of peanut butter and jelly found. The refrigerator contained orange juice and a large container of tea. There were never more than four (4) individual containers of milk. There was ice cream in the freezer, but no fruit, puddings, cookies, or bread. 4) Observations of the nourishment kitchen serving the 100/200 halls were made at 8:45 a.m. on 1/08/14; 2:00 p.m. on 01/09/14; and 8:15 a.m. on 01/14/14. The only snack items available were graham crackers, soda crackers, and individual containers of jelly and peanut butter. On 01/14/14, there was a partial loaf of bread. The refrigerator contained large containers of sweetened iced tea and orange juice and ice cream. There were no puddings, cookies, or fruits. There was no milk on 01/08/14 or 01/09/14 and only four (4) individual containers of milk on 01/14/14. 5) All observations revealed multiple individual containers of ordered supplements labeled for certain residents. There were also cans of soda, provided by purchasing. 6) At 9:30 a.m. on 01/14/14, following the earlier observation at 8:15 a.m., both nourishment kitchens were stocked with at least a dozen individual containers of milk, 3 cans of soup, bread, 4 puddings, and a 2 covered bowls of canned fruit. Employee #18 (Aide), who was present, stated this was . a lot more than we usually have. They continued to be stocked throughout the remainder of the survey. 7) An additional six (6) resident interviews were completed during Stage 2 of the survey at 8:30 a.m. on 01/16/14. The residents were asked, Can you get a snack in the evening? and What would you like to get?. The responses were: 1) Resident #64: . no snacks unless the kitchen sends them. When asked what she would like to have she said Maybe a sandwich or toast. 2) Resident #15: You get drinks for snacks if you ask for one. He said he would like food. 3) Resident #133: No snacks. The resident said he would like A sandwich. 4) Resident #115: They don't bring snacks. They tell you, 'no extra.' She said she prefers fruit or cookies and milk. 5) Resident #58: They don't keep anything but crackers. She said she would like anything but crackers. 6) Resident #210: You only get a snack if you're a diabetic. The resident said cookies would be nice. All of these residents stated they had questioned the staff about snacks, but it had not resulted in them being provided. Some said they just get their family to bring things in. None of the residents had been told why their requests had not been met. 8) During an interview with Employee #109 (Activity Director), at 10:30 a.m. on 01/08/14, she was asked to explain some of the items on the Resident Council Minutes form as she attended the meetings. One of the items listed under, Compliments, comments, on 08/15/13, was Snack machine items - Would like switched but they state they cannot change them. She explained that the residents used the snack machine a lot and when asked, added that the residents say there are not a lot of snacks on the floor in the evening. She stated she had forwarded these complaints to the dietary supervisor and administration. She was not aware of any action taken. In an interview with the Registered Dietitians, at 11:35 a.m. on 01/08/14, they acknowledged awareness of the lack of snacks stocked in the nourishment kitchens and stated they had no control over this as the food supplies were provided by contract with a contracted company. The dietitian who did the assessments said, when interviewing residents, she asked them if they wanted a snack and what their preferences were. She then added it to their food order and had the kitchen send them out, but she stated she only did this for the residents who wanted a snack on a daily basis. The Senior Dietitian stated the nourishment kitchens were stocked daily in the afternoon by the kitchen from a written request from the unit nurse and signed for by a nurse when received. She also stated the aides sign out snacks when they are taken from the room and provided a copy of the Nourishment Room Snack Sign Out Log for January 2013. 9) During an observation of the nourishment kitchens at 1:00 p.m. on 01/08/14, the sign out logs were absent. Employees #98, #7, and #142 (aides) stated they were not required to sign out items from the nourishment kitchen. Employees #116 and #106 (Nurses) verified there was no sign out form in use. Employee #116 stated there had been such a form but the practice had only been in effect for about a month and was dropped. 10) The Senior Dietitian provided an order for [REDACTED]. Of the four (4) types of milk, only a few containers of 2% milk were observed. 11) During an interview with Employee #15 (Food Service Supervisor), at 9:00 a.m. on 01/09/14, she acknowledged the use of the sign-out form for snacks but agreed it had not been used. for a long time. She stated the kitchen did not provide soft drinks, except for ginger ale for therapeutic use. She admitted awareness of complaints from time to time from the residents about snacks, but stated there was nothing she could do about it and did not explain. She provided a copy of the HCR ManorCare HS Snack Rotation schedule which listed puddings, cookies, ice cream, peanut butter crackers, pretzels,cheese its, and graham crackers. 12) An evening visit at 11:30 p.m. on 01/14/14, revealed the same snack items (and same amount) present in the nourishment kitchens as on the earlier visit on the same day (9:30 a.m.). Interviews with Employees #28, #37, #164, #32, and #20 (aides) revealed they had delivered the labeled HS (bedtime) snacks, but had not offered any additional snacks and none had been requested by residents. They expressed surprise at the amount of snacks available and stated that there was usually only Jugs of tea and a juice, and crackers. Employees #32 and #20 stated Resident #29, who was yelling out at that time, could be calmed at times by getting her up and giving her a sandwich, but there was never anything to fix a sandwich with. All of them agreed with this and all agreed a sandwich or toast was the most requested snack. The aides reviewed the HS (hour of sleep) Snack list and said it appeared accurate, but all stated, except for graham crackers and ice cream, none of these items were stocked in the nourishment kitchens. 13) During an interview with the Senior Consultant Dietitian and Employee #15 (Food Service Supervisor) at 12:50 p.m. on 01/14/14, Employee #15 was asked if she had met with the residents to listen to their concerns/requests regarding snacks. She stated a Food Committee met periodically to discuss issues with the food and she attended these meetings, but she had no authority to promise them snacks. She stated she had forwarded the residents' requests to Administration in the past. 14) In an interview with the Administrator, at 8:30 a.m. on 1/24/14, she acknowledged that she was aware of the residents' concerns about the poor amounts and/or variety of snacks available on the units. She could not show any evidence they had discussed or attempted to alleviate the concerns; or had informed the residents of any plans to do so. b) Grievance: The length of time required before the residents' personal needs are met is too long. Twelve (12) of the twenty-seven (27) residents in the Stage 1 sample, who were deemed interviewable by the facility, stated the caregivers were slow to answer their lights and/or to provide assistance promptly. 1) Resident #115 This resident stated the aide would respond to the light, but say, Wait a minute. and not return for a long time. 2) Residents #62 #133, #19, and #141 These residents were re-interviewed in Stage 2 of the survey. They were asked if they had ever complained about the slow provision of care, and what the results of the complaints were. Each of the residents stated they attended Resident Council. they said the slow answering of lights was frequently expressed during the meetings. A review of the minutes from the previous six (6) months revealed concerns addressed about slow response to needs in five (5) of the six (6) months. The September 2013 and October 2013 minutes indicated the call light problem was . a little bit better, but in November 2013, there were again complaints registered. None of the residents interviewed could state what the facility had done to try to solve this problem. 3) Resident #62 This resident was the resident council president. During an interview at 3:30 p.m. on 01/07/14, she stated she depended on the Regional Ombudsman to tell her what was being done about the concerns made by the residents. She added she did not feel the facility was understaffed. The resident said from her room, which was adjacent to the nurses' station, she could hear the aides talking. She said she heard them say such things as, . not me this time and I'm not going in there again. 4) Residents #64, #7, #70, #15, #115, #84, #88, #58, and #65 These residents were interviewed at 10:00 a.m. on 01/16/14. All had complaints about slow response to care needs and all stated they had reported these complaints to staff. None of them could offer any action taken by the facility to resolve this concern, nor had any of them been offered an explanation of what was being done. 5) During an interview with Employee #109 (Activities Director), at 10:30 a.m. on 01/08/14, she acknowledged she attended all resident council meetings and verified there were usually complaints from the residents about staff being slow to respond to lights. She said these concerns were always relayed to administration via the social worker or director of nurses. She admitted that she did not remember anyone coming to resident council to discuss the concern with them. She was not aware of what action may have been done. 6) Employee #122, a social worker, was interviewed at 2:00 p.m. on 01/13/14. She admitted she was aware of the residents' complaints that their lights were slow in being answered. She was not sure what action was planned or if the concern was taken to Quality Assurance Committee. 7) During an interview with the Administrator, a social worker (Employee #175) and the Director of Nursing, and the survey team, at 11:20 a.m. on 01/15/14, they acknowledged awareness of complaints related to the slow answering of lights, but stated action was taken whenever a complaint was made. The minutes of the council meetings were reviewed. The Administrator confirmed there was very little evidence which described what follow-up was done following a complaint. The Administrator assured the group that staffing was adequate. This was verified during the survey. No additional information to validate any response presented to residents individually or to the resident council was provided prior to exit of the facility.",2018-05-01
6357,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,166,D,0,1,OMIN11,"Based on resident interview, record review, staff interview, review of complaints and grievances, and review of resident council meeting minutes, the facility failed to make prompt efforts to resolve grievances voiced by two (2) of two (2) residents interviewed, in the Stage 2 sample of 62 residents, who expressed unresolved concerns. Resident #67 voiced a concern about her roommate keeping the television on all night hindering her ability to sleep. Resident #24 voiced concerns about other residents going into her room when she was not in her room. There was no evidence the facility implemented and/or monitored the effectiveness of interventions to resolve these residents' concerns. Resident identifiers: #67 and #24. Facility Census: 61. Findings include: a) Resident #67 At 2:37 p.m. on 05/19/14, Resident #67 was asked, Have there been any concerns or problems with a roommate or any other resident? Resident #67 stated she had a problem with her roommate playing the television all night. She indicated she had told the social worker who told her she would keep it in mind. Resident #67 was then asked, Has the staff addressed the concern(s) to your satisfaction? The resident replied No. She stated they talked to the roommate, but did not turn down the television. She stated the facility did not offer to do anything else to help her resolve the issue she was having with her roommate. Employee #61, social services supervisor (SSS), was interviewed at 12:33 p.m. on 05/30/14. She stated she remembered Resident #67 talking to her about the issue. She stated she thought it was in March of 2014, but said she could not be certain because she did not write the concern on a Grievance/Complaint Report. Employee #61 reported she talked to the roommate about turning down the television at night. She stated she had not followed up with Resident #67 to ensure her complaint was resolved. The SSS stated the only intervention she put into place was talking to the roommate about the volume of the television. She said she did not offer anything, such as a room change, because Resident #67 did not mention that to her. Employee #61 said, I should have followed up with her, but I just didn't. At 1:01 p.m. on 05/30/14, another interview was conducted with Resident #67. She again stated she could not go to sleep at night because her roommate played her television all night long. The resident confirmed she told the social worker about it, and was told they were going to talk to her roommate about it. Resident #67 said she did not know if they had talked to her about it, because it did not get any better. Resident #67 stated it would be fine if her roommate would just turn off her television around 10:00 or 11:00 p.m. The resident said, They never really did anything to take care of it, so I never mentioned it again. b) Resident #24 During an interview with Resident #24, at 10:30 a.m. on 05/28/14, Resident #24 was asked, Are residents able to exercise their rights? Resident #24 responded with, That's a hard one, I would say no. The resident said she paid the facility $6,000 a month for her private room and she did not have any privacy in her room. She stated there were two (2) occasions the previous week when she came into her room and found other residents of the facility in her bathroom. She stated the interventions the facility attempted did not work. For example, she stated they were supposed to keep her door closed, but it was often left open by the staff. The resident said she also might not get it closed at times, because it was sometimes difficult to shut. The resident stated she felt she was not able to exercise her right to privacy because others went in and out of her room when she was not in there. The facility grievances and complaints were reviewed. This review revealed a Grievance/Complaint Report, dated 02/24/14, for Resident #24. The resident told Employee #61, the social service supervisor (SSS), that housekeeping said her dentures were found on the floor of her room when they went in to mop the floor. Resident #24 also told Employee #61 her bed had been getting messed up. Under the section for documentation of the facility's follow-up, was written, SW (social worker) suggested putting safest knob back on door, make sure door is closed. Resident #24 said they have tried those things as well as a stop sign on the door. Under the section titled, Resolution of Grievance/Complaint, was documented, Staff will continue to monitor situation, staff will redirect any resident seen entering Resident #24's room. Review of the resident's current care plan revealed there were no interventions to keep the resident's door closed, or any interventions to maintain her privacy. An additional Grievance/Complaint form was completed on 02/26/14, after the resident council meeting on 02/26/14. It was indicated as a concern from Resident Council. This form also named Resident #24 as the complainant. The concern was, Other residents coming into rooms, mostly during the day. Under the section titled Resolution of Grievance/Complaint was documented, Staff to monitor Resident who roams into others rooms and redirect. Employee #61 had signed both the forms as the person who completed the forms. Employee #61, SSS, was interviewed at 12:43 p.m. on 05/30/14. She stated Resident #24's room was close to the nurses' station and staff redirected wandering residents when they attempted to go into her room. She stated they did not put any mechanical interventions in place to prevent other residents from entering Resident #24's room. Employee #61 stated keeping the door closed was suggested and should be done. She confirmed there were no interventions on Resident #24's care plan related to keeping her door closed or any other interventions to keep other residents out of her room. The SSS said she was not aware this was still a problem because Resident #24 had not mentioned it to her in a while. She stated she should add keeping the resident's door closed to the care plan, and fix it so the aides could see it on the Kiosk. The SSS said she would follow-up more closely with the resident in the future to ensure her concern was resolved.",2018-04-01
6493,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,166,E,0,1,3WT411,"Based on record review, review of complaints filed with the Office of Health Facility Licensure and Certification, staff interview, confidential interview, and resident interview, the facility failed to make efforts to promptly resolve grievances voiced by the residents. One (1) of two (2) off site complaints investigated concurrently with the Quality Indicator and Licensure Surveys contained an allegation call lights were not being answered timely. During Stage 1 of the Quality Indicator Survey (QIS), one (1) of twenty-five (25) sample residents interviewed voiced a concern about the call lights not being answered timely. Eight (8) of ninety-six (96) Record of Customer and Family Concerns (grievances) filed with the facility in the previous twelve (12) months identified a problem of call lights not being answered timely. This practice had the potential to affect all residents who used their call lights to summon assistance. Resident Identifiers: #234, #233, #232, #231, #229, #228, #200, #50 and #201. Facility Census: 123. Finding include: a) Off Site Complaint On 06/02/14, the State Agency (OHFLAC) received a complaint alleging it took staff 30 to 45 minutes to answer resident call lights. In a confidential interview at 10:25 a.m. on 06/19/14, the complainant again said it took staff 30 to 45 minutes to answer the residents' call lights. The complainant stated he/she would sometimes have to go find someone to help the resident because they would not answer the call light. According to the complainant, the staff had been told about this concern, but the facility never really did anything to resolve the problem. b) Resident #50 During a Stage 1 interview with Resident #50 at 3:06 p.m. on 06/10/14, when asked if she received the care and assistance she needed without having to wait a long time, she stated, No, because she sometimes had to wait a long time for them to answer her call light. She was unable to say how long it took staff to answer her call light, but stated she had to wait longer than she should have to wait. c) Resident concerns Review of the facility's Record of Customer and Family Concerns, at 11:00 a.m. on 06/12/14, found eight (8) concerns related to call lights not being answered timely by facility staff. The concerns were: 1) Resident #229 A concern form, dated 06/20/13, identified the resident's concern was, Resident stated she has been waiting on call light for 20 mins. (minutes). The action taken by the facility was to check call lights and provide education to the staff to answer the call lights quickly. Attached to the grievance was a form titled Call Light Checks, completed by Guest Service Director (GSD) #86 on 06/28/13. This form indicated the GSD had checked the call lights in four (4) random rooms between the times of 10:34 a.m. and 11:00 a.m. on 06/28/13. It took the staff no more than 17 minutes to answer each call light that was randomly selected. The GSD documented he followed up with the resident and the resident was happy with the actions taken by the facility. 2) Resident #231 On 07/10/13, Resident #231's concern was identified as, Resident stated that he was waiting on a CNA (certified nursing assistant) for a really long time when resident turned on call light. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 07/10/13, indicated the GSD had checked the call lights in three (3) random rooms between the times of 2:31 p.m. and 3:05 p.m. It took staff no more than five (5) minutes to answer each call light checked. The GSD documented he had followed up with Resident #231 and he was happy with the actions taken. 3) Resident #232 A concern form dated 11/11/13, identified a concern of, Resident's family stated that it took too long to answer call light. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by Employee #86, GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. The GSD documented he had followed up with Resident #232 and he was happy with the actions taken to resolve this resolution. 4) Resident #233 A concern form dated 11/13/13, identified the resident's concern as, Resident informed GSD that call lights are not being answer(ed) timely. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concern dated 11/11/13. The GSD documented he had followed up with Resident #233 and she was happy with the actions taken. 5) Resident #234 On 11/13/13, this resident's concern was identified as, Resident stated that call lights are not being answered timely. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 11/13/13, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:34 p.m. and 1:41 p.m. It took staff no more than one (1) minute to answer each call light checked. This was the same form which was attached to the concerns for Residents #232 and #233 on 11/11/13 and 11/13/13 respectively. The GSD documented he had followed up with Resident #234 and she was happy with the actions taken. 6) Resident #200 A concern dated 03/18/14 for Resident #200, identified the resident's concern as, Call lights. The action taken by the facility was to check call lights. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 03/18/14, indicated the GSD had checked the call lights in three (3) random rooms between the times of 2:29 p.m. and 2:42 p.m. It took staff no more than two (2) minutes to answer each call light checked. The GSD documented the follow up as GSD pulled call lights. The form did not indicate whether Resident #200 was satisfied with the facility's actions to resolve this concern. 7) Resident #201 This resident's concern, dated 05/09/14, was, Resident is cont. (continually) waiting up to 15 min. to have call light answered, causing resident to have episodes of incont. (incontinence). The action taken by the facility was to check call lights on evening shift. Attached to the concern was a form titled Call Light Checks. This form, completed by the GSD on 05/12/14, indicated the GSD had checked the call lights in four (4) random rooms between the times of 1:54 p.m. and 2:36 p.m. It took staff no more than two (2) minutes to answer each call light checked. The GSD had not documented he had followed up by pulling the call lights, however he did document whether Resident #201 was satisfied with this action. The form indicated the call lights would be checked on evening shift, but in fact the call lights were checked during day shift. 8) Resident #228 According to a concern form dated 06/02/14, Resident #228 had complained, He waited 45 mins. on his call light. The action taken by the facility was to check call lights. There was no form attached to this concern form to indicate the GSD had checked the call lights. The GSD documented he had followed up with Resident #228 and she was happy with the actions taken. During an interview with the GSD at 2:36 p.m. on 06/18/14, he stated when there was a concern with call lights, he would randomly pull call lights and determine the response time. He stated he had done this numerous times and he tried to do it around meal times when the aides were the busiest. When asked how he determined what shift to randomly pull the call lights on, he stated he mostly did it on day shift around meal times unless the concern form indicated it happened on a different shift. When asked whether he spoke to the residents prior to pulling the call lights to determine what shift the lights were not being answered on, or to determine if it was more prevalent when specific staff were working, he stated he did not speak to the residents prior to pulling the call lights. He stated he just went by what the concern form indicated and it usually did not indicate what shift the call lights were not being answered on. The eight (8) concerns were reviewed with the GSD and he confirmed the call lights were all randomly checked during day shift. When asked how he determined whether the concern had been resolved or not, the GSD stated he would just go tell the resident he pulled the call lights and would advise them of the response time the staff had in answering the lights. Then he would ask them if they were happy with the resolution. He stated they seem to always be satisfied with this response to these concerns. d) During an interview at 3:52 p.m. on 06/18/14, the Nursing Home Administrator (NHA), was asked how they resolved concerns related to call lights being answered timely. She stated the GSD would randomly pull call lights and record the time to determine if it was truly taking too long to answer the residents call light. When asked how they determined on which shift or what time of the day to pull the call lights, she stated it would depend on what shift the resident had concerns with. She was asked to review the concerns and the recorded call light checks to determine if they were checked on the appropriate shift. She confirmed all the call light checks were completed on day shift and she did not see where the GSD had attempted to determine what shift the resident had concerns with. She stated she could start having him to do a root cause analysis with the concerns to determine if it was a specific shift or when a specific staff member was working.",2018-03-01
6622,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2014-08-20,166,E,0,1,R6QV11,"Based on review of the facility's complaint and concern files and staff interview, the facility failed to promptly resolve residents' grievances related to the behavior of a specific resident. Over nearly a three (3) month period, multiple residents complained to the facility about the behaviors exhibited by Resident #35. The facility did not ensure each resident's right to prompt efforts to resolve these grievances. In addition, the facility failed to communicative with the residents to ensure they were aware the facility was actively seeking a resolution to the complaints. This practice affected four (4) of four (4) residents reviewed who verbalized complaints involving Resident #35. Resident identifiers: #10, #21, #27, #5, and #35. Facility Census: 34. Findings include: a) Resident #35 Review of the complaint and concern files revealed four (4) residents filed seven (7) complaints (over an 82 day period) about the behavior of the same resident, Resident #35. The first complaint, dated 03/05/14, indicated the resident who filed the complaint was fearful of the resident. There was no evidence the facility made prompt efforts to resolve the complaint, no evidence of an investigation, and no evidence of a follow-up with the residents regarding whether the problems were resolved. The resident's behaviors continued. Six (6) more complaints regarding the resident's behaviors were filed without evidence the facility was actively seeking a resolution. b) Resident #10 1. A complaint, dated 03/05/14 at 7:30 a.m., revealed Resident #10 stated, I did not sleep well after what happened last night. According to the complaint documentation, the resident was questioned about what happened and stated, There was an argument with (Resident #35's name) and an aide. According to Resident #10's statement, Resident #35 took some kind of spray and the aide thought it belonged to Resident #10. She stated, Resident #35 was shoving the aide. The resident then stated, I am a little afraid she gets in my closets and if she may take it out on me. There was no evidence the facility made prompt efforts to resolve the complaint, no evidence of an investigation, and no evidence of a follow-up with the resident regarding whether the problem was resolved. 2. Review of the facility's complaint file also revealed Resident #10 had initiated a complaint on 03/10/14 at 8:25 a.m. According to the complaint, Resident #10 witnessed her roommate, Resident #35, become physically aggressive with staff when they tried to get her to give Resident #10's personal belongings back. Resident #35 took Resident #10's remote control and hid it for a couple days. Resident #35 had also gone through Resident #10's wardrobe. Resident #10 voiced fear that Resident #35 would become aggressive and hit her if she tried to tell her not to take her personal items, as she had seen Resident #35 hit, scratch, and shove an aide. Further review of the facility complaint form revealed this form was not completed. There was no evidence interventions were initiated for the complaint. The section of the form that contained the information to indicate if the complaint was resolved or not resolved to the resident's satisfaction was not completed. c) Resident #27 1. A review of the facility's complaint files found three (3) complaints, over nearly a three (3) month period, filed by Resident #27 concerning the behaviors of Resident #35. A complaint, dated 03/12/14 at 10:30 a.m., was initiated for Resident #27. It stated the call light was on and when it was answered, Resident #27 stated, I already got that crazy woman out of here (identified Resident #35). Resident #27 stated, She said she was gonna clean my bathroom and I told her no and to get out. Now I am tired of this I want someone to do something about this. The response to this complaint, on 03/12/14 at 12:50 p.m. was, I spoke with Resident #27 and advised her we were addressing the problem. I encouraged her to seek assistance ASAP (as soon as possible) should Resident #35 infringe on her rights again. This statement did not provide evidence the facility was making prompt efforts to resolve the complaint. There also was no evidence of a follow-up with the resident regarding whether the problem was resolved. . 2. The complaint file contained another complaint from Resident #27 on 04/11/14. This was one (1) month after the complaint dated 03/12/14. She reported, There was a crazy lady who came into my room last night and she hit me on my right shoulder. We do not need people like that around here. Do we have to get guns? The response to this complaint was, SW (social worker) assured Resident #27 that we were aware of the problem and validated her concerns'. Resident #27 expressed fear and said she did not like it. The SW encouraged the resident to call immediately for staff should the other resident come in her room again. She stated she advised Resident #27 not to touch the resident lest another incident of aggression occur. On 08/19/14 at 5:00 p.m., the Director of Nursing (Employee #27) confirmed Resident #27 was talking about Resident #35 in this complaint. This statement did not provide evidence the facility was making prompt efforts to resolve the complaint. There also was no evidence of a follow-up with the resident regarding whether the problem was resolved. 3. In another complaint by this resident, dated 05/26/14, she stated Resident #35 was keeping her awake by setting off the alarms. She said, I'm not able to get the rest I need because she gets out day and night. The department head's response to this complaint stated, Resident (#35) is being evaluated by a specialist and having medication adjustments in attempt to change her negative behaviors. This statement provided no evidence the facility informed the resident of their efforts and contained no evidence of a follow-up with the resident regarding whether the problem was resolved. d) Resident #21 A complaint was made by the family of Resident #21 on 03/26/14 at 12:30 p.m. The family indicated Resident #35 was in and out of the residents' rooms all day. She stated she noticed snacks missing from her family member's bedside table and the bottom drawer and a Christmas bag with scarf and gift items that were in the closet were also missing. These items were found in the room of Resident #35. The department head's response to this complaint was, Will give a storage container with locking system for closet. It was recorded the family voiced satisfaction with this: however, there was no evidence of a follow-up with the resident/family regarding whether the problem was resolved. e) Resident #5 A complaint statement, dated 04/14/14 at 10:30 a.m., noted Resident #5 told the nursing assistants Resident #35 had been coming into her room all hours of the day and night and if she came in her room again she would knock the h_ _ _ out of her. The complaint form stated the nursing assistant explained that the other resident did not know that she was doing wrong and Resident #5 said, She didn't care she would hit her anyway and tell everyone she doesn't know what she's doing either. Another nursing assistant wrote a statement, at 3:30 p.m. on 04/14/14, and stated Resident #5 complained about Resident #35 coming in her room and bothering her stuff. The resident stated, I could hurt her. The follow up for this complaint stated under the department head's response: SW (social worker) encouraged Resident #5 to call for staff assistance when other resident wandered into her room. SW advised Resident #5 not to engage the other resident or touch her lest the other resident become agitated and aggressive. There was no evidence the facility was making prompt efforts to resolve the complaint and no evidence of a follow-up with the resident regarding whether the problem was resolved. f) The Director of Nursing (DON), Employee #27, was interviewed, on 08/19/14 at 5:00 p.m., about the facility's complaint policy and procedure. Review of the facility's policy titled Resident Complaints, effective 06/15/10, found it included, Findings will be discussed with the resident and /or designee after completed investigation. During the interview, the DON verified the complaint forms contained no evidence the facility was actively seeking a resolution and/or evidence the residents who complained were apprised of progress toward a resolution. The DON stated they sent Resident #35 to another facility and this was now resolved.",2017-12-01
7487,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2015-03-27,166,D,0,1,G4YW11,"Based on resident interview, policy review and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for personal property received prompt efforts by the facility to resolve a grievance. Resident #105 complained to the staff about missing clothing. This complaint was not documented and the facility failed to communicate with Resident #105 regarding their efforts to locate her missing clothes. Resident identifier: #105. Facility census: 118. Findings include: a) Resident #105 On 03/24/15 at 9:41 a.m., during an interview, Resident #105 said she had some missing clothing. She said she had told the lady from laundry about the missing clothes. At 3:00 p.m. on 03/24/15, Employee #12, social worker (SW), said the facility did not have a grievance/complaint form from Resident #105 regarding missing clothing. The SW interviewed the resident on 03/24/15 at 3:30 p.m. The resident described her missing clothing to the SW. The resident specifically mentioned missing a gray Evrerlast brand sweat-pants without an elastic band at the bottom and a charcoal gray sweatshirt. Resident #105 told the social worker she had mentioned these missing items to a woman from laundry. The SW interviewed Laundry Aide (LA) #104 on 03/24/15 at 4:00 p.m. LA #104 knew about the resident's missing clothes and said she had looked for them. She said she had not reported the missing clothing to her supervisor. LA #104 also said she had not talked to the resident and updated her on the efforts made to find her clothing. The SW interviewed Housekeeping/laundry Supervisor #111 on 03/24/15 at 4:15 p.m. Employee #111 said laundry staff had not documented any missing clothing for Resident #105. She agreed LA #104 should have documented Resident #105's missing clothes. The SW said if LA #104 had documented the missing clothing, then the social services department would have become aware of the missing clothing, and would have filled out a grievance report. A review of the facility grievance/concern policy, with a revision date of 06/10/13 revealed under section 4.1, Formal concerns may be registered by telephone, mail, office visit, or direct outreach by staff.",2017-04-01
7498,MOUND VIEW HEALTH CARE,515067,2200 FLORAL STREET,MOUNDSVILLE,WV,26041,2013-06-13,166,D,0,1,9DS111,"Based upon medical record review, policy review, family interview, and staff interview, the facility failed to make prompt efforts to resolve a grievance voiced by a resident's family. The facility staff did not follow the facility's policy and procedure when the resident's family voiced a concern about the way a staff member had spoken to the resident. This was found for one (1) of one (1) resident reviewed. Resident identifier: #145. Facility census: 113. Findings include: a) Resident #145 An interview was conducted with social workers, Employees #146 and #152, on 06/04/13 at 2:30 p.m. When the information requested upon admission regarding the facility's complaints/grievances files was received, it was noted there were no documented complaints of any kind from residents, families, visitors, or staff going back to the year 2012. They were asked how the facility documented complaints. Both social workers said that complaints received by staff were documented in the individual resident's medical record, either in progress notes or in the resident's care plan. They said there was no system of documenting each complaint in writing, or keeping a log of complaints independently of making entries in the medical record. 1) An interview was conducted with a family member of Resident #145 on 06/06/13 at 11:30 a.m. The family member said that shortly after Resident #145's admission to the facility, on 02/08/13, staff had attempted to give her a shower. The family member said this was on a Saturday. When the resident resisted and became agitated, a nurse allegedly said to her (Resident #145), we can do this the easy way, or we can do it the hard way. The family did not observe this interaction personally, but were told about it by someone they trusted. They went to a registered nurse (RN), Employee #31, and, in the presence of the social workers, Employees #146 and #152, they told all three (3) staff about the allegation, saying they were upset that a threat like that may have been made to their family member. Employee #31 said that such an act was not acceptable and they would take care of it. The family has never heard anything further from the facility about the alleged incident, or whether any action at all was taken. 2) Review of the resident's medical record, on 06/06/13 at 9:30 a.m., found no references of any kind regarding the complaint and allegation in the progress notes, the care plan, or any other part of the medical record. 3) An interview was conducted with Employee #31 (an RN) on 06/06/13 at 11:45 a.m. She was asked if she recalled the complaint. She said she did. She said the complaint was made to her and both of the social workers in the social services office. She said the family did not hear the verbal abuse directly, they heard about it from someone else. She said no investigation was done because it was based on hearsay. A second interview was conducted with a social worker, Employee #152, on 06/06/13 at 12:38 p.m. She was asked about the complaint. She said she vaguely recalled the issue. She was advised there had been no documentation found to support the allegation was reported, investigated, nor was the incident noted anywhere in facility records or in the resident's individual medical record. She acknowledged that no documentation could be found. 4) The facility's policy and procedure for complaints and grievances was requested from the assistant director of nursing, (ADON), Employee #25 on 06/10/13 at 3:00 p.m. It was subsequently reviewed with the ADON on 06/11/13 at 9:00 a.m. She agreed that some complaints were made at the facility and that there was no residential care environment that was always complaint free. She confirmed the policy and procedure contained the following items: -- 1. The administrator shall designate an employee with the responsibility for handling complaints. The ADON said that really any staff member may take a complaint, but it was primarily the responsibility of social services to keep track of them and ensure all were investigated and documented. -- 2. The complaint form shall be completed and forwarded to the administrator. -- 3. The administrator shall take necessary steps to resolve the problem and record action taken. -- 4. The staff will be trained in the complaint policies and procedures. -- 5. The administrator will review the complaint, take the necessary action, and document the action that was taken. This record will be placed in the permanent file. -- 6. The equipment required was listed as a) Pen and b) complaint form. There was a form entitled Registration of Complaints included in the policy and procedures provided. 5) An interview was conducted with nursing assistants (NA), Employees #88 and #133, on 06/10/13 at 4:00 p.m. They were asked what they do when a resident, family member, or visitor approaches them with a complaint of any kind. They both said they just did their best to correct whatever the concern was at the time. They agreed that if the concern was something that they could not handle, they would get the charge nurse. They were asked about a form being available to document complaints. Both nursing assistants said they knew nothing about any kind of complaint form. 6) An interview was conducted with a registered nurse (RN), Employee #103, on 6/10/13 at 4:18 p.m. She was asked what she would do if a visitor, family member, or resident approached her with a complaint. She replied she would immediately investigate the concern and attempt to resolve the situation. When asked about a complaint form, she said there was a form at the nurses' station. She could not recall the last time she had completed one. The nurse said there was also a bin filled with the forms by the dining room so families who were reluctant to speak directly with someone could fill them out and slide them under someone's door. Investigation of the area around the main dining room and the surrounding area did not find any complaint forms accessible. 7) An interview was conducted with a registered nurse (RN), Employee #55, on 06/11/13 at 9:08 a.m. She was asked if she knew of a form that was used to document complaints from families, visitors, and residents. She said she was not aware of any form, but offered to see if there was anyone who knew of a form. At 11:15 a.m., Employee #55 said she wanted to provide some forms she had located. She provided an Adult Protective Services reporting form, an employee counseling form, and a copy of the registration of complaints form that was included in the policy and procedure that was reviewed. 8) A second interview was conducted with the ADON, Employee #25, on 06/11/13 at 10:20 a.m. She was advised that the social workers had said there was no method for documenting and tracking complaints. She was advised: -- a family member had made a complaint that was not documented and had never been followed up. -- of the staff responses to questions regarding the complaint procedures. -- that during an interview about the quality assessment and assurance (QAA) committee, it had been said that the committee tracks and trends complaints each month. She was asked about records that might document the staff training on the complaint policy and procedure. Sign-in sheets were furnished that indicated staff were trained on the subject as part of an annual in-service that included complaint procedures, neglect, abuse, misappropriation of personal property, Hoyer pads, and RFA clips (monitor alarms). The in-services were held on 07/05/12 and 07/19/12. She pointed out there was a bin with complaint forms in the dining area of the assisted living unit, but none in the nursing home unit. The complaint policy was not being fully operationalized in the facility.",2017-04-01
7714,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,166,D,0,1,Q01G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to make prompt efforts to resolve grievances for 2 of 3 sampled residents (Resident # 56 and Resident #30) who voiced grievances about missing items, noise level in the resident's room, and wandering residents. There were 6 residents who had concerns related to missing personal property out of 20 residents interviewed. Findings include: 1. Resident #56 was re-admitted to the facility on [DATE] and has multiple [DIAGNOSES REDACTED]. A review of the facility's grievance policy with a revision date of September 2006 revealed in part the following: It is the policy of this facility to provide an environment that encourages receipt and resolution of resident grievances without fear of discrimination or reprisal. The grievance procedure listed in part: 1. The social services director will oversee the resident grievance process. 3. Grievances may be received from residents, family members, responsible parties, visitors, resident council, family council. 4. Grievances may be verbal as well as written. 5. A grievance log will be maintained by social services. 6. The grievance will be forwarded to the appropriate department manager for investigation within 24 hours of receipt. 8. The resident will be informed of the findings of the investigation and actions that will be taken to correct any identified problem within 10 working days of filing a grievance. 9. The completed form will be sent to the facility administrator for oversight. 10. If the grievance has not been resolved to the resident/ responsible party's satisfaction, then the process will be repeated with support and oversight by the facility administrator. 11. Social services will provide in-service training and education to facility staff regarding resident's rights to voice and file grievances and the expectation that all staff will respond promptly to any grievance. The facility also provided a copy of a blank missing items form which listed at the top a section that would include the resident's name, the item missing, description of the item, individual reporting missing item, date item was last seen, was item on resident inventory, is the resident's name on the item, and location of name. At the very bottom of the missing items document was the following statement: Please return this item to front office -attention administration. A review of the Residents Rights document provided by the facility revealed the following entries under the section entitled Grievances: - You may voice grievances concerning your care without fear of discrimination or reprisal -You may expect prompt efforts for resolution of grievances. The Residents Rights document also listed under the section entitled Personal Property: -You can retain and use personal possessions as space permits. An interview was conducted with Resident # 56 on 1/08/2013 at 9:25 AM. The resident voiced that he was missing many items, Too numerous to mention, he stated, but went on to convey that he was missing some cigarettes. A carton taken from my top drawer of my night stand about 3 months ago. he stated. The resident also stated that he was missing some of his clothing and some money. He stated that he was missing $20 dollars, $50 dollars, and $269 dollars, 3 pair of brand new Lee jeans, a packet of tee shirts, and a ten pair packet of white socks. The resident stated, I hadn't even worn them. The resident conveyed that he had reported the missing items to the front office. He confirmed that by the front office he was referring to the social worker's office and the receptionist who are all located in the front of the facility near the administrative offices suites. The resident went on to say, They didn't replace nothing. The resident said when they took the $269 dollars, they took it from his wallet which was in top drawer of his night stand. The resident voiced that when he returned to his room, the wallet was no longer in the night stand. He stated, They left my wallet on the bed. The resident stated that when he opened the wallet the money was gone. He recalled that this incident happened about 4 months ago. The resident re-iterated that he had reported it to the social workers, both desks, which he referred to as the nurse's station and to the front office (receptionist desk). He stated, I reported it everywhere. They said they will check on it. They told me to keep my money up there (in the resident trust account). They never came back at all. The Resident also commented, I don't think they looked for the Lee jeans or the tee shirts nor the socks. They didn't look for nothing. He stated that these items had been missing for about 3 weeks. The Resident re-iterated several times that he has reported all of these missing items to multiple staff, to include both of the facility social workers and also specifically recalled reporting these items missing to a nurse aide. The resident voiced that the items were not all missing at the same time, and that no one has gotten back to him nor replaced these items. The resident voiced further that he is just tired of people taking his stuff. The resident stated that he would obtain money by withdrawing it from his resident trust account up at the front office. A review of the resident trust account revealed that the resident indeed had money in his account and had made at least one or more withdrawals each month. An interview was conducted on 1/09/2013 at approximately 9:35 AM with the business office manager (#85). The business office manager voiced that the resident frequently would come up to her office to make a withdrawal. She reviewed the trust account for Resident #56 and validated that he had made several withdrawals each month over the course of the last several months. The business office manager stated that the resident would typically stop at the receptionist's desk, request a withdrawal, sign the receipt log, but was not usually given a receipt unless he requested one. The business office manager voiced that she was unaware that the resident was missing any money. She recalled that there were items that the facility that had replaced. But stated I'm not sure which were replaced. I only remember a pair of jeans and a radio, but nothing major replaced. An interview was conducted with the facility receptionist (#16) on 1/09/2013 at approximately 10:30 AM. The receptionist voiced that she is the only facility receptionist, but some other staff may monitor the receptionist desk if she were scheduled off or maybe on break. The receptionist stated that she is very familiar with Resident #56, and that he frequents the front office suite where the receptionist desk is located. The receptionist voiced that she was unaware of the resident voicing any grievances about any missing money or any other items. The receptionist stated that she could not recall having completed a grievance form on behalf of the resident at any time. The receptionist also stopped by to visit the resident to see if he could identify her as the person he had reported the concerns to about the missing money and other missing items. The Resident readily identified the receptionist as the staff member that he had reported to about his missing money. The resident stated to this writer and to the receptionist that, Yes, she is the one (that he told), but I don't think that she took my money, he stated. He voiced further that she (receptionist) is one of the good ones. Shortly after the resident began to list the items and reminded the receptionist about his sharing the concerns with her, the receptionist acknowledged that she did vaguely remember the resident voicing these concerns and thought that the former social worker was working on those concerns and had handled the concerns voiced by the resident. The receptionist does not recall having completed a grievance form on behalf of the resident. The receptionist voiced that the former social worker is no longer employed here at the facility and that she is unaware of the results of the outcome that was reached or if the resident's grievance was ever resolved. An interview was conducted on 1/09/2013 at approximately 8:30 PM with a second shift nurse aide (#130). The nurse aide voiced that she recalls the resident stating to her that he was missing $20 dollars, and $50 dollars on two separate occasions. The nurse aide denied being aware that the resident had reported that he was missing $269 dollars. The nurse aide voiced that after the resident voiced the missing money to her, she went down to the facility laundry room to see if the laundry staff had found the money. The nurse aide voiced that the laundry staff was not present as the laundry facility was closed. The nurse aide voiced that she reported the missing money to the RN (Registered Nurse) on duty, but was unable to recall who the RN was either time that the resident had reported the missing money to her. The RN that was working at the time of this interview was sitting at the nurse's station. The nurse aide voiced that she did not report the missing money to that particular RN. The nurse aide voiced that she was able to remember to whom she did not report the missing money, but could not remember the nurse to whom she did report. The nurse aide also stated that the resident never informed her that the facility had found or replaced his money, but commented that he would often state to her that he was just tired of people taking his money. A review of the facility grievance log was reviewed for the past year. One of the two facility social workers (#49) assisted in retrieving the grievances that had been reported by this resident. There were no grievances in the log book that addressed the residents missing money. There were grievances however regarding some missing cologne and and hair cream on 2/1/2012. The cologne was replaced by the facility according to the grievance report. There was also a grievance form dated 6/20/2012 where the resident stated that he was missing two pair of pajamas and some peanut butter. Under the section of the grievance entitled documentation of facility follow-up was the following statement: peanut butter will be replaced. Laundry will locate the pajama bottoms. There was no follow up to support that the pajamas were ever located or replaced. Another grievance was found for this resident dated 11/29/2012. Under the section entitled documentation of concern or grievance was the following statement and comment: Describe the concern using factual terms: Resident reported to SS (social services) that he had items missing in his room. Under the section entitled Documentation of facility follow-up was the following entry, NHA (nursing home administrator) and MSW (masters in social work) went with resident to look for missing items and they were in his room. The grievance form did not identify what the missing items were or the resident's response to the grievance. There were no written grievances addressing the missing money that the resident had reported to the nurse aide or to the facility receptionist. An interview was conducted with one of the two facility social workers (# 49) on 1/09/2013 at 2:30 PM. The social worker voiced that he had only recently within the past several months become the facility social worker and was unaware of reports of missing money for the this resident. He reviewed the grievance log book, but was unable to find any grievances that had been recorded for either $20 dollars, $50 dollars, or for $269 dollars. There were no grievances for any amount of money. An interview was conducted with the facility administrator (#112) on 1/09/2013 at approximately 8:45 PM regarding the missing items and that both the receptionist and the nurse aide had acknowledged that they were notified by the resident that his money was missing. The facility administrator voiced that she was unaware that an aide was aware of the residents missing money. The administrator voiced that she only recalled the resident missing some cologne, but recalled that cologne was replaced by the facility. The administrator also stated that the resident would complain about his missing cigarettes, but stated that his cigarettes were not missing, but rather were being kept in the nurse's safe where he would need to check them out as this is a smoke free facility. The administrator further stated that sometimes the resident would complain of missing property, but later the property would be found in his top drawer. The administrator denied ever finding the residents money in his top drawer. The administrator also stated that there had been some concern with missing items in the facility and that is why she had created the aforementioned missing items form. A follow-up interview was conducted with the resident on 1/11/2013 at approximately 9:15 AM. The resident voiced that the facility had provided him with a lock box and a key. He stated that the box that maybe costs approximately $29 dollars and that is all that he has received from the facility. He stated further that he hopes that facility does not think that the $29 dollar box is going to suffice for replacing his nearly $350 dollars that is missing. A report of lost resident property form was completed on the last day of the survey by the current facility social worker (#126). The lost resident property form indicated under the section entitled Full description of each missing item the following entry, $70.00 cash. Under the section entitled Action taken by the facility was the the following entry: $70.00 replaced to resident and lock box provided, resident agreed to keep small denominations in room/box and obtain receipt for withdrawals from facility account trust. An interview was conducted on 1/11/2013 at 12:40 PM with the facility social worker (#126) who signed and completed the report of lost resident property form which noted that the $70.00 had been replaced to the resident. The social worker was unable to provide any payment method to show that the resident had been reimbursed as the documentation indicated. The social worker stated that she thought the money had been replaced and was just told to complete the resolution form. A follow-up interview with facility administrator was conducted on 1/11/2013 at approximately 12:45 PM. The administrator revealed that the resident's money had not yet been replaced and that the documentation on the report of lost resident property resolution form dated 1/10/2013 was inaccurate. 2. Resident #30 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A review of the residents most recent Mini-Mental Exam dated 1/02/2013 revealed that the resident received a total score of 28/30. The word alert was circled on the front of the document. The comment section was left blank. The document indicated that a score of 24 or less would generally would suggest cognitive impairment. A review of the facility's grievance policy with a revision date of September 2006 revealed the following: It is the policy of this facility to provide an environment that encourages receipt and resolution of resident grievances without fear of discrimination or reprisal. The grievance procedure listed in part: 1. The social services director will oversee the resident grievance process. 3. Grievances may be received from residents, family members, responsible parties, visitors, resident council, family council. 4. Grievances may be verbal as well as written. 5. A grievance log will be maintained by social services. 6. The grievance will be forwarded to the appropriate department manager for investigation within 24 hours of receipt. 8. The resident will be informed of the findings of the investigation and actions that will be taken to correct any identified problem within 10 working days of filing a grievance. 9. The completed form will be sent to the facility administrator for oversight. 10. If the grievance has not been resolved to the resident/ responsible party's satisfaction, then the process will be repeated with support and oversight by the facility administrator. 11. Social services will provide in-service training and education to facility staff regarding resident 's rights to voice and file grievances and the expectation that all staff will respond promptly to any grievance. A review of the facility's Room/Roommate Change policy was conducted and read in part: Room changes are made only at the request or authorization of the resident/responsible party. Under the section entitled Procedure, it also read in part, If psychosocial issues exist between roommates, the roommate with unresolved complaints/issues is the resident who is moved to an alternate room. A review of the medical record per the interdisciplinary progress notes revealed the following entry dated 1/07/2013: 1. Met with resident and she was upset about her roommate being upset today and yelling out. Spoke with resident about options and she declined a room move. The entry was signed by the facility social services director (#126). An interview was conducted with Resident #30, on 1/08/2013 at approximately 11:30 AM and she stated that she has not been able to get any sleep at night, as her roommate is up all night, crying out and making noises. The resident conveyed that this has been going on for more than a week now. She stated that she had reported the concern to multiple facility staff including the facility social services staff, but they have not addressed the concern to her satisfaction. The resident stated that they just told her that since she is the one that has the complaint, she would need to be the one that would need to move out of the room. The resident voiced that she has been in that room for quite a while now (a few years) and that this is her home. She stated that she was there in the room before the roommate was moved in and doesn't understand why she has to be the one to move. The resident stated that she is not the one causing the problem. The resident also shared that it is very frustrating to know that when you share any concerns with the facility, the only thing the facility is willing to do is make you move to another room and not address the problem. Resident #30 also stated that there are several wanderers that come into her room at night and rummage through her trash can that is near the door. She stated that the facility had placed a Velcro stop sign across the doorway entrance to try and keep the wanderers out but, it doesn't help that much. She stated that the Velcro backing just keeps falling off onto the floor whenever someone touches it and then they (other residents) just come right on in. An interview was conducted with the facility social worker #126 on 1/09/2013 at approximately 11:55 AM. The social worker stated that the facility's policy is that the resident that complains has to be the one to move. The social worker was asked if the roommate was capable of complaining. The social worker stated that the roommate was not capable of complaining. The social worker also acknowledged that the roommate does cry out and make noise at night. The social worker was not able to identify other interventions the facility had implemented to address the noise level created by the resident's roommate. The social worker voiced there had been no other measures considered or implemented. The social worker also stated that she was not willing to break policy and move the roommate, because if you do it for one (resident) you will have to do it for all. The facility social services director entered the resident's room on another occasion to interview the resident on 1/09/2013 at approximately 12:30 PM. As she removed one side (left side) of the Velcro tab, that was across the doorway entrance to the resident's room, the entire backing came off and fell to the floor. The social services director stated she would have to get someone to fix that. An interview was conducted on 1/09/2013 with a direct care nurse (#98) on second shift at approximately 8:06 PM who conveyed that the resident's roommate does consistently yell out at night. The nurse stated, she usually yells out at night, but she is quiet tonight. The nurse was unable to convey any measures put in place to address the roommates concerns. The nurse also stated that she was unaware that some of the other residents were entering the resident's room. She stated she knows they usually go up to the door and then just stand there, but was not aware that other residents were entering and going through her trash can. The nurse stated that there are 7 wandering residents on the unit that live on the same hall as does resident #30. The nurse also stated that the roommate of resident #30 is one of a few residents that consistently yell out or scream at night. An interview was also conducted with a second shift nurse aide (#130) on 1/09/2013 at approximately 8:30 PM regarding the roommate of Resident #30. The nurse aide voiced that the resident does yell out at night when she is put to bed. The aide voiced that she (the roommate) and several other residents on this hall consistently scream and yell out all during the night. An interview was also conducted with a third shift nurse (#54) on 1/11/2013 at approximately 7:40 AM just before her shift was ending. The nurse voiced that the roommate of resident #30 sometimes sleeps pretty good, and other times she yells throughout the night. The nurse reported that the roommate does not receive anything to help her sleep. A review of the grievance log book failed to indicate that the facility staff had documented the resident's voiced grievances regarding the noise coming from the roommate at night or about the wandering resident entering the resident's room.",2017-02-01
7861,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2013-01-16,166,E,0,1,ZN3T11,"Based on review of the facility's Record of Customer and Family Concern forms, review of reportable incidents, staff interview, and resident interview, the facility failed to resolve and/or failed to ensure prompt efforts to resolve grievances in regard to misappropriation of resident property. The facility was aware of numerous complaints of missing money and/or property. There was no evidence the facility was working toward a resolution regarding this known problem. The grievances of thirteen (13) residents, from the past year, had no resolution and/or no evidence the facility was actively working toward a solution for concerns of misappropriation of resident property. Resident identifiers: #237, #168, #91, #71, #7, #95, #56, #62, #138, #64, #170, #18, and #11. Facility Census: 124. Findings include: a) Resident #237 Review of the facility's reportable incidents, on 01/09/13, revealed on 03/10/12, Resident #237 reported he was missing $11.00. The facility completed an investigation which found no one had seen any money belonging to this resident. The corrective action taken by the facility was reimbursement of the resident's money and the facility provided the resident a lock box for his room. b) Resident #168 Review of a Record of Customer and Family Concern form, dated 10/22/12, revealed Resident #168's laptop was missing. The facility made attempts to contact the resident's family in order to replace the laptop. However, there was no evidence to suggest the facility had conducted an investigation to determine what had happened to the laptop. c) Resident #91 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 08/14/12, Resident #91 reported $50.00 was missing from his/her room. The facility's investigation revealed no one reported seeing any money belonging to the resident. The corrective action taken by the facility was reimbursement of the resident's money and the facility installed a lock box in the resident's room. d) Resident #71 A review of the facility reportable incidents, conducted on 01/09/13, revealed on 10/09/12, Resident #71 reported she was missing $45.00. After completion of the investigation, the facility could not substantiate any misappropriation of resident funds. The corrective action taken by the facility was education of the resident to not have large amounts of money in her room and to utilize her lock box which had been provided by the facility. Resident #71's money was not reimbursed. e) Resident #7 Review of the facility reportable incidents, conducted on 01/09/13, revealed on 12/09/12, Resident #7's family reported she was missing $25.00. The facility's investigation revealed no one reported seeing any money belonging to the resident being removed from her room. The corrective action taken by the facility was reimbursement of the resident's money and the facility encouraged the resident's family to keep money in the resident fund account instead of the resident's room. f) Resident #95 A review of the facility's reportable incidents, conducted on 01/09/13, revealed on 04/27/12, Resident #95 reported she was missing $50.00 from her change purse. The resident reported she had seen the $50.00 the morning of 04/27/12 and around 4:00 p.m. the same day the money was missing. The facility's investigation revealed no one reported seeing any unusual activity or unusual people entering the resident's room or going through her belongings. The corrective action taken by the facility was encouraging the resident to use the lock box which had been in the resident's room for a lengthy period of time. This resident's money was not reimbursed. During the resident council president interview, on 01/10/13 at 1:30 p.m., Resident #95 (resident council president) revealed missing items and reimbursement for missing/stolen money was an issue residents felt had not been resolved by the facility. g) Resident #56 Review of the facility reportable incidents, conducted on 01/09/13, revealed on 05/26/12, Resident #56 reported missing money from his wallet. The facility's investigation revealed no one had seen any money belonging to this resident, and the resident did not see anyone take the money from his wallet. The corrective action taken by the facility was to educate the resident to lock all money in his lock box and put the key away while sleeping. The facility reimbursed this resident's money. h) Resident #62 A review of the facility's reportable incidents, conducted on 01/09/13, revealed on 03/08/12, the resident reported while she was in the front lobby of the building, her money was stolen from her change purse that was in the top drawer of her night stand beside the bed. The facility's investigation revealed no one had seen any money belonging to this resident. The resident did not know how much money she had lost, and had given the facility staff two (2) different amounts. The resident also did not witness anyone take her money. The corrective action taken by the facility was to educate the resident to lock all money in the lock box in her room. This resident did not have her money reimbursed. i) Resident #138 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 05/28/12, Resident #138 reported missing money from her room. The resident reported she last saw the money on 05/25/12. The facility's investigation revealed that no one reported seeing any money belonging to this resident. The facility's corrective action was to reimburse the missing money and provide the resident with a lock box for her room. They educated the resident to lock all her money in the lock box. j) Resident #64 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 06/01/12, Resident #64 reported she was missing $10 from her lock box. The resident reported the last time she saw the money was 05/30/12. The facility's investigation revealed no one reported seeing any money belonging to this resident. The corrective action taken by the facility was to reimburse the resident's money and offered to keep the key to the lock box locked on the medication cart. They also educated the resident to keep her key in a safe place. k) Resident #170 Review of the facility's reportable incidents, conducted on 01/09/13, revealed on 11/20/12, Resident #70 reported his laptop was missing. The facility's investigation revealed the resident reported a nurse came in and told him she would lock up his computer. The resident was unable to give a description of the nurse. The facility found no one removed the laptop from the resident's room and no one recalled having seen anyone unusual entering the resident's room. The facility was unable to substantiate any employee misappropriated the resident's property. Corrective action taken by the facility was to replace the resident's laptop. Staff interview with the Nursing Home Administrator (NHA) revealed the facility had not yet replaced the laptop, but offered the resident and family the option of replacement. l) At 8:40 a.m. on 01/10/13, an interview was conducted with the NHA. The NHA reported missing money was reimbursed on a case by case basis. She reported the typical practice was, if a resident had a lock box in their room when the money became missing, they would not be reimbursed the missing money; however, if the resident did not have a lock box in their room when the money became missing, the resident was reimbursed the missing the money. The NHA reported residents were educated about the lock box, and their responsibility to keep up with the key to ensure their money was safe. She also stated lock boxes were not appropriate for everyone because of certain cognitive impairments. This practice was not consistently implemented, as evidenced by some residents had their money reimbursed even though they had a lock box already in place, while others did not have their money reimbursed because they had a lock box. m) Resident #18 During an interview with Resident #18, on 01/8/13 at 8:46 a.m., she described three (3) occasions where her personal property was missing, twice with no resolution. The first occurrence resulted in her missing $10. She stated the facility reimbursed the money and she was satisfied with the resolution. The second occurrence was a few months ago and she had $20 come up missing. She said she went to the main woman in charge and was told her own grandson must have taken the money. The resident stated this offended her. She stated her grandson comes to visit and she unlocks her lock box and lets him take the quarters she wins at bingo. She said at no time did her grandson have access to her lock box alone. Resident #18 said she is right beside him when she gives him her quarters. A reportable incident form, regarding the missing $20 was provided by the facility and reviewed. The resolution was to provide her with a lock box, which she refused. This was inconsistent with the information provided by Resident #18. She described having a lock box at the time the money was missing. The third occurrence wa a few weeks after the $20 was stolen. Resident #18 stated she had a bowl of chocolates by her television, and some quarters on her over-the-bed table, all which came up missing. She said she found two (2) quarters on the floor of her bathroom the next morning. She did not report this, as she was discouraged by the manner the facility handled her missing property previously. She stated she did not feel it would benefit her to make a report. n) Resident #11 During Stage one of the Quality Indicator Survey (QIS), the resident was interviewed on 01/08/13 at 10:27 a.m. The resident said she had $200.00 stolen from her locked box in the room. The resident stated she kept her key to the box in a blue change purse under her pillow. She stated she assumed someone took the key while she was out of the room, or perhaps while she was sleeping. She stated the money was a gift from her children given to her for birthdays and Christmas and she intended to use the money to purchase a new pair of glasses. The resident said one day her daughter came to take her out of the facility and when she went to get her money, it was missing. She said she reported the incident but could not recall the exact date. When asked about the facility's resolution to her allegation she stated she did not know what happened. Review of a social services assessment, completed on 11/19/12, found the resident's brief interview of mental status (BIMS) score was 13.0 which indicated the resident was cognitively intact. The facility's reportable allegations of abuse/neglect/and misappropriation of personal property were reviewed. This revealed the resident had reported she was missing $200.00 from her lock box in her room on 11/06/12. The incident of the missing money was reported to the proper state authorities by the facility on 11/06/12. Review of the five-day follow up report found the outcome/results of the investigation were, Per resident and MPOA (medical power of attorney) report, resident had money in her lock box and she had the key hidden. Interviews and witness statements confirmed this. Resident was offered to keep key in nurse's cart but refuses. The administrator was interviewed on 01/09/13 at 2:00 p.m. She stated the facility did not replace the resident's money because the resident was provided a locked box and was responsible for the safekeeping of her funds.",2017-01-01
7915,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2013-12-31,166,D,1,0,XNN411,"Based on review of the facility's grievance/concern forms, review of policies and procedures, and staff interview, the facility failed to promptly address a grievance / concern for Resident #80. Review of the grievance/concern forms found the resident's family had reported a concern to a facility staff member on 11/30/13. Statements were not obtained from staff until 12/09/13 and 12/11/13. The grievance form was also partially completed and there was no evidence the complainant was contacted with regards to the facility's resolution of the grievance/concern. This was true for one (1) of three (3) grievance /concern forms reviewed for the past three (3) months. Resident identifier: #80. Facility census: 116. Findings include: a) Resident #80 Review of the facility's grievance concerns forms, on the morning of 12/30/13, found the daughter of Resident #80 had expressed the following concern: (name of daughter) entered the dining room and stated she was upset because her mother did not receive her dinner tray until 18:15 (6:15 p.m.) on 11/29/13. She stated her mother's dining room ticket was torn in half to represent that the meal had been refused. According to the information on the grievance form, the complaint was reported to Employee #25, a registered nurse. Further review of the grievance form found an attached handwritten statement by Employee #11, the food service director dated 12/09/13. The statement was, I spoke with (name of daughter) on Dec. 1st concerning a voiced complaint that I had learned of thru the administrator, regarding her mother (Name of resident) not receiving a dinner tray. (Name of Daughter) told me that a few days prior she had been in her mothers room from approximately. (approximately) 3:30 p.m. on throughout the evening. She told me that no one had brought in her mothers dinner. When a CNA (certified nursing assistant) came in about 6:15 p.m. to feed the other resident in room she (Name of daughter) inquired about her mothers tray. The CNA told her she would check on her tray and returned a few minutes later (symbol for with) her mothers tray and told (name of daughter) that the tray ticket had been ripped in half and that this indicated that the resident had refused her meal. (Name of daughter) was upset because she said that no one had offered her the meal to begin with. (Name of daughter) stated that her mother got her dinner tray at approximately. 6:30 p that evening. Also attached to the grievance were two (2) additional statements from two (2) nursing assistants, Employee #1 and Employee #87, both nursing assistants. Employee #1's handwritten statement was dated 12/11/13. The employee wrote, We were passing trays and saw that (name of resident's) ticket was torn so we were under the understanding that she had refused her meal so the tray was not taken into the room. We later found out that there had been a misunderstanding and she received her tray, as soon as we found out. It had looked like she had already eaten and her daughter had said that whether or not she had already eaten she deserved to get a tray. Employee #87's handwritten statement was dated 12/11/13. The employee's statement was, About two (2) weeks (name of resident) ticket was torn. Was misunderstanding when trays were passed on that day. She didn't refuse her meal her tray was still brought and she ate dinner. Employee #11, the food services director, was interviewed on 1230/13 at 2:07 p.m. She stated she called the resident's daughter because the administrator had asked her to do so. She stated she thought the problem was related to her kitchen staff not sending out a tray for Resident #80. She said she learned from the daughter it was the nursing staff who did not serve the tray. She did not investigate the situation after she learned the kitchen staff were not responsible for the complaint. Employee #25, the author of the complaint, was interviewed on 12/30/13 at 12:30 p.m. She stated she thought the issue had been settled when she talked to the family on 11/30/13. She stated the resident did receive her tray it was just later than usual. She further added the resident usually ate in the dining room and if the resident did not come to the dining room that evening, someone would have given the ticket to the kitchen staff. The kitchen staff would have prepared the tray and put it on the cart, therefore, the resident would have received her tray later than usual because residents who eat in the dining room are the first to be served and then the food carts go out to the hallways. Further review of the grievance form found Employee #34, the social services worker, had also signed the grievance form. Employee #34 was interviewed on 12/30/13 at 1:30 p.m. She stated she obtained the statements from Employees #11, #31, and #87 when she became aware of the situation. She said she was not aware of the situation on 11/30/13 when the family expressed concern. Employee #34 had no explanation for why the grievance / concern was not signed as completed and the date the complainant was contacted had not been completed. The facility's policy for Grievance / Concern procedures was provided by the director of nursing on the afternoon of 12/30/13. The policy directed, All patient and / or their representatives may voice grievances / concerns and recommendations for changes. Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative. Social Services personnel will serve as patient advocates in the grievance / concern process. Process 4.1, When the formal grievance/concern is logged, the administrator and appropriate department manager will be notified. 5. The department manager will: contact the person filing the grievance to acknowledge receipt; 5.2 Investigate the grievance; 5.4 Notify the person filing the grievance of resolution within 72 hours. The grievance /concern was discussed with the director of nursing at 4:00 p.m. on 12/30/13. She was asked if any statements had been obtained from other staff who may have been working on the day of the alleged incident. She stated Employees #87 and #1 were the only nursing assistants assigned to the resident's hall and verified no statements were obtained from licensed nursing staff or other staff members. She acknowledged the grievance form was not signed as completed and there was no acknowledgement the complainant was promptly notified within 72 hours as to how the facility resolved the grievance.",2016-12-01
8152,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-09-06,166,D,1,0,8W2H11,"Based on medical record review, staff interview, an interview with a representative from the West Virginia advocates, and resident interview, the facility failed to ensure one (1) of five (5) residents received medically-related social services. Resident #99 had filed a complaint with the West Virginia Advocates' office. The facility had not responded to this complaint after being contacted by the West Virginia Advocates office. Resident identifier: #99. Facility census: 104. Findings include: a) Resident #99 On 09/03/13 at 3:00 p.m., an interview with Resident #99 revealed she had filed a grievance with the West Virginia Advocates because she wanted a motorized wheelchair and felt the facility had not acted upon her request. On 09/04/13 at 4:00 p.m., the social workers (Employee #129) (Employee #137) both stated they did not know anything about a grievance filed by Resident #99 with the West Virginia Advocates. On 09/04/13 at 4:15 p.m. Employee #137 presented a packet of information from West Virginia Advocates. She said she did not know anything about the information in the packet. On 09/04/13 at 5:00 p.m., the administrator (Employee #127) said she had a lot of turn over in employees in the social service department. She acknowledged the facility had received the grievance from the West Virginia Advocates on 07/22/13 regarding Resident #99's request for a power chair for mobility. She said she did not know why the facility had not responded to this grievance, but verified they had not.",2016-09-01
8188,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,166,D,0,1,6XWO11,"Based on record review and interview, the facility failed to resolve a grievance related to missing personal property for one (resident #85) of three sampled residents out of eight residents who complained of having missing personal property during resident interviews. Findings include: During interview with Resident # 85 on 05/14/12 at 3:20 p.m., it was stated he had missing shirts and a pair of jeans missing from his room. Resident #85 also stated during the interview he told someone in the laundry department. Review of the medical record for Resident #85 revealed a form titled Inventory of Personal Effects dated 01/13/12. There are 4 slacks listed and 8 shirts. Review of an undated form titled, Process for Missing Items revealed if an item is identified as missing the resident would need to inform the nurse or staff member regarding the missing items with date and time the item was missing, the staff will check the inventory sheet for the description of the item, the staff will complete a concern form with the item identified and complete an in-house communication slip to notify all departments of missing item and the staff will make every effort to locate or find the missing item. During interview with Social Worker (SW) #43 on 05/15/12 at 1:38 p.m. it was stated she doesn't know much about missing property and the Social Worker Manager would know more. SW #43 then phoned the Laundry Department at the time of the interview and asked if any missing items had been reported by Resident #85. They stated there were none at that time. Licensed Practical Nurse (LPN) #50, identified as the Unit Manager, was made aware of the missing personal property by SW #43. LPN #50 stated she would fill out a form and follow up. LPN #50 also verified laundry personnel had taken the report from Resident #85 and stated nursing staff should also have received notice of the missing items. During interview on 05/17/12 with LPN #47, identified as the Social Worker Manager, it was verified there were no missing items reported for Resident #85. During interview with LPN #50 and LPN #47 on 05/17/12, it was verified a missing items form was not completed per the facility's policy when this surveyor informed them about Resident #85's missing personal property.",2016-07-01
8245,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-07-30,166,D,1,0,YIJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and grievance record review, the facility failed to resolve a grievance for one (1) of twelve (12) sampled residents in a timely manner. A resident who allegedly lost her glasses in early March, had no grievance report made until nearly four (4) months later. There was no resolution of the grievance prior to her discharge from the facility. Resident identifier: #122. Facility census: 119. Findings include: a) Resident #122 Review of the medical record, on 07/29/13 at 2:00 p.m., revealed Resident #122 was a [AGE] year old resident with dementia. She was admitted to the facility on [DATE] for rehabilitation following a [MEDICAL CONDITION]. Review of the inventory list, dated 03/05/13, found she had one (1) pair of glasses at the time of admission to the facility. An interview was conducted with the Licensed Social Worker (LSW), Employee #20, on 07/29/13 at 4:00 p.m. She said the Medical Power of Attorney (MPOA) called after the resident's discharge to home on 06/12/13, and asked about the resident's missing glasses. The LSW said an eye exam was done on this resident on 04/03/13 at the facility, and on 05/15/13 she was again seen by the eye doctor at the facility. The LSW said the thought there was some kind of issue at the doctor's office, and a delay with the laboratory (lab) that makes the glasses. She gave this as the reasons the resident did not receive the glasses before going home. Review of the medical record, on 07/29/13 at 4:30 p.m., confirmed a visual analysis was completed by an eye doctor on 05/15/13. The written treatment plan indicated a new prescription was medically necessary to improve distance and near vision in both eyes. On 07/30/13 at 9:00 a.m., review of the grievance reports revealed a grievance dated 06/27/13. The heading was Customer First Concern/Grievance Report. Attached to the grievance was a typed letter from the MPOA of Resident #122, dated 06/24/13, with an allegation that stated, Her glasses were lost the first week she was there and she never received a new pair although I was told that they would be sent to her. Medical record review revealed the resident was discharged from the facility on 06/12/13. On 07/30/13 at 9:15 a.m., an interview was completed with LSW, Employee #72. She said the resident's family told her, possibly in April, that the resident's glasses were missing. The resident was seen in May by the eye doctor. The resident was discharged to home in June, but did not receive her glasses prior to the discharge. The LSW said she assumed this was due to billing issues. She said there was no grievance report completed initially for the glasses when the loss was first discovered. The LSW said she did not know why a grievance report was not done at that time. An interview was conducted with the administrator on 07/30/13 at 9:20 a.m. She said she would have expected a grievance report to have been made initially when there was a complaint about missing glasses. She said the facility was not obligated to purchase new glasses for this resident since she was a short stay customer, but did so as a courtesy. The administrator said there was a delay in payment because the corporate office was not considered a critical vendor, and this negatively affected payment. She produced a copy of the bill for the lenses and frame for $171.00, dated 05/15/13, with a handwritten notation that the bill was paid on 07/01/13. The administrator said after payment of the bill, she thought there was some problem with the lab that makes the glasses. She acknowledged that as of this date, the resident had still not received the new pair of glasses.",2016-07-01
8250,SUNDALE NURSING HOME,515083,800 J D ANDERSON DRIVE,MORGANTOWN,WV,26505,2012-06-08,166,D,0,1,26RQ11,"Based on interview and record review, the facility failed to develop an effective grievance program that included follow-up visits to ensure residents' grievances had been resolved to their satisfaction for three (3) residents reviewed. Resident identifiers: #84, #18, and #74. Findings include: 1. Review of the documentation provided by the Social Services Assistant (SSA) on 6/6/12 revealed the following information: a) Resident #84 The SSA was advised on 01/26/12 that R84 had voiced a complaint about noise on his hallway. The SSA visited R84 on 01/27/12 at 11:56am and he stated that he was disturbed in the middle of the night when the residents on either side of him were yelling and screaming. The SSA documented that there was little the facility could do to prevent the residents in question from yelling at night. She informed R84 that the facility had ear plugs which might help him sleep. The SSA reported R84 ' s concern to the nurse on his unit and the nurse stated that she would make an effort to keep the other residents as quiet as possible at night. As of 06/08/12 at 12:00 noon, there was no subsequent documentation relative to R84 ' s grievance. The facility failed to follow up with R84 to ensure that his grievance had been resolved to his satisfaction. There was no documentation relative to the potential intervention (ear plugs), or if the resident continued to be disturbed in the middle of the night by the loud residents on his hallway. An interview with the SSA on 06/06/12 at 4:00pm confirmed that she had failed to follow up with R84 to ensure that he was able to sleep throughout the night without being disturbed. b) Resident #18 The SSD visited R18 on 02/06/12 at 2:54 pm and again on 4:15pm because she was upset over her roommate (R60) and she was expressing fear of her. The SSD spoke with R18 ' s family and they stated that they did not want R18 to change rooms but they wanted the facility to relocate her roommate, R60 instead. They stated that R18 was in the room first, and felt that she had the right to remain there. Per the documentation, the facility decided to relocate R60 to another room. There was no further documentation. Interview with the SSA on 06/06/12 at 4:00pm confirmed she had not scheduled a follow up visit with R18 and did not know if her grievance had been resolved. c) Resident #74 The SSA visited R74 on 05/07/12 at 12:33pm because she was unhappy with the temperature in her room. R74 stated that she was sensitive to the cold but she did not want to offend her roommate, R73 who was sensitive to the heat. The SSA emphasized to R74 that when two residents share a room, they must compromise in order to make sure both are comfortable. There was no further documentation. Interview with the SSA on 06/06/12 at 4:00 pm confirmed that she had not followed-up with R74 and her roommate.",2016-07-01
8297,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,166,D,0,1,TTVD11,"Based on resident interview, record review, and staff interview, facility failed to investigate and resolve a grievance related to an allegation of missing clothing for one (1) of forty-five (45) Stage II sample residents. Resident identifier: #10. Facility census: 52. Findings include: a) Resident #10 Interview with Resident #10, on 07/16/12 at 9:37 a.m., revealed the resident had missing items such as pajama pants, socks, and underwear. Resident #10 stated the facility investigated the situation, but the situation was not resolved to her satisfaction. Complaints and grievances were reviewed. The files did not contain a complaint regarding Resident #10's missing clothing. Employee #63, the director of social services, was interviewed on 07/23/12 at 2:35 p.m. regarding the resident's missing items. She stated the facility did not keep a record of missing items, as they were usually found in another resident's drawer. This method of handling missing items does not ensure each grievance is acknowledged, acted upon, and the results communicated to the resident. The facility had no means to provide evidence the resident's complaint was acknowledged, no evidence the facility investigated the complaint and/or actively sought a resolution, and no evidence the resident was informed of the facility's findings.",2016-07-01
8383,MADISON PARK HEALTHCARE,515021,"700 MADISON AVENUE, PO BOX 2806",HUNTINGTON,WV,25727,2012-03-22,166,D,0,1,WTH511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, and policy and procedure review, the facility failed to ensure prompt actions were taken to resolve a resident's complaint of missing dentures. This was true for one (1) of twenty-three (23) Stage II sample residents. Resident identifier: #39. Facility census: 41. Findings include: a) Resident #39 During stage I of the survey, on 03/19/12, the resident reported her bottom dentures were missing. She stated, One day I noticed they were missing and I thought I might have left them on my food tray. She asked her nursing assistant to go to the kitchen to look for her dentures. The nursing assistant told her she looked in the kitchen, but could not find the dentures. She was unsure of the exact date the dentures were missing, but thought it was shortly after she came to the facility. Review of the medical record found the resident was admitted to the facility on [DATE]. The admitting nursing assessment documented the resident had both upper and lower dentures upon admission. Review of the facility's policy entitled, Personal Property, found on page 1, The facility will promptly investigate any complaints of misappropriation or mistreatment of [REDACTED]. Interview with the director of nursing, on the afternoon of 03/20/12, confirmed the facility was aware the dentures were missing. No further evidence was presented to indicate the facility further investigated, or attempted to provide assistance, to resolve the resident's allegation of missing dentures.",2016-06-01
8436,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2013-06-18,166,D,1,0,RXW311,"Based on a review of the facility's customer and family concerns /grievances reports, family interview, and staff interview, the facility failed to acknowledge a complaint that was voiced by a responsible party. A complaint was filed with the facility administrator by Resident #50's legal decision maker, that a person who was not authorized to take the resident from the facility, had done so without permission. The complaint also voiced the facility staff had been dishonest with her and told her Resident #50 was in bed asleep when he was actually sitting in her living room. There was no evidence the facility recorded this complaint or investigated it to prevent this from reoccurring. This was true for one (1) of five (5) sampled residents. Resident identifier: #50. Facility Census: 70. Findings include: a) Resident #50 During an interview with the Social Worker (Employee # 57), on 06/18/13 at 12:00 p.m., it was identified Resident #50 had gone away from the facility and off the property without the permission of the legal guardian. She verified the guardian had a note in the front of the chart that the resident was not to be permitted to go out of the facility with anyone other than whom she had specified. She verified the resident's responsible party had come to the facility and she stated the administrator had talked to the responsible party. The administrator (Employee #83) was interviewed at 1:45 p.m. 06/18/13. He verified Resident #50's legal responsible party had called him and then came to the facility. The administrator said she voiced complaints that this resident was permitted to go out of the facility with an unauthorized person after she had told them not to permit him to go out. She also said the staff had not been truthful about where he was. He verified the responsible party had told him the resident was sitting in her living room and was not supposed to be allowed out of the facility. She also told him she called and asked someone at the nurses' station if she could talk to him and they told her he was asleep, then told her he said he would call her back. She verbalized the staff had not been truthful to her. He confirmed that he had not recorded these complaints and had no evidence he had made efforts to resolve the issues identified. According to a telephone interview, on 06/19/13 at 4:00 p.m., the resident's responsible party stated she had called the facility because the resident showed up at her house with an unauthorized person. She called the facility and told them the resident had called her and she needed to talk to him. The facility told her he was asleep. She told them it was an emergency and they told her to hold on. When they returned to the phone, they told her that the resident said he would call her back. She then stated that she knew this was not true because the resident was sitting in her living room. She said she hung up on them. After this took place, she came to the facility and told the administrator. The facility's complaint, grievance files, abuse/neglect reporting, and incident reports were reviewed. There was no evidence that the facility recorded this complaint and investigated it or made efforts to resolve grievances voiced by this resident's responsible party.",2016-06-01
8438,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2012-02-29,166,D,0,1,IR8W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on grievance record review, resident interview, family interview, staff interview, review of the Centers for Medicare and Medicaid (CMS) guidelines, and grievance policy review, the facility failed to follow its own policy and procedures for grievances, and failed to ensure grievances were addressed in a timely manner. The facility failed to show evidence it actively sought a resolution of all grievances, and kept the resident or family appropriately apprised of its progress toward resolution. Also, the facility's grievance/concern policy stated that formal concerns may be registered by telephone, mail, office visit, or direct outreach by staff and must be indicated as being a formal concern. However, CMS guidelines dictate that any grievances, including verbal, and not only formal grievances, must be addressed. Resident identifiers: #15, #54, #46. Facility census: 67. Findings include: a) Resident #15 1) Review of the facility's policy for grievances/concerns found that upon receipt of the formal concern/grievance, the designated form would be completed by the social worker, or whichever professional staff member received the concern. When the concern/grievance was logged, one or more of the following people would be notified: Administrator, Director of Nursing, Director of Social Services, or any other appropriate persons or groups as indicated. The designated form would contain the following information: date, name, nature of concern/grievance, investigation, and any action taken. All formal concerns would be investigated and responded to within five (5) days. Completed reports would be reviewed by the administrator and the director of social services to ensure the customer's interests had been addressed. If the facility was unable to resolve a concern/grievance satisfactorily, the issue would be referred to the ombudsman, or other source of assistance, if more appropriate. 2) During a family interview, on 02/21/12 at 4:32 p.m., the resident's medical power of attorney (MPOA) stated she had made complaints to the evening shift nurses that month about bruises and skin tears on Resident #15. She further stated these injuries had been sustained from the use of the Hoyer lift to transfer the resident from bed to chair and vice versa. She said at first the resident sustained [REDACTED]. She pulled up the resident's pant leg to show an approximately four (4) centimeter sized purplish/blue bruise on the anterior surface of the lower right leg. The MPOA stated the resident had also sustained skin tears on her arms from the use of the Hoyer lift. Review of the grievance reports for the preceding three (3) months found there were no grievances completed for an allegation of Resident #15 having sustained bruises or skin tears while being transferred via the Hoyer lift. Subsequently, there was no investigation or resolution of the grievance. Furthermore, review of the grievance reports for the preceding three (3) months found there were no grievances recorded for any residents. 3) Review of an incident and accident report, dated 02/02/12 at 10:00 a.m., revealed a skin tear had been found after Resident #15 received a shower. The skin tear was to the right forearm, was scabbed, and measured 1.6 x 0.3 centimeters. Review of the investigation found the type of incident was deemed to be a skin tear of unknown origin. Review of an incident and accident report dated 02/16/12 revealed a bruise was discovered at 10:00 p.m. on Resident #15's right lower leg while she was in bed. The injury was described as a blue/purple bruise to R (right) lower leg, swelling noted. Measurement of the size of the bruise was not documented. Follow-up care included ice to the right lower leg for swelling. Review of the investigation found the type of incident was deemed to be a bruise of unknown origin, and it was found right after the resident was transferred back to bed with the Hoyer lift. During an interview with the administrator and the director of nursing (DON), on 02/28/12 at 8:40 a.m., the DON said she was unaware the MPOA of Resident #15 had complained to the evening shift of the Hoyer lift causing bruises and skin tears on the resident. The DON said when there was a complaint or a grievance, it went to social services, and then social services alerted the administrative staff. When asked how they track the grievance and how they know it is resolved, the administrator and the DON gave an example that if the resident council meeting had concerns, they put the resolution on a page attached to the minutes. They do not complete grievance forms for these. The DON said if there was a grievance, she did an in-service education with staff. While interviewing the DON and the administrator, on 02/28/12 at 8:40 a.m., the grievance policy in the facility's admission booklet was read aloud where it discussed formal grievances and how they were to be handled. It was discussed that the Centers for Medicare and Medicaid Services (CMS) guidelines include voicing grievances is not limited to a formal, written grievance process but may include a resident (or family member's) verbalized complaint to facility staff. The administrator at this time said this was their most recent policy on grievances. During an interview with the DON, on 02/28/12 at 9:50 a.m., she said Resident #15's MPOA must have complained to the evening shift about the Hoyer lift transfers, because she found one-on-one education forms dated 02/02/12 for education for eight (8) 3-11 nurse aides related to the use and safety of the Hoyer lift and sling. However, there was no grievance form completed, as there have been no grievances recorded for the past three (3) months. Failure to complete a grievance form was not in accordance with facility policy and procedure. ====== b) Resident #54 During an interview with Resident #54, on 02/27/12, at approximately 10:00 a.m., she stated she had been missing a pair of blue shoes and a pair of white shoes since December 2011. She said she told laundry department employees, and they looked for them, but could not find them. She did not believe the shoes were going to be replaced. During an interview with laundry department Employee #78, on 02/27/12, at approximately 11:00 a.m., she recalled looking for the pair of blue shoes and the white pair of shoes for this resident, but it had been awhile back. She did not know whether the shoes had been found. She said they typically write down the name of the resident and the missing item on the board in the laundry department which alerted other laundry personnel to look for the missing items. Observation of the laundry board found there was no note related to the missing shoes at that time. Review of the policy for resident's personal property found, under section four, that social services would notify the resident and / or responsible party of the loss of personal items, and advise if the loss would or would not be replaced at the facility's expense. Additionally, any loss of a patient's personal items would be properly documented on the property loss form by the person receiving the report, and then referred to the administrator. Section 4.1 of the policy included an investigation would be made for the lost items by the person designated by the administrator. Review of Section 4.3 found the policy directed the results of the investigation be given to the resident / family and documented, and a copy of the report will be sent to the administrator. During an interview with the licensed social worker, on 02/28/12 at 2:30 p.m., she said if no one told her about missing items brought up at the resident council meetings or individually, she would not know to complete a grievance. If a clothing item was reported as missing, staff first looked for it. If it could not be found, then a grievance was filled out. She further stated anyone could complete a grievance form. c) Resident #46 In an interview, on 02/23/12 at 3:30 p.m., with Resident #46's family member, she stated she had found the resident's pants pockets torn. She felt the reason the pockets were torn was due to the staff pulling the resident up in the chair. She further stated this had been reported to the director of nursing,Employee #33, and the administrator,Employee #44. She could not remember an exact date when this occurred. She stated the problem was still not resolved. A review of accident /incident reports, resident council minutes and grievances, on 02/23/12 at 2:00 p.m., did not reveal any information regarding the resident's pants pockets being torn or staff potentially using the pants to pull the resident up in the chair. The facility grievance procedure was reviewed at 3:45 p.m. on 02/27/12. The policy included 1.42 Grievance/Concern: Customer/Family stated All customers, responsible parties, or surrogates may voice grievances/concerns and recommendations for changes through an orderly and timely process. The Center will investigate, document, and follow up on all formal concerns and grievances registered by an customer representative. Social services . A concern is defined as any formal expression of concern regarding the well being of a customer. The section noted as Process number 3 (three) included Formal concerns my be registered by telephone, mail, office visit, or direct outreach by staff and must be indicated as being a formal concern. This policy was dated 12/30/08. Review of the Centers for Medicare/Medicaid Services (CMS) guidelines revealed Interpretive Guidelines ?483.10(f) Voice grievances is not limited to a formal, written grievance process but may include a resident's verbalized complaint to facility staff. Employee #44, interviewed on 02/28/12 at 9:45 a.m., revealed the facility did have a grievance/complaint report form but had not used the report for the past six (6) months to record grievance(s)/complaint(s), follow-ups or resolutions. He did not offer an explanation as to why. He was also unaware of the formal grievance policy.",2016-06-01
8530,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2012-04-26,166,D,0,1,JZJM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interviews, and staff interviews, the facility failed to replace reported missing property after the resident was told the property would be replaced. This affected 1 of 3 sample residents reviewed out of the 6 residents who had reported missing property. (Sample resident #97) Findings include: a) Resident #97 Review of a Resident Missing Item Request form, dated 12/12/11, for Resident #97 noted Resident #97 had reported a box of 64 [MEDICATION NAME] and a box of 50 [MEDICATION NAME] pencils were missing. It was noted the Social Worker (SW) had completed the report portion of the form. Under Follow Up Required, the Housekeeping Supervisor (HS) wrote, Replace the [MEDICATION NAME] and pencil. The HS dated this part of the form 12/14/11. On 04/23/12 at 03:13 p.m., an interview was conducted with Resident #97. Resident #97 stated, Someone stole my new [MEDICATION NAME] and colored pencils about a month ago. She added she had reported the missing property to the staff. An interview was conducted with the SW at 2:44 p.m. on 04/23/12. The SW stated, if something is reported missing, they would come tell me or send an e-mail or leave me a note. I would fill out a missing item form. I would give it to laundry if it was for them. They would look, then give the form back indicating whether the item had been found. Around Christmas (the resident) was missing some [MEDICATION NAME]. We looked for them but couldn't find them. The HS wrote that we would replace them. Activities (staff) probably did that. An interview was conducted on 04/23/12 at 3:13 p.m. with the the HS. The HS said that reports of missing items were turned in to her; then, she and her staff would look for the item. We usually find everything within 2 weeks. If we can't find it, we will replace it. (Resident #97) has lost other stuff, but we found it. After reviewing the Missing Item form, HS said, I wrote on there we would replace the pencils, but I haven't done it yet. I think we found the [MEDICATION NAME]. On 4/23/12 at 3:55 p.m., an interview was completed with the Administrator. The Administrator said that missing items were reported to the SW. There is a missing item form. The SW gives the form to the HS unless it is something medical, (dentures, etc), then the SW gets it to the department that would look for the item. If it is money, jewelry or other property then the form comes to me so we can track it. The HS would search in the resident's room and the laundry or other resident rooms. If it is lost or undiscoverable, we try our best to replace the item. I'd give it about a week or so to find it, then it should be brought to my attention so we can see where we are. The Administrator said that he had not heard about the [MEDICATION NAME] and pencils for Resident #97.",2016-05-01
8606,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,166,D,1,0,5M3K11,"Based on complaint file review, staff interview, and complaint policy review, it was determined the facility failed to thoroughly investigate concerns expressed by family members for two (2) of eight (8) sampled residents. The facility had specific procedures regarding the receipt, documentation, investigation, and follow-up for concerns/complaints. This policy was not implemented for the concerns/complaints lodged by these residents' family members. Resident identifiers: #59 and #61. Census: 78. Findings include: a) Resident #59 Review of the complaint/concern forms, on 05/30/13, revealed a complaint, dated 05/22/13, lodged by the resident's family. The family was concerned the resident was not receiving necessary care and services, such as assistance with oral care and toileting. The complaint included a statement indicating it appeared nothing had been done to correct these issues, which the family member had complained about two (2) weeks prior to the complaint dated 05/22/13. As of 05/30/13, the 05/22/13 complaint had not been addressed or resolved. In addition, there was no documentation regarding the issues which were reported two (2) weeks prior. A discussion regarding the concerns was held with Employee #13, the social worker (SW) and Employee #2, nurse/staff development coordinator, on 05/31/13 at 12:10 p.m. At that time, the SW and Employee #2 were unable to locate any information regarding the original complaint. The family's concerns were not addressed and/or resolved until intervention during the survey on 05/31/13. b) Resident #61 Review of complaint/concern forms revealed this resident's family member felt Employee #50, a nursing assistant (NA), was excessively rude. The family member stated he was offended and insulted by the NA's response to his request for help for the resident. This was reported on 04/30/13. The facility's forms contained a section for the investigating staff member to complete regarding what was found, the final determination, and action taken. Employee #13, the social services supervisor verified, at 3:00 p.m. on 05/30/13, she was unable to find other details on the issue. This section was blank, as of 05/31/13. Later in the day on 05/31/13, and after surveyor intervention, Employee #13 brought the form to the surveyor. The form now contained documentation the family member had been contacted and stated he felt he had just been emotional and had taken the staff member's comments the wrong way. There was no evidence the concern dated 04/30/13 was addressed until 05/31/13, following intervention during the survey. Staff had not responded to this family member's complaint in a timely manner as required by their own corporate policy. c) The facility's Compliant/Concern/Grievance/Request procedure was reviewed on 05/31/13. The following policy and procedures were not implemented, related to the concerns expressed by the families of Residents #59 and #61: -The policy statement included, The facility shall investigate and resolve all complaints/concerns/grievances/requests promptly . -Procedure #6 included in part, All resident/family complaints/concerns/grievances/requests shall be recorded on the complaints/concerns/grievances request form either by the employee who has received the complaint .or by the resident/family member. -Procedure #8 directed the employee receiving the complaint to determine what the complainant wanted corrected or done differently, and to take necessary action if it was within their authority to do so. If not within their authority, the employee was supposed to inform the complainant the proper authority would be contacted. -Procedure #9 directed the completed concern/complaint form be forwarded to the administrator/designee. -Procedure #10 directed a completion of a thorough investigation by the administrator/designee. -Procedure #11 directed the development of a plan of action. -Procedure #12 directed the plan of action be implemented. -Procedure #13 directed administrative follow-up. -Procedure #14 directed the complainant be contacted to assure him/her the concern was resolved. This policy became effective May 1, 2012 and superseded the July 1, 2009 version. Information available at the time of the evaluation of the concerns for Residents #59 and 61 revealed the facility failed to follow their policy for receiving, documenting and investigating, and following up on the complaints/concerns regarding Residents #59 and #61.",2016-05-01
8737,LAKIN HOSPITAL,5.1e+125,1 BATEMAN CIRCLE,WEST COLUMBIA,WV,25287,2012-08-17,166,D,0,1,4EJV11,"Based on resident interview, staff interview, review of facility policy and procedure investigations of complaints/allegations, and medical record review, the facility failed to safeguard the resident's personal property by failing to investigate and seek a resolution when it was discovered the resident's dentures were missing. This was true for one (1) of two (2) residents reviewed for the care area of personal property in Stage II of the quality indicator survey. Resident identifier: #54. Facility census: 95. Findings include: a) Resident #54 During an interview with the resident, on 08/13/12, the resident reported her upper and lower dentures were missing. The resident was unsure how long the dentures had been missing. The resident further stated she needed her dentures and she had told, the girls, her dentures were missing. Review of the medical record found a dental consult had been scheduled for the resident on 07/20/12. An interview with the director of nursing (DON), at 12:20 p.m. on 08/15/12, revealed the resident had not been sent for the dental consult on 07/20/12 as scheduled because the resident's dentures were missing. The director of nursing stated the 07/20/12 appointment was initially scheduled because the resident's dentures were not fitting properly. On 08/16/12 at 3:30 p.m., the DON verified the facility had not initiated a search for the dentures and had not attempted to provide a resolution when it was determined the resident's dentures were missing. She verified a suggestion and complaint form should have been completed when it was discovered the dentures were missing. Review of the facility's policy entitled, Complaint/Allegation Investigation, found: .B. Complaints, Allegations of Abuse, Neglect or other Violations of Resident Rights: Allegations made under this policy may be filed in relation to any aspect of a resident's treatment, housing, services, accommodations, etc. F. Investigation: 1. The Resident Advocate will immediately begin to gather facts, conduct interviews, and review medical records as necessary to determine the circumstances surrounding the allegation (s)",2016-04-01
8874,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2012-05-25,166,D,0,1,ZX7V11,"Based on interview and record review, it was determined the facility failed to provide prompt resolution of a resident's grievance for 1 unsampled resident (R79.) Findings include: A group interview was conducted on 05/22/12 with 12 residents whom the facility had identified as alert, oriented, and credible historians. Interview with R79 revealed that, during the previous week, she had complained about a housekeeping staff member. She related she had told at least two staff about the problem, and although the facility talked to the housekeeper, she was rude to me again. Interview on 05/24/12 at 8:50pm with E14 and E30 confirmed they were aware of R79's complaint. E14 related she told the housekeeping supervisor about the concern, and she replied she would talk to the staff about how she spoke to the resident. Review of facility records revealed neither documentation of nor investigation of this incident. Interview with the Social Services Director (SSD) on 05/23/12 at 2:40pm revealed she is the person responsible for grievances and investigations. She stated that she did not have a record of the incident with R79. Review of the Complaint/Recommendation Procedure revealed, We welcome any complaints or recommendations that you may have. Should you have either a complaint or recommendation - Fill out the complaint form in detail During the 5 days, an investigation will be completed and the results will be available on the 5th day. Further interview with the SSD on 05/15/12 at 10:45am revealed that a resident is not required to make their complaint in writing. The SSD indicated when R79 told staff of the complaint, they should have put the information on a grievance form so the facility could initiate an investigation, and document the findings and the result of the investigation.",2016-03-01
9064,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2011-05-18,166,D,0,1,MU6H11,"Based on resident interview, staff interview, and review of the facility's records of self-reported allegations for abuse, neglect, and misappropriation of personal property, the facility failed to assure prompt actions were taken to resolve a resident's grievance. Resident #45 reported fifty dollars ($50.00) had been taken from his room. The facility resolved the resident's grievance by stating they would purchase any items the resident intended to purchase with his missing money; however, the facility was unable to provide documentation to substantiate any personal items had been purchased for the resident. This was true for one (1) of forty-nine (49) Stage II sample residents. Resident identifier: #45. Facility census: 108. Findings include: a) Resident #45 During an interview with Resident #45 on the morning of 05/10/11, he stated he had personal money taken from his night stand. According to the resident, someone who worked at the facility had taken his money. He said he had reported the theft, and the facility told him it was not their responsibility to keep up with his money and that he should keep his money in the front office. He stated he never received a refund and no items had been purchased for him. Further investigation revealed the facility had reported the missing money to State agencies on 01/15/10 as follows: Resident alleges that on 1/12/10 a staff member who was male with green scrubs took $50.00 out of his bedside table. The facility's five-day investigative follow-up report documented: . Again, we can substantiate that (name of Resident #45) did have money, however we can not substantiate that the male staff member described by the Resident took his money. The facility will purchase any items (name of Resident #45) had intended on buying with his money Employees #111 (the director of social services) and the administrator were interviewed on the afternoon of 05/16/11. Both employees were unable to locate any information verifying the facility purchased any items for Resident #45. The administrator stated, It must have fell through the cracks.",2016-02-01
9497,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2011-06-22,166,D,0,1,DLX411,"Based on family interview, review of the facility's concern / complaint files, staff interview, observation, and a review of a resident's clothing list, the facility failed to provide prompt efforts to resolve grievances related to missing personal items for one (1) of twenty-seven (27) Stage II sample residents. Resident #18's family reported as missing items that were listed on the resident's clothing list. The items were not found, and the facility did not respond to the family member's concern. Facility census: 47. Findings include: a) Resident #18 Resident #18's family member, when interviewed on 06/16/11 at 3:39 p.m., related concerns about missing personal items. The missing items were two (2) gowns, a pair of house shoes, and a fleece blanket. The family member stated these items were marked with the resident's name, and she had talked with both laundry staff and the supervisor about them. The items had been missing for about a month. A review of the facility's complaint / concern files did not find any information about Resident #18's missing items. During an interview with the laundry supervisor (Employee #26) on 06/21/11 at 10:20 a.m., she stated Resident #18's family did not talk with her about any missing laundry. She stated the afternoon shift laundry person (Employee #39) did the resident's personal laundry, and she would have Employee #39 speak with this surveyor when Employee #39 came on duty that afternoon. In an interview during the late afternoon of 06/21/11, Employee #39 said she talked with Resident #18's daughter about two (2) weeks ago. She said she did find the gowns but not the house shoes and blanket. She did not notify the family she found the gowns. She said there was a bulletin board in the laundry where missing items are posted. This was observed with the employee, and information about Resident #18's missing items was not on the bulletin board. Employee #39 said the midnight shift laundry person may have removed it. At this time, the clothing and personal items located by the bulletin board in the laundry were observed, and there were no house shoes or blanket located there. A review of the Resident #18's Inventory of Personal Effects (dated 01/21/10) found three (3) night gowns, one (1) pair of blue slippers with flowers, and three (3) comforter / quilt / afghans were marked on the list. An interview with the facility's administrator, on 06/22/11 at 8:00 a.m., found the facility did not have a written policy or protocol for missing items. He said when something is missing and they are notified, they look for the items, and alert laundry. If they are unable to find it, they will replace the items if they are on the personal clothing list. He said he did not know anything about Resident #18's missing items.",2015-11-01
9835,GOLDEN LIVINGCENTER - RIVERSIDE,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2012-08-02,166,E,1,0,K6SZ11,". Based on confidential resident interviews, confidential family interviews, a review of the facility's grievance reports, review of resident council minutes, and staff interview, the facility failed to actively seek a resolution when complaints and grievances were expressed by residents and families. The grievance reports did not address all of the issues expressed in the statement of concern. There was no evidence the facility followed up with all of the concerns. There were concerns that were not explored further to investigate the reason for the concern or whether there was further investigation that needed to be done to resolve the issues. The resident council minutes contained concerns two (2) months in a row regarding the issue of call lights. There was no evidence the grievances were resolved for eighteen (18) of thirty-seven (37) grievances reviewed. This practice affected fifteen (15) residents who had expressed grievances. Resident identifiers: #53, #20, #6, #60, #17, #70, #73, #59, #52, #55, #89, #46, #87, #66, and #88. Facility Census: 84. Findings include: a) Resident Interviews During confidential interviews with alert and oriented residents, on 07/31/12 through 08/02/12 , it was identified they felt there were often complaints and no one addressed them or let you know what they found out. Three (3) confidential family interviews were conducted on 08/01/12. These families felt the facility did not make efforts to resolve grievances and report the findings back to the grievant. b) Grievance Reports The Social Worker was requested to make copies of the last three (3) months (May, June, and July 2012) grievance reports. The following issues were reviewed in these reports. There was no evidence to indicate that issues in these reports had been resolved or further explored as needed. 1) Resident # 53 A grievance form was completed on 05/29/12 in which the grievant expressed a concern with missing items. There was no evidence this was investigated and no resolution had been recorded on the grievance form. A grievance form was completed on 06/04/12 by this resident's daughter. She expressed multiple concerns. A total of thirteen (13) concerns were expressed and listed on the grievance form. There was no evidence this grievance was investigated and the areas addressed as needed. It was confirmed that some of the issues listed in this 06/04/12 complaint for this resident were still concerns that have not been resolved. 2) Resident #20 A grievance form, dated 06/05/12, listed ten (10) different issues of concerns expressed by Resident #20's family. It was identified there were concerns with missing items, clarification wanted of treatment orders, medication administration concerns, therapy concerns, maintenance concerns, beauty shop concerns. These were expressed to the social worker. There was no evidence these concerns were investigated or resolved. The section at the bottom of the form to indicate if there was satisfaction of those involved, was left blank. 3) Resident #6 A grievance form, competed 06/07/12, for Resident #6 included multiple concerns. The resident expressed he wanted more evening activities, better staff approach, he had missing item, he wanted more fluids between meals, and he had questions about his account. His action plan addressed activities and under comments was a note regarding his participation in activities. There was no evidence that the other items had been addressed and no evidence of resolution of the issues in this grievance. 4) Resident #60 A grievance form, dated 06/07/12, for this resident stated he wanted the food to be warmer and he wanted the staff to be more gentle and have a better approach. The investigation of this complaint stated that on 06/07/12 and 06/18/12, the facility used paper products due to no hot water in the kitchen. There was no evidence that the actual concerns stated in the grievance were addressed. 5) Resident #17 A grievance, dated 06/07/12, contained a statement of concerns about missing clothes, wanting less frequent urinary tract infections, less time spent in bed, less falls, more attention from staff, cleaner floor under the bed, consistent fresh water, better attitude, consistent oxygen, a newer bed, bathroom to smell better, and the resident felt the facility had old furniture. The action plan stated ""delegate to each department to address"". There was a resolution written that stated that the resident was involved in music, church, ball toss, and discussion groups when she was out of bed. There was no evidence that the concerns that were expressed were addressed or that there was satisfaction with the resolution. There was no evidence the other issues in the grievance were addressed. 6) Resident #70 A grievance form was completed on 06/08/12 for this resident. He expressed his concerns were a need for more evening activities, he had socks and underwear missing, and he would like more privacy during his care. The action plan stated ""movie night requested during an interview on 06/08/12 has been scheduled."" There was no evidence the other concerns were addressed. and no evidence of follow up with the resident. 7) Resident #73 A grievance for Resident #73, dated 06/08/12, stated this resident would like more evening activities, the food was not the proper temperature, more midnight staff were needed, and she wanted her teeth done weekly. The action plan included to play cards (rummy, spades). It was also noted that this resident attends resident council meeting and has never voiced issues or requests for card games before. There was no evidence the other concerns voiced to the facility were addressed. 8) Resident #59 A grievance, dated 06/08/12, indicated this resident had a concern with food choices and mouth care only weekly. The resolution stated the new menus were to start in July. The food preferences were updated and it was noted the resident did request substitutes. Items are provided as requested and as available. There was no evidence that the issue with her mouth care was addressed. 9) Resident #52 A grievance form, dated 06/08/12, stated Resident #52 had expressed she would like more food preferences, she had concerns about her bathing schedule, too much noise, complaints of rectal exfoliation, and food being the proper temperature. The resolution stated that the new menus were to start in July. Food preferences were reviewed and the tray card system was updated. It was also noted that paper products were used on 06/07/12 and 06/08/12 due to no hot water in the kitchen. There was no evidence that the other concerns were addressed. The resolution revealed that this was discussed with resident and the dietary issues were resolved. There was no evidence that the other issues that were brought to the facility's attention were addressed (staffing, decision making) or further explored. 10) Resident #55 A grievance form, dated 06/08/12, stated this resident had expressed concerns that he wanted involved in his daily decisions about his daily care, the facility needed more staff, the food did not taste good or look appetizing, and it was not always the proper temperature. The resolution revealed this was discussed with resident and the dietary issues were resolved. There was no evidence the other issues that were brought to the facility's attention were addressed (staffing, decision making) or further explored. 11) Resident #89 A grievance form, dated 06/08/12, revealed Resident #89 expressed a concern in making choices of her clothes she wears, choices in her bath schedule, choice in going to bed and getting up, and choice in her decisions of daily care. She also expressed a concern that the food is not the proper temperature. The resolution to this grievance stated that paper products were used on 06/07/12 and 06/08/12 due to no hot water in the kitchen. There was no evidence that the other allegations were investigated. 12) Resident #46 A grievance report, dated 06/13/12, was reviewed completed by Resident #46. She reported a missing item. It was reported that her ear buds were missing for her audio book. The action plan stated ""look for missing items"". There was no evidence in the report to to indicate whether the missing item had been found or needed to be replaced. There was no evidence that there was satisfaction of the resident involved. 13) Resident #87 A grievance form, dated 07/08/12, noted the resident had voiced his breakfast was cold. He also complained that when his call light was answered, staff would tell him they will be right back and they never did come back. The grievance form was not completed and there was no evidence that his issue had been addressed with the staff. His prior grievance, dated 07/02/12, indicated he wanted his call light answered sooner and the staff were educated on answering it timely. According to that grievance form, the resident was satisfied with the resolution of this grievance, then on 07/08/12, he expressed the same issue with no evidence of follow up. The entire grievance form was left blank containing only the concern. There were no signatures of those who reviewed it and no action plan or evidence the issue was resolved. 14) Resident #66 A grievance form, dated 07/03/12, stated this resident did not want a particular nursing assistant (NA) to assist him. The action plan stated the NA had been rescheduled. The resolution stated the NA was given a new assignment. The charge nurses and the NA will be informed of the residents choice. On 07/05/12 it was recorded that this issue was resolved to the satisfaction of the resident. The follow up stated that discussion with the NA regarding issues. There was no evidence to explain what the issues were that involved the nursing assistant and whether this needed to be further explored. During an interview with Resident #66, on 08/02/12 at 2:00 p.m., he stated this nursing assistant did not do anything to him, he just did not like his attitude because he (the NA) was short with you. He was asked if the nursing assistant yelled at him or spoke to him roughly, he stated ""No just short. If you ask him something he will just say 'yes' or 'no' and not really talk to you and I do not like him taking care of me."" 15) Resident #88 A grievance form was dated 07/08/2012. It stated a nursing assistant had taken all of the resident's clothes off and put her on the toilet. When she asked if he really needed be in there he said ""yes"" and that he had ""seen it all before"". He sat on the tub and stared at her. This was recorded on a grievance form, but the form was not completed in its entirety. The grievance form did not contain a follow up, did not indicate what was done with this concern, or whether it was resolved. There was no signature of those who were to review the grievance and review the resolution. c) Resident Council Minutes The Resident Council Minutes were reviewed for 06/11/12. It was recorded in the area of New Business ""Call lights slow on nights"". There was no evidence that this had been addressed. During a review of the Resident Council Minutes, dated 07/11/12, it was noted the minutes stated in the 'Old Business' directions that a review of each issue brought up as new business at the last meeting was to be addressed. There was no mention of the June concern regarding the call lights discussed as old business in the July meeting. New business was discussed in July 2012 meeting. Again it was listed that call lights at night were slow to be answered. There was no evidence that this issue had been addressed. d) Staff Interviews The Director of Nursing (Employee #67) was interviewed 08/01/12 at 3:30 p.m. She was made aware of the grievances that were not complete and did not have evidence that they had been investigated or resolved. She was questioned if there was further documentation for the grievances and she stated that the social worker might have something. The Social Worker (Employee #36) was interviewed on 08/01/12 at 3:00 p.m. It was identified that when she received a grievance or concern, she gave it to the responsible department. The department was then to address the concern and give it back. She stated she must not have received the reports back from those departments if the concerns were not addressed. .",2015-08-01
9896,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2012-06-21,166,D,1,0,MNCH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility complaint files, family interview, review of facility complaint policy, medical record review, and staff interview, the facility failed to ensure one (1) of five (5) sampled residents was afforded the right to prompt efforts by the facility to resolve grievances. Resident #92 experienced a possible allergic or toxic reaction to cleaning materials causing respiratory [MEDICAL CONDITION] with subsequent intubation and placement on a ventilator. The resident's spouse complained to the head of housekeeping services, Employee #153, concerning the use of fabric freshener on her husband's bedside curtains. Employee #153 failed to comply with facility policy related to voiced concerns in order to resolve the spouses concerns. Resident identifier: #92. Facility census: 117. Findings include: a) Resident #92 An interview was conducted with the spouse of Resident #92 on 06/21/12 at 2:00 p.m. in the resident's room. She stated a member of housekeeping staff (Employee #64) sprayed deodorizer on her husband's bedside curtains on 05/16/12. She stated her husband was allergic to the spray and he got so sick he wound up on the hospital on a ventilator. She stated she complained to the head of housekeeping, Employee #153, about spraying deodorizer on the curtains in her husband's room and asked him to place a sign in the room to keep housekeeping staff from using the deodorizer. She stated Employee #153 refused to place a sign in the room and housekeeping staff were still spraying her husband's bedside curtains. Review of the medical record found an emergency department evaluation dated 05/21/12. According to the document, Resident #92 was intubated and placed on a respirator in the emergency department on 05/21/12 with [DIAGNOSES REDACTED]. Review of the facility's complaint file, on the afternoon of 06/21/12, found no record of a complaint related to Resident #92. An interview with housekeeping aide, Employee #62, was conducted at 2:30 p.m. on 06/21/12. He was pushing a housekeeping cart up the 100 hallway. He verified he had worked in the housekeeping department for approximately 2 years. He was asked if there was deodorizer on the housekeeping cart for use in the resident rooms. He opened the door of the cart and indicated a spray bottle labeled ""fabric freshener"". When asked if he had been instructed to not use the spray in rooms of residents with breathing problems, he stated he had not been told to not use the fabric freshener. An interview was conducted with Employee #153 on 06/21/12 at 2:45 p.m. He stated he had been head of housekeeping for 1 year. and supervised about eight (8) housekeeping staff members. He stated the facility switched to fabric freshener to get away from aerosols. He confirmed the fabric freshener spray was placed on the bedside curtains in resident rooms. When asked if Resident #92's spouse had complained to him about using fabric freshener on her husband's bedside curtains, and had requested him to place a sign in the room, Employee #153 acknowledged the conversation. He stated the resident's spouse told him the fabric freshener and bleach bothered Resident #92. He further acknowledged the resident's spouse asked him to place a sign in her husband's room to keep housekeeping staff members from spraying the bedside curtains. He stated he was not aware of what facility policy was related to the placement of signs in resident rooms, and referred the resident's spouse to the nursing department. He stated he did not bring the resident's concerns to the nursing department. The director of nursing (DON), Employee #10 provided the facility's complaint policy at 1:00 p.m. on 06/20/12. Review of the policy entitled ""Concern Process Flowchart"" found verbal concerns were recorded on a concern form, discussed by staff, assigned to the appropriate department for investigation, initiated corrective action, and notified patient/family of the resolution. The facility could provide no evidence of prompt efforts to resolve complaints voiced by the spouse of Resident #92. .",2015-08-01
10052,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,166,D,0,1,EVU911,"Based on resident group interview, staff interview, and review of reports of lost / missing items, the facility failed to ensure one (1) random resident had received information from staff, keeping her informed of the status of and progress toward finding / replacing her missing items. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 During the resident group interview on 10/14/09 at 3:00 p.m., one (1) resident explained she was missing a couple of personal items. She explained she had moved to a different room in the facility and, after the move, she was not able to locate a calling card and a jar of ""cold cream"". She related the facility had not replaced these items and had not informed her if they had located the items. The two (2) social workers (Employees #89 and #90) were interviewed on 10/14/09 at approximately 5:00 p.m. and again on 10/15/09 at approximately 9:00 a.m., regarding this issue. The social workers provided a copy of the lost / missing item form that documented Resident #55's missing items. The form, dated 03/24/09, indicated the facility would replace the Ponds cold cream, a calling card, one (1) blue flat sheet, and two (2) gowns. The social workers indicated they thought all the items were replaced, but they were not positive. They agreed the documentation of the resolution on the lost / missing item form was unclear and could be more organized. The form contained several hand written notes and no complete / accurate conclusion summarizing what occurred. The administrator reviewed the lost / missing item form, on 10/14/09 at approximately 9:30 a.m., and agreed the form needed improvement. She said she had signed the form and, after signing, the social workers had continued to work on the issue. She said she would prefer the investigation be complete and a resolution reached prior to her signature. Employee #55 (maintenance / housekeeping / laundry) indicated she had no knowledge of the missing calling card or Ponds cold cream. She did talk about the replacement of the resident's gowns. On 10/15/09 at approximately 3:00 p.m., Resident #55 expressed great satisfaction that her cold cream and calling card had been replaced. The activity director purchased the items for the resident on 10/15/09. It took seven (7) months for the facility to replace these items. No one at the facility knew why it had taken so long to replace these items. On 10/16/09 at approximately 10:00 a.m., the administrator provided copies of new missing / lost item forms which she felt would improve the documentation and make the resolution of missing property more accurate and complete. .",2015-07-01
10163,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-02-01,166,D,1,0,RZ6L11,". Based on medical record review, staff interview, and review of facility policy and procedure, the facility failed to promptly resolve a grievance expressed by a resident's family related to missing personal items. This was true for one (1) of forty-nine (49) Stage II sample residents. Resident identifier: #75. Facility census: 82. Findings include: a) Resident #75 Medical record review during Stage II of the survey found a nursing note, dated 08/08/11, which revealed: ""Resident daughter in law (name of daughter-in-law) was in the facility over the weekend and was concerned about a pair of shoes she bought resident and states could not find her shoes. Resident has the white pair of shoes on at this time that (name of daughter-in-law) could not find. All aspects of other care issues are good at this time. (Name of daughter-in-law) stated (name of resident) did not know her on Saturday when she came in to visit. This upset her but she understands it is part of the disease process. One brown shoe and one back shoe is missing at this time. Laundry notified and will continue to look for shoes. Resident is known to take belongings out of room and put in different part of the facility. Family is aware. Resident is happy, sitting in the dining area at this time eating lunch. No distress noted."" The director of nursing (DON) was the author of the 08/08/11 nursing note. The DON was interviewed at 3:00 p.m. on 01/31/12. The DON was unable to produce further evidence the grievance was investigated, documented on the proper form, resolved, or feedback provided to the family member. Review of the facility's Complaint/Concern/Grievance/Request Policy and Procedure found: ""...The facility shall investigate and resolve all complaints/concerns/grievances/requests promptly..."" ""...6. All resident/family complaints/concerns/grievances/requests shall be recorded on the complaints/concerns/grievance/request form either by the employee who has received the complaint/concern/grievance/request and/or by the resident/family member...."" ""...8. The employee will determine exactly what the complainant wants corrected or done differently..."" ""...10. The administrator/designee will conduct a thorough investigation of the compliant..."" ""...14. The administrator/designee shall contact the person making there complaint/concern/grievance/request to assure him/her that it has been resolved."" The facility failed to follow their policy and procedure to investigate and resolve all complaints/concerns/grievances/requests promptly and provide feedback to the complainant. .",2015-06-01
10391,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2009-08-27,166,E,0,1,EK7F11,"Based on confidential resident group interview, staff interview, and a review of the resident council meeting minutes, the facility failed to ensure residents' complaints, about wandering residents and timely response to call lights were, adequately addressed in order to resolve grievances, including those with respect to the behavior of other residents. Resident identifiers: Withheld due to request for anonymity. Facility census: 64. Findings include: a) Call lights During the confidential resident group meeting on 08/24/09 at 1:30 p.m., eight (8) of (15) fifteen residents in attendance indicated call lights were not responded to in a timely manner by staff. Four (4) residents reported having complained to various staff members about the problem. The residents indicated that, sometimes, they had to wait up to forty five (45) minutes before staff responded, or staff would come into the rooms and shut off the lights, telling them they would return later, and then did not do so. Two (2) of the residents indicated they had experienced incontinence episodes as a result of delays in receiving assistance from staff. Two (2) of the residents indicated their complaints were not included in the resident council meeting minutes, as they quit complaining because the issue had been a problem for a long time and was never adequately addressed. b) Wandering residents During the confidential resident group meeting on 08/24/09 at 1:30 p.m., eight (8) of (15) fifteen residents in attendance indicated there were several residents in the facility who wandered into other residents' rooms. They said the facility tried stop signs and barriers on their doors, but this did not work. They said staff responds slowly to call lights and, by the time staff came, the residents wandered out of their rooms. One (1) resident said the wandering residents would take items, climb into other residents' beds, and would not leave when asked. The residents indicated staff at the facility was told of the problem, but it did not seem like anything had changed. c) Review of the resident council meeting minutes, from June through August 2009, found complaints about wandering residents and the facility's plan to purchase ""gates"" to keep residents out of other residents' rooms. An interview with the director of nursing (DON, on the early afternoon of 08/27/09, found she had ordered one (1) gate, but it had not come in yet. She did not want to order any more until she could see if what she ordered would work. The DON also indicated that staff received training in July 2009 regarding wandering residents and behavior problems. She indicated that, currently, no formal method to address these problems was in place. Observation of the facility did not find any other types of barriers in use to keep residents from entering other residents' rooms. d) Review of the previous year's recertification citations (12/09/09) found the facility was cited for residents complaining about wandering residents, as well as a lack of promptness by staff in answering call lights. The facility's plan of correction to address these concerns included monitoring, on a monthly basis, staff's response times to call lights and redirecting wandering residents. .",2015-04-01
10681,SUMMERS NURSING AND REHABILITATION CENTER LLC,515170,"JOHN COOK ROAD, PO BOX 1240",HINTON,WV,25951,2011-09-13,166,D,1,0,8CVP11,". Based on review of the facility's grievance / concern forms, medical record review, and staff interview, the facility failed, after receiving a complaint / grievance, to make prompt efforts to resolve the grievance and to apprise the resident / family of progress toward resolution. On 05/11/11, the daughter of Resident #56 alleged the resident was missing his hearing aids and an IPOD (a portable media player). The facility addressed the missing hearing aids but failed to identify how they would address and resolve the grievance concerning the missing IPOD. This was true for one (1) of ten (10) records reviewed. Resident identifier: #56. Facility census: 110. Findings include: a) Resident #56 Review of the facility's grievance / concern forms revealed a grievance received on 05/11/11 from Resident #56's daughter. The concern was described as follows: ""Spoke with POA (power of attorney) via telephone regarding hearing aids that were lost sometime near his admitted . This SW (social worker) spoke with patient who validated this complaint. POA also voiced that IPOD is missing - was a larger (older model) grayish is color."" The actions taken to resolving this concern were: ""Provided 'listening ears' temporarily to patient while awaiting audiology appt. (appointment) & fitting for replacement hearing aids."" In response to the question ""Was the grievance / complaint resolved?"" was written: ""Provided 'listening ears' and patient does not utilize. Pt. (patient) given appt with (name of company to provide exam) June 29th. Will attempt to arrange sooner appt."" The grievance concern form was signed by the corporate social worker on 05/13/11. There was no documentation on this form as to the status of the missing IPOD or the facility's plans to address / resolve that concern. The documentation provide on the grievance/concern form addressed only the missing hearing aids. Further review of this grievance / concern form revealed the following documentation from Employee #57, a newly hired social worker, on the back of the grievance / concern (dated 06/22/11): ""This social worker contacted (name of daughter) to remind her of (name of company to conduct audiology exam) coming in on June 29th to evaluate and replace hearing aid. In regards to the IPOD missing (name of daughter) does not wish for us to replace it at this time. She has replaced it herself and has asked nursing to keep it locked up at night."" During an interview with Employee #57 at approximately 11:45 a. m.. on 09/12/11, she stated she had called the daughter on 06/23/11 to follow up on the grievance / concern voiced by the daughter on 05/11/11. Employee #57 verified she was not employed at the time the initial grievance was made on 05/11/11. She was unable to provide any evidence to reflect efforts by the facility to search for the missing IPOD or any evidence the daughter was contacted and advised of the status of the IPOD before her call on 06/23/11. On 09/13/11 at approximately 11:45 a.m., the grievance was discussed with the facility's administrator and director of nursing. No further information was provided. The purchase of a new IPOD by the resident's daughter did not eliminate the facility's responsibility to address the missing IPOD when they became aware on 05/11/11 and to provide prompt feedback to the daughter as to the facility's plan for the resolution of the grievance.",2015-01-01
10742,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2011-08-25,166,E,1,0,36XK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's grievance / complaint reports, family interview, resident interview, and staff interview, the facility failed to make prompt efforts resolve grievances. There was no evidence of a thorough investigation into grievances filed by (or on behalf of) two (2) of six (6) sampled residents and four (4) random residents identified through a review of twenty-two (22) grievance reports reviewed. Resident identifiers: #136, #7, #158, #106, #24, #31, and #137. Facility census: 154. Findings include: a) Resident #136 Review of grievance / complaint reports found a report filed by a family member dated 07/05/11, stating (quoted as written): ""Daughter reported concerns of the resident in the room next to her mother and her screaming all of the time. ..."" Under the heading ""Documentation of Facility Follow-up"", and in response to the question ""What other action was taken to resolve this concern (be specific)?"", the author wrote: ""Informed (name of family member filing complaint) we were working /c (with) (name of Resident #155) & collaboration /c Admin, DON (director of nursing),Soc Serv & myself."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""... 3) (name of family member filing complaint) was advised of above re (regarding) (name of Resident #155)."" The author also noted she had a one-to-one conversation with the persona filing the complaint about this resolution on 07/08/11. An interview was conducted with the family member on 08/24/11 at 2:00 p.m., she stated the grievance regarding the resident in the next room (#155) was still an issue, that there had been no resolution of this issue, and that the residents in the vicinity of the room of this resident were complaining. According to the family member, this has been an on-going unresolved issued for the past six (6) weeks. In an interview on 08/25/11 at 11:00 a.m., the director of nursing (DON) and the unit manager reported the facility had implemented measures to address Resident #155's screaming, but nothing seems to work. They stated they could not discuss the specific measures with the family member, but they agreed this grievance has not been resolved. This interview also revealed the facility had not conducted any investigation to see whether the noise level associated with Resident #155's screaming was uncomfortable / disruptive to other residents in the vicinity (beyond Resident #136). Although the above note grievance / complaint report was marked to indicate the concern was resolved, it was, in fact, not resolved and present ongoing concerns to Resident #136. -- b) Resident #7 Review of grievance / complaint reports found a report filed by a family member dated 08/05/11, stating this resident was missing two (2) gowns and some white plastic hangers with the resident's name on them. Under the heading ""Documentation of Facility Follow-up"", the unit manager and housekeeping supervisor were identified as the persons designated to take action on this concern. All of the other sections of the form under follow-up were blank. There were no details of what action(s) was (were) taken to resolve the concern. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Facility was searched, laundry staff interviewed. Unable to locate the clothing. Will see if the facility will replace."" There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- c) Resident #158 Review of grievance / complaint reports found a report filed by a family member dated 08/04/11, stating she was missing a pair of pants with small brown checks, a pair of yellow Capri pants, and a pullover sweater with short sleeves. Under the heading ""Documentation of Facility Follow-up"", the housekeeping supervisor was identified as the person assigned to take action on this concern on 08/05/11, and the concern was to be resolved by 08/12/11. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Facility was searched, unable to locate missing items. Will see if the facility will replace."" There was no evidence to reflect the resident or representative was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing items. -- d) Resident #106 Review of grievance / complaint reports found a report filed by the resident dated 07/27/11, stating: ""She stated she does (symbol for 'not') get her things back from laundry. When they bring her clothes back, they just put them anywhere. Other peoples clothes are put in different closets."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""Had a new girl working in laundry and she was putting the clothes in the wrong closets other laundry aids sorting them out. This documentation provided an explanation as to what happened, but there was no indication as to whether the facility actually found the resident's missing clothes. -- e) Resident #24 Review of grievance / complaint reports found a report filed by a family member dated 07/06/11, stating a cup containing six (6) rings (""good costume jewelry"") at her bedside that missing since 07/01/11. Under the heading ""Documentation of Facility Follow-up"", no individual staff member had been designated as responsible for taking action on this concern; instead, the author of the report noted (quoted as written): ""Asked Staff to watch for these Items."" The date this action was assigned was 07/06/11, and the date to be resoled was 07/07/11. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form did not check either ""Yes"" or ""No"". All that was written in this section was: ""Rings have (symbol for 'not') been located."" During an interview with Resident #24 on 08/25/11 at 2:00 p.m., she stated they never did find her rings. She stated she knew she put them in a cup on her bedside table before she went to sleep. When asked if the facility ever got back with her about the rings, she said she had never heard anything since she reported them missing. -- f) Resident #31 Review of grievance / complaint reports found a report filed by the resident dated 06/09/11, stating she was missing a black hoodie. Under the heading ""Documentation of Facility Follow-up"", the unit manager and ""ESD"" (environmental services director) were identified as the persons designated to take action on this concern, with the concern assigned on 06/09/11 and the date to be resolved identified as 06/16/11. In response to the question ""What other action was taken to resolve this concern (be specific)?"", the author wrote: ""Checked with laundry."" Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""Yes"" and noted (quoted as written): ""Facility was searched, unable to locate hoodie. Will see if facility will replace."" There was no evidence to reflect the resident was notified of the resolution, and there was no indication as to whether the facility actually replaced the missing item. -- g) Resident #137 During an interview with Resident #137, he informed this surveyor that he was not able to find his Kindle (brand-name of a wireless electronic reading device or ""E-reader""). He stated it has been missing since 08/11/11; he reported the missing E-reader to staff a couple weeks ago, but staff still hasn't found it. He stated he fell asleep and he had it in his bed. When he woke up, they changed his sheets, and he thought that maybe it got wrapped up in his sheets. He stated he has checked with the laundry, and they have not found it. He stated he called the police today (08/24/11) and reported it. Resident #137 stated the device cost him over a hundred dollars and he had about fifty (50) books on it that he had bought. He had the two (2) nursing assistants on duty that night to look for it. He stated another nursing assistant came in at shift change, and he helped look. The nursing assistants were aware of the missing electronic device, but they did not report it to the nurse to pursue an investigation. - Review of the facility's grievance / complaint reports for the past three (3) months found no report recording the resident's complaint regarding the missing E-reader. The administrator was questioned about this at 4:15 p.m. on 08/24/11. He stated he would ask the nurses on the unit if they had the complaint form, because they are the ones who do them. On 08/25/11, a copy was provided of a grievance / complaint report dated 08/15/11, which recorded the following concern (quoted as written): ""Reports Loss of E-Reader the last of last wk."" Under the heading ""Documentation of Facility Follow-up"", ""All Departments"" were identified as the persons designated to take action on this concern, with the concern assigned on 08/15/11 and the date to be resolved identified as 08/26/11. In response to the question ""What other action was taken to resolve this concern (be specific)?"", the author noted (quoted as written): ""Questioned (name of resident) if he could have left this somewhere out of Facility. He reports was out of case laying in his room - when he last saw it."" The author also noted all departments were notified, all second floor staff was notified and all department managers were to be notified in the morning. Under the heading ""Resolution of Grievance / Complaint"", in response to the question ""Was the grievance /complaint resolved?"", the person completing the form checked ""No"" and wrote: ""Unable to find missing E-Reader. 8/24 - (Name of resident) filed a report /c (with) Hunt. ([MEDICAL CONDITION]) Police Dept."" There was no written investigation, nor were statements obtained from staff about the missing E-reader. The information the resident reported to this surveyor (about the device being in his bed when he last saw it and then being gone when he woke up), which he had also told the nursing assistants the night the device went missing, was not included in the grievance / complaint report. During an interview with Employee #157 (a nursing assistant) on 08/24/11 at 5:30 p.m., he said he looked for the device and verified the resident reported it missing on 08/11/11. When asked to whom he had reported the resident's complaint about the missing device, he said everyone knew about it and all of the nurses knew. He stated he has picked things up out of the resident's trash can beside his bed many times, where he drops items, and he thinks he may have dropped it in the trash. Employee #175 verified that, when the resident reported this missing, he said had it in bed with him at that time. The administrator, when subsequently interviewed about the facility's practice of replacing missing items, stated that sometimes they do if the family buys something new; they just bring in a receipt. He said that, if the residents have the missing items on their inventory lists, he will replace them, but they do not replace everything that comes up missing. He was not sure if they kept records of what they replaced and the reasons why they chose not to replace certain items. There was no records of these actions provided to the surveyor at the conclusion of this survey on 08/25/11. .",2014-12-01
10889,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,166,D,1,0,LRYJ11,". Based on observation, staff interview, review of the facility's grievance / concern records and self-reported allegations of abuse / neglect, and record review, the facility failed to make prompt efforts to resolve grievances reported by a family member on behalf of one (1) of six (6) sampled residents. A family member requested that Resident #36 be taken to the dining room for all meals. The family had visited the facility and found the resident was not taken to the dining room. This concern was investigated and validated by the facility, and staff instructed to take the resident to the dining room. Review of the facility's complaint records found the family then came in less than one (1) week later and had filed the same grievance. The facility again investigated this and recorded as a resolution: ""Resident will be taken to the dining room for all meals. Family pleased with the outcome."" During an initial tour of the facility on when dinner was served on 07/18/11, observation found Resident #36 in the bed and being fed her dinner; she had not been taken to the dining room. Resident identifier: #36. Facility census: 113. Findings include: a) Resident #36 During the initial tour of the facility at 5:00 p.m. on 07/18/11, observation found Resident #36 in bed in her room. She was awake, mumbled words that could not be comprehended, and smiled when this surveyor spoke to her. After completing the initial tour of the facility, the surveyor went back down this resident's hall found Resident #36 was still in bed. Her evening meal tray was sitting beside her TV on her bedside table at 5:30 p.m. with the lid on it and plastic wrap covering the drinks and fruit. Employee #107 (a nurse aide) came into the resident's room, moved the tray over to the bed, sat down beside the resident, and began to feed her. The resident was fed and did not perform any part of the eating tasks herself. The surveyor questioned Employee #107 at 6:00 p.m. on 07/18/11, about the resident eating in bed. Employee #106 stated she does not always have this resident on her assignment, but sometimes she does. She stated this resident eats in her room sometimes, and sometimes she eats in the dining room. Review of the facility's records of self-reported allegations of abuse / neglect found this resident's daughter stated her mother was not taken to the dining for breakfast on 06/29/11. The facility reported this as an allegation of neglect, investigated the incident, and determined the allegation was substantiated, as the resident was not taken to the dining room. Corrective action by the facility stated: ""All staff in-serviced on if residents are willing to go to the dining room they must go. This includes residents assisted with their meals."" A mandatory in-service was conducted and this was discussed with staff. Review of the facility's grievance / concern records found that, seven (7) days later (on 07/06/11), Resident #36's daughter filed a grievance stating she wanted the resident taken to the dining room for all meals. The daughter had come in for breakfast, found the resident was not in the dining room, and stated that if she had not come in, staff would not have taken her. According to documentation on the concern form, a care plan meeting was held, and this concern was discussed. Additional documentation on the concern form stated: ""The resident will be taken to the dining room for all meals including breakfast. Tray will be delivered directly to the dining room. Will be placed on 24 hour report to verify follow through."" The person completing the form noted this concern was resolved, the resident will be taken to the dining room for all meals, and the family was pleased with the outcome. Review of the resident's current care plan found the following intervention: ""Meals in the dining room when appropriate."" She also had an intervention that stated: ""Meals in dining room most days and meals."" The director of nursing (DON - Employee #82) was questioned about this issue at 2:00 p.m. on 07/19/11. When she was made aware that Resident #36 was observed eating dinner in bed in her room on the prior evening and that she was not in the dining room, the DON stated the resident was sometimes hard to wake up and staff could not transfer her safely. According to the DON, Resident #36 was a large lady and required the assistance of two (2) staff members for transfers; she can stand and pivot but at times, but staff cannot get her to do that because she refuses to get up, and when she is having these type of issues, the staff leaves her in bed and feeds her there. When asked for documentation to verify this, the DON was unable to produce this. She agreed the complaint resolution stated the resident would receive ""all meals in the dining room"" and, if this was not done, the facility needed to record the reason or communicate this with the family. .",2014-11-01
10975,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,166,D,1,0,K8MG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and review of the complaint / concern and abuse files, the facility failed to make prompt efforts to resolve the grievances voiced by or on behalf of residents, including those with respect to the behavior of other residents, for one (1) of fourteen (14) sampled residents whose family filed a complaint. On 05/31/11, Resident #95's family member voiced a complaint to staff regarding Resident #95's fear of her roommate (Resident #119), and the facility did not make prompt efforts to address these concerns. Resident #119's abusive behaviors toward others (including Resident #95) continued until 06/02/11, when Resident #119 threw an object at Resident #95, and Resident #95 sustained a laceration requiring emergency room (ER) treatment. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - ""Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor."" - On 05/31/11 at 3:15 p.m. - ""Roommates continue to argue. Assisted resident to nurses desk to ensure safety."" - On 05/31/11 at 5:20 p.m. - ""Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict."" - On 06/02/11 at 7:00 a.m. - ""Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval. "" On a change in condition documentation form dated 06/02/11 was written (quoted as written): "" 6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures. "" - On 06/02/11 at 12:00 p.m. - "" Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches. "" --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). -- 2. Further review Resident #119 ' s medical record found multiple entries in her nursing notes documenting the resident ' s physically and verbally abusive behavior toward staff and other residents (including Resident #95) leading up to Resident #119 ' s admission to the hospital for inpatient psychiatric services on 05/11/11. Upon her return to the facility following this hospitalization on [DATE], Resident #119 was readmitted to the same room with Resident #95. Resident #119 ' s abusive behaviors toward others (including her roommate) continued - including incidents of physical aggression toward Resident #95 on 05/31/11 - until she was readmitted to the hospital for inpatient psychiatric services on 06/02/11. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found the following entries (quoted as written): - On 05/24/11 at 4:15 p.m. - "" admitted to skilled services of Dr. (name) for care ... "" - On 05/25/11 at 6:50 a.m. - "" Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid ' s faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roommate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident. "" - On 05/25/11 at 1:50 p.m. - ""Throwing Objects @ (at) Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up. "" - 05/26/11 at 10:00 a.m. - "" Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor. "" - 05/26/10 at 9:50 p.m. - "" ... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out. "" - 05/26/11 at 11:50 p.m. - "" Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor."" - 05/27/11 at 8:00 a.m. - "" ... Has been combative /c staff since re-admit from psyche. ... "" - 05/27/11 at 10:15 a.m. - "" Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician."" - 05/28/11 at 10:00 a.m. - "" Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor. "" - 05/30/11 at 9:00 a.m. - "" Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM. "" - 05/30/11 at 1:00 p.m. - "" Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway. "" - 05/30/11 at 1:15 p.m. - "" Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her. "" - 05/30/11 at 1:30 p.m. - "" Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members. "" - 05/30/11 at 4:10 p.m. - "" Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident. "" - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway. "" - 05/30/11 at 10:00 p.m. - "" Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor. "" - 05/30/11 at 11:30 p.m. - "" Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor. "" - 06/02/11 at 12:30 p.m. - "" N/O noted to send (hospital) ER for medical clearance for psych family aware. "" - 06/02/11 at 1:00 p.m. - "" OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych. "" --- c) An interview on 06/28/11 at 10:00 a.m. the administrator reviewed the nursing notes for Resident #95 for 05/31/11 and denied any prior knowledge of the grievance made on behalf of Resident #95 or the incidents reflected in the nursing notes for that day. He provided a statement, on 06/28/11 at 4:40 p.m., to include this same information. -- d) In an interview with Resident #95's daughter on 06/28/11 at 4:15 p.m., she confirmed having filled out a report on 05/31/11 regarding her mother's roommate (Resident #119) standing over her, ""pulling her hair"", and saying, ""You stole my husband."" She and the nurse (Employee #41) and took the report to the social worker (Employee #39). According to the daughter, Employee #39 told her they were full to capacity and there was no where to put her. She said the administrator called her at 7:30 a.m. on 06/28/11 and wanted to discuss this with her, and she came into the facility and spoke with him. -- e) Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statement obtained by the facility from the social worker on 06/28/11: ""I was not aware of an incident where resident's roommate had her hands around her neck and was yelling at resident. I was also not aware of an incident on the same day that an empty coffee cup was thrown at resident. Resident's daughter had talked about a room change based on cognitive functioning of the resident's roommate prior to the incident on 6-2-11. ..."" Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statements obtained by the facility on 06/28/11, all of whom attested to hearing Resident #95 ' s daughter expressing concerns about Resident #95 alleging to the daughter that her roommate (Resident #119) had tried to choke her (all quoted as written): - Employee #106 (medical records) - ""I was at the fax machine at Maple. (Resident #95's) daughter come to the desk & told (Employee #41) the nurse 'I don't know if this is true or not but mother said roommate tried to choke her last night.' (Employee #41) said would you like to file a grievance. (Employee #41) asked me for one. I couldn't find 1 so (Employee #108) reached into file cabinet & handed the grievance to the daughter. The daughter sat in the chair & (Employee #108) told her how to fill it out. She filled it out and asked what to do /c (with) it. (Employee #41) said to give to social worker. Daughter asked where that is & (Employee #41) said I will show you. (Employee #41) brought the daughter around the hallway towards social service office. Later on that day I asked her if she documented on it & told her she needed to. I asked her what the outcome was & she said the daughter said (Employee #39) said there were no empty beds."" - Employee #108 (licensed practical nurse - LPN) - ""Standing at nurses station on May 31, 2011. Dau (daughter) comes up to NS (nurses' station) & said that her mother had told that her room mate had choked her. I 'do not know if it really happened or not.' but mother is terrorized of her room mate. Gave her a grievance form to fill out. Hall nurse brought dau up to talk with (Employee #39). Came back to floor and said (Employee #39) had told her them we were full and could not do a room change."" -- f) Confidential interviews with staff, conducted in the presence of two (2) nurse surveyors on 06/28/11, revealed that, when Resident #119 was ready to return from the hospital for inpatient psychiatric care on 05/24/11, staff expressed concern to the admission coordinator that Resident #119 should not be returned to the room occupied by Resident #95, due to concerns for Resident #95 ' s safety. Confidential interviews with staff also revealed that the daughter ' s report, on 05/31/11, of her concerns about Resident #119 ' s behavior toward Resident #95 were discussed in one (1) or more morning stand-up meetings prior to 06/02/11, when Resident #95 sustained injuries after being hit in the forehead by an object thrown by Resident #119. The facility was aware of Resident #119 ' s abusive behaviors toward others (including Resident #95) and failed to implement measures to protect Resident #95 from harm. (See also citation at F224.) .",2014-10-01
11036,CLAY HEALTH CARE CENTER,515142,"HC 75, BOX 153",IVYDALE,WV,25113,2009-10-16,166,E,0,1,KJ9T11,"Based on resident interview, record review, confidential resident group interview, review of the resident council meeting minutes, and staff interview, the facility failed to make prompt efforts to resolve residents' grievances. This was evident for nine (9) of ten (10) residents in a confidential group meeting and two (2) of thirteen (13) sampled residents. Resident identifiers: #43 and #49 (identifiers of residents attending the group meeting are confidential). Facility census: 57. Findings include: a) Residents #49 and #43 Two (2) female residents reported a male resident on their hall allegedly made unwelcome sexual gestures toward them on many occasions which made them feel very uncomfortable; this problem was reported to the facility but had not been resolved. 1. Resident #49 During an interview with Resident #49 on 10/15/09 at 3:30 p.m., she stated the man next door grabs his ""privates"" through his clothing and shakes himself at her. When questioned, she said he did not expose flesh nor touch her in any way or talk to her. She said once a nurse saw him do this and told him to stop because it wasn't nice. She was unable to give a time frame as to when this last occurred, but she stated he had done this to her many times since she returned from the hospital in September 2009, and he had done this prior to that hospitalization as well. When asked if she told anyone about this, she replied, ""They all know about it"", and added she spoke to the administrator about it last week and complained to a nurse aide yesterday, who allegedly relayed it to a nurse in charge. When asked if she considered moving, she replied in the negative, citing another move with her health conditions was not good. 2. Resident #43 An interview with Resident #43, on 10/15/09 at 3:45 p.m., revealed she, too, was uncomfortable with this same male resident coming out into the hallway and making sexual gestures in front of her and her roommate. She said she and her roommate finally got fed up with it, and they complained to the administrator this week about the situation. 3. During an interview with the director of nursing (DON) on 10/15/09 at approximately 4:00 p.m., she said, most likely, Resident #49 is sitting at her doorway when the male resident comes out of his room and walks down the hallway past her. When asked about room changes, she explained Resident #43 had received a room change to her current room at her request and she did not want to move again. 4. During an interview with the administrator on 10/16/09 at approximately 9:00 a.m., she said Resident #49, Resident #43, and her (#43's) roommate had recently approached her with complaints about the male resident making sexual gestures that they disliked. She explained that interventions were in place, and this problem had been addressed in the male resident's care plan. She said the facility's newly hired social worker ended employment after only two (2) weeks, and the facility had been actively advertising for that position. In the interim, they have contracted a licensed social worker consultant whose first day of employment was 10/12/09 and who will work at the facility two (2) days per week until that position is filled. 5. Review of the male resident's care plan revealed a problem area, dated 09/10/09, related to him exposing himself to female residents and a goal of not exhibiting that behavior. -- b) During a confidential group interview with residents on 10/14/09 at 2:30 p.m., nine (9) of ten (10) residents in attendance reported not having enough daily activities and also reported not getting to go outside the facility on outings due to not having a van. One (1) resident reported there had not been any outings since her arrival in February. Residents said they have to get an ambulance for any appointments outside the facility if they do not have family or friends who can transport them. Review of the previous three (3) months' resident council meeting minutes revealed the request for a facility van was brought up during each of these meetings as follows: on 07/27/09, residents requested a Wal-Mart trip and a stop at a local fast food restaurant; on 08/31/09, residents had questions regarding when the van would be available; on 09/28/09, residents again brought up questions about the van. During an interview with the administrator on 10/15/09 at 12:15 p.m., she stated the old van was unsafe, so a new van was purchased in mid-August. However, they still have no title for this van, which was purchased from another state. During the exit conference with department heads on 10/16/09 at 12:00 p.m., the activity director reported their last activity outing occurred in May 2009 for the Geri Olympics. -- c) Absence of a cordless phone for resident use Review of the 09/28/09 resident council meeting minutes revealed a request for a cordless phone was discussed, as were ongoing plans to obtain one (1) for resident use. During the confidential group meeting on 10/14/09 at 2:30 p.m., residents reported a cordless phone had not yet been obtained. During an interview on 10/15/09 at 3:30 p.m., Resident #49 said she would like to have a cordless phone so she can make and receive phone calls in her room; currently, a resident must go to the nurse's station for phone calls or may take phone calls in the lounge, but this was not feasible for residents with little or no ability to travel independently to other locations. During an interview with the administrator on 10/15/09 at 12:15 p.m., she said they still had no cordless phone and will have to figure out how to tie it in with their phone system. She agreed bedfast residents were not able to make or receive phone calls unless they had their own phone or had a portable phone brought to them. .",2014-09-01
11110,PLEASANT VALLEY NSG. & REHAB C,515064,1200 SAND HILL ROAD,POINT PLEASANT,WV,25550,2011-04-21,166,D,1,0,SI9V11,". Based on interview with interviews with residents, staff, and visitors and record review, the facility failed to make prompt efforts to resolve grievances reported by residents with respect to the disruptive behaviors of their roommates. This was evident for three (3) of eleven (11) sampled residents, whose roommates were identified as having problem behaviors. Resident identifiers: #19, #37, and #46. Facility census: 96. Findings include: a) Residents #19, #37, and #46 1. Resident #19 When interviewed on the afternoon of 04/21/11, Resident #19 reported that her roommate (#39) exhibited behaviors that were disturbing to her, such as yelling out for family members or that she wishes to go home. When asked how staff addressed her roommate's yelling, Resident #19 reported that staff will come in and tell her she has to stay there and try to talk to her. 2. Resident #37 According to a visitor who wished to remain anonymous, when interviewed on the afternoon of 04/21/11, Resident #37 rarely spoke to others but she had, at times, spoken out to say she wished her roommate (Resident #13) would ""shut up"". According to the visitor, Resident #13 yells and makes noise that is disturbing to Resident #37. It was revealed, through other confidential sources, this issue had been brought to the attention of the staff but nothing had been done about it. Review of the facility's internal complaint records found no indication that Resident #37's concern with her roommate's behavior had been documented and addressed by administrative staff. 3. Resident #46 Resident #46 also shared a room with Resident #13. When asked if she had any concerns with her roommates, during an interview on the afternoon of 04/21/11, Resident #46 reported she found Resident #13's behavior to be disturbing. She said Resident #13 yells and makes noises most of the time. -- b) Review of the facility's complaint records for Residents #19, #37, and #46 found no mention of these residents having expressed concerns with the disruptive behaviors of their roommates. -- c) Interview with the administrator (Employee #2), social worker, (Employee #109), and admissions coordinator (Employee #110), on the afternoon of 04/21/11, revealed there was no documentation available regarding how the facility was addressing the residents' concerns about the disruptive behaviors of their roommates.",2014-08-01
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
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
2218,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2017-08-10,167,B,1,0,PUVN11,"> Based on random observation and staff interview, the facility failed to post and/or have readily accessible, the results of the most recent survey. This had the potential to affect any resident or visitor who desired to examine the most recent survey results. Facility census: 57. Findings include: a) Observation on 08/09/17 at 2:00 p.m. found the facility's survey results were kept inside a binder, and stored inside a wall-mounted container which was located on a wall in the main corridor leading to the residents' rooms. Upon inspection, it was found that the facility's most recent quality indicator survey, which concluded on 03/31/17, was not included in the survey book. On 08/09/17 at 2:15 p.m., an interview was completed with the administrator. She checked, then agreed that the most recent annual quality indicator survey result was not in the facility's survey book. The administrator said a resident once took the survey book and put it in a trash can. She said she found it by watching video surveillance tapes of the hallways to see who took it and its final location. She said she thought that the most recent annual quality indicator survey result had been filed inside the survey book. She then obtained a copy of that survey, with survey end date of 03/31/17, and placed it inside the facility's survey book.",2020-09-01
3823,GRANT MEMORIAL HOSPITAL,515045,117 HOSPITAL DRIVE,PETERSBURG,WV,26847,2016-05-11,167,C,0,1,2V8S11,"Based on observation and staff interview, the facility failed to post the results of the most recent survey in a place readily accessible to residents. This practice had the potential to affect all residents residing in the facility. Facility census: 13. Findings include: a) On 05/09/16 at 2:00 p.m., an observation of the survey findings posted in a blue folder on the bulletin board in the hallway revealed the latest survey results had a date of 02/20/14. According to State records, the facility had an annual survey ending (MONTH) 24, (YEAR). During an interview with Nurse Manager #23 on 05/10/16 at 8:30 a.m., she agreed the most recent survey results were not posted. She stated, We were surveyed in (YEAR) and I never noticed the most recent survey results were not posted for examination by residents. On 05/10/16 at 8:55 a.m., Nurse Manager #23 reported, The survey results for (YEAR) are up now on the bulletin board on the unit.",2020-07-01
4406,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2016-08-04,167,C,0,1,BBQT11,"Based on Resident Council President interview, staff interview, and record review, the facility failed to ensure the results of its most recent survey were posted in a place which made them readily accessible for review by residents and/or family members. The facility had a Survey Book located in its lobby; however, the results located in the book were not from the most recent survey. This practice had the potential to affect all residents residing in the facility. Facility Census: 58 Findings Include: a) An interview with the Resident Council President at 1:50 p.m. on 08/01/16 revealed she was not aware of where the current state survey results were posted. She stated that she had never really looked for them but she did not know where to look even if she wanted to. At 2:04 p.m. on 08/01/16, the state survey results were located in a three ring binder in the main lobby labeled, Survey Results for Ohio Valley Health Care. Review of the results located in the three ring binder found it contained the results from the facility's Quality Indicator Survey (QIS) completed on 07/11/14. The results of the facility's last QIS completed on 09/24/15, were not readily accessible for review. An interview with the Director of Nursing at 2:19 p.m. on 08/01/16 confirmed the results in the lobby were from the (MONTH) 2014 survey and not the most recent survey completed on 09/24/15. She stated that she would have to get those results and put them in the survey results binder kept in the main lobby for the residents and families to review.",2019-11-01
5146,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,167,C,0,1,PDA311,"Based on resident interview, observation, and staff interview, the facility failed to ensure residents and other interested persons were made aware of the location of the most recent survey results. In addition, the facility failed to ensure all persons were made aware the results were available for anyone to examine at any time. The posted sign indicating their availability required individuals to ask to see the results. This practice had the potential to affect all residents and other individuals who wished to examine the survey results. Four (4) of four (4) residents who were asked about the location of the survey results were unaware of their location. Resident identifiers: #24 #60, #55, and #40. Facility census: 55. Findings include: a) Resident #24 During an interview with the resident council president, on 06/16/15 at 4:30 p.m., the resident related she did not know the location of the survey results. b) Resident #60 An interview with Resident #60, on 06/16/15 at 7:06 p.m., revealed the resident did not know where to find the survey results. Review of the resident's most recent minimum data set (MDS) revealed a Brief Mental Status Score (BIMS) of fifteen (15), the highest possible score, which indicated the resident was cognitively intact. c) Resident #40 On 06/17/15 at 10:18 a.m., an interview revealed the resident did not know where to find the survey results. Review of the resident's most recent MDS revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact. d) Resident #55 When asked on 06/17/15 at 1:17 p.m., the resident did not know where to find the survey results. Review of the resident's most recent MDS revealed a BIMS score of fifteen (15), which indicated the resident was cognitively intact. e) An observation, on 06/18/15 at 10:21 a.m., revealed a corporate sign on the bulletin board in the front hallway, which read, This center has reports of surveys, certifications and complaint investigations for the preceding three years available for any individual to review upon request. Please see the administrator to inquire. The book containing the survey results was found on a table on the other side of the wall; however, there was no signage present which indicated its location and/or that it was accessible for review without asking staff. f) An interview with the administrator on 06/18/15 at 10:48 a.m., confirmed the signage indicated the results of the surveys could only be obtained upon request. It was not a sign which indicated the availably and location of the survey results.",2019-03-01
5230,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,167,B,0,1,76WG11,"Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on the wall at a height not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 160. Findings include: a) An observation on 07/22/15 at 1:35 p.m., revealed the survey results book was located in a plastic holder that hung against a wall in the front lobby. The book was too high for residents in a wheelchair to reach. On 07/22/15 at 3:07 p.m., the Nursing Home Administrator agreed the survey book was not located at a height accessible to a resident in a wheelchair. She stated the survey book would be moved to a location accessible to residents in wheelchairs.",2019-02-01
5344,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2015-01-28,167,B,0,1,11X211,"Based on observation and staff interview, the facility failed to post the annual survey results in a prominent and readily available area where residents and families may access without asking for assistance. This practice had the potential to affect more than an isolated number of residents. Facility census: 64 Finding include: a) Observation on 01/20/15 at 3:30 p.m. revealed the results of the past annual survey were located on the wall at the nursing station. They were located high on the wall, behind a tall medication cart. b) An observation and interview with Employee #78, on 01/28/15 at 3:30 p.m., indicated a resident in a wheelchair would not be able to reach the annual survey results without difficulty. Facility personal moved the survey results to a more accessible location for residents.",2019-01-01
5369,MEADOW GARDEN,515121,606 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2015-06-25,167,B,0,1,1EZS11,"Based on observation and staff interview, the facility failed to ensure a notice of the results of the most recent survey and any plans of correction were in a place readily accessible to residents. The survey results book was located on a wall at a height that was not accessible to residents in wheelchairs. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) An observation on 06/24/15 at 9:00 a.m., revealed the survey results book was located on the wall in front of the nurse's station. The book was placed in a plastic holder that was too high for residents in wheelchairs to reach. On 06/25/15 at 1:33 p.m., a second observation of the survey results book revealed it was still located at a height that was not accessible to residents in wheelchairs. At 1:45 p.m. on 06/25/15, Director of Nursing #68 agreed the survey book was located at a height that was not accessible to residents in wheelchairs. She said she could move the survey book to a lower level which would make it easier to view if someone was in a wheelchair.",2019-01-01
5571,PRINCETON HEALTH CARE CENTER,515187,315 COURTHOUSE RD.,PRINCETON,WV,24740,2015-10-07,167,C,1,0,52YO11,"Based on observation and staff interview, the facility failed to ensure the results of the most recent survey were posted. In addition, the facility also did not post a notice of the availability of the survey results. This had the potential to affect all residents in the facility. Facility census: 118. Findings include: a) On 10/06/15 at 1:00 p.m., observation of the survey results book revealed the book contained survey results from 2009, 2010, and 2011. The most recent survey results were not in the survey book. The facility's most recent survey was conducted on 02/19/15. At 1:30 p.m. on 10/06/15, Registered Nurse (RN) #6 and Social Worker (SW) #152 agreed the results of the most recent survey were not posted in the survey results book. On 10/07/15 at 1:12 p.m., an observation of the survey results book revealed a blue three (3) ring binder was used as the survey results book. The book was located in a wooden rack mounted on the wall. A notice of the location of the survey results book was not posted anywhere in the facility, to let the residents or visitors know where they could locate the results. SW #152 agreed the facility did not have a notice posted identifying the location of the survey results.",2018-10-01
5788,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2014-10-07,167,C,0,1,U60O11,"Based on observation and staff interview, the facility failed to make the results of the most recent survey of the facility conducted by Federal or State surveyors readily accessible to residents. In addition, there was no notice of their availability. This had the potential to affect all residents and visitors. Facility census: 132. Findings include: a) During the general tour of the facility, at 10:40 a.m. on 09/29/14, there was no evidence near either of the first floor entries, of a posting which described the location of the most recent survey results. b) Manuals containing survey results were located near the nurses' stations on each unit, although none of them were up to date. Three (3) of them contained results of a complaint survey on 05/28/13, the most recent Quality Indicator Survey (QIS) completed on 06/06/13, and a life safety survey on 06/05/13. One (1) did not contain the 06/06/13 QIS survey results. c) At 4:00 p.m. on 09/29/14, a manual was located on a bookshelf in a lobby area at the first floor entry near the business office. It was labeled as 2013 Survey Results. It contained results from 06/05/13 Life Safety Survey, 05/28/13 Complaint Survey, 10/27/11 Revisit Survey, and 07/27/2011 Annual Survey and complaints. It did not contain the results of the most recent QIS survey on 06/06/13. d) None of the manuals found included the results of the previous four (4) complaint surveys dated: 07/25/14, 05/16/14, 02/20/14, or 11/06/13. During an interview with the Administrator, at 10:00 a.m. on 09/30/14, she offered a sixth manual which she said was kept in her office and contained all results except these four (4) complaints. She stated someone must have removed the missing survey results from manuals and she did not think Complaint surveys needed to be included. .",2018-07-01
6066,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2015-06-12,167,C,1,0,J3JQ11,"Based on observation, review of the State Operations Manual (SOM), and staff interview, the facility failed to ensure a notice of the results of the most recent survey, and any plans of correction, were in a place readily accessible to residents. The facility notice of survey results was posted at level that residents in a wheelchair could not read. In addition, a request had to be made to review the results with instructions to see the Administrator. This practice had the potential to affect all residents/responsible parties/public. Facility census: 67. Findings include: a) A random observation revealed, on 06/10/12 at 11:42 a.m., a sign posted in the entrance hallway which read This center has reports of surveys, certifications and complaint investigations for the preceding three years available for any individual to review upon request. Please see the administrator to inquire. Per the Social Security Act at 42 U.S.C. (United States Code) 139r. A review of the SOM, on 06/10/15 at 12:15 a.m., revealed A resident has the right to examine the results of the most recent survey of the facility In the guidance to surveyors the SOM states the results of the most recent survey means the Statement of Deficiencies (2567) and the Statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys, and any deficiencies resulting from any subsequent complaint investigation(s). In addition, the guidance states . and are available to residents without having to ask a staff person . where individuals wishing to examine survey results do not have to ask to see them. On 06/10/15 at 2:10 p.m., in an interview with the administrator and the director of nursing, both agreed the sign was posted too high for residents in a wheelchair to see and/or read. Both also agreed the survey results should be available to any one interested in reviewing the survey results without having to ask staff.",2018-05-01
6174,MILETREE CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2014-09-23,167,B,0,1,577211,"Based on observation, resident interview, and staff interview, the facility failed to make survey results of Federal and State surveys readily accessible to residents. The facility posted the survey too high for a person sitting in a wheelchair to reach This had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) Upon initial entry into the facility, on 09/14/14 at 4:15 p.m., the survey results were observed attached to the wall at a height too high to be accessible to a person sitting in a wheelchair. On 09/17/14 at 2:25 p.m., a resident who was sitting in a wheelchair was asked to attempt to reach the survey results. The resident was unable to obtain the survey results. At 3:45 p.m., on this same date, the Administrator was made aware the survey results were not accessible to all residents. The next day the survey results were placed on the wall within reach of all residents.",2018-05-01
6358,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,167,C,0,1,OMIN11,". Based on observations, resident interview, and staff interview, the facility failed to post a sign informing residents of where the most recent State and Federal survey results were located. This practice had the potential to affect all residents who resided in the facility. Facility Census: 61. Findings include: a) On 05/21/14 at 4:30 p.m., Resident #3 was interviewed. Resident #3 was asked, Without having to ask, are the results of the state inspection available to read? Resident #3 replied, I guess they are. She was asked if she knew were the results were located, and she stated, I don't know. b) At 10:30 a.m. on 05/28/14, Resident #24 was asked, Without having to ask, are the results of the state inspection available to read? She replied, Well I guess they are. I have never asked. She was asked if she knew were the results were located and she replied, I don't know where they are located. c) Observation of the survey results was made on 05/23/14 at 1:00 p.m. The binder containing the survey results was positioned between the nurses' station and the dining room. They were hanging on a chain from the bulletin board. At this time, observations of the main lobby and other locations where additional resident information was posted, found no posted notice of the availability of the survey results. d) Employee #70, the administrator, was interviewed on 05/29/14 at 2:15 p.m. regarding the survey results. He stated the survey results were posted on the board beside the nursing station. He confirmed there were no notices posted in the facility about the availability of the survey results. He stated new admissions were given the information upon admission, but there were no notices posted.",2018-04-01
6494,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,167,C,0,1,3WT411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make the results of the most recent survey of the facility by Federal or State surveyors, and any plan of correction in effect, available for examination. The facility also failed to post a notice of the availability of the survey results in a readily accessible place. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 123. Findings include: a) Upon initial entrance to the facility on [DATE] at 9:45 a.m., the binder containing the survey results and/or notice could not be located. Employee #42, the director of nursing (DON) was approached about the inability of the surveyor to locate the survey results and/or the notice as to the location of the survey results. The DON said the results were in a black binder located in the bookcase in the front lobby. The binder had a small white label noting Survey. When asked where the notice indicating the location of the survey results could be located, the DON found the notice was obscured in a corner of the bookcase in the front lobby.",2018-03-01
6675,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-10-01,167,C,0,1,KBHF11,"Based on staff interview, and observation, the facility failed to ensure that survey results were readily accessible to residents. Survey results were posted too high for residents and/or visitors in wheelchairs to access readily. This had the potential to affect all residents and visitors using a wheelchair. Facility census: 87. Findings include: During an interview on 09/24/14 at 2:00 p.m., Resident #10 stated he did not know where the State inspection results were located. The resident was observed sitting in a wheelchair at the time of the interview. On 09/24/14 at 5:00 p.m., the resident was observed propelling his wheelchair in the hallway. During a tour of the facility on 09/30/14 at 1:50 p.m., the following was observed: -- On the first floor A and B hallways and on the second floor A and B hallways, the State inspection report was contained in a plastic sleeve which was attached to a bulletin board. -- The state inspection report was approximately 5 feet from the floor. -- Residents and visitors using a wheelchair would not be able to access the State inspection report without having to ask for staff assistance. The aforementioned observations were verified at the time of discovery by Activities Supervisor #136.",2017-12-01
6750,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2014-07-15,167,C,0,1,Q9U911,"Based on observation, resident interview, staff interviews, and documentation review, the facility failed to make available for examination the most recent standard survey results. This had the potential to affect all 36 residents at the facility. Facility census: 36. Findings include: a) During an interview on 07/08/14 at 10:25 a.m., the resident council president, Resident #2, stated she did not know where the results of the most recent survey were located. She said, I have never seen them. b) The monthly minutes, from the resident council meetings, were reviewed from January 2014 to June 2014. The minutes contained no evidence residents were informed of the location or availability of the most recent survey results. c) Observation at 10:25 a.m. on 07/08/14 found a sign, posted on the bulletin board across from the nurses' station, indicating the survey results were available at the nurses' station. d) On 07/08/14 at 10:30 a.m., the assistant activity director, Employee #40, was unable to locate the survey results at the nurses' station. e) At 10:35 a.m. on 07/08/14 a registered nurse, Employee #62, stated she thought the survey results were located in the blue room. Observation found a notebook located in the blue room, entitled survey results. Further observation of the found the facility's most recent survey, dated 01/31/13, was not in the notebook. Employee #62 stated she would call the administrator to see if she know where the survey results were located. f) At 10:51 a.m. on 07/08/14 the administrator confirmed the most recent survey results were not available for examination. The administrator placed a copy of the survey results from the survey dated 01/31/13 in the notebook.",2017-11-01
7049,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,167,B,0,1,GJXP11,"Based on observation and staff interview, the facility failed to ensure survey results and the approved plans of correction were available to residents without having to ask a staff person. An observation revealed residents in a wheelchair were not able to review the survey results without asking staff for assistance. This had the potential to affect more than a minimal number of residents. Facility census: 61. Findings include: a) On 09/12/13 at 3:15 p.m., an observation of the survey results book revealed it was located at a height of approximately five (5) feet. Any resident who could not stand or was confined to a wheelchair could not reach the book without having to ask staff to retrieve the survey results book. On this same day, the administrator was informed of this finding and agreed the survey results book was located at a height which made the survey results inaccessible to residents who could not stand or were confined to wheelchair without asking the staff for assistance. The survey results book was relocated to above the handrail in the administrative hallway prior to exiting the facility on 09/13/13 making it accessible to any resident without asking for staff assistance.",2017-09-01
7096,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,167,C,0,1,1ZMG11,"Based on observation, staff interview, and resident interview, the facility failed to ensure residents had the right to examine the results of the most recent standard survey. The facility had not posted a copy of the results from the most recent standard survey. This practice had the potential to affect all residents and/or their responsible parties. Facility census: 118. Findings include: a) On 09/16/13 at 4:00 p.m., the resident council president (Resident #61) indicated she did not know where the facility kept the survey results. At 4:30 p.m. on 09/16/13, observation revealed the facility did not have the results of the most recent standard survey in the binder labeled survey results. The administrator (Employee #66), was interviewed on 09/16/13. He confirmed the survey results were not in the binder, and indicated he would copy the results and place them in the binder.",2017-08-01
7359,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-07-22,167,C,0,1,MT7G11,"Based on random observation and staff interview, the facility failed to post a notice of the availability of the most recent survey results. In addition, the location of the survey results was not in a place in which individuals wishing to examine them could do so without having to ask for them. This practice had the potential to affect all residents. Facility census: 104. Findings include: a) Observation on 07/18/13 found no evidence of the facility's most recent survey results. There was no evidence of any posting that would alert residents and/or visitors as to the location of the survey results. On 07/18/13 at 2:45 p.m., the receptionist produced, when asked, a black, three-ring binder that was housed in a box at the reception desk. There was no writing on the side of the binder that was visible when the binder was in its box, to give any indication of its contents. At this time, the administrator was unable to locate any posting to tell where the survey book was located. She said they once had a posted sign indicating where survey results could be found, but removed it last week.",2017-05-01
7558,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2013-06-13,167,C,0,1,UM2S11,"Based on observation of survey result postings and through staff interview, it was determined a notebook with past survey results was in a location not easily accessible by residents. Additionally, a notice of where the survey results were located was not posted in a manner in which the whole document could be seen. This practice had the potential to affect all residents as all residents are to have access to this information. Census: 88. Findings include: a) On 06/11/13 at 1:20 p.m., the survey book which had previous survey results was observed to be in a location not easily accessible by the residents. As you entered the front door there was a little entry way. The survey book was located in a plastic pocket on the wall of this entry way which was not noticeable and was very high up on the wall. Residents would not have easily noticed this book, nor been able to reach it from wheelchair height. In an enclosed glass case where information was posted and visible when going down the main hallway, there was a note that stated survey results were located in a notebook in the main lobby. All of this note was not visible to the reader. The part of the note stating where the results were located was blocked by the frame of the glass case and could not be seen. This was verified with the administrator, Employee #91, at the time.",2017-04-01
7587,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2013-03-21,167,C,0,1,OKIC11,"Based on observation and staff interview, the facility did not ensure the residents had the opportunity to examine the results of the most recent survey of the facility conducted by the State surveyors. The facility had not posted the results of their most recent complaint investigation. This practice had the potential to affect all residents in the facility. Facility census: 60. Findings include: a) On 03/19/13 at 9:50 a.m., an observation of the facility's survey results book revealed the book did not contain the results of the most recent complaint investigation. The facility had a complaint investigation on 08/24/11 that resulted in four (4) D level deficiencies. The facility had not posted the statement of deficiencies associated with this complaint. On 03/19/13 at 10:00 a.m., the senior vice president (Employee #11) confirmed the survey results book did not contain the results of the 08/21/11 complaint investigation.",2017-03-01
7715,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,167,B,0,1,Q01G11,"Based on observations and staff interviews, the facility failed to make previous survey results available for review. Findings include: During a tour of the facility on 1/11/2013 at 9:15 AM with Maintenance Supervisor #65, survey results could not be located. Maintenance Supervisor #65 asked the facility Administrator where the results were posted. The Administrator went to a place on the wall where she said the survey results were supposed to be inside an open storage bracket mounted on the wall in the main hallway. She also noted that the notebook had a chain attached securing it to the wall. The Administrator said, I don't know where they are. I saw them there yesterday. You see the holes where they were attached. I will find them. No bracket or chain was observed. There were 4 holes noted in the wall. On 1/13/2013 at 9:20 AM, the survey results notebook was located inside the mail room inside the administrative offices.",2017-02-01
7804,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2013-03-07,167,E,0,1,22CL11,"Based on observation and staff interview, the facility failed to ensure survey results were posted in an easily accessible location. This practice had the potential to affect all residents and the public who might wish to have access to this information. Facility census: 33. Findings include: a) A copy of survey results were observed to be in a binder that was then placed inside a plastic device mounted on the wall across from the nursing station. This device was located very high on the wall and residents in wheelchairs would not be easily able to retrieve them for viewing if they so desired. This was discussed with Employee #6, the director of nursing for the LTC/SNF (Long term care/ Skilled nursing facility) unit on 03/05/13 at 2:15 p.m.",2017-01-01
8271,UNITED TRANSITIONAL CARE CENTER,515107,327 MEDICAL PARK DRIVE,BRIDGEPORT,WV,26330,2013-01-23,167,D,0,1,C0FX11,"Based on observation and staff interview, the facility failed to ensure it had posted a sign informing residents of where the state and federal survey results were located. This practice had the potential to affect more than an isolated number of the facility's residents. Facility census: 26. Findings include: a) On 01/22/13 at 1:00 p.m., an observation revealed the facility had a folder inside a plastic box mounted on the wall across from the nursing station. Further observation revealed the folder contained the survey results. Without inspecting the folder one would not have known it contained the results of the facility's last inspection. On 01/22/13 at 1:10 p.m., the director of nursing (Employee #10) agreed to put a sign on the plastic box notifying residents the survey results were inside the box.",2016-07-01
8298,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,167,C,0,1,TTVD11,"Based on family interview, observation, and staff interview, the facility failed to make survey results readily available to residents for examination, and failed to post a notice of their availability. This had the potential to affect all residents and families desiring to view this information. Facility census: 52. Findings include: a) Resident #54 During an interview with a family member of Resident #54, on 07/17/12 at 1:25 p.m., it was revealed he was unaware of the availability of the survey results and was not aware of where they were located. An observation was made of the facility, on 07/17/12 at 1:45 p.m A notice regarding the availability of the survey results was not found during this observation. On 07/17/12 at 1:50 p.m., Employee #22, the office manager, was interviewed regarding the location of the survey results. At that time, Employee #22 confirmed there was no notice of the availability of the survey results. Upon inquiry, this employee was unsure of the location of survey results, and stated they possibly are located at the nurses' station.",2016-07-01
8326,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2012-09-20,167,E,0,1,XHRZ11,"Based on record review, observation, and resident interviews, and staff interviews, the facility failed to post the most recent survey results and failed to inform residents of the location of survey results. A review of Resident Council meeting minutes from March 2012 through September 2012 revealed there were no notations regarding the availability of past survey results. On 09/19/2012 at 1:20 PM, an interview was completed with Resident #7. Resident #7 was identified as a resident who frequently participated in Resident Council meetings. Resident #7 stated that she was not aware of the availability of survey results. The resident stated, They might be down there by the telephone. There is a board down there with information hanging on it. On 09/19/2012 at 1:35 PM an observation was made of a bulletin board located across from the nurses' station on the second floor beside the elevator. Information observed on the board included a facility map and a Resident Right's poster. There were no State survey results found. An interview was completed with Nursing Assistant #63 (NA #63) on 09/19/2012 at 1:37 PM. NA #63 said that she was not aware of posting of State survey results. I haven't seen them. NA #63 asked another staff member who also said she did not know the location of State survey results, but this staff member made a phone call, then directed the surveyor to a second bulletin board. An observation of a second bulletin board outside the dining room was completed on 09/19/2012 at 1:40 PM. Survey results from 2009 were found tacked up on the bulletin board outside the dining room. The last survey had been completed in 2010. An interview was completed with Activity Assistant #48 (AA #48) on 09/19/2012 at 1:46 PM. AA #48 said, After the survey last year, we told them we had a survey and that there were results, but we wouldn't mention it every meeting. I don't think we would have told them in the last 8 or 9 months. The last time was probably after the last survey (2010). During an environmental tour of the facility on 09/19/12 at 12:16 P.M., with the facility Administrator and the Director of Maintenance, a clear plastic folder was observed to be tacked on a cork board just outside the dining room on the second floor. The folder contained a copy of the 2009 CMS-2567, the results of the 2009 annual survey. The facility Administrator verified the survey results posted were not the most recent. The Administrator stated there were also survey results posted on the first floor, however there were no residents residing on the first floor and residents residing on the second floor were not able to access the first floor information without assistance of the facility staff.",2016-07-01
8354,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2012-11-07,167,B,0,1,CDQ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and observations, the facility failed to ensure that survey results were accessible to all residents without having to ask. Findings include: Observations were conducted on November 5, 6, and 7, 2012, of a binder labeled Survey Results, located on a wall near the front entrance of the facility. The survey results were contained within a plastic holder, attached to the wall, approximately 5 and a half feet high. It did not appear that residents in wheelchairs would be able to reach the survey results without having to ask for assistance. Resident #20 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #20 on November 7, 2012. During the interview, the resident stated he was not aware of where the survey results were located and that he would have to ask staff. Resident #55 was admitted on [DATE], with [DIAGNOSES REDACTED]. An interview was conducted with resident #55 on November 7, 2012. During the interview, the resident stated that the survey results were too high for her to reach while in her wheelchair and that she would have to stand to access the survey results which she stated she was not able to do. An interview with the Recreational Director, staff #73, was conducted on November 7, 2012. Staff #73 stated that residents could ask the receptionist for assistance to access the survey results and agreed that residents in wheelchairs would not be able to reach the binder independently because they were located too high upon the wall.",2016-07-01
8550,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2012-03-15,167,B,0,1,17TQ11,"Based on the resident council president interview, observation, and staff interview, it was found the facility failed to post their survey results in a place readily accessible to residents, and failed to post a notice of their availability. The survey results were in a bookcase in the lobby, blending in with several books. This practice had the potential to affect any resident or family member wishing to examine the survey results without asking a staff member where they were located. Facility census: 66. Findings include: a) An interview conducted with the resident council president, on 03/13/12 at 9:30 a.m., revealed the resident council president did not know the location of the state survey results. The survey results were not found during an observation of the front lobby, on 03/13/12, at approximately 2:00 p.m., after the interview with the council president. During an interview with the interim Nursing Home Administrator (NHA), Employee #97, on 03/14/12 at 12:00 p.m., the location of the survey results was requested. The NHA located the survey results in the front lobby in a bookcase that contained many books and survey results book blended in with other books. There was also no notice posted of their availability. The NHA agreed the survey results were not posted in an area that was readily available to residents and families without asking staff for their location.",2016-05-01
8699,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,167,C,0,1,S3DJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to make available for examination and post in a readily accessible place a notice of their availability, the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. This practice had the potential to affect all residents and visitors wishing to review this information. Facility census: 57. Findings include: a) Upon initial entrance to the facility on [DATE] at approximately 10:45 a.m., a notice was observed in the entrance hallway on a board with other mandatory posting, stating survey results and information related to applying for Medicaid and Medicare could be found in the white binder in the front lobby. Employee #59 (front office personnel), when questioned, confirmed the front lobby was considered to be an area by the front door where two (2) chairs and a table were located. This area was searched, and no white binder was located. Employee #59, when subsequently approached about the inability of the surveyor to locate the binder of information, confirmed it was not in the designated location. This employee further stated residents sometimes carried the notebook off. In approximately fifteen (15) minutes, Employee #59 returned and had located the white binder. The necessary information was included, as stated in the posting on the information board.",2016-04-01
8897,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2012-03-29,167,B,0,1,EEP611,"Based on observation and staff interview, the facility failed to ensure the results of the most recent surveys were available for examination. The facility's survey results book did not contain the results of the last annual survey and subsequent complaint investigations which were completed after the last annual survey. This issue had the potential to affect more than an isolated number of residents. Facility census: 60. Findings include: a) On 03/28/12, observation of the facility's survey results book revealed the results of a revisit to a complaint investigation completed in August 2011. According to the Centers for Medicare and Medicaid Services (CMS), results of the most recent survey means the statement of deficiencies (HCFA-2567) and the statement of Isolated Deficiencies generated by the most recent standard survey and any subsequent extended surveys and any deficiencies from any subsequent complaint investigation(s). On 03/19/12 at 9:00 a.m., the executive director (Employee #72) said she had taken out the last resurvey results and other complaints and agreed the only thing in the book was the result of the 08/16/11 complaint revisit.",2016-03-01
8917,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,167,C,0,1,NP7N11,"Based on observation and staff interview, the facility failed to ensure the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect were accessible to residents. The failure to place the survey results in a place that made them readily accessible to residents had the potential to affect all facility residents. Facility census: 90. Findings include: a) On 12/07/11, at approximately 5:00 p.m., a tour of the facility revealed a sign on unit one (1) which stated survey results were available in the lobby. After touring the lobby area these results were not located. On 12/07/11, at approximately 5:10 p.m., Employee #128 (telephone operator) indicated the survey results were on her desk. She said they were moved there after the Christmas decorations were put up in the lobby. Employee #128 then moved the survey results (Statement of Deficiencies (HCFA-2567)) to a table where they were readily accessible to residents.",2016-03-01
8968,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,167,B,0,1,VDMM11,"Based on observation and staff interview, the facility failed to ensure all survey results were available for examination, and posted in a place readily accessible to residents. The survey book was in a container on a wall in the dining room that was not accessible to residents in wheelchairs who were unable to stand. In addition, the book did not contain the results of the three (3) most recent complaint investigations. This had the potential to affect more than a limited number of residents. Facility census: 42. Findings include: a) On 04/23/14 at 1:00 p.m., the survey book was reviewed. The annual recertification survey, dated 09/27/12, was the most recent survey filed in the survey book. The reports for the three (3) complaint investigation surveys (abbreviated surveys) conducted since 09/27/12, were not filed in the survey book for residents and/or visitors review. All three (3) of the complaint investigations had deficient practices cited. On 04/23/14 at 1:40 p.m., the administrator acknowledged the complaint investigations completed since the annual recertification survey were not filed in the survey book. She located copies of the three (3) complaint investigation surveys, dated 11/30/12, 10/17/13, and 01/16/14, and filed them in the survey book. b) Observations, on 04/24/14 at 1:00 p.m., found the survey results were located in the dining room. The book containing the results was in a file holder attached to the wall. The file holder was mounted above the height of a resident's head, if he/she were sitting in a wheelchair. At 1:27 p.m. on 04/24/14, the social worker (Employee #35), agreed the survey results were posted at a height too high for all residents to access. On 04/29/14 at 3:35 p.m., an interview was conducted with the director of nursing (DON). She said all surveys, which included annual surveys and complaint investigation surveys, were supposed to be made available and easily accessible for review by residents, visitors, or staff. She acknowledged the survey book, which was kept on the dining room wall, was too high for residents in wheelchairs to reach.",2016-03-01
9231,"ROANE GENERAL HOSPITAL, D/P",515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2011-06-08,167,C,0,1,O68G11,"Based on observations and staff interview, the facility had failed to post a notice of the availability of the most recent survey results. This has the potential to affect all residents and visitors. Facility census: 31. Findings include: a) Observations by the surveyor, on 06/07/11 at 10:30 a.m., did not find any survey results of the most recent survey available for review by residents and visitors. When staff at the nursing station was asked where the survey results were posted, they were unaware of the location as well. At 10:40 a.m. on 06/07/11, a registered nurse (Employee #26) informed the surveyor that the information was in a notebook on a bookcase in the activity / dining room area. Subsequent observation of this area found all types of books, such as reading novels, etc., on this bookcase for resident access, including the survey results. There was no signage posted to inform residents or visitors where this information could be located for review.",2016-01-01
9569,TEAYS VALLEY CENTER,515106,590 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2011-07-14,167,C,0,1,L3JB11,"Based on observation and staff interview, the facility failed to ensure survey results were accessible and available to residents. This practice had the potential to affect all residents and visitors. Facility census: 114. Findings include: a) On 07/11/11 at approximately 11:45 a.m., observation revealed the survey results were not accessible and available for review. The maintenance supervisor (Employee #89) also verified the survey results were not available for review. Employee #89 stated he would locate the survey results book and put it out in a prominent place for residents and others to review. On 07/14/11 at approximately 10:00 a.m., a visitor to the facility had requested to view the survey results book. The book was not accessible to the visitor, and the visitor had to ask someone at the facility to locate the survey results. The administrator said he would locate the survey results for the visitor.",2015-10-01
9659,GRANT COUNTY NURSING HOME,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2010-08-24,167,B,0,1,GDQ711,"Based on resident interview, observation, and staff interview, the facility failed to make readily accessible to all residents wishing to review the results of the most recent survey of the facility conducted by State surveyor and any plan of correction in effect. The survey results were kept out of reach of residents who were wheelchair-dependent, with no posting to direct residents to their current location in the facility. Facility census: 110. Findings include: a) Interview with Resident #9, on 08/16/10 at 1:50 p.m., found she did not know where the survey results were kept. Observations, made on 08/24/10 at 1:00 p.m., failed to find the survey results that were supposed to be located at the front nurse's station. Interview at this time with the social services secretary (Employee #93) found the results were usually kept on the top of a file cabinet located just to the left of the nurse's station, but they were not there. At 2:00 p.m., the person-in-charge (Employee #132) said the survey results were usually kept on an end table beside of a chair by the nursing station, but some of the residents who were on the hallway just off of the nursing station picked them up, so they were moved to the top of the filing cabinet. Residents who were in wheelchairs and could not stand would not be able to access the survey results without asking for assistance.",2015-10-01
10338,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,167,B,1,0,VNEB11,". Based on observation and staff interview, the facility failed to ensure the results of all surveys were readily accessible for resident or visitor viewing. Review of the survey book, located in the lobby of the facility, found the absence of the two (2) most recent complaint investigation surveys. Findings include: a) On 01/12/12, review of the survey book, located in the lobby at the entrance of the facility, revealed the most recent survey result posted was a complaint investigation survey completed in February 2011. During an interview with the director of nursing (DON), on 01/12/12 at 8:45 a.m., she stated she thought there was a complaint survey in December 2011. She was uncertain whether there were any others between February and December 2011. The DON stated the administrator would have copies of any surveys in his office. Interview with the administrator, on 01/12/12 at 9:00 a.m., revealed he had two (2) complaint surveys with deficiencies in his office that were not posted in the survey book in the lobby. One (1) missing complaint survey with citations was conducted in April 2011, and the other missing complaint survey with citations was conducted in October 2011. .",2015-05-01
10454,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2009-08-13,167,C,0,1,924C11,"Based on staff interview and observation, the facility failed to post the most recent survey results for examination. This practice has the potential to affect all residents, their legal representatives, and members of the general public wishing to review this information. Facility census: 153. Findings include: a) Review of a binder located in the lobby area of the facility and labeled ""Survey Result: found the binder only contained the results from a recent complaint survey. The binder did not contain the results of the facility's last annual standard survey and all complaint investigations conducted from the date of the last annual survey (05/08/08) to the present. This was brought to the attention of the administrator on the early afternoon of 08/13/09, at which time he verified the results of the last annual survey were missing from the binder. He related that someone must have removed the full set of survey results and he would replace the report. .",2015-03-01
10623,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,167,C,0,1,GCMN11,". Based on observation and staff interview, the facility failed to assure the facility's survey results were posted in an area that was accessible to all residents. The results that were in the posting did not include the deficiencies cited during complaint investigations that were conducted since the facility's last standard annual survey. This practice had the potential to affect all residents who desire to review the facilities survey results. Facility census: 83. Findings include: a) Observation of the facility's publicly posted information, on the morning of 12/01/10, found the facility's survey results were posted between the two (2) front double doors in an area where most of the residents were not permitted. Review of the survey results that were posted found they did not contain the results of complaint investigations that had been conducted since the facility's last standard annual survey, during which the facility was cited deficiencies. The administrator was notified of this finding at 12:45 p.m. on 12/08/10. She verified the survey results that were posted were not complete and were not posted in an area that was accessible to all residents. .",2015-01-01
1922,MEADOW GARDEN,515121,276 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2017-08-03,170,E,0,1,7YX611,"Based on resident interview and staff interview, the facility failed to ensure mail delivery was available to the resident's within 24 hours of delivery to the facility. This had the potential to effect more than an isolated number of residents. Facility census: 50. Resident identifier: #28. Findings include: a) Resident counsel president interview At 9:38 a.m. on 08/02/17, the resident counsel president said the facility received mail on Saturdays but resident's personal mail was not always delivered on Saturdays. She said the mail was delivered to the resident's on Saturdays by the activity assistant in the past. The activity assistant was now the director of the activity program and this employee no longer worked every Saturday. At 10:05 a.m. on 08/02/17, the business office manager, (BOM) #47, verified the mail is delivered to the facility on Saturdays. She said, The nurse locks it (referring to the mail) up in the medication room until Monday, when I get it. When ask about residents personal mail, BOM #47 said, If a resident asks and is expecting something important then the nurse would give it to them, like a package. An interview with the director of nursing (DON) at at 2:16 p.m. on 08/03/17, found she was unaware personal mail, belonging to the residents, was not being delivered on Saturdays. She said the weekend Registered Nurse manager had been in-serviced about passing the resident's mail on the weekends.",2020-09-01
4197,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,170,C,0,1,XDKG11,"Based on staff interview and resident interview, the facility failed to ensure residents received mail delivery on Saturdays. This practice had the potential to affect all residents at the facility. Resident identifier: #121. Facility census: 113. Findings include: a) Resident #121 At 3:00 p.m. on 04/03/17, when asked about mail delivery on Saturdays, Resident #121 (the resident council president) said she did not believe residents received mail on Saturdays. She said the activities staff delivered the mail to the residents. Activity Director (AD) #98, when interviewed at 6:40 a.m. on 04/06/17, said there was no mail delivery on Saturdays. At 04/06/17 at 7:15 a.m., the administrator confirmed there was mail delivery from the post office in the neighborhood on Saturdays. At 8:11 a.m. on 04/11/17, the administrator said he arranged for the mail carrier to deliver the mail to the facility on Saturdays. I guess he (the mail man) didn't come before because he knew there was nobody in the office on Saturdays.",2020-02-01
5828,ROSEWOOD CENTER,515105,8 ROSE STREET,GRAFTON,WV,26354,2015-01-29,170,D,0,1,3O8G11,"Based on staff interviews and resident interviews, the facility failed to ensure a resident promptly received mail. One (1) randomly interviewed resident received a package marked perishable, on 01/10/15, but it was not delivered to the resident until 01/11/15. Resident identifier: #43. Facility census: 67. Findings include: a) Resident #43 In an interview with Employee #24 on 01/21/15 at 8:49 a.m., the employee stated Resident #43 said he was to receive a package on 01/10/15. The resident stated the family member, who sent the package, called Federal Express (FedEx) and was informed the package was delivered on 01/10/15 at 12:00 p.m. It was signed for by the Manager-Office Centers (Employee #64). Employee #24 stated Resident #43 was upset and demanded the package. The employee stated a search was conducted for the package, but it was not found. On 01/11/15, Employee #24 asked Employee #64 if a package had been delivered for Resident #43. Employee #64 retrieved the package from under her desk. Employee #24 delivered the package to Resident #43, who was upset the package had been opened. In an interview with Resident #43, on 01/22/15 at 8:43 a.m., the resident stated a family member sent a large box of candy to him on 01/10/15. Resident #43 stated he did not receive the box of candy until 01/11/15, and the package had been opened. The resident told staff about the package and that he was upset the package had been opened. On 01/22/15 at 11:17 a.m., an interview with Employee #64 revealed the employee received and signed for a package on 01/10/15. The employee stated the package was addressed to the facility and was marked perishable. Employee #64 stated, because the package was addressed to the facility and was marked perishable, she opened the package. She stated a card with the name of Resident #43 was inside the package. In addition, Employee #64 stated because the package was delivered at 12:00 p.m., and she only worked until 12:00 p.m., she placed the box of candy under her desk and left for the day. Employee #64 stated the package was delivered to Resident #43 on 01/11/15 at approximately 8:00 a.m The employee further stated she did not take any extra precautions to preserve the box of candy, even though the package was marked perishable. She also stated she probably should have taken the package to Resident #43 when the package arrived.",2018-07-01
6614,HAMPSHIRE MEMORIAL HOSPITAL,515080,363 SUNRISE BLVD,ROMNEY,WV,26757,2014-04-04,170,B,0,1,EI1111,"Based on resident interview and staff interview, the facility failed to ensure residents received mail on Saturdays when mail delivery was scheduled and available through the postal service. This had the potential to affect all thirty (30) residents residing at the facility. Facility census: 30. Findings include: a) An interview was conducted on 04/03/14 at 8:30 a.m. with the resident council president, Resident #13. During this interview, the resident stated she did not think residents received mail on Saturdays. b) The activity director, Employee #42, was interviewed at 8:48 a.m. on 04/03/14. Employee #42 confirmed residents do not receive mail on Saturdays. She stated, Mail does not run on Saturdays. c) On 04/03/14 at 1:15 p.m., the administrator was interviewed. She stated the facility does not receive mail on Saturdays. d) At 1:52 p.m. on 04/03/14, the administrator contacted the postmaster of the local post office, who stated mail could be delivered to the facility on Saturdays, but was not because the facility had requested the mail not be delivered on Saturdays. The administrator stated she asked the postmaster to deliver the mail on Saturdays.",2017-12-01
6751,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2014-07-15,170,C,0,1,Q9U911,"Based on resident interview and staff interviews, the facility failed to ensure residents received mail delivery on Saturdays when regular mail delivery was scheduled and available through the postal service. This had the potential to affect all thirty - six (36) residents residing at the facility. Facility census: 36. Findings include: a) During a resident interview on 07/08/14 at 10:10 a.m., Resident #2 stated the residents did not receive mail on Saturdays. b) Employee #40, the activity assistant was interviewed at 10:19 a.m. on 07/08/14 regarding mail delivery at the facility. She stated, The mail truck does not run on Saturdays because the clinic downstairs is closed. c) At 10:55 a.m. on 07/08/14 the administrator stated the facility did not have anyone working downstairs on Saturdays so the mail was not delivered. She confirmed mail could be available to residents on Saturdays.",2017-11-01
7066,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2014-07-14,170,B,0,1,U25211,"Based on staff interviews and resident interviews, the facility failed to ensure personal mail was delivered to the residents within 24 hours of delivery to the facility by the postal service. This had the potential to affect more than an isolated number of residents. Facility census: 64. Findings include: a) During an interview with the resident council president (Resident #13) on 07/09/14 at 9:00 a.m., the president said the facility did not deliver residents' mail on Saturdays. On 07/09/14 at 9:40 a.m., Employee #25 (business office) said the facility delivered the mail from Saturday on Monday morning. On 07/09/14 at 9:30 a.m., the activity director (Employee #59) said she worked three (3) Saturday's a month and would be glad to distribute the mail on those days.",2017-09-01
7637,MONTGOMERY GENERAL ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2013-04-25,170,B,0,1,BHXG11,"Based on an interview with the president of the resident council (Resident #3) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery on this day of the week. This had the potential to affect more than an isolated number of residents. Facility census: 55. Findings include: a) During an interview, on 04/23/13 at 3:30 p.m., the resident council president (Resident #3), stated residents do not receive mail on Saturdays. The activity director, Employee #25, was interviewed at 4:04 p.m. on 04/23/13. She stated the mail comes to the storage department at the hospital and We don't deliver the mail on Saturdays. The administrator, Employee #5, was interviewed on 04/23/13 at 4:22 p.m. She stated the facility shares a post office box at the post office with the hospital next door, who also owns the nursing facility. The mail is picked up and sorted by hospital personnel on Monday through Friday and no one from the hospital picks up the mail on Saturdays.",2017-03-01
7686,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2013-03-22,170,B,0,1,B0M411,"Based on interviews and policy review, the facility failed to deliver mail to residents on Saturdays. This had the potential to affect all residents who received mail at the facility. Findings include: On 3/18/13 at 2:10 P.M. the Resident Council President #11 was interviewed. During the interview the Resident Council President stated she was not sure if mail was delivered to residents on Saturdays or not. She stated in the past the residents did get mail on Saturdays. At 2:20 P.M. the Activity Director (AD) #44 was interviewed. The AD stated she only works two Saturdays a month and she does not deliver mail on Saturdays when she works. At 2:30 P.M. the Director of Nursing (DON) #73 was interviewed. She stated there was no staff on the weekend to go get the mail from the post office on Saturdays to deliver to the residents and verified residents did not receive mail on Saturday. At 3:05 P.M. the Assistant Administrator #79 was interviewed. The Assistant Administrator verified the facility used to pick up the mail on Saturday and deliver it to the residents, but not anymore. She stated the mail is picked up from the post office daily Monday through Friday and there was no mail delivery to residents on Saturday. If residents did receive mail delivery on Saturdays it was not delivered to them by facility staff until Monday. The policy and procedure for mail delivery was reviewed. The policy indicated each resident has the right to send and receive mail promptly and delivered to the resident within 24 hours.",2017-02-01
7948,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2012-08-20,170,B,0,1,HTLJ11,"Based on resident and staff interviews, the facility failed to ensure privacy for each resident who receives mail in the facility. The facility failed to ensure that mail was unopened upon delivery to the residents. Findings include: An interview was conducted on 8/14/2012 at 3:00 PM with a member of the resident council (Resident # 60). The resident stated that the residents do not always receive their mail unopened. She stated that she has even received her mail unopened. The resident stated that the type of mail opened usually has to do with health benefits or benefit cards. The resident shared that she prefers to open her own mail and has not signed any document permitting the facility to open her mail. The resident council member stated that the activity director (#79) gives the mail to another resident, who is also a resident council member and that resident delivers the mail. An interview was conducted with the activity director on 8/14/2012 at 5:25 PM. The activity director stated that the activity staff sorts the mail, and we only open the mail for those who cannot. The activity director stated that the mail is open when she receives it from the business office staff. The activity director stated further, The only mail that is opened is their health care cards for Medicaid. Usually something from Medicare or Medicaid. The activity director stated that no one ever questioned the mail being opened. She voiced that she could not remember how many resident's mail would be already open when she received it from the business office. An interview was conducted with the business office manager (#17) on 8/17/2012 at 8:45 AM. She voiced that the facility does open all residents' mail that contains Medicaid information. The business office manager shared that the mail is opened and they take out what they need, make copies and then deliver the mail to the residents. When asked why the business office staff opened resident mail without allowing the resident to first open their own mail, the business office manager replied, Because we can't see what's in it without opening it first. Additionally, the business office manager stated that they do not permit the residents to open their own mail first, because We would never get it. The business office manager stated that the facility does not have a policy requiring that resident mailed be opened before delivering it to the residents. She also conveyed that the facility has not requested consent from any resident to open their mail. Based on the findings, the facility failed to ensure that Medicaid residents receive mail that is un-opened.",2016-12-01
8119,SPRINGFIELD CENTER,515188,ROUTE 1 BOX 101-A,LINDSIDE,WV,24951,2013-10-31,170,D,1,0,H12K11,"Based on record review, resident interview, and staff interview, the facility failed to allow one (1) resident to promptly receive mail that was unopened. A box of items Resident #3 had ordered was opened before it was given to the resident. One (1) of three (3) residents reviewed was affected. Resident identifier: #3. Facility census: 59. Findings include: a) Resident #3 During an interview with Resident #3, on 10/29/13 at 4:00 p.m., the resident said that on 10/15/13 he had received a box in the mail. The resident said the administrator had opened this box and had removed his knives, then retaped the box. He stated he knew he had received the knives due to the information listed on the package insert. The resident stated he was upset because his mail was opened and he had not given the facility permission to open his mail. Resident #3 also stated he did not get to look at the knives he had ordered through the mail until a couple of days later when Employee #57, the business office manager, and Employee #52, the activity director, brought him the knives. An interview was conducted on 10/31/13 at 12:20 p.m., with Employee #56, the admission coordinator. She was asked whether Resident #3 had given the facility permission to open his mail. She stated no, he had only signed the information on admission that he could send and receive mail. She confirmed that Resident #3 opened his own mail. In an interview on 10/29/13 at 3:30 p.m., Employee #1, the administrator, stated she had discovered this resident was keeping knives and a stun gun in his room. She said she and the resident had a verbal agreement that he would review the items that he ordered through the mail, then give her anything that she felt was a danger to him or other residents. She stated this resident received a box the same day this had happened and she felt like she needed to open the box in order to know what was in the box that could be harmful to others residents. She stated there were knives in the box, and she had removed the knives and re-taped the box. The box was then taken to the resident so he could review what was left in the box that he had ordered. On 10/29/13 at 4:45 p.m., Employee # 57, the business office manager (BOM), was asked about the package Resident #3 had received on 10/15/13. She stated earlier that day several knives and a stun gun were found in the resident's room. The items were taken by the administrator to be placed in the safe. She confirmed since this had just happened, Employee #1 did open the box and remove the knives. The box was retaped prior to Resident #3 receiving his package. She stated a couple days later Employee #1 told her to take the resident his knives back so he could look at the knives. She stated she and the activities director had taken the knives back to the resident.",2016-10-01
8700,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2011-11-03,170,B,0,1,S3DJ11,"Based on resident council representative interview and staff interview, the facility failed to ensure residents received prompt delivery of mail. The facility elected not to have mail delivered on Saturdays. Therefore, residents had to wait until Monday to receive mail when the postal service would normally deliver mail to persons living in the community on Saturdays. This practice had the potential to affect more than an isolated number of residents. Facility census: 57. Findings include: a) During an interview on 11/02/11 at approximately 9:00 a.m., Resident #29 (who represents the resident council as president) reported that residents at this facility did not receive mail on Saturdays. When interviewed on 11/02/11 at approximately 9:30 a.m., Employee #60 (administrative assistant) acknowledged the facility had the mail delivery stopped on Saturday due to the mail box being broken into and mail being stolen. On 11/03/11 at approximately 1:00 p.m., the director of nursing (DON) reported an activity assistant would start getting the mail out of the box after the facility resumed Saturday delivery. According to the guidance to surveyors for determining a nursing facility's compliance with this requirement: 'Promptly' means delivery of mail or other materials to the resident within 24 hours of delivery by the postal service (including a post office box) and delivery of outgoing mail to the postal service within 24 hours, except when there is no regularly scheduled postal delivery and pick-up service.",2016-04-01
9117,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2011-09-22,170,B,0,1,REFP11,"Based on an interview with the president of the resident council (Resident #1) and staff interview, the facility failed to afford residents with the right to promptly receive mail. The facility did not distribute resident mail on Saturdays, although mail was available for delivery to the facility on this day of the week. This deficient practice had the potential to affect more than an isolated number of residents. Facility census: 50. Findings include: a) An interview with the president of the resident council (Resident #1), on the afternoon of 09/14/11, elicited that the residents did not receive mail on Saturdays. An interview with the facility's bookkeeper (Employee #22), on the morning of 09/15/11, confirmed the facility does not distribute mail to residents on Saturdays. Employee #22 stated they have the post office hold the mail until Monday, in case the mail contains any money. According to Employee #22, the facility has both delivery at the facility and a post office box, and they do not check the post office box for mail on Saturdays. Mail is delivered to the front office, sorted, and given to the activity director to distribute to the residents. An interview with the activities director (Employee #38), at 9:25 a.m. on 09/15/11, revealed she does not go to the post office on Saturdays and mail is not delivered to the facility due to no one being in the front office to receive it. She agreed she did not check the post office box on Saturdays.",2016-02-01
7716,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2013-01-11,172,B,0,1,Q01G11,"Based on record review and staff and resident interviews, the facility failed to make residents aware of the ombudsman. Findings include: A review of Resident Council minutes from July through December 2012 revealed no mention of the ombudsman. An interview was completed with Resident #18 on 1/09/2013 at 7:15 PM. Resident #18 stated that she regularly attended Resident Council meetings. Resident #18 said that she did not know the Ombudsman and said she didn't know the term. She also said that she did not recognize the name of the ombudsman. On 1/10/2013 at 9:10 AM, an interview was completed with Activity Director #55 (AD#55) AD #55 said, The Ombudsman shows up once in a while. She probably hasn't been to one (Resident Council meeting) in six months. She calls and asks when they are, but she says she can't always make it. I've told them (Resident Council) what the Ombudsman is and they can ask her to come to the meetings if they want. They know they can get her number if they need it. If someone has a problem that isn't resolved, I tell them we can call the Ombudsman. Every once in a while, I mention it during the meetings. I guess I didn't write it in the minutes. An interview was completed with Social Worker #49 (SW#49) on 1/10/2013 at 9:27 AM. SW #49 said, I have been to most of the Resident Council meeting since June. The Ombudsman hasn't been to any of the meeting that I've gone. Her information is posted on the wall. When she is here she meets with some residents. My opinion is that the residents that she visits would probably be the only ones that know who she is. I haven't even met her yet. On 1/10/2013 9:45 AM, an interview was completed with Resident #35. Resident #35 stated that he frequently attended Resident Council meetings. Resident #35 said that he was not familiar with the term ombudsman or the ombudsman's name. I go to every meeting. I go door to door and invite everyone to the meetings.",2017-02-01
4135,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,174,D,0,1,JLJC11,"Based on resident interview, record review, and staff interview, the facility failed to ensure a resident's personal property was safe at the facility. This was true for (1) of three (3) residents reviewed for the care area of personal property during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #15. Facility census: 29. Findings Include: a) Resident #15 At 9:12 a.m. on 11/01/16, Resident #15 said she had some very expensive lotions for her face and body stolen from her room. The resident identified the name brand of these items and said they were only available at very expensive stores. She estimated the cost of the lotions was over $100.00. She said she had an anxiety attack when she found out the items were missing and it still upsets her to talk about it now. She added, I always heard when you come to the nursing home they take everything. The resident said she told staff about the missing item. Staff looked for the lotion but could not locate the items. The resident said, They said they would order me some new lotion, but they never did. At 12:30 p.m. on 11/02/16, the social worker, #31 was asked what happens when a resident reports missing items. She stated, we start looking for it and call the families if needed. We also keep a complaint book about it. SW #31 provided a copy of the following narrative, dated 05/12/16. (Typed as written.) SW was called upstairs to the nursing unit because resident (Name of resident) was having a panic attack per (name of registered nurse). SW went to resident's room where she was having trouble breathing and she said that three bottles of makeup that were missing that her daughter had gotten for her. Many staff were in resident's room looking for the makeup. SW called daughter and MPOA (medical power of attorney), (name of daughter) and she said that there were two small royal blue bottles of Artistic natural lotion and cleanser that she had gotten her as well as two small bottles of (name of manufacture) day and night cream. SW relayed this to the staff. One small bottle was found, overturned and empty on the roommates bed side table. The record noted, .Resident continued to be quite upset for over an hour . Attached to the report was a note the maintenance supervisor was going to check to see if the facility had any more locked boxes to place in the resident's room. Employee #31 was asked about the facility's policy for replacing missing items. She said, We could have done so, I will look. She stated the resident was offered another room but she refused at that time. At 8:15 a.m. on 11/03/16, the administrator said the daughter said she was going to take care of the missing items. She confirmed she had no written information to verify her statement. Normally, we would have purchased these items if the family wanted. The daughter would have needed to bring in the receipt. At 2:45 p.m. on 11/03/16, the resident said she never received a locked box but, One of the nurses just came in yesterday and asked me if I wanted a locked box to keep my stuff in. I told her it wouldn't do any good because they would just steal the box. The nurse offered me a lock for my night stand drawer and I told her that would be good. At 2:47 p.m. on 11/03/16, licensed practical nurse (LPN), #23 said she talked with maintenance and they were going to take care of the issue. At 8:40 a.m. on 11/04/16, a second SW, #42, said the resident never received a locked box because we thought the daughter was bringing one in for the resident. Further review of the resident's medical record found the resident has capacity to make medical decisions. Her brief interview for mental status (BIMS) score was 15 on the last quarterly Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 10/16/16. A score of 15 indicates the resident is cognitively intact.",2020-02-01
4258,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,174,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff and resident interviews and record reviews, the facility failed to encourage residents to create a homelike environment and failed to attempt to locate reported missing resident personal property. This affected two (#31 and #6) of 3 residents reviewed for personal property out of a Stage 2 sample of 30. Findings include: 1. During an interview on 10/03/16 at 1:52 PM, Resident #31 stated she had not been encouraged by staff to bring in any personal items to make her room more homelike. Review of the clinical record of Resident #31 on 10/05/16 revealed the resident was admitted to the facility on [DATE]. During interview on 10/05/16 at 12:45 PM, Registered Nurse (RN) #40 stated she was a supervisor and she worked with many residents to complete admission assessments. RN #40 stated Residents get oriented to their room by the nurse. We tell them things they should bring in, like necessities, like shoes and clothes. We don't have anything that encourages them to bring in things that make it a personal environment. During interview on 10/06/16 at 8:55 AM, the Guest Services Director (GSD) stated I have an interview process for new admissions. We see how the transition was, let them know about activities and meals. It's really an orientation. If I have family members present, I tell them they are welcome to bring in personal items. The rooms have a locking drawer. We tell them what things they can bring in. Based on staff interview, resident interview and record review, the facility failed to encourage residents to create a homelike environment and failed to attempt to locate reported missing personal property for two (2) out of three (3) residents reviewed for personal property. This failed practice had the potential to affect for than a limited number of people. Resident identifiers: #31 and #6. Facility census: 69. Findings include: a) Resident #31 During an interview on 10/03/16 at 1:52 p.m., Resident #31 stated she had not been encouraged by staff to bring in any personal items to make her room more homelike. Review of the clinical record for Resident #31 revealed the resident was admitted to the facility nearly 8 months ago. During interview on 10/05/16 at 12:45 p.m., Registered Nurse (RN) #40 stated she was a supervisor and she worked with many residents to complete admission assessments. RN #40 stated, Residents get oriented to their room by the nurse. We tell them things they should bring in, like necessities, like shoes and clothes. We don't have anything that encourages them to bring in things that make it a personal environment. During interview on 10/06/16 at 8:55 a.m., the Guest Services Director (GSD) stated, I have an interview process for new admissions. We see how the transition was, let them know about activities and meals. It's really an orientation. If I have family members present, I tell them they are welcome to bring in personal items. The rooms have a locking drawer. We tell them what things they can bring in. b) Resident #6 During interview on 10/04/16 at 11:15 a.m., the family member of Resident #6 stated the resident had a quilt with two matching pillow shams for her bed and sometime in late (MONTH) or early (MONTH) (YEAR) one of the shams disappeared. The family member stated facility staff had been told about the missing sham in late (MONTH) or early (MONTH) but the sham had not been located nor had there been a status report on the facility's search for the item. During an interview on 10/05/16 at 10:00 a.m., Social Worker (SW) #31 stated missing items should be reported to social service staff and then social services staff would complete a Grievance/Concern Form. SW #31 stated dates are recorded for each concern and the resolution date established. SW #31 further stated she did not currently have a Grievance/Concern Form identifying the missing sham for Resident #6. On 10/06/16 at 10:20 a.m., nurse aide (NA) #61, identified by the family as who they reported the missing sham to, was interviewed. NA #61 stated she recalled the family member had told her about the missing sham on a weekend just a little over a month ago but she could not recall the exact date. NA #61 stated she reported the missing item to facility laundry aide #28. Laundry aide #28 was unavailable for interview during the days of the recertification survey. An interview was conducted with the facility Administrator on 10/06/16 at 10:50 a.m. to clarify the facility policy regarding searches for missing resident possessions, particularly on the weekends. The Administrator stated if staff received a report of a missing item and it was not immediately located, staff have four options of whom to inform so that a more in-depth search may be initiated and the missing item can be logged into the reporting system. The four reporting options are: 1) guest services; 2) weekend manager; 3) social services; or, 4) the nurse manager on duty. The Administrator confirmed that until the concern of the missing sham was raised during the annual recertification survey on 10/05/16, no search had been initiated.",2020-02-01
7378,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-06-21,174,E,0,1,EUJZ11,"Based on observations and resident and staff interviews, the facility failed to ensure residents had private access to a telephone. Findings include: On 6/18/2013 at 10:39 AM, Resident #93 stated that he did not have privacy when he was on the telephone. He said the only phone available for him to use was in the hallway. An interview was completed on 06/19/2013 at 2:14 PM with Nursing Assistant (NA) #65. NA #65 said, There is a phone in the hall, we can take them up to the desk, or there is one in the activity room if they want privacy. There is a phone on the north front that is in a little cubby they can use. On 06/19/2013 at 2:17 PM, a phone was noted to be located on North Hall in a small alcove. The phone was blocked from view by a treatment cart, wheelchair and rolling blood pressure cuff. The phone was not accessible without moving the treatment cart. The phone was not plugged in and did not work. Other phones were noted midway down each hallway that had been mounted on the wall offering no visual or auditory privacy. The phones are mounted too high to be reached from a seated position in a wheelchair. On 06/19/2013 at 2:40 PM, an interview was completed with Unit Manager (UM) #94. UM #94 said, There is a phone in the activity room and one down each hallway. For privacy, they can go in the activity lounge. There isn't much activity going on in there. There is a phone in the alcove. The surveyor went with UM #94 to the phone in the alcove. UM #94 moved the treatment cart and noted the phone was not plugged in. She put the treatment cart back in front of the phone. On 06/19/2013 at 3:43 PM, an interview was completed with Nurse #91. Nurse #91 said, I do some admissions. There is a check list we talk to them about. We tell them how to use the phones in the rooms. Social Services talks to them about resident rights. There is a phone in the hall and one in the activity room they can use. If they need a private call, I would take them to the activity room and shut the door. We would redirect other residents. I could take them to an office. The phone that is behind the treatment cart may not even function. That isn't really private. On 06/20/2013 at 8:50 AM, a follow up observation was made of the alcove where the resident phone was located. The treatment cart was still in front of the phone and there was no phone cord to the phone jack. On 06/20/2013 at 8:54 AM, an interview was completed with Administrator #115. Administrator #115 said, There is a pay phone up in the front of the facility and there is a phone in the activity room. They could also use an office. We had a cordless phone for the residents to use, but it isn't working. We unplugged the phone in the alcove so a resident could have a phone in their room. An observation on 06/20/2013 at 9:00 AM noted a payphone just inside the entry doors in the main lobby.",2017-05-01
8774,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2011-07-27,174,D,0,1,WXEM11,"Based on observation, resident interview, and staff interview, the facility failed to provide to one (1) of forty-six (46) Stage II sample residents (#10) reasonable access to the use of a telephone where calls can be made without being overheard. Resident #10 was asking to call a family member at the nurses' station. The ward clerk was attempting to dial the telephone number given by Resident #10, another resident who was seated nearby (#51) kept yelling out repeatedly. There were other residents present around the nurses' station. Whenever the ward clerk was asked about a private place for Resident #10 to make phone calls, she stated the only other place was the medication room. Interview with the director of nursing found there was a phone in the hallway available for resident use that provided privacy and the ward clerk should have taken the resident to that phone instead of trying to make the call from the nurses' station. Facility census: 134. Findings include: a) Resident #10 On 07/26/11 at 2:55 p.m., observation found Resident #10 at the nurses' station asking the ward clerk (Employee #245) to place a call for her to a family member. The ward clerk was attempting to dial the number given by Resident #10, while Resident #51 (who was seated right beside of Resident #10) kept yelling out repeatedly. Other residents were also present around the nurses' station. When the ward clerk was asked about a private place for the resident to make phone calls, she stated the only other place was the medication room. Immediately after this observation was made, an interview with the director of nursing (DON) revealed there was a phone available for resident use in the hallway that would provide privacy. She said the ward clerk should have taken the resident to that phone instead of trying to make the call from the nurses' station.",2016-03-01
10285,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-04-14,174,D,0,1,KZR811,". Based on resident interview, observation, and staff interview, the facility failed to provide reasonable access to the use of a telephone where calls can be made without being overheard, for one (1) of thirty-seven (37) Stage II sample residents. Resident identifier: #42. Facility census: 115. Findings include: a) Resident #42 During an interview with Resident #42 on 04/13/11 at 5:00 p.m., she complained she did not have a private way to have a conversation with her son when he calls her. She stated facility staff has to come to her room, get her out of bed, and take her to the nursing station to receive telephone calls - where everyone could hear her. She stated she wanted to remain in her room to speak with her son when he called. Observation of the telephones present at the nursing station noted a portable phone was on the countertop. On 04/13/11 at 5:09 p.m., a member of the maintenance staff (Employee #26) inspected the portable phones purchased for resident use at 5:09 p.m. on 04/13/11. He stated a switch was missing and the phones were not functional. The facility failed to maintain the portable phones intended for residents to make private calls. .",2015-05-01
10843,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,174,D,0,1,ZHEQ11,". Based on resident interview, staff interview, and record review the facility failed to allow one (1) of thirty-two (32) Stage II sampled residents to make personal phone calls in a private area where she could not be overheard. Resident identifier: #84. Facility census: 95. Findings include: a) Resident #84 During an interview on 02/02/10 at 11:00 a.m., Resident #84 stated she was only allowed to make one (1) phone call each week to her son, and she had to make that phone call in the social worker's office with the social worker present. When questioned as to why she thought she could not make a private call, the resident stated she did not know. The resident's hard copy medical record located at the nurses' station, when reviewed on 02/08/10 at 1:00 p.m., contained a note taped to the inner front cover of the record which stated the resident was to make her phone calls from the social worker's office; the note also identified one (1) individual she was not to receive calls from at all. The resident's care plan, when reviewed, made no mention of these phone restrictions, the reason for the restrictions, or the expected outcome of the restrictions. On the afternoon of 02/08/10, a facility social worker (Employee #80), when interviewed related to these phone restrictions, stated that, at one time, the resident was taking advantage of phone use and making too many calls. At that time, it was decided that her access to telephone privileges be limited. Since that time, the problem had resolved, and the resident could now make calls when she chose. She further stated the resident had her own cell phone which required her to pay for the addition of call minutes, but she could use it anytime she wanted to. The social worker further agreed the phone restrictions had never been part of her care plan and the note on her medical record had not been removed to allow the resident privacy with her phone calls. .",2014-12-01
11083,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2009-06-04,174,E,0,1,CKVD11,"Based on observation and staff interview, the facility failed to provide a private location for a resident's phone call; this was true for one (1) of fifteen (15) sampled residents. A resident was observed utilizing the telephone at the facility's nursing station to have a conversation with a family member. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. This practice has the potential to affect more than an isolated number of residents, including those who wish to make and receive calls and do not have private telephones in their rooms. Resident identifier: #51. Facility census: 89. Findings include: a) Resident #51 On 06/04/09 at 11:30 a.m., Resident #51 was wheeled down to the west wing nursing station and handed the telephone receiver. Several staff members were observed standing near the resident. The resident was observed to become tearful and visibly upset during the conversation. The resident was not offered a private location to have a phone conversation with a family member. Staff interview with a licensed practical nurse (LPN - Employee #1), on 06/04/09 at 11:35 a.m., revealed the resident was not offered a private location for the phone call. The LPN further stated the west wing nurses' station does not have a cordless phone for the residents to use. The LPN stated the residents use the activity office to make personal calls at times, yet this option was not offered to Resident #51 for this phone call. .",2014-09-01
8338,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2012-04-27,175,D,0,1,N6W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, it was determined the facility failed to provide an opportunity for two (2) of twenty-one (21) sampled residents, (a married couple, R81 and R82) to share a room. Findings: 1. During the initial tour of Unit 4, on 04/24/12 at 9:05 a.m., Licensed Practical Nurse (LPN) 88 assigned to provide resident information, revealed R82 was admitted after his wife and the married couple had never lived together in the facility. She further stated R82 had lived on Unit 2, near his wife for some time prior to being moved to Unit 4. An interview with R82 on 04/26/12, at 11:10 a.m., revealed he missed his wife and would like to live with her. The clinical record contained a request from the resident's son (responsible party) asking the facility to move his parents on the same floor and eventually in the same room. Review of the clinical record for R82 revealed no documentation of any attempt to accommodate the married couple's right to cohabitate. Interview on 04/26/12 at 3:30 p.m ., revealed R81 missed her husband and wanted to share the room with him. She further stated that he did come up and spend time with her, but it was not the same and she would like to room with him. During an interview with the Director of Social Services (DSS) and the Director of Admissions on 04/27/12 at 8:30 a.m., the Director of Admissions indicated she was working as the facility DSS when R82 was admitted on [DATE]. The facility did not have a room available to accommodate the married couple at that time. She also said the facility had no policy in place to address a resident's right to cohabitate. Neither the DSS nor the Director of Admissions could provide any further documentation.",2016-07-01
3064,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,176,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review and staff interview, the facility failed to ensure the interdisciplinary team (IDT) completed an assessment for a resident to self administer medications. This affected one (1) of five (5) residents reviewed for the medication regimen review. Resident identifier: #74. Facility census: 59. Findings include: a) Resident #74 A review of Resident #74's clinical record began on 06/06/17 at 8:30 a.m. and revealed the resident was admitted on [DATE]. The resident's most recent Quarterly Minimum Data Set (MDS) Section C0500 dated 05/11/17 specified the resident scored a 15 on the Brief Interview for Mental Status (BIMS); thereby, indicating the resident was cognitively intact. On 06/05/17 at 10:27 a.m., Resident #74 was observed in her room. A one (1) ounce bottle [MEDICATION NAME] spray used to ease nasal congestion and sinusitis was setting on the resident's overbed table. Review of the clinical record on 06/06/17 at 8:30 a.m., revealed the clinical record did not contain a physician order [REDACTED]. During an interview and observation conducted on 06/06/17 at 8:57 a.m., Assistant Director of Nursing #37 verified the presence of [MEDICATION NAME] the resident's overbed table. Assistant Director of Nursing Staff #37 verified the resident had not been assessed for the ability to self-administer medications.",2020-09-01
4165,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2016-02-05,176,D,0,1,5SB711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, staff interviews, and review of the facility's policy, the facility failed to assess a resident for self-administration of medication for one (1) of three (3) residents observed during medication administration pass. Resident #11 self-administered an inhalation and eye drops, but her ability to correctly administer the medications had not been assessed, a care plan was not developed, and self-administration had not been authorized by her physician. Resident Identifier: #11. Facility census: 60. Findings include: a) Resident #11 During the medication administration pass observations with Licensed Practical Nurse (LPN) #23 on 02/04/16, Resident #11 self-administered Atrovent solution 0.3% two (2) inhalations in both nostrils at 7:37 a.m. The resident also self-administered [MEDICATION NAME] alcohol solution (artificial tears) one (1) drop in both eyes at 7:44 a.m. In an interview during the medication administration pass on 02/04/16 at 7:45 a.m., the LPN #23 confirmed that Resident #11 had been self-administrating the artificial tears and Atrovent nasal inhalation for a long time. Review of Resident #11's medical records on 02/04/16 at 8:45 a.m., found no assessment to determine whether the resident should exercise the right to self-administer any of her medications. When asked on 02/04/16 at 9:15 a.m., How long have you been self-administering the artificial tears into your eyes and Atrovent nasal inhalation, the resident stated, I have been giving myself these two (2) medications for about six (6) to eight (8) months now. The director of nursing ( DON) confirmed on 02/04/16 at 9:45 a.m., that Resident #11 had been self-administering the artificial tears and the Atrovent nasal inhaler for a long time. The DON stated, We did not obtain a physician's orders [REDACTED]. The facility's policy revealed patients who requested to perform self-treatments would be evaluated for capability. If it was determined that the patient could self-treat, a physician/mid-level provider order was required, self-treatment must be care planned, the patient must be able to demonstrate self-treatment, and periodic evaluation of capability must be performed. The self-administration evaluation assessment and the care plan were developed after inquiry about Resident #11 abilities to self-administer any of her medications. The facility did not obtain a physician/mid-level level provider order. .",2020-02-01
6113,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,176,D,0,1,L8JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, resident interview, and staff interview, the facility failed to ensure residents were not permitted to self-administer drugs unless the interdisciplinary team had determined this was a safe practice for the individual. A randomly observed resident, who was deemed to be incapable of self-administering her own medications, was observed taking pills that were left sitting on her bedside table. Resident identifier: #8. Facility census: 111. Findings include: a) Resident #8 Resident #8 was interviewed on 05/13/14 from 09:30 a.m. to 09:45 a.m. During this time period, a medication cup with pills was observed on her bedside table. At the end of the interview the resident was observed taking the medication that had been on the bedside table. The resident confirmed these were her morning pills which had been left for her to take. A medication nurse was not observed in the area of the resident's room during this time. Review of the resident's medical record on 05/14/14 at 2:00 p.m., found this eighty-nine (89) year old resident with a Brief Interview for Mental Status (BIMS) Score of ten (10), was considered unsafe to self-administer her own medications. Her current active physician's orders [REDACTED]. The resident's quarterly assessment with an assessment reference date of 03/27/14, was coded as 0 for item S2000 which indicated the resident was not capable of self-administering medications. The facility's policy titled NSG305 Medication: Administration: General stated under the Practice Standards for medication administration in section 5.2: Remain with the patient until administration is complete. Do not leave medications at the patient's bedside. An interview, on 05/14/14 at 8:30 a.m., with registered nurse (RN) #36 confirmed the facility's policy was to stay with the resident until her medications were taken. During an interview with the Assistant Director of Nursing (ADON), Employee #25, she confirmed the medications were not to be left at Resident #8's bedside. The ADON reviewed the resident's care plan and reported there was no documentation in the plan to reflect the resident's non-compliance with the facility's medication administration policy.",2018-05-01
6475,TEAYS VALLEY CENTER,515106,1390 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2014-06-12,176,D,0,1,0V8S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, resident interview, observations, review of facility policy/procedure, and record review, the facility failed to ensure that one resident (#142) did not self-administer medication in the absence of an assessment and physician order [REDACTED]. Resident identifier: #142. Facility census: 121. Findings include: a) Resident #142 This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The annual Minimum Data Set ((MDS) dated [DATE] assessed the resident to be cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15. During observations conducted on June 9, 2014, and on June 12, 2014, the resident was observed to have a medicine cup with a small amount of powder sitting on her bedside table. During an interview conducted with the resident at the time of the observation, the resident stated that a nurse had given her the powder so that the resident could pat the powder under her breast. A review of the resident's clinical record revealed a physician's orders [REDACTED]. During an interview conducted with the Director of Nurses (DON), Employee #44, on June 12, 2014, the DON stated the resident had not been assessed and care planned to self-administer medications. During an interview with the Administrator, Employee #58 on June 12, 2014, he stated this resident probably could self-administer the powder, but the resident had not been assessed and care planned to do so. Review of facility policy and procedures regarding self-administration of medications revealed that residents who request to self-administer medications would be assessed for capability and if it was determined the resident was able to self-administer, a physician's orders [REDACTED]. The resident would be provided with a secure, locked area to maintain medications, the resident must be instructed in self-administration and a periodic evaluation of capability must be performed.",2018-03-01
8059,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2013-10-24,176,D,1,0,S5LG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the interdisciplinary team failed to ensure Resident #31 was able to safely self-administer prescribed topical medications. This resident was also found with her oral medications which she had not taken while being supervised. This practice affected one (1) of six (6) sampled residents. Resident identifier: #31. Facility census: 116. Findings include: a) Resident #31 1) On 10/23/13 at 9:35 a.m., during a random observation, Resident #31 was observed in bed with her eyes closed. She was holding a medication cup with pills in it and some had spilled onto her blanket. This observation was verified with Employee #144, a registered nurse unit manager. She stated the medications should not have been left with the resident since she does not self-administer medications. 2) On 10/24/13 at 9:35 a.m., during a random observation, Resident #31 was observed to have the following prescribed topical medications located on her bedside table: mometasone furoate 0.1% cream, [MEDICATION NAME] powder 100,000 usp, and [MEDICATION NAME] 2% cream. The facility allowed this resident to keep prescription topical medications in her possession without an assessment to determine whether she was able to safely self-administer these medications. On 10/24/13 at 9:40 a.m., an interview was conducted with Employee #144, a registered nurse unit manager. She verified the topical medications should not be allowed at the resident's bedside without an order for [REDACTED]. b) A review of the medical record on 10/24/13 at 10:00 a.m., revealed this resident did not have a physician's orders [REDACTED].",2016-10-01
9549,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,176,D,0,1,5V2011,"Based on observation and medical record review, the facility failed to assure one (1) of twenty-one (21) facility residents was safe to self-administer drugs prior to allowing the resident to keep medication at the bedside. Resident identifier: #112. Facility census: 157. Findings include: a) Resident #112 During observation of the medication administration pass on 11/17/09 at 10:00 a.m., Resident #112 was overheard telling to the licensed practical nurse (LPN - Employee #195) that the night shift nurse gave her Aspercreme to keep in her room. Employee #195 reported the resident's statement. The assistant administrator (Employee #74) retrieved two (2) used tubes of Aspercreme from the resident's nightstand with her permission. Review of the medical record found the current minimum data set (MDS) with an assessment reference date (ARD) of 09/15/09. Review of this MDS found, in Section S1, the assessor determined the resident was not capable of safe self-administration of medications.",2015-10-01
9681,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2010-02-25,176,D,0,1,WXCT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, review of the facility's policy and procedure for Self-Administration of Medication, and staff interview, the interdisciplinary team failed to identify who would be responsible for the documentation of administration of medications by a resident who kept medications at her bedside. The resident had physician's orders [REDACTED]. [REDACTED]. One (1) of eighteen (18) current residents on the sample was affected. Resident identifier: #46. Facility census: 101. Findings include: a) Resident #46 Review of the resident's medical record found physician's orders [REDACTED].>- Pro-Air HFA (MDI - multi-dose inhaler) - Use PRN (as needed) as directed; Dx (diagnosis) [MEDICAL CONDITIONS]; Resident may keep medication at bedside; - [MEDICATION NAME] Inhaler ([MEDICATION NAME]-[MEDICATION NAME]) MDI - Use PRN as directed; Dx [MEDICAL CONDITION]; Resident may keep medication at bedside; - [MEDICATION NAME] Propionate 50 mcg Nasal spray 2 sprays into each nostril Q (every) Day and PRN. Resident may keep medication @ bedside; and - Vicks Nasal Inhaler - Use in nostrils as directed. Resident may keep at bedside. The orders for these four (4) medications to be kept at the resident's bedside were dated 11/12/09. There was no evidence to reflect the interdisciplinary team had ascertained whether the resident understood how often each of the medications could be used and in what dosage. Additionally, each of the medications was listed on the Medication Administration Record, [REDACTED]. However, there was no documented evidence to reflect the resident had actually used the medications. This information would be needed to ascertain how often the resident self-administered each medication to ensure proper usage. Also, the number of times the inhaler was used would be needed, as the manufacturer's instructions include the inhaler should not be used for more than two hundred (200) sprays. The facility's policy and procedure for Self-Administration of Medication indicated the unit charge nurse was to interview the resident each shift to verify all ordered self-administered medications were taken. A check mark was to be placed on the Medication Administration Record [REDACTED] The instructions for [MEDICATION NAME] and Pro-Air HFA inhalers included individuals with [MEDICAL CONDITION] or diabetes may need special considerations with regards to dosage. The resident's [DIAGNOSES REDACTED]. Therefore, monitoring the frequency of use of the inhalers was needed. In mid-morning on 02/25/10, the director of nursing was asked how the use of the medications was to be documented. She was unable to provide an answer at that time.",2015-10-01
10995,MONTGOMERY GEN. ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2010-07-21,176,D,0,1,9CS011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and record review, the facility failed to assure residents who are assessed as being unable to self-administer their own medications are not allowed to do so. This was evident for one (1) of ten (10) sampled residents, wherein the nurse failed to complete the medication administration process when she left the resident's medication at the bedside for him to take without her oversight. Resident identifier: #45. Facility census: 50. Findings include: a) Resident #45 Observation of a medication pass, on 07/12/10 at 4:29 p.m., revealed the nurse (Employee #59) administered Resident #45's insulin, gave him water with which to take three (3) medications / tablets, then turned and left the room without witnessing him take the oral medications. After completion of all the medication passes, this observation was shared with the nurse, and she acknowledged she should have stayed with him until he took his medications. Review of the medical record revealed physician's orders [REDACTED]. The director of nursing was informed of the above findings at about 12:00 p.m. on 07/15/10, and she presented no further information. .",2014-10-01
7990,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2013-11-11,201,D,1,0,0RE211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, family interview, and interview with outside behavioral health professionals, the facility failed to ensure a resident was involuntarily discharged on ly when her needs could not be met at the facility. There was no evidence of any attempts to assess, monitor, and manage her admitting [DIAGNOSES REDACTED]. This was found for one (1) of twelve (12) residents whose records were reviewed. Resident identifier: #91. Facility census: 90. Findings include: a) Resident #91 1) This [AGE] year old resident was admitted to the facility on [DATE]. She was discharged on [DATE]. Her [DIAGNOSES REDACTED]. Review of the resident's medical record, beginning on 11/04/13 at 11:00 a.m., found she was assessed as having severe cognitive impairment. Her Brief Interview for Mental Status (BIMS) score as assessed on 08/12/13 was 06 indicating severe cognitive impairment. Review of the Pre-admission Screening form, required by the West Virginia Department of Health and Human Resources (WVDHHR), found Resident #91 was residing at a local geriatric behavioral health unit at the time of the initial referral. The [DIAGNOSES REDACTED]. The physician from the behavioral health unit signed attesting she required nursing home care and would not be able to return home or be discharged . A Level II, or Mental Illness/Mental [MEDICAL CONDITION] Screen, needed to be done to ensure that nursing home placement was appropriate. The required screen was completed on 07/28/13, with a recommendation of nursing facility services with no specialized services needed. The social services history/admission assessment completed 08/06/13, under the Behavior: (check all that apply.) section had checkmarks indicating Physical behavior symptoms directed towards others. (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually.), and Verbal behavioral symptoms directed toward others. (e.g., threatening others, screaming at others, cursing at others.) Under the section Impact on others - Did any of the identified symptoms: was checked Put others at significant risk for physical injury. Under the section Discharge plan review checkmarks were made that indicated discharge to the community was not feasible, and that long-term placement was anticipated. There was an incident report for an altercation between Resident #91 and Resident #16 on 08/12/13 at 7:45 p.m. The report described the circumstances as (typed as written): (#91) grabbed (#16) and tossed him down the hallway. He landed on his side hurting his right hip and receiving a skin tear to his right elbow. The report indicted the care plan of Resident #91 was updated. The question Was there a change in behavioral status in the last 90-days? was marked No. There were no interviews, summary of findings, or corrective or proactive action noted in the text fields for those items. The status was marked Not Complete. The medical record of Resident #91 contained a Change of Condition Documentation form dated 08/12/13 at 8:30 p.m. The section of the form Nursing Progress Note - A.P.I.E. was completed as follows (typed as written): 19:45 Resident witnessed resident (#12) hit (another female, Resident #74) in the face. She (Resident #91) reacted by grabbing (Resident #12) and tossed him down this hallway. (Resident #12) landed on his right side on his shoulder & hip. She (Resident #91) then looked at (Resident #74) and said that's how you take care of that. Dr. (name) called @ (at) 8 pm Family called @ 8:05 pm Left message to call back Called (director of nursing, Employee #15) & left a message to call back. The note was written by a licensed practical nurse (LPN), Employee #12. Medical record review found no evidence the behavior issues noted in the documentation available from the admitting facility or assessed by the social worker upon admission were ever included in a care plan. Although the admitting [DIAGNOSES REDACTED]. There was a hand written addition to the care plan, which was not dated, stating: Resident to resident altercation The goal associated with this item was: To keep resident from injuring other residents. Interventions written were: 1. redirect resident 2. Keep resident busy in activities 3. Instruct resident to ask for help if she feels threatened. The facility was unable to locate any KARDEX, or specific instruction to nursing assistants to guide them in providing for the individualized care needs of Resident #91. 2) Resident #91 came to the facility from a local behavioral health facility. The nurse manager and a therapist from that facility were interviewed on 11/05/13 at 12:10 p.m. They said representatives from the facility came to their unit to assess another resident, Resident #74, for possible admission. During that visit, Resident #91 stayed by the side of Resident #74. They said the two (2) had become almost inseparable in the brief time they had been there together. The facility decided Resident #74 was appropriate for admission, and they asked about the possibility of also admitting Resident #91 because of their relationship. The therapist said the family of Resident #91 was contacted , was advised the facility would like for them to consider placing their mother in the facility, and gave them the phone number. They said the two (2) residents were subsequently discharged and admitted to the facility's Alzheimer's unit just a few days apart. 3) During an interview on 11/06/13 at 11:20 a.m., the director of the Alzheimer's unit, Employee #88 confirmed the visit, stating while they were speaking with Resident #74, Resident #91 came in and they felt she would be a good fit for the unit. She said their relationship was felt to be a strength that would help them adjust to the admission and residence in the facility. 4) A family member of Resident #91 was interviewed on 11/06/13 at 11:00 a.m. The family member confirmed the behavioral unit had given them the facility's number and explained they were interested in admitting their mother. They spoke with them, and arrangements were made for a tour of the Alzheimer's unit. When they went for the tour, they were told the unit was designed to care for Alzheimer's patients like their mother, they had twenty-four (24) hour programming, the staff was trained in monitoring and managing the behaviors that come with the disease, and they would like them to consider placing their mother. They decided to proceed with the placement. They said it sounded like a great idea, that their mother could get the care and supervision she needed. The family said however, their experience was that the facility could not provide the care they said they would provide. On the evening of the incident, the male resident had come down the hallway unnoticed, began to argue with Resident #74. They said their mother thought Resident #74 was her mother. During the argument, he slapped Resident #74 in the face. Their mother tossed him to the floor trying to protect her. The family said if staff witnessed the incident play out, why did they not intervene to de-escalate the situation, or redirect the residents to prevent the altercation from even occurring? 5) The Dementia Care Disclosure agreement signed by the family and the facility stated in part (typed as written): Individual assessment and care planning begins with preadmission interviews with the individual, family and physician and is based upon medical history, physical assessment, and psychosocial history . pain management, medication effect, behavior assessment, nutrition, and functional abilities are assessed on an ongoing basis and documented according to Federal and State guidelines. 6) The facility administrator, Employee #48, was interviewed on 11/07/13 at 10:47 a.m. She was asked about the operation of the Alzheimer's unit. She said the unit was currently attempting to transition to the model used by the corporation that recently purchased the facility, but had not been certified by the company at this time. The previous owner's model was still in use. Review of the Alzheimer's Care Program Guide identified as the current model found a section entitled (typed as written): Things to consider regarding Potentially Harmful behaviors . Some of the instruction in that section included (typed as written): Before Admission Complete typical history and physical, background and behavioral history information to:Identify any behavioral issues and patterns;Determine if additional information is needed on these behaviors;Determine whether a dementia care program is needed. If additional information is required, contact attending physician, meet with the resident and/or significant other face to face, or seek a mental health consult, as appropriate.Determine whether any of the identified behaviors are potentially harmful and whether they can be appropriately managed in the dementia program.Determine whether resident is a likely admission to the center. During Residence If a behavioral concern is identified pre-admission or during the admission process , then continually monitor, observe and evaluate the resident to determine whether: Care plan goals for managing the behavior are being met.Goals need to change.Interventions used are effective and sufficient. 7) The licensed practical nurse (LPN), Employee #12, who had written the note describing the incident was interviewed on 11/06/13 at 1:19 p.m. She said she was passing medications on the evening of the altercation. There were two (2) nursing assistants and herself working in the Alzheimer's unit. There were thirty (30) residents in the unit. She said she did not think there were any activities staff working at that time. This was later confirmed by the director of the unit, Employee #88 on 11/06/13 at 4:00 p.m. 8) Payroll records showed the activities staff had left at 5:04 p.m. on 08/12/13. She said they normally only work from 9:30 a.m. to 8:00 p.m. LPN #12 said at that time of the evening, the nursing assistants (NAs) would be in resident rooms getting them ready for bed, and she would be passing medications. She said Resident #16 lived in a room down at the end of one of the two (2) main wings that formed the L shaped unit. Resident #91 and Resident #74 lived at the end of the other wing. She said Resident #16 had gone from his room at the end of one hall, and had gone down the other hall to the end where the ladies were sitting and talking. No one noticed his whereabouts or attempted to redirect him, because the aides were in other residents' rooms and she was passing medications. She said she was approaching the corner of the L shaped wings when she heard the argument between Resident #16 and Resident #74. She said he had gone into the room the ladies were in talking and they were trying to get him out. As she began to make her way down the hall, he slapped Resident #74. She heard Resident #91 say He slapped my mother, and she tossed him to the floor. She was not able to get to them in time to intervene or redirect Resident #16. She said following the altercation, Resident #91 was fine, she just went to her room, and later went to bed. She said, especially at that time of the evening, there are lots of fights and spats, but usually no injuries to the extent suffered by Resident #16. She said many of the residents exhibit sundowners behaviors. There were a few male residents who go in the women's rooms, and it frightens them. The normal scheduled staffing is one (1) nurse and two (2) aides, and it is just not enough staff to monitor and redirect all the residents in the evening while trying to do the individual care in the rooms and also pass evening medications. She said sometimes the aides or the nurse have to scream at the top of their voices to try to get help for situations like this, and there could be some that no one was ever aware of. She said Resident #91 was just trying to protect her mother. 9) Nursing assistant (NA), Employee #2, one of the NAs working the evening of the incident, was interviewed on 11/06/13 at 3:22 p.m. She said she was in another room caring for a resident when she heard the nurse scream for help. By the time she was able to get there, Resident #16 was on the floor. The ladies were just sitting there watching the situation. She said it is not uncommon for there to be spats and fights. The outcome was unusual with the extent of the injuries. She said they could have been separated and the incident avoided if there were more staff. With one (1) nurse doing medication pass and two (2) aides getting people ready for bed, it is not possible for residents to be monitored and interventions to be made promptly to prevent accidents. This was just a more serious injury. 10) The record documented a care plan meeting with the family of Resident #91 on 8/14/13 at 2:15 p.m., one (1) day, eighteen and one half (18 ?) hours after the altercation resulting in the injury to Resident #16. The note stated (typed as written): Careplan meeting held with daughters - (name) and (name). Discussed residents current status. Recent resident to resident altercation on 8/12/13 and possible transfer to shortterm placement at (local behavioral health unit) for behavioral management. Family discussed past history of behaviors. Discussed her hospitalization at (local behavioral health unit) prior to placement here. Stated that if she starts shaking her fist, this is a trigger that she is becoming agitated. Both stated that they love her being here. No complaints voiced. 11) During the interview conducted on 11/05/13 at 12:10 p.m., the therapist from the (local behavioral health unit) said when the facility called regarding Resident #91 returning to the unit on 08/14/13 for short term behavioral management, they were asked, as is the customary protocol, if they agreed to take the resident back after she was stabilized. An Intake Screening Form was reviewed which indicated the facility's Alzheimer's unit director, Employee #88 had agreed to the planned re-admission. The therapist stated facility staff had come to the unit on 08/27/13 to re-assess Resident #91, and then later they were notified that individuals from the facility's corporation had regionally denied her admission to any of their facilities. The therapist stated Resident #91 is basically the same today as she was on the day before they admitted her on 08/05/13. She had [MEDICAL CONDITION] with behavioral disturbances that required monitoring and management. She does not require a psychiatric facility. A telephone contact note dated 08/28/13 stated (typed as written): Spoke with PT's daughter this morning to discuss PT's return to (the facility). Discussed my previous day's discussion with (the facility), where they had stated the PT would be readmitted to a different (corporately owned) facility. After this conversation ended I was contacted by (name) from (corporation) who stated that PT would not be reaccepted back into any (corporate) facilities. I attempted to contact PT's daughter again, but was unable to reach her. The therapist said contact was made later and the family was informed of the decision. Resident #91 remained at the (local behavioral health unit) as of this investigation. 12) A request was made on the morning of 11/07/13 for documentation of any written discharge notice and/or notice of right to appeal the discharge of Resident #91 from the facility. No documents were provided by the time of exit on 11/11/13. A discharge summary was found signed by the physician on 10/15/13. It listed the discharge date as 08/14/13. The sections of the form Brief History:, Pertinent Physical and Laboratory Findings:, Condition on discharge:, discharged to:, and Follow-Up and discharge Medication Instruction: were blank. 13) The investigation found sixteen (16) documented resident to resident altercations since 08/01/13. Some residents with repeated instances of aggression, such as Resident #16, were never sent out for evaluation. Three (3) residents were sent to the (local behavioral health unit) following altercations. Resident #12 was sent out on 03/18/13, and was accepted back after evaluation. Resident #85 was sent out on 04/30/13, and was accepted back after evaluation. Resident #91, who did not initiate the altercation of 08/12/13 at 7:45 p.m., was sent out for evaluation one (1) day, eighteen and one half (18 1/2) hours later on 08/14/13, and then not accepted back because she was considered a danger to other residents.",2016-11-01
8597,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,201,D,1,0,BVS711,"The facility must permit each resident to remain in the facility, and not transfer or discharge the resident from the facility unless the transfer or discharge is necessary for the resident's welfare and the resident's needs cannot be met in the facility; The transfer or discharge is appropriate because the resident's health has improved sufficiently so the resident no longer needs the services provided by the facility; The safety of individuals in the facility is endangered; The health of individuals in the facility would otherwise be endangered; If transfer is due to a significant change in the resident's condition, but not an emergency requiring an immediate transfer, then prior to any action, the facility must conduct the appropriate assessment to determine if a new care plan would allow the facility to meet the resident's needs. (See ?483.20(b)(4)(iv), F274, for information concerning assessment upon significant change.) Refusal of treatment would not constitute grounds for transfer, unless the facility is unable to meet the needs of the resident or protect the health and safety of others. Documentation of the transfer/discharge may be completed by a physician extender unless prohibited by State law or facility policy. Procedures: During closed record review, determine the reasons for transfer/discharge. o Do records document accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines? o Did a physician document the record if residents were transferred because the health of individuals in the facility is endangered? o Do the records of residents transferred/discharged due to safety reasons reflect the process by which the facility concluded that in each instance transfer or discharge was necessary? Did the survey team observe residents with similar safety concerns in the facility? If so, determine differences between these residents and those who were transferred or discharged . o Ask the ombudsman if there were any complaints regarding transfer and/or discharge. If there were, what was the result of the ombudsman's investigation? o If the entity to which the resident was discharged is another long term care facility, evaluate the extent to which the discharge summary and the resident's physician justify why the facility could not meet the needs of this resident. Based on staff interview, medical record review, and family interview, the facility failed to ensure a resident was not permitted to remain in ould not receive an inappropriate discharge. The facility stated the resident had behaviors that made him a danger to other residents, visitors, and staff. The facility failed to implement measures to ensure this resident could remain in the facility. Resident identifier: #16 Facility census: #78 Findings include: a) Resident #16 Medical record review was conducted on 05/30/13 at 2:00 p.m. during the review of the care plan it was revealed the resident had multiple interventions regarding behaviors the facility would use to care for the resident. During review of the resident's nursing notes from January 2013 thru May 2013 the facility failed to document the interventions had be implemented for the resident. The resident has one on one (1:1) care at all times. The resident has one (1) documented incident that occurred 04/04/13 at which time he attempted to hit a visitor, but did not. The facility issued a thirty (30) day discharge 04/11/13 following the attempt to hit a visitor. Family interview was conducted on 05/30/13 at 2:50 p.m. with the resident's spouse she stated she is happy with the care that her husband receives in the facility and she did not feel he was a danger to others especially since his recent admission to River Park Hospital during the month of April. An interview was conducted with the facility's medical director on 05/31/13 at 2:15 p.m. when asked what had changed with this resident's behavior since his admission to the facility he stated nothing had changed. When asked if the resident needed to remain on 1:1 care he said he would not be comfortable discontinuing it since it is in place and there had been incidents with the resident hitting staff and the attempt to hit a visitor and he often will wander. When asked about the recent medication changes and recommendations from the psychiatric group he stated he was looking at all the recommendations and considering them at this point. When asked if he felt the resident needed to be moved to another facility he stated it wasn't his idea to discharge the resident.",2016-05-01
8634,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,201,D,1,0,CZR411,"Based on medical record review, staff interview, and family interview, the facility failed to permit a resident to stay in the facility and not transfer or discharge the resident when she did not meet the discharge requirements. The facility provided information to the resident's responsible party he/she would have to move the resident because the facility did not have long term beds available and her stay there was only temporary. The facility gave a date to the family and they were told they had to come and get the resident on that date. This practice was identified for one (1) of five (5) sampled discharged residents. Resident identifier: 185. Findings include: a) Resident #185 A social service note, dated 01/02/13, reflected the Social Worker (SW) met with Resident #185's Power of Attorney (POA) and the family requested the facility cancel the transfer plans to another nursing home they had been working on for this resident. The note said the SW explained that the transfer was already in progress and there were no long term beds available at this facility and that the resident's stay here was a temporary circumstance. The note indicated this facility had no long term care beds at that point and she was a skilled resident with days left for available service. A note, dated 01/29/12, indicated another nursing home was looking to take the resident and the facility informed the family the resident would either discharge home with the family or transfer to the other facility on Friday 02/01/13. Then the nursing home refused to take the resident. According to the notes, Resident #185 was transferred to another nursing facility on 02/01/13. 04/10/13 at 10:45 a.m., Employee #134 (Social Worker) was interviewed about this resident's discharge. She stated she was not aware all beds could be long term care when she told the resident's family the resident would be discharged after her skilled days were up. She indicated the family wanted to take her out anyway and move her closer to them. A family interview was conducted on 04/15/12 at 7:00 p.m. This family member stated they did not want to move the resident so far away from her sons, but that was what they had to do because the facility told them the resident could not stay at this facility because they did not have a bed available. The family member stated the resident's sons live close and could visit her at this facility. According to the family member, the resident still needed nursing home care, which they could not provide, so they had to move her to another long term care facility a couple hours away that was closer to the resident's sister. The family moved the resident to a location that was inconvenient for the resident's children to visit. According to the family member, they would have left her at this facility. .",2016-04-01
10903,GOLDEN LIVINGCENTER - GLASGOW,515118,PO BOX 350,GLASGOW,WV,25086,2009-09-11,201,B,0,1,OF0Z11,"Based on staff interview and review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with four (4) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This had the potential to affect all residents in the facility who are transferred or discharged . Facility census: 92. Findings include: a) Review of the uniform discharge notice of transfer / discharge form provided by the facility revealed the following: ""If you disagree with this transfer/discharge or wish to appeal this transfer/discharge...:"" This was followed by the names and contact information of the State Long-Term Care Ombudsman, Medicaid Fraud, and the WV Advocates. Below the above list of names and addresses was ""For Medicaid Residents: Please include the provided self addressed stamped envelope which includes the address of the.... Inspector General"". This uniform notification form contained the following error: The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the three (3) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Interview with the director of nursing, on 09/10/09, revealed the facility changed this form a year or more ago and they were under the impression this form in its current format was appropriate. .",2014-11-01
11147,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,201,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to afford one (1) of thirteen (13) sampled residents, who was transferred to the hospital, an opportunity to return to the facility. Resident #51 was transferred to the hospital for evaluation due to problem behaviors on 08/06/09, and after this transfer occurred, Resident #51's family was told the facility would not re-admit the resident. Facility census: 50. Findings include: a) Resident #51 Resident #51 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the resident's medical records prior to admission (dated 04/20/09) found, ""... improved speech and walking with [MEDICATION NAME], but has become very aggressive and combative at times..."" Review of the resident's nursing notes, from 05/31/09 through 08/06/09, and the facility's incident / accident reports found numerous resident-to-resident altercations involving Resident #51, including three (3) incidents which resulted in injury to the other residents. A psychological consult, dated 08/03/09, stated, ""As per history of the last five years as given to me by family, patient has continued to deteriorate to present condition of full care and supervision, and has an extended history of combativeness and aggression as per family and nurses notes. As her present placement allows for freedom of movement, and social interaction between patients, I would recommend a more restrictive environment for the safety of patient and others."" A 08/06/09 physician's orders [REDACTED]."" A social service note, dated 07/24/09, stated, ""... request him (Resident #51' medical power of attorney representative - MPOA) to call next week when he gets settled and we can have a meeting to discuss what is the best plan for (Resident #51's) safety."" After requesting additional information on the late afternoon of 08/12/09, the social worker produced two (2) additional unsigned social services notes. A 08/06/09 note stated, ""... discussed resident hitting another resident last night and the aide. Advised she will be sent to (hospital) for evaluation. He agreed. Spoke with (discharge planner at hospital). Advised him that (Resident #51) cannot accept back resident do (sic) to behaviors. Referral had been made to ______."" Another unsigned note, dated 08/06/09, stated, ""... discussed the recommendations of the psychologist to have her in a more secured setting. Discussed him taking her home another facility cannot accept. He agreed to a referral be sent to ____. They can provide the secured environment that we cannot. She wanders outside the facility almost daily. She has become aggressive with other residents."" .",2014-08-01
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
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
7375,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2014-05-15,202,D,1,0,2OSX11,"Based on record review and staff interview, the facility failed to ensure the resident's clinical record was documented by a physician when a discharge occurred under specific situations. A resident with behaviors was discharged when the facility deemed the resident's needs could not be met in the facility, and/or the safety of individuals in the facility was endangered. The facility could provide no evidence a physician had documented the reason for the resident's discharge. This was evident for one (1) of seven (7) sampled residents. Resident identifier: #102. Facility census: 101. Findings include: a) Resident #102 Review of the medical record, on 05/15/14 at 10:00 a.m., revealed this resident was transferred/discharged from the facility on 04/21/14 at 11:30 a.m. to (name of hospital). A licensed nurse, Employee #32, received an order from the Family Nurse Practitioner (FNP) on 04/21/14 to send the resident to (name of hospital) emergency room for evaluation. Review of the medical record found no evidence of a physician's documentation related to the discharge. During an interview, on 05/15/14 at 12:00 p.m., with licensed social workers (LSW) #11 and #25, the interim director of nursing (DON), and the administrator, they said this resident was discharged to (name of hospital) on 04/21/14 because it was felt that the facility could no longer meet her needs adequately and could not keep her, or other residents, safe from harm due to her behaviors. They said the facility was unable to give thirty (30) days notice due to the immediacy of her behaviors. An interview was conducted with the medical records coordinator, on 05/15/14 at 3:00 p.m. She looked through the resident's medical record. She said she was unable to find any physician's progress notes, or other documentation by a physician, related to the resident's 04/21/14 discharge from the facility. The director of nursing (DON) and the administrator were informed of these findings. They were unable to provide physician's documentation related to the resident's 04/21/14 discharge prior to exit.",2017-05-01
7899,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2013-12-31,202,D,1,0,6YCS11,"Based on medical record review, staff interview, and family interview, the facility failed to ensure the physician documented, in the medical record, the reason for an involuntary discharge of (1) of six (6) residents reviewed for discharge. The physician did not document why there was a necessity to issue a thirty (30) day discharge notice for a resident who had been transferred to an acute care hospital. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 The medical record was reviewed on 12/30/13 at 2:00 p.m. It indicated Resident #115 was transferred to an acute care hospital for psychological treatment related to behaviors of physical and verbal aggression. The nursing progress notes and assessments indicated the resident had placed herself on the floor constantly, requested pain medication, and hit staff. An interview with Interviewee #1, on 12/31/13 at 2:30 p.m., revealed the facility provided the family with a thirty (30) day discharge notice while the resident was in the hospital. The medical record contained no documentation, by the physician, regarding why the resident was issued an involuntary discharge from the nursing facility. During interviews with Employee #73, social work liaison, on 12/31/13 at 10:45 a.m., and Employee #55 (social worker) on 12/31/13 at 11:00 a.m., both stated the physician had written a letter to the family. The letter was reviewed. It had it been signed by the physician. An interview with the director of nursing on 12/31/13 at 12:35 p.m., confirmed the facility had dictated the letter. They said the physician was aware of the discharge. Employee #63, director of care delivery (DCD), was interviewed on 12/31/13 at 3:45 p.m She reviewed the medical record and was unable to provide evidence the physician had documented a reason for discharge from the facility. In addition, medical record review revealed the physician documented the resident was stable on multiple medications, on an entry dated 12/02/13.",2016-12-01
10778,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2011-08-04,202,D,1,0,S9PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to adequately document the reasons and conditions surrounding a resident's discharge from the facility due to safety reasons. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): ""3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which is not working. 3:20pm, contacted (name of director of nursing) RN, DON, also contacted (name of social worker) SS, who will be contacting (name of administrator) CEO. 3:25pm, Contacted (name of resident's responsible party) MPOA (medical power of attorney)who is in agreement to transport resident to FGH Behavior unit. 3:50pm, left message for Dr. (name). 3:50pm Contacted MCRS to transport resident to FGH for evaluation. Son, (name) MPOA in to see resident. (Name) Called and was told of behavior and going to FGH ... 4:15pm, MCRS here to transport resident to FGH for evaluation. Also contacted FGH ER and spoke with Nurse (name) who was informed of residents behavior and arrival by squad. 5:18pm, Dr. (name) returned call re: residents behavior and transport to FGH for evaluation."" - Review of documentation concerning Resident #43's discharge, conducted on 08/04/11 at 1:00 p.m., disclosed a notice of resident transfer and bedhold policy dated 06/26/11. The form was filled out by hand and stated ""(Name of Resident #43) will be transferred to FGH (local hospital) due to: behavior."" There followed a statement of facility bedhold policy, which included the statement: ""It is the policy of John Manchin Sr. Healthcare to hold the resident's bed for 30 days ... The bedhold will continue unless permanent determination is made regarding the resident's need for care the facility is unable to provide."" There followed a section Titled ""State Bed Hold Policy"", a statement that ""The resident has the right to appeal this action to the agencies listed below"", and a listing of contact information for the West Virginia Inspector General, the West Virginia Commission on Aging, West Virginia Advocates, and the Regional Ombudsman. The form concluded with the following: ""I certify that this notification was given to the party named above: (name of Resident #43), and was dated by hand 6/26/11. Signature of staff member was completed by hand as (Employee #68, LPN)."" The final section of the transfer notice stated: ""Verification of receipt of notification: This acknowledges that I received the notice of resident transfer and bedhold policy."" The ""signature of resident / legal representative"" field was blank. - In an interview with Employee #68 on 08/03/11 at 2:45 p.m., when asked if she had given a copy of the form to the resident or to the MPOA, replied that that form was not given to either of those individuals, that it was a form that was sent with the emergency squad when a resident is sent out. - During an earlier interview with the nurse manager of the Behavioral Health Unit on 08/03/11 at 11:00 a.m., she had pointed out that the facility sends a form when residents are transferred for evaluation that states they will hold the resident's bed for thirty (30) days. - An interview was conducted with a son of Resident #43 by telephone at 11:30 a.m. on 08/03/11. He stated the family did not have enough time to transfer their mother to another facility. He further stated he felt administration at this facility did not seem to understand how to care for Alzheimer's patients. He also stated the floor nurses at the facility did the best they could, but administration just did something drastic. - In an interview with the facility's health information management director (Employee #45) on 08/03/11 at 1:25 p.m., when asked to clarify the facility's bedhold policy, she stated the facility holds the bed of a transferred resident for thirty (30) days regardless of payor source or availability of bedhold days through the Medicaid program. She stated that, if a resident's Medicaid allotment of twelve (12) paid bedhold days had already been used, the facility would still hold the bed free of charge for thirty (30) days. - The only documented meeting between the facility's interdisciplinary team and Resident #43's MPOA was a care plan review meeting held on 04/06/11. A social services note stated: ""Annual Assessment was done today for (Name of Resident #43). Her son and MPOA, (name), attended the meeting. The IDT (interdisciplinary team) members reviewed the care needs of (Resident #43) with (name of son) and a new plan of care will be done reflecting new changes in her care."" A review of the care plan that was developed found the problems / strengths identified were in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to Resident #43's MPOA about the continued stay of Resident #43 at this facility. There were no other documented discussions or meetings with the family. - A review of social services notes found there was no note regarding the resident's transfer to the Behavioral Health Unit at the local hospital on [DATE]. There was a note dated 06/27/11 which stated: ""Called and cancelled (Resident #43's) appointments with physical therapy this week."" This was the final social services note in the medical record. A review of physician's progress notes found the last documented note was dated 06/15/11, and stated: ""(Rt) (right) ear redness (illegible) tissue. Pressure related sleep changes."" The nurses' note from that visit stated: ""MD vs (visit) and examined right ear that was red and stated that it was pressure related from lying on the right side. Orders received to DC (discontinue) [MEDICATION NAME] at this time."" There was no further documentation found by the attending physician. physician's orders [REDACTED].#43. It was explained by Employee #41 (a registered nurse assessment coordinator) that, since the electronic medical record was closed, all orders printed had ""dc"" at the beginning and "" "" at the end. The final physician's orders [REDACTED]."" There were no further orders for permanent discharge from the facility. A discharge summary form, dated 07/13/11 and signed Employee #41, stated the resident was discharged to the local hospital. The course of treatment while in the nursing home was described as: ""Alert, but confusion. Needs assist. Of one for all care to ensure optimum level of personal hygiene. Independent ambulation. Needed supervision to prevent resident from leaving facility property. Redirection for aggressive behavior."" Pertinent diagnostic findings were described as ""N/A"" (not applicable). Essential information regarding illnesses or problems was described as: ""Increased confusion, Redirection not always effective. Repeated attempts to leave facility + (and) facility property."" Restorative procedures were described as: ""Psyche consults medication adjustments."" The section titled ""Written discharge instructions given to"" was not completed. The section for Physician Signature was blank. - The administrator, (Employee #2), DON (Employee #46), and social worker (Employee #34) all stated, during an interview of 08/02/11 at 3:00 p.m., that they had ongoing discussions with the family about their concerns for the safety of Resident #43 and their growing conviction that they could no longer ensure her safety as a resident of their facility. There was, however, no documentation to support that those exchanges occurred, and there was documentation that showed that both the Behavioral Health Unit at hospital and the family were clearly expecting the resident to be readmitted until the phone conversation of 07/11/11. The family was then required to make an unplanned admission to another nursing facility that provided the same level of care. The record of Resident #43, whom the facility maintained was transferred / discharged due to safety reasons, did not reflect the process by which the facility concluded that transfer or discharge was necessary and did not contain evidence of accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines, and there was no documentation from the resident's physician that the resident was transferred / discharged for the sake of the resident's welfare and/or the resident's needs could not be met in the facility. .",2014-12-01
10935,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2011-07-19,202,D,1,0,UZ6R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, and staff interview, the facility failed to provide the medical power of attorney representative (MPOA) and/or interested family members with a reason for discharge and/or alternatives to discharge, including appeal rights, for one (1) of nine (9) sampled residents. Resident identifier: #70. Facility census: 67. Findings include: a) Resident #70 A review of the closed medical record of Resident #70 revealed this [AGE] year old female had been determined by her physician, on 04/03/11, to lack the cognitive ability to make healthcare decisions. She was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The admission physician's note dated 03/31/11 stated she was ""... alert / oriented and agreeable with POC (plan of care)."" A review of her care plan, dated 04/22/11, revealed she ""... exhibited some behaviors during my review period such as yelling, and becoming tearful"" and that she had difficulty understanding and processing information. Nursing interventions were planned which remained unchanged throughout her admission. Documentation on her pre-admission screening (form PAS-2000) indicated her nursing home stay was planned for less that three (3) months, and the discharge plan indicated, on 04/22/11, that her stay was ""short-term"" and she was to return home with home health care. She was receiving no psychoactive medications at the time of admission. In May 2011, the resident had a psychiatric consult and was started on [MEDICATION NAME] and [MEDICATION NAME] because of ""generalized anxiety disorder AEB (as exhibited by) increased agitation and crying episodes"". The nurses notes in June 2011 intermittently recorded increased behavioral episodes which included combativeness, resisting care, and cursing at staff. This was reported to the physician, who ordered [MEDICATION NAME] on 06/16/11. This medication was started at 9:00 a.m. on 06/20/11. The resident's care plan was revised on 06/21/11 to include: ""... at risk for leaving the building unassisted. I am confused and agitated at times."" However, the care plan did not identify any concerns related to physically and/or verbally abusive behaviors. The record revealed the social worker (Employee #4) met with the resident's MPOA on 06/17/11, discussed ""behaviors occurring daily"" with the resident, and suggested that they may need to consider moving her to a facility better equipped to care for persons with her problems. This was confirmed during an interview with the social worker at 11:10 a.m. on 07/19/11, who stated this was her last conversation with the son, because she was not on duty when the resident was transferred out of the facility on 06/21/11. The resident was transferred to an acute care hospital at 5:00 p.m. on 06/21/11, after a behavioral episode which included throwing objects across her room. The nurse's entry at that time stated: ""(Resident #70) transferred to hospital - unplanned for evaluation and treatment via ambulance to (hospital). Physician notified of transfer. ... Copy of advance directives sent. See transfer form for additional clinical findings."" The only clinical finding documented on the transfer form was ""behaviors"", which was entered as the [DIAGNOSES REDACTED]. A nurse's note, which was recorded as a late entry at 2:17 p.m. on 06/22/11 by the registered nurse (RN) manager (Employee #3), stated: ""Client had several episodes of behaviors outbursts. Client found in room with possessions on bedside table, and table it self, thrown across room. When staff nurse asked client what had occurred and who had thrown objects, Client stated, 'the cat did it, I was sitting on the couch.' Client's MPOA called by staff nurse with fell ow staff nurse present. Asked MPOA to come in and try to calm down client. MPOA stated he'd be there in one hour. Client's daughter arrived shortly after. Staff nurse and administrator discussed recent outbursts of behavior and other options that might be more beneficial to client. Staff nurse mentioned family might be interested in having her evaluated by a hospital that has a unit more specialized to her needs, ex. (hospital name). Daughter discussed with son, MPOA. Both agreed that would be a good option for client to receive further evaluation and treatment. Staff nurse call to set up transport... Staff nurse stated several times to family that this would be private pay transportation. MPOA stated that he understood and that would not be a problem. Staff nurse's also reeducated that although client was going for evaluation and treatment to hospital, does not mean that she would be admitted . MPOA stated he understood. Client with family for remainder of afternoon and dinner until transportation arrived. Report called to receiving facility."" During an interview with Employee #3 at 12:50 p.m. on 07/19/11, she confirmed she made the above entry and stated the resident had begun to calm down and became calm when the family arrived. Employee #3 stated she told them they should consider a facility better equipped to handle the behaviors and they agreed. During an interview with the resident's daughter at 11:40 a.m. on 09/19/11, she stated that, on the day of the transfer, she arrived at the hospital shortly before her brother and they spoke to the nurse who stated she was the supervisor in charge. They were told that the facility ""couldn't handle her anymore"" and they were given two (2) hospital options. She and her brother talked and chose which hospital and an ambulance was called. She stated she called back to the facility the next day and talked to the administrator, telling her the resident had been admitted to the hospital with [REDACTED]. The daughter stated, ""The administrator did not comment other than expressing surprise."" She stated that no one mentioned to either of them about readmission to this facility and her understanding was that they could not bring her back. She added that, after being treated for [REDACTED]. During an interview with the administrator at 8:30 a.m. on 07/19/11, she stated there were problems with the resident throughout her stay at the facility, which included physical aggression that escalated prior to discharge. She stated it was her understanding that the MPOA placed the resident in a behavioral treatment facility when she was released from the hospital. The administrator also stated she thought there was a payment problem because her Medicare had been depleted, but she acknowledged she was not sure of the source of this information and that she had not discussed this with the family, although she thought the social worker was attempting alternative placement. A review of the medical record revealed a Notice of Transfer or Discharge form containing the resident's last name and medical record number written in at the bottom, but the rest of the form was blank. This was presented to the administrator (Employee #1) at 10:54 a.m. on 07/19/11 with a request for any evidence that the family had been informed of the final disposition of the resident at the time of transfer and/or discharge. During an interview with the administrator and the social worker at 11:10 a.m. on 07/19/11, they acknowledged there was no additional documentation and both stated they had not spoken to the family since the resident was transferred. The social worker stated she had recently mailed a form to the MPOA containing the Right to Appeal process, but she had no proof of this and had received no response. The social worker again stated the aforementioned conversation with the MPOA was the extent of her involvement. In a follow-up interview with the administrator at 1:10 p.m. on 07/19/11, after the interview with the daughter of the resident, the administrator again stated she had not spoken with the family after the transfer and further stated she had not refused to readmit the resident after hospitalization . At the time of exit at 2:30 p.m. on 07/19/11, this surveyor had received no information stating the reason for discharge or any discharge planning information indicating that alternative placement had been requested or was being sought by the facility.",2014-11-01
2126,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2016-08-30,203,C,0,1,6MCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer/discharge form and staff interview, the facility failed to provide residents and responsible parties with the correct contact information of the single State agency responsible for reviewing making decisions for all transfer/discharge appeals. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia (WV) to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. These findings had the potential to affect more than a limited number of residents. Facility census: 53. Findings include: a) Review of the facility's uniform notification of transfer/discharge form provided by the facility on 08/25/16, revealed it included, You have the right to appeal this action to: , This was followed by the names and contact information of the regional Ombudsman, State Ombudsman, Office of Heath Facility Licensure and Certification, and the Board of Review. Immediately following the list of names and contact information of appeals was Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: . This was followed by the contact information for West Virginia Advocates and for Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of the Inspector General's Board of Review is the only agency in WV which hears and makes determinations about appeals of transfer/discharge. None of the five (5) other agencies identified in the notice are responsible for this activity. This misinformation has the potential to delay a decision for an appeal should the resident/resident's representative submit the appeal to the wrong agency. 2. The single agency designated in WV to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. Medicaid Fraud does not provide these services. On 08/30/16 at 1:25 p.m., Medical Records Employee #54 provided a copy of the facility's Notification of Transfer/Discharge form. She said that form was provided to all residents when they were discharged from the facility to a hospital, another nursing home facility, or to a private home. The administrator was interviewed at this time also. No further information was provided prior to exit.",2020-09-01
4028,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2016-10-17,203,B,0,1,353M11,"Based on review of the facility's notification of transfer/discharge form and staff interview, the facility failed to ensure the notice provided complete and correct information regarding the current professional person who reviews transfer/discharge appeals at the Inspector General's office Board of Review. and contained no telephone number. This had the potential to affect more than a limited number of residents. Facility census: 91. Findings include: a) On 10/13/16 at 4:30 p.m., review of the notification of transfer/discharge form provided by the facility found it included the name of the former professional person who reviewed transfer/discharge appeals at the Inspector General's Board of Review office and it's address. The name of the professional person who reviews transfer/discharge appeals in the Inspector General's Board of Review Office was incorrect. The current professional person assumed that position approximately one and one-half year's ago, and the facility's uniform notice was not revised to reflect this. The uniform transfer/discharge form did not contain the telephone number for the office of the Inspector General's Board of Review. During interview with the DON and the administrator on 10/13/16 at 4:30 p.m., they said they were unaware of those inaccuracies.",2020-02-01
5691,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2015-01-29,203,D,0,1,WCKU11,"**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 resident and/or the family in writing of: 1) the reason for the resident's discharge from the facility, 2) the effective date of transfer or discharge, 3) a statement that the resident had the right to appeal the action to the State, and 4) the name, address and telephone number of the State long term care ombudsman. This was evident for one (1) of three (3) residents reviewed for the care area of admission, transfer, and discharge. Resident #83 was transferred to a local hospital for exit seeking behaviors. The facility did not provide the resident or family member/legal representative the necessary documentation necessary at the time of the discharge. Resident identifier: #83. Facility census: 108. Findings include: a) Resident #83 The record review for Resident #83, on 01/28/15 at 1:30 p.m., revealed the facility discharged Resident #83 to a local hospital on [DATE] for exit seeking and combative behaviors. During Stage 1 of the Quality Indicator Survey (QIS), the facility provided a copy of information provided to residents upon transfer or discharge. The facility provided a form entitled, Notification of Transfer/Discharge. The form required the facility to complete the effective date of the transfer, the reason for the resident's discharge, a statement that the resident had the right to appeal the action to the State, and the name, address and telephone number of the State long term care ombudsman. At 2:30 p.m. on 01/28/15, the administrator was asked for a copy of the information provided to the Resident #83 and/or his family at the time of discharge. Review of the facility's policy, entitled, Discharge and Transfer found, All patients will receive a Notice of Transfer or Discharge and/or Discharge Transition Plan whenever a voluntary or involuntary transfer/discharge occurs . At 3:00 p.m. on 01/28/15 the medical record clerk, Employee #100, and the administrator confirmed they could find no evidence the required information was provided to the resident/and or the family at the time of discharge.",2018-08-01
6527,EASTBROOK CENTER,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2015-02-17,203,D,1,0,O5Z211,"Based on medical record review and staff interview, the facility failed to notify the resident and/or the family in writing of: 1) the effective date of transfer or discharge and 2) the correct address of the Office of Health Facility Licensure and Certification. This was evident for three (3) of eight (8) sampled residents. Residents #131 and #61 were issued notices of transfer and discharge which contained the wrong address for the State survey agency. Resident #126 was issued a notice of transfer and discharge which did not contain the effective date of the transfer or discharge. Resident Identifiers: #131, #61, and #126. Facility Census: 125. Findings Include: a) Resident #131 A review of Resident #131's medical record, at 9:32 a.m. on 02/17/15, found Resident #131 was issued a notice of transfer or discharge on 02/06/15. This form instructed the resident and/or responsible party to contact the Office of Health Facility Licensure and Certification (OHFLAC) should they have concerns related to this transfer and/or discharge. The form listed the incorrect address for the OHFLAC office. An interview with medical records personnel, Licensed Practical Nurse (LPN) #152, at 1:40 p.m. on 02/17/15, revealed Resident #131 was issued the wrong notice of transfer and discharge. She indicated they began using a new form in August or September of 2014 which included the correct address of the OHFLAC office. During an interview with the Nursing Home Administrator, at 1:40 p.m. on 02/17/15, she stated the facility did not use the new (corrected) transfer or discharge form for the resident. At 1:45 p.m. on 02/17/15, the Administrator confirmed the wrong form was sent for Resident #131. She confirmed the Notice of Transfer or Discharge form issued to Resident #131 on 02/06/15 listed the wrong address for the OHFLAC office. b) Resident #61 A review of Resident #61's medical record, at 1:30 p.m. on 02/16/15, found Resident #61 was issued a notice of transfer or discharge on 07/29/14 and on 08/06/14. Both forms instructed the resident and/or responsible party to contact the OHFLAC office should they have concerns related to the transfers and/or discharges. Both forms listed the incorrect address for the OHFLAC office. In an interview at 1:30 p.m. on 02/17/15, the Administrator confirmed the address for the OHFLAC office was not correct on either of the Notice of Transfer or Discharge forms. She stated they did not start using the new form with the correct address until August of September of 2014. c) Resident #126 Review of the resident's medical record on 02/16/15, found the facility issued a thirty (30) day notice of discharge from the facility for Resident #126. The letter was dated 01/14/15. According to the information contained in the discharge letter, the resident's behavior escalated to the point the facility felt the resident was a danger to other residents and staff at the facility. All required information for the discharge was contained in the notice, except the effective date of the discharge. A copy of the notice of discharge was provided to the resident's court appointed guardian. At 4:15 p.m. on 02/16/15, the administrator verified she had written the letter. She verified the letter did not contain the effective date of the discharge from the facility.",2018-02-01
6554,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2014-03-06,203,D,0,1,3XP811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer/discharge forms, medical record review, and staff interview, the facility failed to communicate to all residents and responsible parties their appeal rights at discharge, and to whom they could make their appeal. The facility failed to provide the contact information of the single State agency responsible for reviewing all appeals of the transfer/discharge decision. This practice had the potential to affect all residents discharged from the facility. Resident identifiers: #149, #21. Facility census: 58. Findings include: a) Resident #149 On 03/05/14 at 12:00 p.m., the medical record review revealed Resident #149 was discharged to the hospital on [DATE]. The record review found no evidence of information provided at discharge regarding the resident's/responsible party's right to appeal the transfer/discharge decision to the State Board of Review or the appropriate information regarding how to do so. b) Resident #21 The medical record reviewed for Resident #21 on 03/05/14 at 12:30 p.m., revealed Resident #21 was transferred to the hospital on [DATE]. Review of the medical record found no evidence of information provided at discharge regarding the residents' /responsible parties' right to appeal the transfer/discharge decision to the State Board of Review, or the appropriate information regarding how to do so. An interview was conducted with licensed social worker, Employee #27, on 03/05/14 at 1:00 p.m. Upon inquiry, she said she was unaware of appeals information being required whenever a resident is discharged or transferred out of the facility to another location. She said she did not provide appeals information to Resident #149 or to Resident #21 and/or the responsible parties at the time of discharge. On 03/05/14 at 1:45 p.m., during an interview with Employee #27 and Employee #57 (admission coordinator), the admissions coordinator said the facility does not provide information to residents or their responsible parties regarding whom, or how to, appeal in the event of any type of discharge or transfer from the facility to another location. She said the facility does not include that in the admission packet. During an interview conducted with the administrator on 03/05/14 at 3:00 p.m. She said that in the past the facility gave information to the residents and/or their responsible parties when discharged to another location regarding who to appeal to, and how to appeal. She was not sure, why this practice stopped, or when.",2018-01-01
6928,GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2014-10-22,203,E,1,0,53PI11,"Based on review of the facility's uniform notification of transfer/discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of transfer/discharge decision. Instead, the uniform notice gave residents/responsible parties the option to file such an appeal with five (5) different agencies. This error in the uniform notice may have led a resident to mistakenly file an appeal request with the wrong agency, and interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided the incorrect address for The Office of Health Facility Licensure and Certification (OHFLAC), the agency to be contacted regarding complaints/concerns. This had the potential to affect more than a limited number of residents. Facility census: 59. Findings include: a) Review of the uniform notification of transfer/discharge form on 10/21/14 at 8:20 a.m. revealed the following: If there are concerns about this move or if you would like to appeal this decision . You may also contact the following agencies:. This was followed by the names and contact information of the Office of Health Facility Licensure and Certification, and the regional Ombudsman. Immediately following was the statement: If the resident has a developmental disability or a mental illness and has questions or complaints about the transfer or discharge or would help to appeal, call or write the appropriate agency listed below:. This was followed by the names and contact information for the West Virginia Advocates for the Developmentally Disabled, and the State ombudsman. The latter was listed under the heading of Mental Health Agency. The name and contact information of the Office of Inspector General was listed at the bottom of the page. This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in West Virginia to which appeals of transfer/discharge decisions may be made. None of the other four (4) agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The address of the Office of Health Facility Licensure and Certification was incorrect. 3. The regional Ombudsman's name and address was erroneously listed as a Mental Health Agency. An interview was conducted with the Administrator on 10/22/14 at 5:30 p.m. She said this was the notification of transfer or discharge they always used for their residents. She was unaware of any inaccuracies in the form.",2017-10-01
7028,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2013-08-14,203,E,0,1,66WU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to provide a written notice to six (6) of six (6) sampled residents upon discharge and/or transfer from the facility. The facility did not provide a notice which included the right to appeal the discharge the contact information for the appropriate agency and/or person. Resident identifiers: #25, #4, #78, #69, #28, and #34. Facility census 68. Findings include: a) a) Residents #25, #4, #78, #69, #28, and #34 At 10:00 a.m. on 08/07/13, the Administrator presented a requested copy of the information given to residents upon transfer or discharge from the facility. It did not include written information about bed hold and/or appeal rights. After a second request, the Administrator provided a copy of a Notification of Transfer / Discharge letter, which he stated was used by the facility. The letter did not include the name, phone number, or address of the Ombudsman and the address of the Office of Licensure and Certification (OHFLAC) was incorrect. When this was pointed out to the Administrator, he said to ask the Social Worker (SW), Employee # 68, for an explanation of the use of the notification. When interviewed at 10:20 a.m. on 08/07/13, the SW stated she was not responsible for the notice. She suggested speaking with Employee #79, the Admissions Coordinator. The SW stated she had been in her position for a year. At 10:40 a.m. on 08/07/13, Employee #79 stated she did not supply written information to residents being transferred or discharged . She said she had been in her present position for four (4) years. Review of the records of these six (6) recently transferred or discharged residents revealed no evidence they were provided the required written Notification of Transfer/Discharge information. During an interview with the Director of Nurses, Social Worker, Administrator, and the Corporate Consultant (Employee #93) at 11:50 a.m. on 08/07/13, they were informed no written evidence was found to show the notices were being distributed. The Administrator expressed surprised and stated he would investigate this. At the time of exit, no additional information regarding this had been presented. b) The facility's policy entitled: Discharge and Transfer included the following statement: All patients will receive a 'Notice of Transfer or Discharge or Discharge Transition Plan whenever a voluntary or involuntary transfer / discharge occurs. The timing of notifications will be based on state and federal regulations. Under the heading PROCESS was the following:: 2. Social Services will ensure systems are implemented to provide written notification to the patient/responsible party prior to the transfer. 2.1 Notification will include: 2.1.1 Reason for and effective date of transfer; 2.1.2 Location of transfer; 2.1.3 Explanation of right to appeal; 2.1.4 Name, address, and telephone number of Ombudsman and other parties/agencies required by the state; and 2.1.5 When applicable, the name, address, and telephone number of protection and advocacy agency for individuals with developmental disabilities, mental [MEDICAL CONDITION], or mental illness.",2017-09-01
7165,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2014-07-29,203,B,1,0,EYNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure residents were provided the required information at discharge. There was no evidence seven (7) of eight (8) residents and/or the responsible party were notified of the reason for transfer or discharge, the effective date of transfer or discharge, the location to which the resident was transferred, the right of appeal, or how to notify the ombudsman and the appropriate protection and advocacy agency, with the addresses and telephone numbers as required. The facility had no process to ensure this information was completed and provided at the time of discharge. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, found no evidence the information provided at discharge included the reason for transfer or discharge, effective date of transfer or discharge, location, right to appeal, or how to notify the ombudsman and the appropriate protection and advocacy agencies with the addresses and telephone numbers for these agencies as required. The following residents were transferred from the facility without evidence they were provided this required information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the facility did not keep copies of the transfer information provided residents. The DON stated nurses were instructed to provide this notice when a resident was transferred or discharged . She said sometimes the fact the information was sent was recorded in the narrative notes, but sometimes the nurses did not record it. The DON said she was unable to provide evidence the form contained the appropriate information or that it was actually completed and put in the transfer packet, since the facility did not keep a copy. She stated in the past, before the computer system they use, a copy was kept with the records, but they did not do this anymore. The DON verified there was no way to provide evidence each of these residents was provided this information. .",2017-07-01
7376,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2014-05-15,203,D,1,0,2OSX11,"Based on medical record review and staff interview, the facility failed to notify the resident and/or the family in writing, of 1) the reason for the resident's discharge from the facility, 2) the effective date of transfer or discharge, 3) a statement that the resident had the right to appeal the action to the State, and 4) the name, address, and telephone number of the State long term care ombudsman. This was evident for one (1) of seven (7) sampled residents. Resident identifier: #102. Facility census: 101. Findings include: a) Resident #102 Review of the resident's medical record on 05/15/14 at 10:00 a.m., found a nurse's progress note, dated 04/21/14, indicating Resident #102 went by ambulance to (name of hospital) for evaluation. The family was notified. An order, dated 04/21/14, indicated the resident was going to (name of hospital) emergency room for evaluation. This order was written by licensed nurse, Employee #32, as ordered by the Family Nurse Practitioner. During an interview on 05/15/14 at 12:00 p.m., with licensed social workers (LSW) #11 and #25, the interim director of nursing (DON), and the administrator, they said this resident was discharged to (name of hospital) on 04/21/14 because it was felt that the facility could no longer meet her needs adequately, or keep other residents safe from harm due to her behaviors. The administrator said they planned on finding her placement in a more suitable location for her behaviors during the hospitalization . He said the facility was unable to give thirty (30) days notice due to the immediacy of her behaviors. Upon inquiry about the appeals notice and the transfer form, they said they would look for it. They said the former DON gave face to face verbal notice of the transfer/discharge to the responsible party the day after the resident left the facility. At 3:00 p.m. on 05/15/14, Employee #11 provided a copy of the facility's Uniform Notification of Transfer/Discharge form. She said they used this form for all transfers and discharges, even when residents only went out for doctor's appointments. There was a place on this form to notify the resident and/or responsible party the effective date of discharge, the transfer or discharge location, and the reason for this action. Bed-hold information was included on this form, as well as information about the right to appeal a transfer/discharge, and other resources such as the State ombudsman and West Virginia Advocates. She said they gave one (1) copy to the resident/responsible party, and filed one (1) copy on the resident's clinical record. Employee #11 said she could find no evidence that the former DON had given the resident or family member the transfer/discharge notification and appeals information. At that time, the administrator agreed this information could not be found. Employee #11 said the former DON should have documented something about the discharge in the nurses' notes, and should have given the family written transfer information, but failed to do so.",2017-05-01
7900,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2013-12-31,203,D,1,0,6YCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and family interview, the facility failed to provide a family member with written notification that contained the reason for a resident's involuntary discharge. This was found for one (1) of six (6) residents reviewed. Resident identifier: #115. Facility census: 114. Findings included: a) Resident #115 Review of the medical record on 12/30/13 at 12:59 p.m., revealed Resident #115 was transferred to the hospital on [DATE] related to behavioral concerns. An interview with Employee #66, director of care delivery (DCD), on 12/30/13, revealed a discharge packet was completed. It contained a transfer/discharge notice and bed hold policy form. He said a copy went to the hospital with the resident, otherwise nursing had no other responsibility related to the discharge. During an interview on 12/31/13 at 2:30 p.m., Interviewee #2, said she had not received a copy of the discharge notice, dated 12/03/13. The facility liaison, Employee #73 (social worker) was interviewed on 12/31/13 at 10:45 a.m. She said the medical record department followed up to ensure notices were provided. Employee #31 (health information management director) was interviewed on 12/31/13 at 11:45 a.m. She said she no longer tracked discharge records. She indicated Employee #55, quality assurance (QA) coordinator, was responsible for tracking. The QA coordinator was interviewed on 12/31/13 at 11:55 a.m. She said she monitored unexpected discharges, but was unable to provide confirmation the family was notified. The coordinator said she had no formal way of tracking this information. The QA coordinator said she would relay the information to the medical records department. The medical record was reviewed with Employee #63 (DCD) on 12/31/13 at 3:45 p.m. She reviewed the discharge records and confirmed no evidence was present to indicate the family had received a copy of the transfer/discharge notice, dated 12/03/13. She acknowledged all carbon copies of the transfer/discharge notice remained in the medical record, and no evidence was present to indicate a copy had been provided to the family.",2016-12-01
7991,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2013-11-11,203,D,1,0,0RE211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Surveyor: Clevenger, Tom Based upon record review and the inability of the facility to provide evidence, the facility failed to notify the family of one (1) of twelve (12) residents reviewed a written discharge notice and a notice of the right to appeal the discharge. There was no notice which included the reason for discharge, the effective date of discharge, a statement that the resident has the right to appeal the action to the State, and the name, and the address and telephone number of the State long term care ombudsman. Resident identifier: #91 Facility census: 90. Findings include: a) Resident #91 This [AGE] years old resident was admitted to the facility on [DATE], and involuntarily discharged on [DATE]. The record review was begun on 11/4/13 at 11:00 a.m. Medical record review found no evidence the responsible party was provided a written discharge notice which included the reason for discharge, the effective date of discharge, a statement that the resident has the right to appeal the action to the State, and the name, and the address and telephone number of the State long term care ombudsman. A request was made on the morning of 11/07/13 for documentation of any written discharge notice and/or notice of right to appeal the discharge of Resident #91 from the facility. No documents were provided by the time of exit on 11/11/13. A discharge summary was found signed by the physician on 10/15/13. It listed the discharge date as 08/14/13. The sections of the form Brief History:, Pertinent Physical and Laboratory Findings:, Condition on discharge:, discharged to:, and Follow-Up and discharge Medication Instruction: were blank.",2016-11-01
8635,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,203,D,1,0,CZR411,"Based on medical record review, review of a resident's discharge notice, and staff interview, the facility failed to ensure before, or as soon as practicable after, a resident was discharged , a written notice of discharge was provided that included required information, such as the location to which the resident would be transferred and his right to appeal the transfer/discharge. This was identified for one (1) of five (5) discharged residents. Resident identifier: #182. Facility Census: 181. Findings include: a) Resident #182 The discharge letter, dated 03/07/13, was reviewed for Resident #182. This letter stated the resident had become progressively more combative with multiple episodes of hitting other residents. The letter explained multiple interventions had been attempted and that the resident was continuously combative with staff and co-residents. The letter also stated they were giving an immediate discharge notice as of 03/07/13. This letter did not include the physician ordered the resident be discharged to the acute care hospital. The letter included eight (8) State agency names, addresses, and telephone numbers. There was no explanation of what these agencies were, nor was there an explanation the resident had the right to appeal the action to the State. There was no information provide to guide the resident to which agency would be appropriate for the appeal of this discharge. An interview, conducted with the Director of Nursing on 04/10/13 at 10:00 a.m., confirmed Resident #182 did not have the required information provided in his discharge letter. She confirmed this information was provided orally on the phone, but was not included in the letter.",2016-04-01
8753,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-03-13,203,D,1,0,MS9D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview the facility failed, before a discharge, to notify the resident and, if known, a family member or legal representative of the resident of the transfer or discharge in writing and in a language and manner they understood, the reason for transfer or discharge; the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement the resident had the right to appeal the action to the State; and the name, address and telephone number of the State long term care ombudsman. This was found for two (2) of four (4) residents whose records were reviewed. Facility census: 115 Findings include: a) Resident #116 The medical record of Resident #116 was reviewed on 03/11/13 at 3:40 p.m. Resident #116 was admitted to the facility on [DATE], and discharged on [DATE]. Resident #116 was discharged back to his son's home on 3/10/13. Discharge planning was appropriate, but there was no evidence the health care surrogate (HCS) received any written notice of discharge and applicable appeal rights. This information was specifically requested from administrator on 03/13/13 at 8:45 a.m., but could not be located by the time of exit. b) Resident #117 The medical record of resident #117 was begun on 03/11/3 at 3:00 p.m. and continued on 03/12/13 at 8:59 a.m. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. He was subsequently discharged to an adult care home on 11/08/12. The administrator, Employee #38, was interviewed on 03/12/13 at 3:47 p.m. She was not able to provide any supporting documentation to show that Resident #117's sister, who the facility considered the legally appointed health care surrogate (HCS), was notified in writing of his discharge and thereby given her appeal rights and contact information.",2016-03-01
8969,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,203,B,0,1,VDMM11,"Based on medical record review, review of the facility's uniform notification of transfer/discharge form, and staff interview, the facility failed to provide all necessary information for residents transferred or discharged from the facility. The transfer/discharge information provided to residents who were transferred to another facility did not contain all necessary components for the transfer/discharge. The form did not contain a written reason for the resident's transfer/discharge, or a statement informing the resident or responsible party of his/her right to appeal the action to the state. This affected one (1) resident, but had the potential to affect all residents discharged or transferred from the facility. Resident identifier: #51. Facility census: 42 Findings include: a) Resident #51 A closed record reviewed for transfer/discharge requirements, on 04/30/14 at 3:00 p.m., revealed the transfer/discharge form used by the facility did not contain the reason for the resident's transfer to another facility or inform the resident or medical power of attorney (MPOA) of the resident's right to appeal the discharge from the facility. On 04/30/14 at 3:15 p.m., an interview was conducted with the licensed social worker (Employee #35). She acknowledged she was in charge of completing transfer and discharge notices, and did so for Resident #51's discharge to another facility. The social worker provided a copy of Resident #51's transfer/discharge report, dated 04/10/14. She said she was unaware of the need to give appeals notice information to a resident and/or MPOA at the time of discharge. She said she was also unaware the reason for the discharge or transfer from the facility was supposed to be included with the discharge/transfer notice.",2016-03-01
9461,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,203,D,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide a thirty (30) day written notice of discharge and refused to allow the resident to return to the facility after hospitalization . The facility failed to provide advance notice of the discharge, the reason for the discharge, and the right to appeal the decision. This was true for one (1) of three (3) closed records reviewed. Resident identifier: # 129. Facility census: 128. Findings include: a) Resident #129 Resident #129 was a thirty-seven (37) year old individual admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. On 06/28/12, the facility physician determined the resident had capacity to make medical decisions. The social service assessment, completed on 06/28/12, found the resident achieved a score of fifteen (15) on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact. Medical record review found the facility transferred the resident to a local hospital on [DATE] for evaluation of [MEDICAL CONDITION]. The discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/24/12, found the resident's return to the facility was anticipated; however, the resident did not return to the facility. An interview was conducted with the social worker, Employee #70, and the administrator on 11/19/12 at 3:00 p.m. The administrator stated the resident's behavior made him a danger to himself and the facility did not want to take the resident back from the hospital. The administrator explained that the staff and the nurse practitioner felt the family members were bringing in drugs to the resident, since pills were found on the resident's floor on two (2) separate occasions. She was concerned the resident would overdose on medication being brought into the facility by family members. Further review of the medical record found a nurse practitioner's notes on 07/23/12, NP (nurse practitioner) found a light green, rectangle shaped pill in the floor beside resident's bed. The pill is a [MEDICATION NAME], but we do not have any like it here at (name of nursing home). On 07/20/12, a nurse found a pill in the resident's cigarette pack, a green long bar looking pill. On 07/20/12, the physician ordered a toxicology screen panel due to discovering medication in the resident's possession. The toxicology screen was positive for benzodiazepines and opiates. Review of the Medication Administration Record [REDACTED]. During an interview with the director of nursing (DON) and the administrator, on 11/19/12 at 3:35 p.m., the DON verified the toxicology report did not prove the resident was taking extra medication. She stated, We would need a level for that and we do not have one. Review of the 07/24/12 admission summary of the admitting hospital found the resident was admitted to the hospital for right lobe pneumonia, acute [MEDICAL CONDITION], urinary tract infection, and metabolic [MEDICAL CONDITION]. Further review of the discharge summary from the admitting hospital, dated 08/01/12 found, . Arrangements have been made for him to go to a (name of facility and location) as the patient was not able to return to (name of discharging nursing home) with questionable concern that his family was bringing in narcotics into the patient, potentially compromising his health as well as his care at the facility. He is aware and does know why the move has to take place and though he is not happy, but does understand why he has to be transferred to this facility outside the area with strict visitation rights. The social services director, Employee #70, was interviewed on 11/20/12 at 1:30 p.m. The social worker was unable to provide any documentation of discussions with the resident, who had capacity, regarding the allegations of family members bringing in medications to the resident at the facility. She verified she did not have any documentation about the resident during his stay at the facility. Review of the facility's policy and procedure for discharge and transfer found: . All patients will receive a notice of transfer or discharge or discharge or discharge transition plan whenever a voluntary or involuntary transfer / discharge occurs. The timing of notifications will be based on state and federal regulations. Patients and / or legal representatives will be provided proper notice in accordance with state and federal regulations should a transfer or discharge be initiated by a (name of the company healthcare center). The administrator was interviewed again on 11/19/12 at 4:10 p.m. regarding the facility's refusal to allow the resident to return to the facility. She was unable to provide documentation from the physician the resident's discharge was necessary and was unable to provide any evidence the resident was actually taking medication supplied by family members. She verified the written information required for a discharge, as required by the regulations was not given to the resident. She stated she had planned on giving the resident a thirty day (30) notice of discharge, but he went to the hospital before she could provide the information. The administrator also verified the facility did have beds available but chose not to allow the resident to return to the facility.",2015-11-01
9638,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,203,C,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the uniform notice may lead a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility. Facility census: 105. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: You have the right to appeal this action to: This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, and the Regional Ombudsman. Immediately following the above list of names and addresses was: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates, Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may lead a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc. (not Local Mental Health). Medicaid Fraud does not provide these services.",2015-10-01
9693,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2010-01-07,203,B,0,1,9PJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form and staff interview, the facility failed to correctly communicate to all residents and responsible parties the contact information of the appropriate state agencies for residents with developmental disabilities or those who are mentally ill. This error in the uniform notice has the potential to lead a resident/responsible party to contact the wrong agency to provide assistance, and may interfere in the resident's ability to exercise his or her right to contact. The uniform discharge notice provided incorrect information regarding the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility with developmental disabilities or mental illness. Facility census: 72. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: Or, for the resident with developmental disabilities or those who are mentally ill, you may contact: This was followed by the names and contact information for West Virginia Advocates Local Mental Health and Medicaid Fraud. This uniform notification form contained the following errors: - The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is West Virginia Advocates, Inc, not West Virginia Advocates Local Mental Health. - Medicaid Fraud does not provide protection and advocacy services to persons with mental [MEDICAL CONDITION] and/or mental illness.",2015-10-01
9704,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-08-12,203,E,0,1,RDGV12,"Based on record review and staff interview, the facility failed to provide the correct information for the right to appeal in their uniform notice of transfer / discharge information. The facility's form guided residents to appeal a transfer / discharge decision to the regional ombudsman, the State long-term care (LTC) ombudsman, and the Office of Inspector General (OIG), whereas the OIG is on the only State agency vested with the authority to hear and act upon such appeal requests. This was true for two (2) of nine (9) sampled residents and one (1) resident of random opportunity and had the potential to affect any resident who may be transferred / discharged from the facility. Resident identifiers: #25, #59, and #66. Facility census: 65. Findings include: a) Resident #25 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to scheduled appointments outside the facility on 08/31/10, 09/09/10, 09/16/10, 09/21/10, 10/04/10, 10/12/10, 10/26/10, and 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. b) Resident #59 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to a scheduled appointment outside the facility on 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. c) Resident #66 During interview with the licensed social worker (LSW) on 11/03/10, she produced a discharge record of her choice (for Resident #66). Review of this resident's closed record revealed he was discharged to home on 10/29/10 and was given a notification of transfer / discharge form which identified his right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. The LSW acknowledged the OIG was the only State agency that heard such appeal requests, although the facility's uniform notice identified the regional ombudsman and the State LTC ombudsman as other agencies to which such appeal could be made. The LSW later contacted the corporate website and downloaded the correct transfer / discharge information, and she stated all the old transfer / discharge forms were thrown away.",2015-10-01
9784,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,203,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to provide a written notice of transfer or discharge (to include the reasons for the move and a notice of the right to appeal this action to the State) to the resident's legal representative at least thirty (30) days before the resident was transferred or discharged . Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. The resident's closed record contained no evidence that a written notice of transfer or discharge was provided by the facility to the resident's legal representative at least thirty (30) days before the resident was moved, to include the reasons for the transfer / discharge and a notice of the right to appeal this action to the State. - 2. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. - 3. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. - 4. Review of the facility policy titled 2.11 Discharge and Transfer (revision date 04/01/03), on 08/05/09 at 9:00 a.m., found: 1. The social service department is responsible for coordinating transfers and discharges. 2. All customers will receive a Notice of Transfer or discharge whenever a voluntary or involuntary transfer / discharge occurs. This includes customers being transferred to the hospital of discharges from a certified bed to a non-certified bed. 2.1. The charge nurse will provide the Notice of Transfer or Discharge in the absence of the social worker. 3. If the discharge is involuntary, 30 days advance notice in writing of the proposed transfer or discharge must be given to the customer, family member, or legal representative (if known). A copy of the notice is placed in the clinical record and a copy forwarded to the local district Ombudsmen council. 4. The notice must include the appeal procedure. - 5. On 08/09/10 at 12:03 p.m., the State survey agency forwarded to this surveyor information received from the facility following the survey team's exit. These materials contained no evidence to reflect the facility had provided a written notice at least thirty (30) days before the resident's transfer / discharge from the facility, to include the reasons for the move. Other items that should also have been included in such a written notice were: the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. .",2015-09-01
9817,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2012-09-05,203,D,1,0,MNKD11,". Based upon record review and staff interview, the facility failed to provide a written notice of discharge and the resident's right to appeal the discharge to the State. This was found for one (1) of six (6) residents reviewed. Resident identifier: #69. Facility census: 67. Findings include: a) Resident #69 The medical record of Resident #69 was reviewed on 09/05/12 at 9:27 p.m. There was a notice of transfer or discharge found that gave the date of verbal notification as 08/16/12. The form stated the verbal notification was given by a licensed practical nurse, Employee #16. A social services note, dated 08/16/12 stated (typed as written): (Resident #69)'s behaviors were out of control today - threatening staff, etc. I called and made a referral to _____ Hospital and sent the requested information. I explained to them that I did not know if we could meet her needs here at this facility and had real concerns as we had to send her out more and more. I was concerned that her cycles were closer and closer. - she was either hyper and out of control or very depressed in bed refusing to get up. They called back and stated they had a room and could take her. I then called her sister/POA and explained the condition of (Resident #69). (MPOA), came to the facility and signed the admission papers to send (Resident #69) to _____Hospital. There was no evidence a written notice of the discharge and the resident's appeal rights had been provided to the MPOA in the medical record. .",2015-09-01
9881,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2012-05-09,203,D,1,0,SZNR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a closed medical record review and staff interview, the facility failed to ensure two (2) of five (5) residents were provided with a written discharge notice thirty (30) days prior to their discharge date s. This notice must include the reason for discharge, the effective date, the location to which the resident was being discharged , the right to appeal, how to notify the ombudsman, and how to notify appropriate protection and advocacy agencies. Resident identifiers: #57 and #85. Facility census: 77. Findings include: a) Resident #57 The medical record review for Resident #57, conducted on 05/08/12, at approximately 1:00 p.m., revealed this eighty seven (87) year resident was admitted to the facility on [DATE]. The resident left the faciity on [DATE]. According to the medical record, she now resides in a personal care home. Medical record review revealed several social service and nursing notes, dating back to November 2011, reflecting the resident's desire to return home. The facility completed a pre admission screening (PAS) on the resident. A progress note, dated 05/01/12, stated, ""Resident is in process of discharge planning. She no longer qualifies for nursing home care. At this point plans will be for her to go to (name of personal care home). The ombudsman will be here on Wednesday 05/02/12 to meet with res. and her family. The son who is health care surrogate will not transport to new facility. He wants her transferred by ambulance. "" Another progress note, dated 05/04/12, stated, ""Resident d/c (discharged ) to a personal care home due to no longer being eligible for nursing home level of care. Her son has made all the financial needs for the transfer. "" On 05/09/12, at approximately 11:00 a.m., the former business office manager (Employee #65) and the medical records clerk (Employee #14) reviewed the resident's closed record. The record did not contain information indicating the health care surrogate was provided a thirty (30) day discharge notice as required. b) Resident #85 This resident was also discharged due to not meeting the PAS requirements for nursing home care. The facility initiated a PAS for Resident #85 on 10/26/11. She remained at the facility until her appeal was heard. She was discharged on [DATE]. Resident #85 had the Department of Health and Human Resources (DHHR) as her appointed guardian. The DHHR appealed the discharge decision, but there was no evidence a thirty (30) day written notice, containing the required information, was given. .",2015-08-01
9901,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2012-05-30,203,D,1,0,0XPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide written information to the resident or family member or legal representative, regarding the agencies with which complaints or appeals might be made. This was evident for two (2) of six (6) sampled residents. Resident identifiers: #127 and #107. Facility census: 125. Findings include: a) Resident #127 Record review found that Resident #127 was discharged from the facility to an acute care hospital on [DATE]. Record review found no evidence of a transfer sheet that was given to this resident at the time of discharge, listing entities where appeals or concerns may be communicated. b) Resident #107 Record review found that Resident #107 was discharged from the facility to an acute care hospital on [DATE]. No evidence was found of the resident being provided with a list of agencies with which an appeal or concern might be filed. During interview with the Director of Nursing on 05/30/12 at 2:45 p.m., she was unable to find the transfer sheet for this resident's transfer. .",2015-08-01
9909,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,203,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, facility policy review, and review of information submitted to the State survey agency following the survey team's exit conference, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to provide a written notice of transfer or discharge (to include the reasons for the move and a notice of the right to appeal this action to the State) to the resident's legal representative at least thirty (30) days before the resident was transferred or discharged . Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. The resident's closed record contained no evidence that a written notice of transfer or discharge was provided by the facility to the resident's legal representative at least thirty (30) days before the resident was moved, to include the reasons for the transfer / discharge and a notice of the right to appeal this action to the State. - 2. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. - 3. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. - 4. Review of the facility policy titled ""2.11 Discharge and Transfer"" (revision date 04/01/03), on 08/05/09 at 9:00 a.m., found: ""1. The social service department is responsible for coordinating transfers and discharges. ""2. All customers will receive a Notice of Transfer or discharge whenever a voluntary or involuntary transfer / discharge occurs. This includes customers being transferred to the hospital of discharges from a certified bed to a non-certified bed. ""2.1. The charge nurse will provide the Notice of Transfer or Discharge in the absence of the social worker. ""3. If the discharge is involuntary, 30 days advance notice in writing of the proposed transfer or discharge must be given to the customer, family member, or legal representative (if known). A copy of the notice is placed in the clinical record and a copy forwarded to the local district Ombudsmen council. ""4. The notice must include the appeal procedure."" - 5. On 08/09/10 at 12:03 p.m., the State survey agency forwarded to this surveyor information received from the facility following the survey team's exit. These materials contained no evidence to reflect the facility had provided a written notice at least thirty (30) days before the resident's transfer / discharge from the facility, to include the reasons for the move. Other items that should also have been included in such a written notice were: the effective date of transfer or discharge; the location to which the resident was being transferred or discharged ; a statement that the resident has the right to appeal the action to the State; the name, address and telephone number of the State long term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals established under the Protection and Advocacy for Mentally Ill Individuals Act. .",2015-08-01
9968,LOGAN CENTER,515175,P.O. BOX 540,LOGAN,WV,25601,2010-11-04,203,E,0,1,RDGV12,". Based on record review and staff interview, the facility failed to provide the correct information for the right to appeal in their uniform notice of transfer / discharge information. The facility's form guided residents to appeal a transfer / discharge decision to the regional ombudsman, the State long-term care (LTC) ombudsman, and the Office of Inspector General (OIG), whereas the OIG is on the only State agency vested with the authority to hear and act upon such appeal requests. This was true for two (2) of nine (9) sampled residents and one (1) resident of random opportunity and had the potential to affect any resident who may be transferred / discharged from the facility. Resident identifiers: #25, #59, and #66. Facility census: 65. Findings include: a) Resident #25 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to scheduled appointments outside the facility on 08/31/10, 09/09/10, 09/16/10, 09/21/10, 10/04/10, 10/12/10, 10/26/10, and 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. b) Resident #59 Record review revealed this resident was given a notification of transfer / discharge form when she was transported to a scheduled appointment outside the facility on 11/01/10. Information on the reverse side of the form identified the resident's right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. c) Resident #66 During interview with the licensed social worker (LSW) on 11/03/10, she produced a discharge record of her choice (for Resident #66). Review of this resident's closed record revealed he was discharged to home on 10/29/10 and was given a notification of transfer / discharge form which identified his right to appeal the action to the regional ombudsman, the State LTC ombudsman, and the OIG. The LSW acknowledged the OIG was the only State agency that heard such appeal requests, although the facility's uniform notice identified the regional ombudsman and the State LTC ombudsman as other agencies to which such appeal could be made. The LSW later contacted the corporate website and downloaded the correct transfer / discharge information, and she stated all the old transfer / discharge forms were thrown away. .",2015-08-01
10085,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,203,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed record review, the facility failed to provide correct contact information on its uniform transfer / discharge notice for the State long-term care ombudsman and the single State agency responsible for the protection and advocacy of persons with [DIAGNOSES REDACTED]. This had the potential to affect any resident who might need to contact these organizations. Facility census: 112. Finding include: a) Resident #114 Closed record review of Resident #114 revealed she was given a uniform transfer / discharge notice which contained inaccurate information. The notice she received directed persons with a developmental disability or mental illness to contact the ""West Virginia Developmental Disabilities Council"" for assistance. However, the single agency designated in West Virginia to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."" (not West Virginia Developmental Disabilities Council). Also, the appeals notice lacked the name of the State long-term care ombudsman, although it did list the name of the regional ombudsman. .",2015-07-01
10250,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2012-09-26,203,C,0,1,FJI611,". Based on record review and staff interview, the facility failed to provide a discharged resident with the correct name and contact information should the resident wish to appeal her discharge from the facility. Instead, the form listed numerous agencies to which to appeal, none of which were correct. This information was lacking for one (1) resident who was discharged , and was found to be the standardized form that was provided for all residents who were transferred or discharged from the facility. This had the potential to affect all discharged and transferred residents in the facility. Resident identifier: #14. Facility census: 109. a) Resident #14 Record review of a discharged resident's medical record, found a Notice of Transfer or Discharge form, with revision date 11/2009. On this form, the discharged resident was informed of the right to appeal the center's decision for transfer or discharge, and listed multiple agencies with their contact information. None of the listed agencies was the correct appeals agency. During an interview with the administrator, on 09/25/12 at 10:00 a.m., she stated this was the facility's standardized form used for all transfers and discharges. She acknowledged the contact name and contact information of the agency to appeal decisions, was absent on the form. .",2015-05-01
10438,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,203,C,0,1,Z0GS11,"Based on review of the uniform notice provided to residents at the time of transfer / discharge related to their right to appeal that transfer / discharge, the facility failed to provide accurate information as stated in this requirement. Several agencies were erroneously identified in this uniform notice. This practice has the potential to affect all residents of the facility. Facility census: 93. Findings include a) Review of the facility's ""Notification of Transfer or Discharge"", which was provided by the facility to all residents upon transfer / discharge from the facility, revealed the document did not provide the correct information for a resident wishing to appeal the transfer / discharge decision. The required information, as stated in Federal regulation, includes the name, address, and telephone number of the State long-term care ombudsman; for nursing facility residents with developmental disabilities, the mailing address and telephone number of the agency responsible for the protection and advocacy of developmentally disabled individuals; and for nursing facility residents who are mentally ill, the mailing address and telephone number of the agency responsible for the protection and advocacy of mentally ill individuals. The uniform notice provided by the facility erroneously identified, as agencies to which an appeal of a transfer / discharge decision may be made, Adult Protective Services, Legal Aid Society, State Board of Regents, and the area long term care ombudsman. The last page of the information incorrectly directed that a copy of the appeal be sent to OHFLAC (Office of Health Care Licensure and Certification) and to the Office of Medical Services; there is no statutory requirement for copies of appeals to be sent to either of these offices. The sole State agency having the authority to rule on appeals of a transfer / discharge decision in West Virginia is the Board of Review within the Office of Inspector General, which was not correctly identified anywhere in the facility's uniform notice. .",2015-04-01
10568,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2009-10-29,203,E,0,1,0YSZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of discharge / transfer appeal rights form, given to one (1) of twenty (20) sampled residents (#2), the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with six (6) different agencies. This error in the notice may led a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. This deficient practice has the potential to affect more than an isolated number of residents. Facility census: 114. Findings include: a) Resident #2 Review of the uniform notification of discharge / transfer appeal rights form, provided by the facility for Resident #2 and dated 07/09/09, revealed the following: ""This is to inform you that you have the right to appeal the decision made by this facility to transfer discharge you to..."" This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, the local mental health center, Advocates for Developmentally Disabled and Mentally Ill, Legal Aid of West Virginia, and Office of Heath Facility Licensure and Certification. This notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the five (5) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may led a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."", not the ""Advocates for Developmentally Disabled and Mentally Ill"". .",2015-01-01
10799,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2009-09-25,203,D,0,1,7F5X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and a copy of the current information provided to residents at the time of discharge or transfer from the facility, the facility failed to provide accurate information to residents and their responsible parties upon transfer / discharge. Under the section informing the resident / responsible party of the State agency to which an appeal of a transfer / discharge decision could be made, the information sheet listed two (2) State agencies that were not appropriate. Additionally, one (1) resident who was transferred to another facility was not provided with the required notice. Three (3) of eighteen (18) residents on the sample were affected. Resident identifiers: #6, #87, #88, and any resident who was provided a copy of the notice when transferred or discharged . Facility census: 86. Findings include: a) Resident #6 Resident #6 was discharged during the course of the survey. Additional review of her medical record after her discharge to home found the notice of transfer form, dated 09/22/09, informed the resident she could appeal the discharge or transfer to the regional ombudsman or the State ombudsman, in addition to the DHHR Office of the Inspector General. Only the latter agency has the authority to hear such appeals. This prompted a review of the information provided at the time of discharge / transfer, to ascertain whether this same inaccurate information was being provided to all residents. The copy of the form received from the administrator, on 09/25/09, was the same as that provided to Resident #6. b) Resident #87 Closed medical record review, on 09/24/09, revealed this resident was admitted on [DATE]. On 07/18/09, the resident was discharged home. The advocacy information, provided to the resident upon discharge, noted the resident could appeal the discharge to the State ombudsman and to the regional ombudsman. This was incorrect information, as the only State agency to whom a resident may appeal a discharge discharge is the DHHR Office of Inspector General. c) Resident #88 Review of closed medical record revealed Resident #88 was discharged to another facility, but there was no evidence that he or his representative was given an appeals notice upon discharge. The current director of nursing (who was not employed at the facility at the time of this resident's discharge) was informed, on 09/25/09 at approximately 9:30 a.m., of the absence of an appeals notice for Resident #88's discharge. No appeals notice was produced prior to survey exit. .",2014-12-01
10828,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-08-16,203,D,1,0,XG6O11,"**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 an adequate discharge notice for one (1) of six (6) residents who had been discharged or transferred from the facility. Resident #67 was sent out to the hospital for an acute medical problem and discharged from the facility. A family interview revealed the facility did not notify the family that the resident was being discharged and would not be returning to the facility. There was nothing in the transfer / discharge notice given to the family at the time of the resident's transfer to the hospital that would indicate to the resident's family that the facility was discharging the resident with the intention of not allowing him to return. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Closed record review found Resident #67 had been admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Further review revealed the resident was sent out to the hospital on [DATE] for an acute medical problem. Review of a copy of the transfer / discharge notice form that had been provided to the resident's family at the time of his transfer found form indicated the resident was being transferred to the hospital. The resident subsequently returned to the facility on [DATE]. Review of multidisciplinary notes found that, following the resident's return from the hospital on [DATE], the resident began exhibiting combative / abusive behaviors toward staff and other residents. Further review of multidisciplinary notes found the resident's medical condition continued to deteriorate and the facility encouraged the resident's medical power of attorney representative (MPOA) to agree to transferring the resident to the hospital for evaluation of acute medical problems, including [MEDICAL CONDITION], increased BUN (blood urea nitrogen), increased confusion, and low hemoglobin and hematocrit. The resident was transported to the hospital on [DATE], and the transfer / discharge notice form did not indicate whether the resident was being transferred or discharged . During an interview on 08/15/11, at 9:00 p.m., Resident #67's MPOA reported he had not been notified the resident had been permanently discharged (as opposed to being temporarily transferred) as soon as he left the facility. The MPOA stated the family was not aware that Resident #67 would not be permitted to return to the facility until the hospital notified the facility that the resident was ready to be discharged back to the facility. The MPOA further stated the hospital was told by the facility that the resident had behaviors and they could not provide care for him, and the family and hospital were forced to find an alternative placement for the resident. The MPOA also stated the facility did not inform him of its bed hold policy. Review of multidisciplinary notes found no documentation, recorded in his medical record prior to his discharge to the hospital, to reflect the facility had informed the resident's MPOA of the possibility the facility may refuse to take the resident back unless his behaviors were controlled. An interview with the facility's social worker (Employee #20), on 08/15/11 at 3:15 p.m., confirmed the resident's MPOA had not been notified the resident had been discharged from the facility. .",2014-12-01
10890,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-07-20,203,D,1,0,LRYJ11,". Based on record review and staff interview, the facility failed to complete the Notice of Transfer or Discharge form to include the reason for a resident's transfer or discharge for one (1) of six (6) sampled residents. This section was left blank on the form completed for Resident #6 on two (2) separate occasions, with no reason given for a transfer that occurred on 07/07/11 and another transfer that occurred on 07/08/11. Resident identifier: #6. Facility census: 113. Findings include: a) Resident #6 Record review revealed a nursing note, entered at 2:30 p.m. on 07/07/11, stating: ""Resident hit another resident. Called MD (medical doctor) and RP (responsible party). Resident sent to hospital (named the hospital) ER (emergency room ) for eval (evaluation)."" The Notice of Transfer or Discharge form, when reviewed, was left blank where the facility was to specify the ""reason"" for the transfer or discharge. A late entry note indicated this resident returned from the hospital at 8:15 p.m. on 07/07/11. According to the medical record, the resident then sustained a fall and was sent back to the hospital at 11:30 p.m. on 07/08/11. Another Notice of Transfer or Discharge form was completed and, again, no reason for the transfer was recorded. The director of nursing (DON - Employee #82) verified the reason for transfer had not been recorded as required on either of these notices. .",2014-11-01
11130,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2011-04-28,203,D,1,0,SX1V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the resident's legal representative, the facility failed to notify, either verbally or in writing, known family members and/or the legal representative of the discharge of one (1) of thirteen (13) sampled residents prior to or as soon as practicable after the discharge. Resident identifier: #120. Facility census: 119. Findings include: a) Resident #120 Record review of Resident #120's closed record revealed this [AGE] year old female was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was transferred from a like-facility to be closer to family. She has been determined by her attending physician to lack the capacity to form her own healthcare decisions, and her surrogate decision-maker / legal representative was a social worker employed by the WV Department of Health and Human Resources (DHHR). The resident's two (2) brothers, sister, and son would visit and attend care plan meetings. A pre-admission screening (PAS) form sent with her stated, on 04/20/10, she had been determined ""Medically Eligible for Nursing Facility Services"". However, after her arrival, when a new PAS was submitted, the application was denied. At that point, an appeal was filed by DHHR and a hearing was pending at the time of survey. Resident #120 had continued to reside in this facility until 04/17/11, when there was an incident that resulted in her emergency transfer to a hospital for a psychiatric evaluation after eloping from the facility and refusing to return inside the facility. She did agree to go to the hospital, and DHHR was notified via phone message that the resident had been sent to the hospital. The resident was admitted to psychiatric care at the hospital. On 04/25/11, the hospital submitted a new PAS and, on 04/26/11, received a determination that this application was ""Denied"". The hospital notified the facility that the resident was being discharged and returned to this facility. This facility refused to accept the resident for readmission. This was confirmed by the administrator at 10:00 a.m. on 04/27/11. He stated that Medicaid had denied payment and, since this was her second denial, ""My hands are tied."" -- During a phone interview with one (1) of the resident's brothers at 11:50 a.m. on 04/27/11, he stated the hospital had contacted him earlier today (04/27/11) and informed him that her readmission to the nursing home had been denied, because they had ""given up her bed"". He was very upset and stated he had not been informed that she was actually discharged from the facility and had definitely not received advance notice that they would not take her back. He stated he had spoken to the facility after his sister was sent to the hospital and had been told that she ""was sent to the hospital for psychiatric treatment, because she had been refusing her medication and left the nursing home on her own."" They said she was to return there, but when he contacted the facility earlier today, they told him they had ""no beds available"". At the time of this conversation, there were ten (10) empty beds in the facility. -- In an interview with the DHHR Supervisor at 12:30 p.m. on 04/27/11, she verified their office acted as the legal representative for health care decisions for Resident #120. She stated she had spoken to the hospital social worker, who informed her the resident was ready for discharge, but that the facility told her there was ""no bed"". She said she had called the nursing home herself this morning and spoke to the admissions clerk (Employee #100), who told her they had ""no appropriate bed"". The DHHR supervisor stated they had been notified in a phone message that the resident had attempted to elope and was sent by ambulance to the hospital. Until she was contacted this morning by the hospital, she did not realize Resident #120 had been discharged from the facility or that they were not going to accept the resident back. The DHHR Supervisor was aware of the Medicaid denial and was awaiting the hearing. At 1:50 p.m. on 04/27/11, a follow-up phone conversation with the DHHR supervisor confirmed she had inquired of the other social workers in her office, and no one in her office had received any written or verbal discharge planning information from the facility in regards to Resident #120 prior to today. She said she asked to speak to the administrator but was told he was unavailable for calls. -- During an interview with the administrator and the director of nursing (DON) at 2:00 p.m. on 04/27/11, they were asked what discharge planning had been done for Resident #120. The DON stated that, since it had been an emergency situation, there wasn't any discharge planning except a transfer form to the hospital. The administrator added that DHHR already knew the resident needed to be placed elsewhere, because they were the ones who denied nursing home care. When asked if the facility had given any type of discharge letter to the responsible party, the DON provided a blank ""Discharge Letter"" and said they always give this when a resident is being discharged , but she did not know the resident was being discharged when she left the facility to go to the hospital. Neither the administrator nor the DON provided any evidence that either DHHR or an interested family member had been notified of the resident's discharge, the hospital admission, or the intention to deny readmission of this resident, prior to the exit conference. At the exit conference at 4:30 p.m. on 04/28/11, the administrator stated he understood that written information (discharge letter) had to be given to the legal party.",2014-08-01
11146,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,203,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the transfer notice and staff interview, the facility failed to include the reason for the discharge on the written Notice of Transfer or Discharge for one (1) of thirteen (13) sampled residents (Resident #51). Facility census: 50. Findings include: a) Resident #51 Resident #51 was transferred to the hospital on [DATE]. Review of the transfer / discharge notice found in Resident #51's record disclosed no documented reason for discharge. A review of the notice was completed in the late afternoon with the social worker, and a request for additional information was made. As of exit at 7:00 p.m. on 08/12/09, no additional information was available. .",2014-08-01
11170,TYGART CENTER AT FAIRMONT CAMPUS,515053,1539 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2009-11-24,203,D,1,0,PYDH11,"Based on record review and staff interview, the facility failed to provide required contact information on a thirty (30) day discharge notice for one (1) of four (4) sampled residents. The thirty (30) day discharge notice the facility provided to the resident's medical power of attorney representative did not include the address and telephone number of the West Virginia State Board of Review, which is the sole State agency with the authority to act upon an appeal of the discharge decision. Resident identifier: #7. Facility census: 110. Findings include: a) Resident #7 Resident #7's medical record, when reviewed on 11/24/09 at 10:30 a.m., disclosed the resident's son was sent a thirty (30) day discharge notice. The social worker (SW- Employee #118), when interviewed on 11/24/09 at 11:30 a.m., disclosed a copy of the thirty (30) day discharge notice was located in the business office. Review of a copy of the discharge notice, when provided by the SW, found the form did not contain the address and telephone number of the West Virginia State Board of Review, the sole State agency with the authority to act upon an appeal of the discharge decision. The medical records clerk (Employee #121), when interviewed on 11/24/09 at 1:30 p.m., acknowledged there were no additional discharge notices available in the resident's medical record that contained the required contact information for the West Virginia State Board of Review. The administrator (Employee #120), when interviewed on 11/24/09 at 11:35 a.m., stated, ""No other thirty (30) day discharge notices have been sent in the past three (3) years."" The administrator acknowledged the discharge notice sent to the resident's medical power of attorney representative did not contain the required address and phone number for the West Virginia State Board of Review.",2014-07-01
11238,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,203,C,0,1,Q61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's uniform notification of transfer / discharge form, the facility failed to correctly communicate to all residents and responsible parties the contact information of the single State agency responsible for reviewing all appeals of the transfer / discharge decision. Instead, the uniform notice gave residents / responsible parties the option to file such an appeal with five (5) different agencies. This error in the uniform notice may led a resident to mistakenly file an appeal request with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. Additionally, the uniform discharge notice provided incorrect information regarding the current State long-term care (LTC) ombudsman, who has held this position since May 2008, and the agency designated in West Virginia to provide protection and advocacy to individuals with mental [MEDICAL CONDITION] and mental illness. This deficient practice has the potential to affect all residents of the facility. Facility census: 55. Findings include: a) Review of the uniform notification of transfer / discharge form provided by the facility revealed the following: ""You have the right to appeal this action to:"" This was followed by the names and contact information of the Office of Inspector General Board of Review, the State Ombudsman, and the Regional Ombudsman. Immediately following the above list of names and addresses was: ""Or, for the resident with developmental disabilities or those who are mentally ill, you may contact:"" This was followed by the names and contact information for ""West Virginia Advocates Local Mental Health"" and ""Medicaid Fraud"". This uniform notification form contained the following errors: 1. The Office of Inspector General is the only agency in WV to which appeals of transfer / discharge decisions may be made. None of the four (4) other agencies identified in the notice is responsible for this activity. This error in the uniform notice may led a resident to mistakenly file an appeal with the wrong agency and may interfere in the resident's ability to exercise his or her right to the appeal. 2. The name of the State LTC ombudsman was incorrect. The current State LTC ombudsman assumed the position in May 2008, and the facility's uniform notice was not revised to reflect this. 3. The single agency designated in WV to provide protection and advocacy to individuals with both mental [MEDICAL CONDITION] and mental illness is ""West Virginia Advocates, Inc."" (not ""West Virginia Advocates Local Mental Health""). ""Medicaid Fraud"" does not provide these services. .",2014-07-01
11328,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-02-03,203,D,1,0,F0ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of closed medical records [REDACTED]. Four (4) of four (4) residents whose closed records were reviewed did not have evidence of this notice being issued. Resident identifiers: Residents #139, #140, #141, and #142. Facility census: 138. Findings include: a) Residents #139, #140, #141, and #142 Review of the closed medical records [REDACTED]. On the afternoon of 02/03/11, Employee #40, a registered nurse (RN) who worked on the second floor, was asked where the information regarding transfers and discharges would be located. He said there should be a copy in the residents' medical records. He provided copies of forms that had been completed at the time of transfer / discharge which contained the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident was being transferred or discharged . He said these forms were sent with each resident. Upon further description of the information being sought, the employee said they also sent a multi part form with the residents. He went to a desk drawer, but no forms were in the file folder. In late afternoon on 02/03/11, the assistant director of nursing was asked where evidence of the information having been given to the resident / responsible party might be found. She said it should be in the residents' medical records. She looked in the four (4) residents' records and was unable to locate the information for each resident's most recent transfer / discharge. Review of Resident #141's medical record found bed hold notices and appeals notices had been issued on 02/02/10, 03/02/10, 03/05/10, 03/13/10, 05/07/10, and 11/20/10, but one was not found for his 01/04/11 discharge. .",2014-06-01
396,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2017-08-11,204,D,1,0,C6IS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on family interview, staff interviews, clinical record review, and review of home health records, the facility failed to provide a safe and orderly discharge for Resident #115. The facility failed to arrange for post discharge services as ordered by the physician. This affected one (1) of four (4) sampled residents reviewed for discharged to home with home health services. Facility census: 114. Findings include: a) Resident #115 Clinical record review revealed Resident #115 was admitted to the facility on [DATE] and discharged to home on 07/03/17. On 07/03/17, the physician ordered, Discharge to home with home health, physical therapy, occupational therapy, nurse aide, and nursing. The 07/03/17 nursing discharge summary did not include any evidence of a referral to home health services. The 07/03/17 Physical Therapy (PT) discharge summary recommended, Continued home health services and 24/7 (24 hours a day, 7 days a week) supervision due to poor safety awareness. The Occupational Therapy (OT) discharge summary stated discharge destination, Private home with home health services. The resident's clinical record contained no evidence of an assessment or discharge planning done by Social Work (SW). The clinical record contained no evidence of a referral to home health services. During an interview on 08/08/17 at 1:59 p.m., PT #23 stated Resident #115 required ongoing PT services at discharge. PT #23 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 2:17 p.m., OT #14 stated Resident #115 required ongoing OT services at discharge. OT #14 stated the SW made the referrals to a home health agency. During an interview on 08/08/17 at 4:01 p.m., SW #38 stated she had not completed an admission assessment for Resident #115 for determining his discharge needs. SW #38 stated she saw the resident only on his day of discharge. SW #38 stated she was unable to provide any evidence that a referral to home health services had been done. During an interview on 08/09/17 at 10:21 a.m., Licensed Practical Nurse (LPN) #114 stated she completed the nursing discharge summary for Resident #115. LPN #114 stated if she had been aware of a need for home health services she would have included the information in the discharge summary. Additionally, LPN #114 stated the SW set up home health services. During an interview on 08/09/17 at 10:55 a.m., Assistant Director of Nursing (ADON) #65 she had met with resident's representative on 07/03/17. The representative wanted to take Resident #115 home. ADON #65 stated she obtained the physician order [REDACTED].#38 to make the referral and the rehabilitation department to supply a walker with wheels and a wheelchair with leg rests. In a telephone interview on 08/09/17 at 1:21 p.m., the family representative confirmed ADON #65 had informed her the facility would make a referral to home health on 07/03/17. The representative stated they had left the facility at 1:00 p.m. on 07/03/17. She said she contacted the home health provider on 07/05/17 at 10:00 a.m. and was informed no home health referral had been made from the facility. The representative provided intake information and the name of the resident's community physician at that time. Review of Home Health records reveal the initial intake for services was obtained on 07/05/17. Initial physician orders [REDACTED]. The facility provided the home health agency with information via fax on 07/06/17 at 2:20 p.m.",2020-09-01
4453,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2016-10-19,204,E,1,0,43HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to assure residents are transferred from the facility to the hospital, and timely admission to the hospital when transfer is medically appropriate, and medical and other information was exchanged between the institutions. Resident #40 and #78 were transferred to the hospital after they experienced a change in their condition. Resident identifiers: #40 and #78. Facility Census: 83. Findings include: a) Resident #40 A review of Resident #40's medical record found on three (3) separate occasions (09/19/16, 09/23/16 and 10/13/16), the resident experienced a change in condition, which required the resident to be transferred to an acute care facility for treatment. The record contained no evidence the hospital received a transfer form, pertinent medical information including medications and current medical condition to direct the emergency room physician in providing appropriate and prompt medical care. On 10/18/16 at 11:30 a.m., the Director of Nursing was asked to provide a discharge/transfer policy. At 2:30 p.m. on 10/18/16, the Assistant Director of Nursing (ADON), confirmed they have no discharge/transfer policy. I then requested the practice or expectations of staff when the residents needed transferred and/or discharged . She confirmed there is nothing in writing to instruct the staff what to provide the transferring facility. At 3:50 p.m. on 10/18/16, the Administrator and the ADON confirmed the facility has no practice and/or policy to instruct the staff on the items needed to be sent with the resident at the time of transfer and or discharge. They also confirm their corporate office was unable to provide a transfer policy. On 10/19/16 at 8:35 a.m., the Administrator provided a Discharge/Transfer policy and an Acute Care Transfer Documentation Checklist. Review of the Discharge/Transfer Policy found the purpose of the policy to provide safe departure from the facility and to provide sufficient information for after care of the resident. Further review of the policy found the following procedures for transfer: --Obtain physician order [REDACTED].>--Call ambulance for transfer. --Explain transfer and reason to the resident and/or representative and give copy of signed transfer or discharge notice to the resident and/or representative or person (s) responsible for care. --Explain and give copy of Bed hold form to the resident and/or representative. --Complete transfer form, copy any portion of the medical record necessary for care of resident. (E.g. physician's orders [REDACTED].). --Send original of transfer form and portions of medical record that was copied with the resident. --Notify Business office, Social Service and/or Administration of transfer. b) Resident #78 A review of #78's medical record found the resident experienced a change in condition on 10/08/16, which required the resident to be transferred to an acute care facility for treatment. Continued review of medical records found an acute care admission summary with a date of 10/18/16. The reason for admission included, acute hypoxic and hypercarbic [MEDICAL CONDITION]. The history of present illness portion of the summary revealed the facility did not send information to the hospital concerning the resident. Review of nursing notes concerning the transfer of the resident to an acute care facility for treatment revealed information of the reason for transfer . There was no documentation of giving verbal report to acute care or completion of documentation sent out of the facility to acute care concerning the reason for residents transfer. c) Interviews On 10/18/16 at 3:30 p.m., an interview with Employee # 52, licensed practical nurse, revealed she had transferred Resident #78 to the hospital. She stated, I called the physician and obtained and order and then I called 911. I then copied the face sheet, the Post form and the medication list. I called a report to whoever answered the phone at the emergency room . No transfer form was completed and sent with the resident. Interview with the ADON on 10/18/16 at 3:30 p.m., revealed there is no written practice and/or protocol available to direct the staff in what is needed to transfer a resident out. She further explained the staff is verbally instructed during orientation. She confirmed a transfer form is not currently being utilized by the facility.",2019-10-01
7901,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2013-12-31,204,D,1,0,6YCS11,"The facility failed to provide a safe and orderly discharge from the facility for one (1) of eleven (11) residents reviewed. A resident was transferred to an acute care hospital. The resident was provided a thirty (3) day involuntary discharge notice during the hospital stay. There was no evidence the facility actively assisted the resident and the family in selecting a new residence. Resident identifier: #115. Facility census: 114. Findings include: a) Resident #115 Review of the medical record on 12/31/13 at 2:00 p.m., revealed Resident #115 was transferred to an acute care hospital for a psychiatric evaluation on 12/03/13. The minimum data set (MDS), with an assessment reference date (ARD) of 12/03/13, indicated the resident was discharged with return anticipated. An interview with the family (Interviewee #2) on 12/31/13 at 2:30 p.m., revealed the facility provided them a thirty (30) day discharge notice dated 12/19/13. She said the facility refused to readmit Resident #115 and wanted to refer her to another psychiatric facility. She said one other option was given at a location over two (2) hours away. The family member said she asked the social worker to try to transfer Resident #115 to a facility in the surrounding area, and was told no one would take the resident. Further review of the medical record, on 12/31/13 at 3:00 p.m., revealed no evidence the family was provided information indicating the resident would not be allowed to return to the facility. Additionally, no evidence was present to indicate the facility had adequately attempted to facilitate the relocation of Resident #115. The social worker, Employee #55 , was interviewed on 12/31/13 at 12:15 p.m. She confirmed no referrals had been made to assist with relocation of the resident. She also confirmed no evidence was present to indicate the situation had been discussed with the family, prior to the hospitalization or during the course of the hospital stay. Employee #55 said she had called the power of attorney and discussed a referral to another psychiatric facility, but the daughter did not give permission. She said no other attempts were made for assistance with relocation. The care plan, dated 12/06/13, was reviewed on 12/30/13 at 2:30 p.m. No evidence was present to indicate a planned discharge. It was reviewed with Employee #63 during an interview on 12/31/13 at 3:45 p.m., and with Employee #55 during an interview at 12:15 p.m. Each confirmed no evidence of discharge planning was evident.",2016-12-01
8616,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2013-05-30,204,D,1,0,104T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of clinic notes, adult protective services worker interview, staff interview, and an interview with the social worker at the apartment complex, the facility failed to provide sufficient discharge preparation for one (1) of six (6) sampled residents who was discharged from the facility. A resident diagnosed with [REDACTED]. Resident identifier: #87. Facility census: 85. Findings include: a) Resident #87 Review of the Minimum Data Set (MDS) assessment, with an assessment reference date (ARD) of 02/04/13, revealed this [AGE] year old resident had a planned discharge to the community on this date, after having resided at the facility since 2003. [DIAGNOSES REDACTED]. The Brief Interview for Mental Status (BIMS) indicated she was alert, but she was unable to correctly identify the current month. Although independent with most of her activities of daily living, she required supervision with bathing at the time of discharge. Review of the annual MDS, with an ARD of 01/31/13, Item A1410, identified she had a serious mental illness. An assessment of capacity to make medical and financial decisions, signed and dated on 11/02/2007 by the facility's psychologist, indicated that she has a history of non-compliance with medical regimens in the community. Her medication taking behavior would need to be monitored if she is placed in the community. Medical record review revealed this resident desired to live independently in an apartment in the community. A progress note by the facility's psychiatrist, dated 11/19/12, indicated this resident was reporting that she has been accepted for an apartment with supervision, and his belief that such a move could be successful if she is provided frequent monitoring and supervision during more pronounced hypomanic and manic periods. Review of physician's orders [REDACTED]. In review of the care plan, no evidence was found of interventions to provide frequent monitoring and supervision in the apartment setting after discharge from the facility. Nursing interventions consisted of training her to do fingerstick blood sugar testing, and preparing seven (7) days of medications to take with her. There was no mention of assessing if she was able to prepare and take her own medications independently, or of giving her a trial in self-medication prior to discharge, or of linking her to services for home monitoring of medication taking. Review of the medical record found no evidence of social services having set up linkages for in-home assistance for frequent monitoring and supervision during more pronounced manic and hypomanic periods, during this transition to independent living. An interview conducted with the licensed social worker, Employee #126, on 05/28/13 at 4:10 p.m., revealed the resident had not been self-medicating at the facility prior to discharge. A pill planner with a one week supply of medications, and another seven (7) day supply of medications in individual bottles, was sent with her at discharge. She arranged an appointment for the resident to go to an outpatient clinic by herself seven (7) days following discharge, to obtain prescriptions and a linkage to a pharmacy that would deliver medications to the home. She stated her belief that some mom and pop pharmacies deliver medications to the home and set up weekly pill planners, although she was unable to name a pharmacy that would do so. She acknowledged that she had not set up homemaker services, or nursing in-home visits, and there was no one to check daily to make sure the resident was taking her medications. She said she was not familiar with community resources in that area. She stated her belief that a licensed social worker ((LSW) at the apartment complex could link the resident for needed services. She said she had not spoken with the LSW about discharge needs prior to the resident's transfer to the apartment. An interview was conducted with the DON on 05/29/13 at 9:45 a.m. She stated her belief that the resident was not an altogether person. She thought on a good day, the resident would not need someone to make sure she ate and took her medications, but said the resident would get mixed up when she was cycling (behavior changes during bi-polar episodes), and would need someone to check on her during those times, such as the LSW at the apartment complex. An interview was conducted with the administrator, the Director of Nursing (DON) and Employee #126 on 05/29/13 at 2:00 p.m. The latter said it was her belief that the LSW at the apartment complex would be the resident's liaison. She acknowledged that the LSW did not say how often she would check on the resident, or see if she was cooking and eating, or check the medications. She did not know if anyone prepared the second week of medications that were sent with the resident in bottles. The administrator and Employee #126 stated they assumed the LSW at the apartment would be liable to ensure she met the care needs of the residents for needed referrals. The administrator said the purpose of the outpatient clinic visit was to set up prescriptions to a pharmacy that would deliver medications to the home, and it was not the responsibility of Employee #126 to accompany her because the initial appointment was a week after discharge from the facility. Besides, they had previously faxed information to the clinic, and provided the resident a packet of papers to hand deliver to the clinic on her first visit, so the clinic would have necessary information. Review of an outpatient clinic note, dated 02/12/13, found clinic staff was unaware as to why she was discharged from the facility, and as far as they could tell, the resident had no family to call. They had concerns as to whether the resident was able to set up medications and take them herself, as the resident at times understood, but was concrete in her thinking. A telephone interview was conducted with the LSW at the apartment complex on 05/30/13 at 9:00 a.m. She stated she did not provide case management services, and was not made aware of the resident's history. She said she was not told what medications the resident was on, or that someone needed to check the medications with the resident, or that the resident needed assistance with seeing if she was cooking and eating. She acknowledged that she can and does make referrals for residents, but there was always a waiting list. She said there were available resources in the community that could have helped meet this resident's needs, and stated her belief that needed referrals should have been made by the facility prior to her arrival at the apartment, and be ready to start immediately upon her arrival. As an emergency request, the Senior Center agreed to come to the apartment and complete an assessment on 02/19/13. Meals on Wheels had a six (6) month waiting list. She said she was unaware this resident cycled until one of the resident's adult children called and mentioned that she cycled. After learning some of her history, she planned to link to a local mental health clinic that would provide an aide to take the resident grocery shopping and make home visits. When asked to describe problems the resident had experienced, she said Resident #87 was disoriented and wandered, and other residents found her lost and brought her to the LSW's office. She was unable to locate her own apartment, although it could be seen from the elevator and had a large wreath on the door. She left her apartment unlocked because she could not use the key. She missed the clinic appointment on 02/11/13 because she could not identify the day of the week. Two (2) more appointments were scheduled, and the LSW had to physically be with her to ensure she got on the bus. While at the clinic, staff there had to get her back on the bus. Upon return, the bus driver had to leave the bus and escort her to the apartment building. She pulled the emergency cord when the toaster was not working, but it was only unplugged. When the responder prepared to leave, she turned back around and found the resident lying on the floor, and called the paramedics to get her up off the floor. She fell two (2) or three (3) times at the apartment. At the last fall, she was not speaking sensibly when the paramedics arrived. They transported her to the hospital, and she later was discharged to a nursing home. An interview was conducted with the Administrator and with licensed social worker Employee #75, on 05/30/13 at 11:15 a.m. They said they assumed the LSW at the apartment complex would make referrals for the resident after her arrival, as the LSW had done so in the past for another resident who resided at the apartment for a year. Several times they stated this was the way they did it before and it worked, and their assumption was that it would work this time. Review of the outpatient clinic note, dated 02/15/13, found the nurse called Resident #87, who reported she had just fallen on the floor and crawled up to the chair, and stated You need to get in here to bring me a pain pill. The resident reported that she took her pills when she thought about it, and was unable to twist the top off the medication bottles to get into them. After then speaking with the apartment LSW and finding that the resident had fallen several times at the apartment, got confused as to where her apartment was located, did not know how to use her key to get into the apartment building, and had come down and asked staff to do her laundry and make her meals, she then made a referral to Adult Protective Services (APS). An interview was conducted with an APS worker by telephone on 05/30/13 at 10:00 a.m. She said this resident was admitted to the hospital after a fall, then was admitted to a long term care nursing facility in the state around 02/14/13.",2016-05-01
8754,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2013-03-13,204,D,1,0,MS9D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, interview of the owner of a receiving facility, and family interview, the facility failed to provide sufficient preparation and orientation to residents to ensure safe and orderly transfer or discharge from the facility to a legally unlicensed adult care home. This was found for one (1) of four (4) records reviewed. Facility census: 115. Findings include: a) Resident #117 The medical record of Resident #117, was begun on 03/11/3 at 3:00 p.m. and continued on 3/12/13 at 8:59 a.m. This fifty-nine (59) year old man, was admitted to the facility on [DATE], and discharged on [DATE]. His [DIAGNOSES REDACTED]. Resident #117 was admitted following hospitalization for a fall resulting in a head injury. The hospital discharged him to the facility on [DATE]. Upon admission to the nursing home, his comprehensive assessment (MDS) of 03/13/12, under section G0110, G0120, and G0300 documented his ability as: Bed Mobility coded: 0,0 indicating 'independent with no help from staff Transfer ability coded: 2,2 indicating 'limited assistance of one staff Walking in room coded: 3,3 indicating 'extensive assistance of two or more staff Walk in corridor coded: 8,8 indicating 'did not occur Locomotion on unit coded: 3,2 indicating 'extensive assistance of one staff Locomotion off unit coded: 3,2 indicating 'extensive assistance of one staff Dressing coded: 3,2 indicating 'extensive assistance of one staff Eating coded: 0,1 indicating 'independent with set up help only Toileting coded: indicating 'limited assistance of one staff Personal Hygiene coded: 0,1 indicating 'set up help only Bathing coded: 3,2 indicating 'extensive assistance of one staff Balance sitting to standing coded: 2 indicating 'not steady, only able to stabilize with staff assistance Balance Walking coded: 2 indicating 'not steady, only able to stabilize with staff assistance Turning around coded: 8 indicating 'activity did not occur Moving on/off toilet coded: 2 indicating 'not steady, only able to stabilize with staff assistance Surface to surface transfer coded: 2 indicating 'not steady, only able to stabilize with staff assistance He was placed on therapy services for strengthening and improvement in his independence with activities of daily living (ADL's). His therapy services were stopped on 04/19/12 because he had met all his goals. He did not resume therapy during his stay. His preadmission screening and eligibility determination form (PAS) was approved for payment by Medicaid for three (3) months, with the physician estimating a stay of approximately twenty-one (21) days. The facility subsequently had to submit a PAS to resume payment on 04/26/12. This application was approved for a recommended period of three (3) to six (6) months on 05/07/12. He improved with therapy, and by 06/11/12, his comprehensive assessment (MDS), under section G0110, G0120, and G0300 documented his ability as: Bed Mobility coded: 0,0 indicating 'independent with no help from staff Transfer ability coded: 0,0 indicating 'independent with no help from staff Walking in room coded: as 'not assessed Walk in corridor coded: 8,8 indicating 'activity did not occur Locomotion on unit coded: 0,0 indicating 'independent with no help from staff Locomotion off unit coded: 0,0 indicating 'independent with no help from staff Dressing coded: 0,0 indicating 'independent with no help from staff Eating coded: 0,0 indicating 'independent with no help from staff Toileting coded: 0,0 indicating 'independent with no help from staff Personal Hygiene coded: 0,0 indicating 'independent with no help from staff Bathing coded: 0,0 indicating 'independent with no help from staff Balance sitting to standing coded: 0 indicating 'steady at all times Balance Walking coded: 0 indicating 'steady at all times Turning around coded: 0 indicating 'steady at all times Moving on/off toilet coded: 0 indicating 'steady at all times Surface to surface transfer coded: 0 indicating 'steady at all times The facility again allowed the PAS approval to expire, and this necessitated another submission for approval for Medicaid coverage for long term care level services. With the improvements in his functional abilities, the reviewer denied the application stating he did not require long term care services on 08/20/12. He had to undergo surgery for [REDACTED]. His MDS of 09/10/12 assessed his functional ability as: Bed Mobility coded: 3,2 indicating 'extensive assistance of one staff Transfer ability coded: 3,2 indicating 'extensive assistance of one staff Walking in room coded: 3,2 indicating 'extensive assistance of one staff Walk in corridor coded: 3,2 indicating 'extensive assistance of one staff Locomotion on unit coded: 0,0 indicating 'independent with no help from staff Locomotion off unit coded: 0,0 indicating 'independent with no help from staff Dressing coded: 3,2 indicating 'extensive assistance of one staff Eating coded: 0,1 indicating 'independent with set up help only Toileting coded: 2,3 indicating 'limited assistance of two or more staff Personal Hygiene coded: 3,2 indicating 'extensive assistance of one staff Bathing coded: 3,2 indicating 'extensive assistance of two or more staff Balance sitting to standing coded: 2 indicating 'not steady, only able to stabilize with staff assistance Balance Walking coded: 2 indicating 'not steady, only able to stabilize with staff assistance Turning around coded: 2 indicating 'not steady, only able to stabilize with staff assistance Moving on/off toilet coded: 2 indicating 'not steady, only able to stabilize with staff assistance Surface to surface transfer coded: 2 indicating 'not steady, only able to stabilize with staff assistance An interview was conducted with the comprehensive assessment (MDS) coordinator, registered nurse (RN), Employee #54 on 03/12/13 at 10:00 a.m. She was asked why a significant change of status comprehensive assessment (MDS) was not considered for Resident #117 upon his return from hernia repair surgery. She agreed that his functional ability had declined markedly following the procedure, but said that the interdisciplinary team was in agreement that they anticipated a fairly rapid return to his baseline, and decided to wait for a time to see what happened. She said that he did improve rapidly, and within a couple of weeks, he had returned to near his functional level as assessed on 06/11/12. The facility once again submitted another PAS form for a change in condition, to attempt to get Medicaid payments resumed. This form was submitted on 10/01/12, following his improvement following surgery in September, and was again denied on 10/02/12. The facility was still receiving no reimbursement for Resident #117's stay. There was documentation that numerous attempts were being made to find a location that would accept Resident #117 to allow the facility to discharge him. Social services notes documented that beginning on 09/11/12, assisted living facilities were contacted. The note stated that all were private pay, which Resident #117 could not afford on his approximately $432.00 per month disability benefits. The note said that legally unlicensed adult care homes would be contacted. The record showed that from 09/17/12 until 09/28/12, attempts were made to arrange placement at twenty-seven (27) legally unlicensed adult care homes all over the region. They all had concerns over the care required, they did not accept smokers, or only accepted private pay residents. The record indicated that on 09/28/12, the unlicensed care home to which Resident #117 was ultimately discharged , called to let the social worker know that she would accept him, but needed time to prepare his room. Earlier efforts to obtain placement in another state where Resident #117's sister lived were unsuccessful as the facility there also refused to accept him. The record documents that she was contacted on 09/28/12 and notified of Resident #117's upcoming placement. Transportation problems with two (2) different ambulance services, complications from hernia surgery, and an unspecified emergency at the unlicensed care home delayed the discharge until 11/08/12, when the record shows he was taken to the unlicensed home in the facility van, with a wheelchair and a cane. The social worker for Resident #117, Employee #37, was interviewed on 03/12/13 at 2:40 p.m. He confirmed that Resident #117 had improved following his hernia surgery and within a couple of weeks was back walking with his cane, although he always used his wheelchair to go any appreciable distance. He said that when the preadmission screening was denied, the facility stopped getting paid, and he began to pursue locations for discharge. He said it was very difficult due to Resident #117 having [MEDICAL CONDITION] C, being a smoker, exhibiting inappropriate and aggressive behaviors at times, and not being covered by Medicaid. He said that finally an unlicensed adult care home agreed to take Resident #117 on 09/28/12. Following several logistical problems with the provider and the ambulance services, the facility activities director and a nursing assistant drove Resident #117 to the unlicensed care home in the facility van. He was asked if he had visited the home prior to the discharge to see if it was a safe appropriate location for the discharge. He replied that he had not. He said he spoke with the owner on the phone. He said that she had told him there were seven (7) or eight (8) steps that Resident #117 would have to negotiate. He was asked if he made any effort to determine if Resident #117 could safely negotiate steps. He said he asked the resident, who told him it would be no problem. He was asked if physical therapy was consulted for an assessment of the resident's ability to climb stairs. He stated he thought he had asked them about it, but no formal assessment was requested or completed. None of the goals met when resident #117 was discharged from therapy on 04/19/12 addressed stairs. There was a goal that stated he should be able to negotiate ramps, grass, and gravel. There was no documentation in the record regarding any stairs or any attempts to determine if the location was appropriate for discharge. He was asked if the staff that transported the resident to the home had gone inside to make any assessment of the suitability. He replied that he did not know. He offered that the regional ombudsman had visited the facility later following the discharge and had told him that there were eighteen (18) steps to Resident #117's room, and that he was in a bad situation. The activities director, Employee #87, was interviewed on 03/12/13 at 3:34 p.m. She confirmed that she and a nursing assistant had transported Resident #117 to the unlicensed care home on 11/08/12 in the facility van. She said that they had a TV, three (3) boxes of clothing and personal items, a cane, and a wheelchair. She said she had a bag with his medications. She took it to the front room. The owner was not there, but her son signed for the medications. She said that Resident #117 walked around the front yard, and talked with another resident. She said they left his belongings there, the resident hugged her, and we dropped him off and left. The owner of the legally unlicensed home was interviewed on the telephone on 03/11/13 at 3:23 p.m. She was asked if Resident #117 was still living in her home. S he replied that he was still there. She asked if there was someone who could get him placed somewhere else. She said that he needed to stay over there (the facility). She said he can't get around here, he is not doing good. She said they are trying to find someplace for him to go. He wants to go back to the facility or somewhere closer to his sister (out of state). She said they were having trouble with his medications and that he needed nursing home care. She was asked if she had spoken with the facility about this. She said that she had talked with that man (Employee #37). She stated she told him that Resident #117 needed to stay over there. The health care surrogate was interviewed by telephone on 03/12/13 at 1:59 p.m. She related that she had no problems with the facility, that they treated him very well there. She said that he was in a wheelchair, that it was still sitting on the front porch. She said there were fifteen (15) steps up to his room and he could not get up or down by himself. He just sat up there and smoked. She said the ombudsman was working with him on finding a new place. She stated that the facility did not assess the place, they did not check it to see if it was safe, they just took him there in the van and dropped him off. The administrator was interviewed on 03/12/13 at 3:47 p.m. She confirmed there was no documented effort to ensure a safe and orderly discharge for Resident #117.",2016-03-01
8990,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-09-25,204,D,1,0,UPSW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, medical record review, facility record review, and policy review, the facility failed to provide sufficient preparation and orientation to three (3) of three (3) residents reviewed, to ensure a safe and orderly transfer or discharge from the facility. The facility failed to complete a discharge plan and/or to minimize avoidable anxiety with relocation for residents who were given eviction notices. Resident identifiers: Resident #9, #12, and #34. Facility census: 32. Findings include: a) Resident #9 During an investigation related to inappropriate discharge processes, review of the medical record revealed no evidence of a discharge planning process. The medical record, reviewed on 09/23/14, revealed minimum data sets (MDS) with assessment reference dates (ARD) of 02/16/14, 05/09/14 and 08/08/14. -Section Q, noted a response of No to the question, Is active discharge planning already occurring for the resident to return to the community? -Section C , noted the brief interview for mental status (BIMS) score as 03, which indicated the severe cognitive impairment -Review of the electronic census indicated the resident received West Virginia Medicaid on 11/15/12, 02/14/13, was private pay on 07/01/13, and received Medicaid again on 12/01/13. -Social service health status notes, dated 05/21/14 at 11:00 a.m., I called ____ on May 19th and spoke with her regarding receiving paperwork that she needed to complete for her court hearing on May 22nd A confidential interview, on 09/23/14 at 12:45 p.m., revealed staff had provided a discharge notice to the resident, but provided no assistance to help the resident and family with placement. During an interview with Family Member #3, on 09/25/14 at 10:55 a.m., she indicated the corporate office was suing her grandmother for about sixty thousand (60,000) dollars for time the resident was private pay status. She related she had received a telephone call from the social worker indicating the facility was going to serve her grandmother with wrongful occupation. Upon inquiry, she indicated the facility did not offer to help find placement. She related, Not at all. They didn't even ask. Further review of the medical record, on 09/25/14 at 10.30 a.m., revealed a pre-admission screening, dated 02/28/14, noted as approved . The physician noted the recommended level of care as nursing home. Financial records, reviewed with the business office director, on 9/25/14 at 3:00 p.m., revealed a thirty day notice of discharge and transfer, dated 03/28/14. The notice related the community would assist with finding housing and care options, and noted the name of a facility. During an interview with the executive director, on 09/25/14 at 3:30 p.m., she confirmed the facility had made no referrals for placement to other facilities, including the facility noted as having an available bed. b) Resident #12 A confidential interview on 09/25/14, revealed Resident #12 had received a discharge notice, administered by the sheriff's department, and the resident threatened suicide. Review of the electronic medical record, on 09/25/4 at 12:50 p.m., revealed a census which indicated Resident#12 was private pay status from admission 07/14/13. The minimum data set (MDS), with an assessment reference date (ARD), of 04/12/14, 06/20/14, and 09/15/14, indicated the resident expected to remain in the facility, and the facility had no active discharge plan. Section Q was marked referral not needed. A social service progress note, dated 04/30/14, indicated the social worker, and the director of nursing met with resident to ask him if he felt like he was going to harm himself related to the eviction notice. Family member #4, interviewed on 09/25/14 at 3:45 p.m., revealed the resident's daughter-in-law had received a discharge notice, taking him to court. Upon inquiry, she also indicated the facility had provided one to the resident. She related they gave it to her father-in-law, and he gave the letter to her. She said the last time they served him with papers he tried to commit suicide by not eating. The family member said A sheriff served it on him, and he didn't even know what was going on; he thought he was going to jail. The family member said the sheriff called her, and said her father-in-law was hysterical. Upon further inquiry, she related the facility never offered to make applications to other facilities. She said Resident #12 called her and said he was going to kill himself, and she was concerned because he had tried to hang himself at home. Family Member #3 related she had not received a letter initially, but got a copy about two (2) weeks later. She further added, Why would you serve a [AGE] year old man that doesn't even know what is going on?' An interview with the business office director (BOD), 09/25/14 at 4:00 p.m., confirmed the family member's account of the eviction notice. She related the resident and processor had utilized her office to call the daughter, because he was so upset. Further inquiry, and review of the business office files, revealed a thirty day discharge notice dated 04/25/14. An address, located at the bottom of page one of the letter, indicated bed availability at another facility, and indicated the community would assist with finding placement. An interview with the administrator, on 09/25/14 at 4:30 p.m., confirmed the facility had no discharge plans put into place to assist the family with placement in another facility, and confirmed the facility had not made referrals to other facilities. c) Resident #34 Review of the electronic medical record, on 09/24/14 at 11:35 a.m., revealed the resident census indicated Resident #34 was private pay status on 05/19/11, and then Medicaid on 06/01/11. The minimum data sets (MDS) with assessment reference dates of 02/09/14, and 05/09/14, indicated the resident had no plans for discharge, and no active discharge planning was in progress. An interview with Family Member #1 on 09/25/14 from 4:10 p.m. - 4:30 p.m., revealed the resident received notices addressed to him, and placed under his phone. She indicated the financial issue wasn't brought up for discussion, they just brought it up in December, just hit me with it. Another interview at 4:57 p.m. revealed she remembered a stamp with a facility name on the third letter. She said No, they never did any of that, upon inquiry about assistance with transfer/discharge status, and being made part of the discharge process. Family member #1 related the facility never discussed it with her. She said she took the letter as a threat, and contacted the ombudsman and her attorney. An interview with the business office manager, on 09/25/14 at 6:00 p.m., revealed the facility provided a 30-day notice to pay or terminate, dated 03/26/14. The letter indicated failure to pay the bill would result in a requirement to immediately move from and surrender possession of his room. Another letter, dated 05/19/14, indicated payment would not constitute a waiver of this Notice. A review of the discharge planning process indicated: -discharge planning would be done in collaboration with the resident and/or surrogate -coordinate care between agencies. The administrator, interviewed at 4:50 p.m. on 09/25/14, related she had no additional information, no evidence anyone was contacted or the family/responsible party was made part of the discharge process. She confirmed the facility made no referrals to assist the resident/family with relocation. .",2016-03-01
9286,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2013-01-10,204,D,1,0,2S6811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, family interview, staff interview, and interview of employees at a the discharge location, a personal care home, it was determined the facility failed to provide sufficient preparation and orientation to ensure a safe and orderly transfer or discharge from the facility by sending a resident with an intravenous line in place to a facility that was not licensed, staffed, or equipped to administer that level of care. This was found for one (1) of eight (8) records reviewed. Resident identifier: #94. Facility census: 93. Findings include: a) Resident #94 The medical record of Resident #94 was reviewed on 01/09/13 at 1:00 p.m. Resident #94 was an eighty-seven (87) year old woman who was discharged from the adjoining assisted living facility to the hospital, and then admitted to the nursing facility on 10/19/12. She was subsequently discharged to a local personal care home on 11/30/12. Her [DIAGNOSES REDACTED]. Resident #94 was experiencing a rapid decline in her overall condition, and was requiring more extensive assistance with all her activities of daily living. She was originally admitted to the facility following a brief hospitalization for left great toe [MEDICAL CONDITION] with [MEDICAL CONDITION] (MRSA) osteo[DIAGNOSES REDACTED]. The responsible party elected not to have the recommended amputation performed. The resident began to have respiratory problems as well, and was on multiple antibiotics. She had a peripherally inserted central catheter (PICC) line placed for that purpose on 11/17/12. The family elected Hospice services on 11/16/12. A significant change in status comprehensive assessment (MDS) was completed on 11/25/12. New care areas were initiated for [MEDICAL CONDITION], cognitive loss, communication, and pain. The already existing care areas of urinary continence, falls, dehydration, pressure ulcers, and [MEDICAL CONDITION] medications were modified. The discharge summary note of 11/30/12 stated (typed as written): Pt. (patient) was admitted to (facility) following hospitalization for osteo[DIAGNOSES REDACTED] (MRSA) for medical care and therapy. Pt. cont. to decline after admission developing [MEDICAL CONDITION] treated with 2 different antibiotics, UTI (urinary tract infection) requiring IV antibiotics and significant [MEDICAL CONDITION]. She didn't improve strength with therapy. Daughter decided to make her palliative care and Hospice services were arranged. Following the decision to initiate palliative care, Resident #94's daughter and medical power of attorney decided to transfer her to a local personal care home due to dissatisfaction with multiple issues at the facility. During an interview on 01/10/13 at 2:44 p.m., Resident #94's daughter stated that upon their arrival at the personal care home, it was discovered that the PICC line was still intact in the resident's arm, although it was the understanding of both the daughter and the personal care home that the line would be removed prior to the transfer. She said she called the facility and that a licensed practical nurse, Employee #85 told her she thought it had been removed, and would check with the unit manager. The daughter said she assumed the line had been removed because the list of current medications sent with the family included only oral medications. Review of the record had found that the intravenous medications had been discontinued by physician's orders [REDACTED]. Nurses' notes continued to reference the line, with an entry for 11/29/12 at 4:00 p.m. (typed as written: . Right arm PICC is intact. The resident's discharge to the personal care home was referenced in a nurses' note of 11/30/12 at 1:13 p.m. (typed as written): Resident discharged to (personal care home), meds sent with resident. (county emergency squad) picked up resident. A visit was made to the personal home on 01/09/13 at 4:00 p.m. The director, a licensed practical nurse, agreed to an interview. She was asked about Resident #94's PICC line. She said it was discovered in place during the admission process on Friday 11/30/12. It had been her understanding it would be removed prior to the transfer, as her facility was not licensed, staffed, or equipped to provide that level of care. She said she called the facility and spoke to one of the nurses, who said someone would call her back, but she received no call. She called the Hospice, and was told that the nurse on call would come out and remove it. Then they called back and said the nurse on call was not trained to remove the catheter. The Hospice called the facility, and eventually the PICC line was removed on the next Tuesday or Wednesday. She said the family had wanted to admit their mother to the personal care home earlier, but that her personal care home could not take residents [MEDICAL CONDITION], so they had to wait. She presented a document with nurses' notes from the admission. A note dated 11/30/12 at 2:00 p.m. stated (typed as written): RN supervisor notified of Pt. (patient) transfer by (local emergency squad) to our facility. During body audit we found on resident's right arm IV in place (PICC line), insertion date 11/18/12. Family states nursing home told her it was removed on Tuesday 11/27/12. Licensed practical Nurse, Employee #85, was interviewed on 01/10/13 at 11:40 a.m. She confirmed that she was the nurse that had been called by the daughter. She said a day or two (2) before the discharge, she had asked the unit manager, a registered nurse (Employee #74), what was going to be done about Resident #94's PICC line. She was told that she had asked the physician, who said he was going to call the daughter, and let the facility know. When she received the second call from the daughter, she asked Employee #74 if she had removed the PICC line. She replied that she had not, as the physician did not tell them to. She confirmed that only oral medications were sent with the resident. The director of nursing, Employee #134, was interviewed on 01/10/13 at 12:28 p.m. He did not know that Resident #94 had been transferred to the personal care home with the PICC line intact. He stated she should never had gone to a personal care home with a PICC line intact. He said if he had known, he would have gone there himself and taken it out.",2016-01-01
9785,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-06-01,204,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and review of information provided by the facility to the State survey agency after the survey team's exit, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, .Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. Also on page 2 was stated, Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time. (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: 5. Activity is ambulation with assist and a walker. A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under A/P (assessment and plan): 5. Alcohol dependence: Abstain from future use . - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading Summary of Care was noted: Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair). Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading Summary of Care was noted: Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment. Under the heading Discharge Recommendations was noted: Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker). Review of the speech therapy progress notes, for 07/20/10, revealed under the heading Current Status: Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners. Under the heading Encounter Summary was noted: . SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/21/10 revealed, . D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids). Review of the facility's Rehab UM Meeting notes for Resident #57 on 07/27/10 revealed, . D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance. Handwritten in the block containing Resident #57's name was: DC tom (discharge tomorrow) pm. Review of the resident's telephone orders found an order dated 07/27/10 for: Home Health w/ (with) PT & OT. Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was rough. According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. - 6. On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Review of these materials, including the resident's discharge transition plan dated 07/29/10, revealed the following: You can get around (at discharge): With a little help. Devices used: wheelchair (There was no mention of a front-wheeled or roller walker.) Get up/down from a seated position (at discharge): W/ at great deal of help (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) Your dietary recommendations are: Regular Diet (There was no mention pureed foods or thickened liquids.) On page 3, under the heading of Your physician follow-ups, nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) On page 5 of this document, under the heading Your health services provider follow-ups were checked Physical Therapy, Home Medical Equipment / Supplies, and Pharmacy Provider. None of the services under Home Care Services was checked, nor was Occupational Therapy checked under Therapy Services, as had been ordered by the physician on 07/27/10. Under Home Medical Equipment / Supplies, someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. The facility failed to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. .",2015-09-01
9910,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2010-08-05,204,D,0,1,2XEX12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, and review of information provided by the facility to the State survey agency after the survey team's exit, the facility failed, for one (1) of five (5) residents whose closed records were reviewed, to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. Resident identifier: #57. Facility census: 54. Findings include: a) Resident #57 1. On 08/03/10 at 3:00 p.m., review of Resident #57's medical record revealed this [AGE] year old female was admitted to the nursing facility from a local hospital on [DATE], and she was discharged to a legally unlicensed care home on 07/29/10. Review of Resident #57's admission record (face sheet) revealed her [DIAGNOSES REDACTED]. According to her hospital discharge summary, dictated and transcribed on 07/06/10, she was admitted to the hospital on [DATE]. Her discharge [DIAGNOSES REDACTED]. On page 2 of the discharge summary, the physician noted, ""...Because of her moderate dementia and alcohol dependence she was given [MEDICATION NAME] to prevent withdrawal. ..."" Also on page 2 was stated, ""Physical Therapy notes that patient does require a walker and assistance for ambulation and has easy fatigue and endurance. They do emphasize that she is not safe of independent gait and transfers at this time."" (This last sentence was written in bold font and was underlined.) On page 3 under Discharge Disposition and Special Discharge Instructions was: ""5. Activity is ambulation with assist and a walker."" A progress note by the certified physician's assistant (PA-C), dated 07/16/10, noted under ""A/P"" (""assessment"" and ""plan""): ""5. Alcohol dependence: Abstain from future use ...."" - 2. According to her comprehensive admission assessment, with an assessment reference date (ARD) of 07/13/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for bed mobility, transfer, locomotion, dressing, toilet use, personal hygiene, and bathing, and she was frequently incontinent of both bowel and bladder. During this assessment reference period, the resident did not walk, and her primary mode of locomotion was via a wheelchair. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. According to a Medicare 14-day full assessment, with an ARD of 07/17/10, she had problems with both long and short term memory, she was not oriented to person, place, or season, her cognitive skills for daily decision making were moderately impaired, she required the extensive physical assistance of one (1) person for locomotion, dressing, and personal hygiene, and she required the extensive physical assistance of two (2) persons for bed mobility, transfer, and toilet use. During this assessment reference period, the resident did not walk. She received the services of speech, occupational, and physical therapy five (5) days a week during this assessment period, and a trunk restraint was used daily. - 3. Documentation by the physical therapist revealed Resident #57 received physical therapy from 07/07/10 through 07/27/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: pt. (sic) not progressing well, difficulty with cooperation and partiicipation (sic) secondary to dementia and decreased insight and safety, decreased intake as well as making participation difficult. family (sic) not in for training or education. recommend (sic) assist and continued PT if able to maximize functional mobility and assisted mobility."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: Home Health Services, A (assistance) with all mobility; Equipment recommended upon discharge: w/c (wheelchair)."" Documentation by the occupational therapist revealed she received occupational therapy from 07/07/10 through 07/28/10. Under the heading ""Summary of Care"" was noted: ""Summary of Progress:: Pt. demo(nstrated) limited progress toward goals due to cognitive level and lack of participation in therapy. Pt. at times will refuse or become beligerant (sic) with therapist. Family and SW (social worker) decided to transfer patient to a personal care home closer to family. Discharge skilled OT treatment."" Under the heading ""Discharge Recommendations"" was noted: ""Discharge Setting: Other (personal care home); Recommended services upon discharge: 24/7 care; Equipment recommended upon discharge: pt. could benefit from w/c and FWW (front-wheeled walker)."" Review of the speech therapy progress notes, for 07/20/10, revealed under the heading ""Current Status"": ""Precautions: puree (diet); nectar-thick fluids; fall risk; easily agitated per hospital records; sundowners"". Under the heading ""Encounter Summary"" was noted: ""... SLP (speech language pathologist) suggested that PCH (personal care home) staff come to facility next week to observe pt in tx (treatment) and determine if she will be appropriate for their setting. Pt's POA (power of attorney) to set this up for next week. ..."" Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/21/10 revealed, ""... D/C (discharge) plan? Lap buddy. Transfers with mod A (moderate assistance) for safety. AMb (sic) (ambulate) - 30ft with Mod A and RW (roller walker).; MBSS (modified [MEDICATION NAME] swallow study) on 7/22 at noon. PO (oral) intake is extremely poor; drinks better on nectar (thickened liquids)."" Review of the facility's ""Rehab UM Meeting"" notes for Resident #57 on 07/27/10 revealed, ""... D/C plan? Lap buddy. Transfers with max A (maximum assistance) for safety. Pt now not ambulating.; Question pt with UTI (urinary tract infection). Pt with decreased performance."" Handwritten in the block containing Resident #57's name was: ""DC tom (discharge tomorrow) pm"". Review of the resident's telephone orders found an order dated 07/27/10 for: ""Home Health w/ (with) PT & OT."" Review of the social service notes revealed Resident #57 was discharged from the nursing facility at 6:00 p.m. on 07/29/10. Review of facility records found no evidence to reflect there had been any discussion between the social worker and the resident's legal representative regarding the appropriateness of discharging Resident #57 from a skilled nursing facility to a legally unlicensed care home in the community, in view of the resident's assessed needs with respect to her level of dependence on staff with activities of daily living, her dysphagia, and her need for monitoring related to her recently diagnosed urinary tract infection. - 4. In an interview on 08/04/10 at 10:45 a.m., the facility's social worker (Employee #59) reported there was no discharge planning meeting held or discharge notice given to the resident's legal representative, but they did discuss discharge during the resident's last care plan meeting. Review of the care plan meeting notes with the social worker, at this time, found no mention of any discharge plan. The social worker reported the physical therapist expressed that Resident #57 had reached a plateau. The social worker reported she then contacted the resident's legal representative, who set everything up for the discharge herself. The social worker did contact the unlicensed care home to ensure they had a mechanical (Hoyer) lift available for use at the facility and twenty-four (24) hour care. The social worker confirmed that no follow-up appointment with a physician had been made, she did not communicate to staff at the unlicensed home that the resident had a history of [REDACTED]. - 5. In a telephone interview on 08/04/10 at 11:10 a.m., Resident #57's legal representative reported she did not receive anything in writing from the facility, but that the social worker called and informed her that Resident #57 had reached a plateau in therapy and needed to be discharged . The legal representative stated the resident's intended discharge date was projected to be in August, but no set date was mentioned, and upon admission she knew there were no long term care beds available at the nursing facility. The legal representative was not sure why the discharge date was moved up and she wished Resident #57 could have stayed at the nursing facility longer, since she was only able to take a few steps with the assistance of two (2) people, one (1) on each side of her. She also reported that Resident #57's transition from the nursing facility to the unlicensed care home was ""rough"". According to the legal representative, Resident #57 had resided in an assisted living facility in Ohio prior to being admitted to the hospital on [DATE]; while there, staff gave Resident #57 alcoholic beverages to drink, and during a visit there, the legal representative found both the resident and her caregiver were intoxicated. During a visit at the unlicensed care home (after her discharge from the nursing facility on 07/29/10), the legal representative found that staff at the unlicensed care home was giving Resident #57 alcoholic beverages; the legal representative quickly intervened but noted the nursing facility failed to inform staff at the unlicensed care home of the need for Resident #57 to abstain from alcohol. Additional information obtained from Resident #57's legal representative during this telephone interview included: - No information had been communicated to the staff at the unlicensed home regarding how to safely assist Resident #57 out of the legal representative's personal vehicle (from a sitting to a standing position), and she reported the mechanical lift at the facility was broken. - No information was communicated to the staff at the unlicensed home of the need to obtain follow-up services from a physician related to the resident's urinary tract infection. The legal representative reported having to take Resident #57 to an Urgent Care provider after her discharge from the facility, because the resident's urine was dark-colored and foul-smelling, and she could not get an appointment with a primary care physician until 08/30/10. - No physical therapy or occupational therapy services had yet been provided to Resident #57 since her admission to the unlicensed care home. - 6. On 08/09/10, the surveyor received additional information that had been submitted by the facility to the State survey agency after the survey team's exit. Review of these materials, including the resident's discharge transition plan dated 07/29/10, revealed the following: ""You can get around (at discharge): With a little help. Devices used: wheelchair"" (There was no mention of a front-wheeled or roller walker.) ""Get up/down from a seated position (at discharge): W/ at great deal of help"" (There was no mention of the need for the use of any devices when transferring, such as a walker or a mechanical lift.) ""Your dietary recommendations are: Regular Diet"" (There was no mention pureed foods or thickened liquids.) On page 3, under the heading of ""Your physician follow-ups"", nothing was written to direct either the resident's family or the receiving facility's staff to contact any physician. (There was no mention of the need to monitor the resident for signs / symptoms of a UTI.) On page 5 of this document, under the heading ""Your health services provider follow-ups"" were checked ""Physical Therapy"", ""Home Medical Equipment / Supplies"", and ""Pharmacy Provider"". None of the services under ""Home Care Services"" was checked, nor was ""Occupational Therapy"" checked under ""Therapy Services"", as had been ordered by the physician on 07/27/10. Under ""Home Medical Equipment / Supplies"", someone had scratched through information regarding the provider of a wheelchair, but there was no information to indicate a walker had been ordered. There was no mention anywhere on the document of the need to monitor the resident for falling, in view of the fact that she had used a lap buddy when at the nursing facility and had been identified as being at risk for falls by all of the rehabilitative therapy services. No information was communicated in the discharge transition plan regarding any special feeding techniques or alterations needed in the consistencies of foods and fluids to address her dysphagia, the transition plan incorrectly identified her diet as being of regular consistency, and there was no evidence that staff from the unlicensed home had come to the nursing facility to observe the resident during speech therapy to determine if she will be appropriate for their setting, as recommended by the SLP. The facility failed to take steps within its control to ensure a safe and orderly discharge of Resident #57 from the nursing facility to a legally unlicensed care home. .",2015-08-01
10382,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2011-12-09,204,D,1,0,JVY911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility did not ensure that information related to the allergy to [MEDICATION NAME] for one (1) resident of a sample of five (5) reviewed, was provided to the receiving facility when the resident was transferred to the hospital. Resident #92 was admitted to the facility from another nursing home, the history and physical listed the resident as being allergic to [MEDICATION NAME]. The facility failed to document the allergy on the transfer form when the resident was next transferred and the hospital gave the resident an antibiotic ([MEDICATION NAME]) causing the resident to have an allergic reaction. Facility census 92. Findings include: a) Resident #92 A review of physician's orders [REDACTED]. The nursing assessment on admission to the current nursing home on 08/10/2011 did not list any allergies [REDACTED]. An interview with the director of nursing, on 12/08/2011 at 12:45 p.m., revealed that it was her expectation that nurses document the resident's allergies [REDACTED]. The nurses know that the allergies [REDACTED]. The director of nursing verified this resident's allergy to [MEDICATION NAME] was not listed so that the nurses would be aware. She also verified the resident had been transferred to the hospital and was administered an antibiotic, [MEDICATION NAME]. The resident had an allergic reaction to the antibiotic. The physician was notified and immediately stopped the medication and ordered [MEDICATION NAME]. The resident did not need to go back to the hospital. A nursing entry, dated 10/29/2011 at 10:10 p.m., revealed, ""res (resident) returned from hospital (name) via ambulance and 2 attendants. Res (resident) was given tetanus shot in left deltoid at the hospital (name). She was also given [MEDICATION NAME] 875/12.5 mg PO."" On 10/29/2011 at 11:00 p.m., a nursing note indicated, ""res (resident) c/o (complain of) itching on R (right) 3rd digit of hand. Noted red hives and swelling. Resident then c/o itching on left arm. Noted hives, redness on upper and lower arm checked chart for allergies [REDACTED]. Found in H&P, allergies [REDACTED]. Physician (name) notified of resident receiving [MEDICATION NAME] at hospital, and of allergy. New orders per physician (name) to give 50mg of [MEDICATION NAME] x 1 stat. Change antibiotic to [MEDICATION NAME] 300mg 4 x a day for 7 days."" At 11:30 p.m. a nursing note indicated, ""hives still present on digit and left arm. No s/s of respiratory distress noted."" At 1:00 a.m. on 10/30/2011, a nurse noted ""hives still present, not spreading. Left arm hives have become large patch. No distress noted."" At 3:00 a.m., a nurse note ""No change with hives. Resident resting comfortably. No c/o itching. Red and swollen."" At 5:00 a.m. the nursing entry included ""no change in hives digit on R hand still red and swollen. L arm upper one band of red and swollen hives. No c/o of itching."" .",2015-04-01
10777,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2011-08-04,204,D,1,0,S9PC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, family interview, staff interview, and interview with staff at the local hospital, the facility failed to provide sufficient preparation and notice to a resident and her family to ensure an orderly discharge from the facility in a manner that minimizes unnecessary and avoidable anxiety. This was found for one (1) of eight (8) residents' whose records were reviewed. Resident identifier: #43. Facility census: 41. Findings include: a) Resident #43 Closed record review revealed Resident #43 was an [AGE] year old woman who was admitted to the facility on [DATE]. She was transferred to the Behavioral Health Unit at a local hospital for evaluation on 06/26/11, and subsequently discharged permanently from the nursing home on 07/11/11. - The facility's social worker (Employee #34), when interviewed about the 07/11/11 discharge of Resident #43 on 08/02/11 at 2:00 p.m., stated the facility discharged the resident due to concerns about elopements and aggressive behavior. She stated the resident was sent to the Behavioral Health Unit following an elopement on 06/26/11 that had found her some distance away from the facility. A member of the community returned the resident to the facility. The social worker stated the resident had not returned to this nursing home, and the Behavioral Health Unit had discharged her to another nursing facility in Grafton. - Nurses' notes, when reviewed on 08/04/11 at 8:41 a.m., found an entry by a licensed practical nurse (LPN - Employee #68) dated 06/26/11, stating (quoted as written): ""3:10pm, received call from a (name of person from community), that she found resident on Market Street by Wes Banco bank. (Name of person from community) brought resident back to facility. Resident very unsteady on her feet and sat down in the nearest chair. Resident continues to say 'They are all jealous of me because I have the spaghetti sauce from Muriales and they don't' Also 'I am getting out of here no matter what you have to say'. Attempted to redirect resident, which is not working. 3:20pm, contacted (name of director of nursing) RN, DON, also contacted (name of social worker) SS, who will be contacting (name of administrator) CEO. 3:25pm, Contacted (name of resident's responsible party) MPOA (medical power of attorney)who is in agreement to transport resident to FGH Behavior unit. 3:50pm, left message for Dr. (name). 3:50pm Contacted MCRS to transport resident to FGH for evaluation. Son, (name) MPOA in to see resident. (Name) Called and was told of behavior and going to FGH ... 4:15pm, MCRS here to transport resident to FGH for evaluation. Also contacted FGH ER and spoke with Nurse (name) who was informed of residents behavior and arrival by squad. 5:18pm, Dr. (name) returned call re: residents behavior and transport to FGH for evaluation."" - Review of documentation concerning Resident #43's discharge, conducted on 08/04/11 at 1:00 p.m., disclosed a notice of resident transfer and bedhold policy dated 06/26/11. The form was filled out by hand and stated ""(Name of Resident #43) will be transferred to FGH (local hospital) due to: behavior."" There followed a statement of facility bedhold policy, which included the statement: ""It is the policy of John Manchin Sr. Healthcare to hold the resident's bed for 30 days ... The bedhold will continue unless permanent determination is made regarding the resident's need for care the facility is unable to provide."" There followed a section Titled ""State Bed Hold Policy"", a statement that ""The resident has the right to appeal this action to the agencies listed below"", and a listing of contact information for the West Virginia Inspector General, the West Virginia Commission on Aging, West Virginia Advocates, and the Regional Ombudsman. The form concluded with the following: ""I certify that this notification was given to the party named above: (name of Resident #43), and was dated by hand 6/26/11. Signature of staff member was completed by hand as (Employee #68, LPN)."" The final section of the transfer notice stated: ""Verification of receipt of notification: This acknowledges that I received the notice of resident transfer and bedhold policy."" The ""signature of resident / legal representative"" field was blank. - In an interview with Employee #68 on 08/03/11 at 2:45 p.m., when asked if she had given a copy of the form to the resident or to the MPOA, replied that that form was not given to either of those individuals, that it was a form that was sent with the emergency squad when a resident is sent out. - During an earlier interview with the nurse manager of the Behavioral Health Unit on 08/03/11 at 11:00 a.m., she had pointed out that the facility sends a form when residents are transferred for evaluation that states they will hold the resident's bed for thirty (30) days. d) A visit was made to the Behavioral Health Unit at Fairmont General hospital on [DATE] at 11:00 a.m. The director and the nurse manager of this unit were interviewed regarding the issues surrounding Resident #43's admission for evaluation and her subsequent discharge to a nursing facility in Grafton. Supporting documentation was requested and provided. The nurse manager stated they had expected Resident #43 to return to the facility, as she had following a brief admission for evaluation in March 2011. Documentation was reviewed as follows: A psychosocial assessment, completed 07/05/11, included under the section ""CURRENT LIVING SITUATION / SOCIAL AND COMMUNITY SUPPORT"": ""... She should be able to return to John Manchin Senior Center pending a completed PAS (pre-admission screen). That will be continuously evaluated by the treatment team; however in a conversation on June 28, 2011, with (Name of son), he stated that it was his goal for their mother to return to that facility."" Under the section ""SUMMARY AND RECOMMENDATIONS"" was found: ""... She should be able to return to John Manchin Senior center following discharge."" Under the section ""INITIAL TREATMENT GOALS / INTERVENTIONS"" was found: ""... Goals: 1. Prevention of deterioration. 2. Decrease any agitation, aggressiveness and wandering behaviors. 3. Help reorient the patient and maybe decrease some of the agitation through ongoing reorientation to time, place, and situation. Interventions: 1. Medication stabilization. 2. One-on-one interaction to develop some effective coping skills and help facilitate group and individual sessions."" Under the section ""INITIAL DISCHARGE PLANNING"" was found: ""... Return to John Manchin Senior Healthcare Center where she currently resides."" Phone contact notes stated: On 06/29/11 - ""Spoke with (name) at John Manchin Nursing home this day. Discussed DC (discharge) for Friday. (Name) states that PT's (patients) will need to be transported to that facility before 12 so that prescriptions can be filled."" On 06/30/11 - ""Spoke with (nursing home's social worker) this day regarding DC (discharge) for (Resident #43). Discussed (Resident #43's) recent aggressiveness and behaviors. Discussed a possible DC for Tuesday 7/5/11 pending continued observation. The initial projected DC date was to be 7/1/11, however it is the opinion of TX (treatment) teams at both facilities that PT needs more observation and time for med adjustments to occur."" On 07/07/11: ""Attempted to contact (name of social worker) at Manchin Healthcare to discuss DC for 7/8/11 as per discussion with Dr. (name) this day. (Name of social worker) was unavailable, message was left on her personal answering machine."" On 07/11/11: ""Spoke with (nursing home's social worker) at John Manchin Healthcare this day to discuss PT discharge. (social worker) states that John Manchin will not be able to accept PT back, states that this decision is based PT safety concerns and OHFLAC regulations. (social worker) states that she did not agree to accept patient back in her conversation with Dr. (name) which occurred on Friday 7/8/11."" A treatment progress note dated 07/11/11 stated: ""Met with PT's son's (names), and PT's daughters (names) this day following a discussion with (nursing home's social worker) at John Manchin Sr. Healthcare. On this day PT was to be DC as per a conversation that occurred on 7/8/11 between (social worker) and Dr. (name). When the RN on duty called John Manchin to give DC report (hospital) was informed that John Manchin would not accept the PT back. Discussed with PT's family several options for placement, including (name of another nursing home) which had been contacted with referral information. PT's family prompted this author to make several other referrals, which were faxed this day. PT's family is visiting several nursing homes this day, will contact tomorrow."" It was apparent that both Resident #43's family and staff at the Behavioral Health Unit were expecting the resident's return to John Manchin right up until the refusal expressed over the telephone on 07/11/11. The resident was subsequently discharged to another area facility. - An interview was conducted with a son of Resident #43 by telephone at 11:30 a.m. on 08/03/11. He stated the family did not have enough time to transfer their mother to another facility. He further stated he felt administration at this facility did not seem to understand how to care for Alzheimer's patients. He also stated the floor nurses at the facility did the best they could, but administration just did something drastic. - In an interview with the facility's health information management director (Employee #45) on 08/03/11 at 1:25 p.m., when asked to clarify the facility's bedhold policy, she stated the facility holds the bed of a transferred resident for thirty (30) days regardless of payor source or availability of bedhold days through the Medicaid program. She stated that, if a resident's Medicaid allotment of twelve (12) paid bedhold days had already been used, the facility would still hold the bed free of charge for thirty (30) days. - The only documented meeting between the facility's interdisciplinary team and Resident #43's MPOA was a care plan review meeting held on 04/06/11. A social services note stated: ""Annual Assessment was done today for (Name of Resident #43). Her son and MPOA, (name), attended the meeting. The IDT (interdisciplinary team) members reviewed the care needs of (Resident #43) with (name of son) and a new plan of care will be done reflecting new changes in her care."" A review of the care plan that was developed found the problems / strengths identified were in the following areas: Compromised short term memory, persistent episodes of anger manifested by her thinking that she does not need long term care, conflict with her family as demonstrated by her not being pleased with her placement, strong identification with past roles, as manifested by her believing she is capable of independent living, risk of low self-esteem as manifested by her admission to the facility, risk for falls, risk of side effects from antipsychotic medication use, and requiring assistance with personal hygiene tasks. There was no evidence of discussion of elopements or physical aggression and no evidence of the facility expressing concern to Resident #43's MPOA about the continued stay of Resident #43 at this facility. There were no other documented discussions or meetings with the family. - A review of social services notes found there was no note regarding the resident's transfer to the Behavioral Health Unit at the local hospital on [DATE]. There was a note dated 06/27/11 which stated: ""Called and cancelled (Resident #43's) appointments with physical therapy this week."" This was the final social services note in the medical record. A review of physician's progress notes found the last documented note was dated 06/15/11, and stated: ""(Rt) (right) ear redness (illegible) tissue. Pressure related sleep changes."" The nurses' note from that visit stated: ""MD vs (visit) and examined right ear that was red and stated that it was pressure related from lying on the right side. Orders received to DC (discontinue) [MEDICATION NAME] at this time."" There was no further documentation found by the attending physician. physician's orders [REDACTED].#43. It was explained by Employee #41 (a registered nurse assessment coordinator) that, since the electronic medical record was closed, all orders printed had ""dc"" at the beginning and "" "" at the end. The final physician's orders [REDACTED]."" There were no further orders for permanent discharge from the facility. A discharge summary form, dated 07/13/11 and signed Employee #41, stated the resident was discharged to the local hospital. The course of treatment while in the nursing home was described as: ""Alert, but confusion. Needs assist. Of one for all care to ensure optimum level of personal hygiene. Independent ambulation. Needed supervision to prevent resident from leaving facility property. Redirection for aggressive behavior."" Pertinent diagnostic findings were described as ""N/A"" (not applicable). Essential information regarding illnesses or problems was described as: ""Increased confusion, Redirection not always effective. Repeated attempts to leave facility + (and) facility property."" Restorative procedures were described as: ""Psyche consults medication adjustments."" The section titled ""Written discharge instructions given to"" was not completed. The section for Physician Signature was blank. - The administrator, (Employee #2), DON (Employee #46), and social worker (Employee #34) all stated, during an interview of 08/02/11 at 3:00 p.m., that they had ongoing discussions with the family about their concerns for the safety of Resident #43 and their growing conviction that they could no longer ensure her safety as a resident of their facility. There was, however, no documentation to support that those exchanges occurred, and there was documentation that showed that both the Behavioral Health Unit at hospital and the family were clearly expecting the resident to be readmitted until the phone conversation of 07/11/11. The family was then required to make an unplanned admission to another nursing facility that provided the same level of care. - The record of Resident #43, whom the facility maintained was transferred / discharged due to safety reasons, did not reflect the process by which the facility concluded that transfer or discharge was necessary and did not contain evidence of accurate assessments and attempts through care planning to address resident's needs through multi-disciplinary interventions, accommodation of individual needs and attention to the resident's customary routines, and there was no documentation from the resident's physician that the resident was transferred / discharged for the sake of the resident's welfare and/or the resident's needs could not be met in the facility. .",2014-12-01
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
4021,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2017-03-09,205,D,1,0,U91Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to provide notification of bed hold policy at time of hospital transfer for two (2) of six (6) sampled residents. Resident identifier: #3 and #4. Facility census: 70. a) Resident #3 Review of the minimum data set (MDS) revealed Resident #3 was discharged out of the facility to the hospital on [DATE], and 02/04/17 with return to the facility anticipated for both discharges. No bed hold documentation was presented by the facility. b) Resident #4 Review of the MDS revealed Resident #4, was discharged out of the facility to the hospital on [DATE], 12/05/16 and 12/28/16, with return to the facility anticipated on all three discharges. No bed hold documentation was presented by the facility. On 03/08/17 at 11:34 a.m., the facility administrator stated the facility verbally notified Resident #3 and #4 and/or their medical power of attorney, but, at the time of discharge, did not completed the bed-hold documentation. The administrator went on to explain the facility recognized a failure to complete required bed-hold documentation and as of 01/01/17 put in place the requirement to complete documentation of the bed hold notice of policy & authorization form.",2020-03-01
4454,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2016-10-19,205,D,1,0,43HD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interviews, the facility did not provide a bed hold notice to the resident and/or family/responsible party for two (2) of two (2) residents reviewed for bed hold notification. Resident #40 was transferred to the hospital on [DATE], 09/23/16 and 10/13/16, after experiencing a change of condition. Resident #78 was transferred to the hospital on [DATE], after experiencing a change in condition. There was no evidence the facility provided a bed hold notice to the residents that specified the duration of the bed-hold policy during which the resident was permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods. This deficient practice has the potential to affect more than an isolated number of residents. Resident identifiers: #40 and #78. Facility census: 83. Findings include: a) Resident #40 A review of Resident #40's medical record found on three (3) separate occasions (09/19/16, 09/23/16 and 10/13/16), the resident experienced a change in condition, which required the resident to be transferred to an acute care facility for treatment. On 10/18/16, the facility was asked for a copy of the bed hold sent with Resident #40, when hosptalized on [DATE], 09/23/16 and 10/13/16. At 4:15 p.m. On 10/18/16, a copy of the facility's bed hold policy was provided by the Assistant Director of Nursing (ADON). Review of the facility's bed hold policy found the following: --Any patient who leaves the (Facility name) for temporary hospitalization or therapies reasons may request that his/her bed be held open until his/her return. Bed holds will be granted in accordance with the policies outlined in a company approved resident admission agreement. --All residents, and their designated agents or legal representative, regardless of the patient's financial status, must be given notice of their bed hold options, rights and responsibilities at the time of hospitalization or therapeutic leave. b) Resident #78 A review of #78's medical record found the resident experienced a change in condition on 10/08/16 which required the resident to be transferred to an acute care facility for treatment. On 10/18/16 at 4:50 p.m., the assistant director of nursing (ADON) stated the facility was not providing residents being transferred and or discharge with the required bed hold notice. c) Interview An interview with the ADON and the Administrator, on 10/18/16 at 4:50 p.m., found the facility was not providing residents being transferred and or discharge with the required bed hold notice. They indicated they were working on creating a bed hold notice to be given to the resident.",2019-10-01
5218,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2016-02-12,205,D,1,0,3UXN11,"> Based on record review, staff interview, and review of the facility's admission bed-hold notice policy, the facility failed to ensure two (2) of five (5) residents reviewed for written bed-hold notice had been provided with the necessary bed hold information at the time of transfer to a acute care hospital. Resident Identifiers: #120 and #121. Facility census: 119. Findings include: a) Resident #120 A review of Resident #120's record on 02/09/16 at 11:00 a.m., found no evidence a written bed-hold notice was provided on 09/09/15, when the resident transferred to an acute-care facility. The Regional Resource Nurse-Interim Director of Nursing (RRN-IDON) #114 on 02/10/16 at 11:30 a.m., when asked for evidence the bed-hold notice was provided to Resident #120 and/or his representative, she confirmed Resident #120's record did not contain a bed-hold notice for 09/09/15. She stated, I cannot provide any evidence the bed-hold was given to the resident or the resident's representative at the time (resident's name) left the facility. b) Resident #121 A review of Resident #121's record on 02/09/16 at 1:50 p.m., found there was no evidence a written bed-hold notice was provided on 10/18/15, when the resident transferred to an acute-care facility. On 02/09/16 at 2:00 p.m., when asked for evidence a written bed-hold notice was provided, Medical Records/Admission Clerk (MR-AC) #20 stated, I have no record a written bed-hold notice was provided to (resident name) or to her representative on 10/18/15. In an interview on 02/09/15 at 3:18 p.m., Registered Nurse (RN) #11, who had sent Resident #121 out to the acute-care facility on 10/18/15, verified that a notice of transfer or discharge was discussed with the resident's representative, but she did not discuss a bed-hold policy notice. This RN said, We usually send a bed-hold policy with the resident to the acute care facility, but we do not discuss this form with the resident or the resident's representative. She revealed that she could not say whether she had sent a bed-hold notice with this resident on that date. The Administrator, on 10/09/16 at 4:15 p.m., confirmed that no written bed-hold notice form could be found for this resident. c) The facility's bed-hold policy included all residents were provided the bed-hold policy notice as part of the admission packet. The bed hold policy notice was to be given again at the time of actual discharge or transfer of a resident. d) As of the time of exit on 02/10/16, the facility had provided no evidence a bed-hold notice was provided for Residents #120 and #121.",2019-02-01
7029,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2013-08-14,205,E,0,1,66WU11,"Based on record review, policy review, and staff interview, the facility failed to provide written information regarding the facility's bed-hold policy for six (6) of six (6) sampled residents, at the time of their transfer from the facility. Resident identifiers: #25, #4, #78, #69, #28, and #34. Facility census 68. Findings include: a) Residents #25, #4, #78, #69, #28, and #34 At 10:00 a.m. on 08/07/13, the Administrator presented a requested copy of the information given to residents upon transfer or discharge from the facility. It did not include written information about bed hold and/or appeal rights. After a second request, the Administrator provided a copy of a Notification of Transfer / Discharge letter, which he stated was used by the facility which included the facility's Bed-hold policy. Review of the records of these six (6) recently transferred or discharged residents revealed no evidence they were provided written information specifying the duration of the facility's bed-hold policy. When this was pointed out to the Administrator, he asked this question be directed to the Social Worker (SW), Employee # 68, for an explanation of the use of the notification. When interviewed at 10:20 a.m. on 08/07/13, Employee #68 stated she had been in her position for a year and was not responsible for the bed hold notice. She referred the question to Employee #79, the Admissions Coordinator. At 10:40 a.m. on 08/07/13, Employee #79 stated she did not supply written information to residents when they were transferred or discharged . She stated she had been in her present position for four (4) years. Employee #79 stated she phoned the responsible party as soon as possible after the transfer. She said she gave them the status of the bed-hold days available at that time. Employee #79 said she was unsure how long this practice had been followed. Employee #79 presented phone records which indicated she had contacted family members and discussed, among other things, bed-hold information. In a follow-up interview at 10:45 a.m. on 08/13/13, she acknowledged the phone records were not a part of the medical record. She also stated the information was not exact. b) The facility's policy entitled: Discharge and Transfer included the following: All patients will receive a 'Notice of Transfer or Discharge or Discharge Transition Plan whenever a voluntary or involuntary transfer / discharge occurs. The timing of notifications will be based on state and federal regulations. Under the heading 5. For patients transferred to a hospital:was the following: 5.1 For unplanned, acute transfers, patients, family, and legal guardian will be notified verbally. 5.1.1 Written notice will follow verbal notification per state requirements. 5.1.2 A copy of the written notice of transfer will be placed in the patient's medical record.",2017-09-01
7166,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2014-07-29,205,B,1,0,EYNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure written information, regarding the facility's bed-hold policy was provided to the residents or a legal representative, at the time of transfer of the residents from the facility. This was found for seven (7) of eight (8) sample residents who had been transferred from the facility. Resident identifiers: #113, #10, #115, #79, #76, #114, and #95. Facility Census: 112. Findings include: a) Residents #113, #10, #115, #79, #76, #114, and #95 Review of the medical records for these residents, who had been transferred from the facility, revealed no evidence information regarding the facility's bed-hold policy was provided at the time of transfer to another facility. The following residents were transferred from the facility without evidence they were provided bed-hold information: 1. Resident #113 - transferred to the hospital on [DATE] 2. Resident #10 - transferred to the hospital on [DATE] 3. Resident #115 - transferred to the hospital on [DATE] 4. Resident #79 - transferred to the hospital on [DATE] 5. Resident #76 - transferred to the hospital on [DATE] 6. Resident #114 - transferred to the hospital on [DATE] 7. Resident #95 - transferred to the hospital on [DATE] An interview was conducted with the director of nursing (DON), Employee #97, on 07/29/2014 at 2:40 p.m. She stated the bed-hold policy and re-admission rights information were on the same form as the transfer/discharge information provided residents upon discharge. The DON stated nurses were instructed to provide this information when a resident was transferred or discharged . She said sometimes the fact the information was sent was recorded in the narrative notes, but sometimes the nurses did not record it. The DON said she was unable to provide evidence the information was provided these residents, or that it was actually put in the transfer packet, since the facility did not keep a copy. She stated in the past, before the computer system they use, a copy was kept with the records, but they did not do this anymore.",2017-07-01
8219,HILLTOP CENTER,515061,PO BOX 125,HILLTOP,WV,25855,2013-07-25,205,E,1,0,1LKT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide a discharge/transfer bed-hold policy notice that included the contact names and information should the resident wish to appeal the discharge/transfer from the facility. This was found for three (3) of three (3) residents reviewed for notice of the bed-hold policy at the time of transfer. This had the potential to affect all residents discharged /transferred from the facility. Resident identifiers: #116, #44, and #123. Facility census: 112. Findings include: a) Resident #116 Medical record review, on 07/23/13 at 11:00 a.m., revealed the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 06/27/13. The resident was readmitted to the facility on [DATE], then transferred again on 07/04/13. No evidence was found in the resident's medical records that the resident or family was given a transfer/discharge bed-hold policy at the time of either transfer from the facility. During an interview on 07/24/13 at 3:00 p.m., with Employee #123, the director of nursing (DON), she was unable to provide evidence the bed-hold policy, either verbal or written notice, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. b) Resident #44 Medical record review on 07/23/13 at 1:00 p.m., found the resident was originally admitted to the facility on [DATE]. The resident was transferred to an acute care facility on 07/18/13. No evidence was found in the resident's medical records that the resident/family was given a transfer/discharge bed-hold policy upon transfer from the facility. During an interview, on 07/24/13 at 3:00 p.m., with the DON, she was unable to provide evidence the bed-hold policy notice, either verbal or written, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. c) Resident #123 Review of the resident's medical record, on 07/24/13 at 2:00 p.m., revealed the resident was originally admitted to the facility on [DATE]. A physician's orders [REDACTED].Transfer to ER for evaluation d/t irregular heartbeat and HTN. No other documentation of resident's condition or transfer could be located. During an interview, on 07/24/13 at 3:00 p.m., the DON, she was unable to provide evidence notice the bed-hold policy, either verbal or written, was provided to the resident/family. In addition, a copy of the written notice of transfer was not included in the resident's medical record as required by facility policy. d) Review of the facility's policy on Discharge and Transfers found, 5.1. For unplanned, acute transfers, patients, family, and legal guardian will be notified verbally. 5.1.1 Written notice will follow verbal notification per state requirements. 5.1.2 A copy of the written notices of transfer will be placed in the patient's medical records.",2016-07-01
8918,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,205,C,0,1,NP7N11,"Based on review of the facility's notification of admission/bed hold policy (revision date 03/24/11) and staff interview, the facility failed to ensure residents who were transferred to a hospital, or went on therapeutic leave, received correct information regarding names and addresses of who to contact if they wanted to appeal a decision made by the facility regarding admission or bed hold. This issue had the potential to affect all facility residents. Facility census: 90. Findings include: a) The facility's admission information, reviewed on 12/06/11 at approximately 9:00 a.m., revealed issues with the contact agencies and advocates listed in the notification of admission/bed hold policy. The facility provided this policy to residents who were going on therapeutic leave, or a medical leave of absence, from the facility. In this notice, the facility listed an incorrect name and address for the regional long-term care ombudsman. In addition, the facility listed the incorrect address for the state survey agency, which is the agency with which residents can file confidential complaints. On 12/06/11 at approximately 10:00 a.m., the administrator (Employee #10) was informed of the incorrect information in the admission/bed hold policy.",2016-03-01
9462,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,205,E,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's discharge policy, and staff interview, the facility failed to ensure transferred / discharged residents / responsible parties received written notice of the bed hold policy at the time of transfer. This was true for three (3) of three (3) residents reviewed who were transferred / discharged to the hospital. Resident identifiers: # 129, # 131, and # 132. Facility census: 128. Findings include: a) Resident # 129 Medical record review found the resident was admitted to a local hospital on [DATE]. b) Resident # 131 Medical record review found the resident was admitted to a local hospital on [DATE]. c) Resident #132 Medical record review found the resident was admitted to the hospital on [DATE]. At 4:10 p.m. on 11/19/12 the director of nursing, Employee #4 and the administrator, Employee #103 provided a copy of the information to be sent with the resident upon transfer or discharge from the facility. Included in the packet was the facility's bed-hold policy. Neither employee was able to provide verification a copy of the bed-hold agreement had beengiven to the resident / responsible party at the time of transfer. Review of the facility's policy and procedure entitled, Discharge and Transfer found: . For patients transferred to a hospital: 5.1 For unplanned, acute transfers, patients, family and legal guardian will be notified verbally. 5.1.1 Written notice will follow verbal notification per state requirements. 5.1.2 A copy of the written notice of transfer will be placed in the patients medical record.",2015-11-01
9818,CAREHAVEN OF PLEASANTS,515191,PO BOX 625,BELMONT,WV,26134,2012-09-05,205,D,1,0,MNKD11,". Based upon record review and staff interview, the facility failed to provide written information regarding bed-hold policy in a timely manner (within 24 hours of transfer). This was found for one (1) of six (6) residents reviewed. Resident identifier: #69. Facility census: 67. Findings include: a) Resident #69 The medical record of Resident #69 was reviewed on 9/5/12 at 9:27 p.m. The nursing transfer/discharge summary dated 08/16/12 does not list any times of discharge. It did indicate that the medical power of attorney (MPOA) was notified on 8/16/12, but no time was given. There was a notice of transfer or discharge found that gave the date of verbal notification as 08/16/12. There was no evidence of any written notice of discharge or bed-hold and appeal rights notice in the record. A social services note dated 08/16/12 stated (typed as written): (Resident #69)'s behaviors were out of control today - threatening staff, etc. I called and made a referral to ____ Hospital and sent the requested information. I explained to them that I did not know if we could meet her needs here at this facility and had real concerns as we had to send her out more and more. I was concerned that her cycles were closer and closer. - she was either hyper and out of control or very depressed in bed refusing to get up. They called back and stated they had a room and could take her. I then called her sister/POA and explained the condition of (Resident #69). (MPOA), came to the facility and signed the admission papers to send (Resident #69) to _____ Hospital. There was no evidence the medical power of attorney had been provided with written information that specified the duration of the bed-hold policy under the State plan, during which the resident would be permitted to return and resume residence in the nursing facility, and the nursing facility's policies regarding bed-hold periods The admission contract, completed on 09/07/12, and signed by the MPOA on 09/21/07, stated that the MPOA wished to reserve the bed, and had been given a copy of the bed reservation policy. There was no evidence that she had amended that decision at any time. .",2015-09-01
9902,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2012-05-30,205,D,1,0,0XPG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide written information, to the resident or family member or legal representative, of the nursing facility's policies regarding bed-hold periods at the time of transfer. This was evident for three (3) of six (6) sampled residents. Resident identifiers: #129, #127, and #107. Facility census: 125. Findings include: a) Resident #129 Record review found Resident #129 was discharged from the facility to an acute care hospital on [DATE]. Further record review found no evidence of a bed hold notice given to this resident at the time of discharge, or within the first 24 hours. b) Resident #127 Record review found that Resident #127 was discharged from the facility to an acute care hospital on [DATE]. Record review found no evidence of a bed hold notice that was given to this resident at the time of discharge, or within the first 24 hours. c) Resident #107 Record review found that Resident #107 was discharged from the facility to an acute care hospital on [DATE]. Further record review found no evidence of a bed hold notice that was given to this resident at the time of discharge, or within the first 24 hours. d) During interview with the Director of Nursing on 05/30/12 at 2:45 p.m., she stated it was not necessary to give a bed hold notice when the census was less than 90% occupancy. She said the facility was licensed for 184 residents, but had only 124 beds occupied. .",2015-08-01
10335,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2011-03-18,205,D,1,1,I28Y12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to provide to the resident (and a family member or legal representative) a written notice which specified the duration of the facility's bed-hold policy when one (1) of sixteen (16) sample residents was transferred to the hospital due to urgent medical needs. Resident identifier: #102. Facility census: 116. Findings include: a) Resident #102 Medical record review, on 03/16/11, revealed this resident was admitted to the facility on [DATE]. On 03/14/11, the resident was transferred to the hospital due to an acute change in condition. The medical record contained no evidence the resident was provided a written notice which specified the duration of the facility's bed-hold policy. At 1:45 p.m. on 03/16/11, an interview was conducted with the director of nursing (DON - Employee #45). When asked for evidence the required information was provided to the resident and a family member or legal representative, the DON stated the information was included in a packet of information which the facility sent to the hospital with Emergency Medical Services (EMS) upon transfer. Further interview revealed the facility was unable to provide evidence this information was sent with the resident; and there was no evidence a family member or legal representative was also provided the written bed-hold policy when Resident #102 was transferred to the hospital. In addition, the facility had no means of assuring the resident and a family member or legal representative got this information, since it was included in a packet of medical information intended for the hospital. On 03/17/11 at 9:00 a.m., a discussion was held with the facility's administrator (ADM - Employee #10), regarding the provision of a written bed-hold policy to the resident and a family member or legal representative upon transfer to the hospital. At that time, the ADM confirmed the facility had not been providing the information to a family member or legal representative, and confirmed he was unable to provide evidence the information was sent with the resident at the time of transfer. The ADM also confirmed the information was not actually provided to the resident; therefore, there was no assurance the resident received the information, from the packet sent to the receiving hospital. .",2015-05-01
10451,HEARTLAND OF MARTINSBURG,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2011-11-09,205,D,1,0,XRXW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, policy review, and staff interview, the facility failed to provide written notification to the responsible party of the facility's bedhold policy and appeal rights of one (1) of thirty-five (35) sampled residents, who was transferred to an acute care facility. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 A review of the medical record revealed Resident #108 was a [AGE] year old female with [DIAGNOSES REDACTED]. She had resided at the facility since 12/17/08. The resident was transported to an acute care facility on 09/24/11, after complaining of severe back pain (""9"" on a scale of ""1 - 10""). She was admitted for medical treatment due to a urinary tract infection, [MEDICAL CONDITION], and back pain. The resident's daughter and medical power of attorney (MPOA) stated, in a signed letter, that she had not been given written notice of her bedhold options after the resident was admitted to the hospital and discharged from the facility, prior to being told that her mother (Resident #108) was not going to be readmitted following her acute care stay. The date of her notification was unclear, both by the complainant and the facility. A social service note stated that the daughter / MPOA of the resident was contacted via phone by the admissions director on 09/26/11 and offered the option to hold the bed for her mother, but no answer was received. There was a ""late entry"" dated 09/30/11, signed by the admissions person (Employee #78), stating that a phone message had been left for the MPOA telling her that the resident ""would be placed on North Station in a room cohorted with a pt (patient) who has similar infections"" and ""... of bed availability ..."". During an interview with the administrator at 11:00 a.m. on 11/08/11, she stated the MPOA had been informed by staff that, when Resident #108 was discharged from the hospital, she would have to be readmitted to a room on another hall, because she would have to be in isolation and that was the only available room with an appropriate resident for cohorting. A review of the medical record failed to reveal evidence of this conversation, or any evidence that a written notice had been issued to the MPOA communicating the facility's bed-hold policy and/or the appeal rights of the resident. When questioned about this in the interview on 11/08/11, the administrator stated the facility's practice was for the nurse transferring the resident to give the resident a ""Discharge Packet"" containing all necessary information and to document this in the nurse's notes. This practice was confirmed by the director of nurses at 2:30 p.m. on 11/08/11, although she acknowledged she could not locate any evidence that this had been done when Resident #108 was transferred. This was confirmed by the administrator and the corporate nurse consultant after the chart review had been completed at 4:00 p.m. on 11/08/11.",2015-03-01
11151,EMERITUS AT THE HERITAGE,5.1e+153,"RT. 4, BOX 17",BRIDGEPORT,WV,26330,2009-08-12,205,D,0,1,OCKG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide written information regarding the facility's bed-hold policy to one (1) of thirteen (13) sampled residents, who was transferred to a hospital, to include the duration of the bed-hold policy under the State plan during which the resident would be permitted to return and resume residence in the nursing facility. Resident identifier: #51. Facility census: 50. Findings include: a) Resident #50 A review of Resident #51's closed medical record revealed Resident #51 was transferred to the hospital on [DATE]. Evidence that a copy of the facility's bed hold policy was provided to Resident #51's responsible party was not found in the medical record. On 08/12/09 at 10:00 a.m., a request for the information was made to the social worker. At exit on the evening on 08/12/09, no additional information was provided other than the social worker stating the resident was not returning to the facility, so no bed hold information was given to the resident or legal representative. .",2014-08-01
11329,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-02-03,205,D,1,0,F0ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of closed medical records [REDACTED]'s bed-hold policy. Four (4) of four (4) residents whose closed records were reviewed did not have evidence of this notice being issued. Resident identifiers: #139, #140, #141, and #142. Facility census: 138. Findings include: a) Residents #139, #140, #141, and #142 Review of the closed medical records [REDACTED]. On the afternoon of 02/03/11, Employee #40, a registered nurse who worked on the second floor, was asked where the information regarding transfers and discharges would be located. He said there should be a copy in the residents' medical records. He provided copies of forms that had been completed at the time of transfer / discharge which contained the reason for transfer or discharge, the effective date of transfer or discharge, and the location to which the resident was being transferred or discharged . He said these forms were sent with the residents. Upon further description of the information being sought, he provided a copy of the facility's bed-hold policy. He stated there should be a copy in each resident's medical records. In late afternoon on 02/03/11, the assistant director of nursing was asked where evidence of the information regarding the bed-hold policy having been given to the resident / responsible party might be found. She said it should be in the residents' medical records. She looked in the four (4) records and was unable to locate the information for each resident's most recent transfer / discharge. Review of Resident #141's medical record found bed hold notices had been issued (and signed by a family member) on 02/02/10, 03/02/10, 03/05/10, 03/13/10, 05/07/10, and 11/20/10, but one was not found for his 01/04/11 discharge.",2014-06-01
7167,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2014-07-29,206,D,1,0,EYNI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, hospital record review, and staff interviews, the facility failed to permit one (1) of eight (8) sample residents re-admission after a hospitalization for an acute illness. Resident #113 was not afforded the right to be readmitted to the facility immediately upon the first availability of a bed in a semi-private room, if the resident required the services provided by the facility. There was no evidence the resident's needs could not be met at the facility. Resident identifier: #113. Facility census: 112. Findings include: a) Resident #113 Medical record review, on 07/28/14 at 2:00 p.m., indicated this resident was transferred to an acute care hospital, on 05/05/14 at 10:59 a.m. According to the nursing note, the resident was transferred to the hospital for an unplanned evaluation and treatment. The resident was receiving antibiotics for [MEDICAL CONDITION], his oxygen saturation was in the 70s, he had a temperature of 102 degrees Fahrenheit axillary, and he was very confused, and was unable to answer simple questions. The nursing note also indicated a copy of the advance directives were sent with the resident to the hospital. The next entry in the medical record, dated 05/25/14, said the resident's daughter was in the facility and picked up his belongings. The note said she stated the resident was released from the hospital last Friday and she found a job in another state. She reportedly stated her family and the resident were moving there. On 07/28/14 at 3:30 p.m., an interview was conducted with Resident #113's nursing home Social Worker, Employee #22. Upon inquiry, she said the resident went to the hospital and she did not know where he went or why he did not come back. The facility's admission director, Employee #81, was interviewed on 07/28/14 at 3:50 p.m. She stated, as far as she could remember, the resident exhausted his bed hold days and his bed was given up. She stated the resident tried to come back, but the facility did not have a bed at that time. Employee #81 provided a census report for the month of May 2013. The facility was not at maximum capacity on the dates the resident was hospitalized . There was no evidence the facility did not have available beds for the resident. Employee #81 stated the resident called and talked to the administrator about coming back, but she did not talk to him about it. The administrator was interviewed on 07/28/14 at 4:30 p.m. He stated he received information from the hospital the resident was admitted with a drug overdose. He said the facility had suspicions and had talked about not taking him back. The resident's daughter called and talked to him and he told her he could not talk to her about this because the resident had capacity. The resident then called him, and told him the doctor at the hospital said he did not overdose, but instead, his body was not metabolizing medications. The administrator stated he told the resident he could not come back to the nursing home, and if his medical record was not correct he (the resident) needed to have the physician correct it. During the interview, the administrator verified the reason the resident was not allowed to come back to the facility was because he had taken a drug overdose. Resident #113's hospital record was obtained on 07/29/2014 at 10:00 a.m. It indicated the hospital discharge planner had been in contact with the nursing home on different occasions to discuss the resident's discharge plans. The hospital records contained the following entries about the discharge: -- 05/15/2014 The discharge planning note included: The patient would not be able to return to the nursing home as the police had been called multiple times due to alleged drug trafficking. The discharge planner suggested talking to the patient about going to another center out of the area so his visitors would not be around to engage in the same activities. The discharge planner stated she met with the patient to see if he had thought of any other options for discharge. According to the note, he said he would go back to that facility for a couple months until he could move with his daughter. He was informed at that time he would not be able to return to that facility . -- 05/16/14 This note, regarding hospital discharge planning, stated there was alleged drug trafficking between the patient and his visitors, and the facility would not be able to accept the resident back because of this. -- 05/19/14 This discharge note stated the SNF (skilled nursing facility) will not take him back due to narcotic abuse and sales. -- 05/23/14 The physician's note, written by the hospital physician, stated: He is unable to get back to the nursing facility due to being caught selling narcotics. The nursing home refused to take him back. Review of Resident #113's nursing home medical record, for the last six (6) months, found no evidence to support the allegation the resident was involved in any illegal drug activity during his stay at the facility. There also was no evidence to support the statement that police had been involved with this resident. The medical record, at the nursing home, did not reflect any reason the resident should not have been permitted to return to the facility. In addition, it contained nothing about the facility's decision to not readmit the resident.",2017-07-01
9463,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2012-11-20,206,D,1,0,UMPL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's bed hold policy, and staff interview, the facility failed to allow a resident, who wanted to return to the facility, re-admission after hospitalization when the facility had empty beds available. This was true for one (1) of three (3) closed records reviewed. Resident identifier: # 129. Facility census: 128. Findings include: a) Resident #129 Resident #129 was a thirty-seven (37) year individual admitted to the facility on [DATE]. admitting [DIAGNOSES REDACTED]. On 06/28/12, the facility physician determined the resident had capacity to make medical decisions. The social service assessment, completed on 06/28/12, found the resident achieved a score of fifteen (15) on the brief interview for mental status (BIMS) which indicated the resident was cognitively intact. Medical record review found the facility transferred the resident to a local hospital on [DATE] for evaluation of [MEDICAL CONDITION]. The discharge minimum data set (MDS) assessment, with an assessment reference date (ARD) of 07/24/12, found the resident's return to the facility was anticipated; however, the resident did not return to the facility. An interview was conducted with the social worker, Employee # 70, and the administrator on 11/19/12 at 3:00 p.m. The administrator stated the resident's behavior made him a danger to himself and the facility did not want to take the resident back from the hospital. The administrator explained the staff and the nurse practitioner had felt the family members were bringing in drugs to the resident, since pills were found on the resident's floor on two (2) separate occasions. She was concerned the resident would overdose on medication being brought into the facility by family members. Further review of the medical record found a nurse practitioner's notes on 07/23/12, NP (nurse practitioner) found a light green, rectangle shaped pill in the floor beside resident's bed. The pill is a [MEDICATION NAME], but we do not have any like it here at (name of nursing home). On 07/20/12, a nurse found a pill in the resident's cigarette pack, a green long bar looking pill. On 07/20/12, the physician ordered a toxicology screen panel due to discovering medication in the resident's possession. The toxicology screen was positive for benzodiazepines and opiates. Review of the Medication Administration Record [REDACTED]. During an interview with the director of nursing (DON) and the administrator, on 11/19/12 at 3:35 p.m., the DON verified the toxicology report did not prove the resident was taking extra medication and she stated, We would need a level for that and we do not have one. Review of the admission summary of the admitting hospital on [DATE] found the resident was admitted to the hospital for right lobe pneumonia, acute [MEDICAL CONDITION], urinary tract infection, and metabolic [MEDICAL CONDITION]. Further review of the discharge summary from the admitting hospital, dated 08/01/12 found, . Arrangements have been made for him to go to a (name of facility and location) as the patient was not able to return to (name of discharging nursing home) with questionable concern that his family was bringing in narcotics into the patient, potentially compromising his health as well as his care at the facility. He is aware and does know why the move has to take place and though he is not happy, but does understand why he has to be transferred to this facility outside the area with strict visitation rights. The social services director, Employee #70 was interviewed on 11/20/12 at 1:30 p.m. The social worker was unable to provide any documentation of discussions with the resident, who had capacity, regarding the allegations of family members bringing in medications to the resident at the facility. She verified she did not have any documentation about the resident during his stay at the facility. Review of the facility's bed hold policy found: In the event that the resident is absent from the facility for more than twenty-four (24) hours, bed reservation privileges are available, if the facility's occupancy rate is greater than 95% and there is a waiting list for admission,. The maximum reimbursement by Medicaid will be twelve (12) days annually for medical leave and six (6) days for therapeutic leave. Placement is to be in the same bed and living space occupied by the resident prior to the hospital or therapeutic leave unless the resident's physical condition upon returning to the facility prohibits access to the bed previously occupied. If the bed is not held the resident will be placed on the facility referral list and readmitted to the facility immediately upon the first availability of a bed in a semi-private room providing the resident requires the services provided by the facility. Review of the daily census report found the facility had five (5) empty beds on the date of the resident's discharge from the hospital. The administrator was interviewed again on 11/19/12 at 4:10 p.m. regarding the facility's refusal to allow the resident to return to the facility. She stated the resident had a Medicaid bed hold available, but the facility chose not to use the bed hold. She also verified the facility did have a bed available for the resident, but he was not readmitted as the facility felt the resident was a danger to himself.",2015-11-01
8636,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2013-04-10,207,D,1,0,CZR411,"Based on medical record review, staff interview, and family interview, the facility failed to allow a resident to remain in the facility regardless of her source of payment. When the skilled services ended for Resident #185, the facility instructed the family that they would have to take her somewhere else or come and get her because they did not have any long term care beds available at the facility. This practice of discharging residents after they were no longer eligible for Medicare benefits, affected one (1) of five (5) sampled closed records reviewed for discharged residents. Resident identifier: #185. Facility Census: 181. Findings include: a) Resident # 185 A social service note, dated 01/02/13, reflected the Social Worker (SW) met with Resident #185's Power of Attorney (POA), and the family requested the facility cancel the transfer plans to another nursing home. The note said the SW explained the transfer was already in progress and there were no long term beds available at this facility and that the stay there was a temporary circumstance. The note indicated this facility had no long term care Medicaid beds at that point. It also noted the resident was a skilled resident with days left for available service. The other home then called and refused to take the resident. A note, dated 01/29/12, indicated yet another nursing home was looking to take the resident and the facility informed the family the resident would either be discharged to home with the family or transferred to the other facility on Friday, 02/01/13. According to the notes, Resident #185 was transferred to another facility on 02/01/13. 04/10/13 at 10:45 a.m. Employee #134 (Social Worker) was interviewed about the Social Service notes. She stated she was not aware all beds could be long term care when she told the resident's family the resident would be discharged after her skilled days were up. A family interview was conducted on 04/15/12 at 7:00 p.m. This family member confirmed the facility told them they had to take the resident out of the facility after her Medicare services ended. It was confirmed the family would have left the resident in this facility because it was closer to her sons and they could visit.",2016-04-01
8775,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2011-07-27,208,C,0,1,WXEM11,"Based on review of the facility's admission agreement, policy review, and staff interview, the facility failed to ensure persons having legal access to a resident's income or resources were not required to incur personal financial liability when providing payment from a resident's income or resources to the facility for the cost of all or part of the resident's care. This had the potential to affect all residents. Facility census: 134. Findings include: a) Review of the facility's admission agreement found an addendum to the financial agreement (dated 07/03) which stated: The patient or responsible party agrees to pay when billed and the nursing home will accept arrangement in full consideration for care and services rendered as follows: 1. Room, board, laundered linens and bedding, nursing and personal care $_____/a day. 2. When the patient is permanently discharged , the unused portion of this money will be refunded. 3. The physician will bill for any services rendered by the physician to the patient. 4. Medication ordered by the physician will be billed to the patient by the pharmacy. 5. The services for physical therapy, occupational therapy, speech therapy, oxygen, special dressing, etc. will be billed in addition to the above. 6. In the event the patient is placed on the West Virginia Medicaid Program, they are not responsible for any of the above financial agreements, with the exception of the Hold Bed Fee, if the bed is to be held. The patient or family is responsible for the fee. Either party may terminate or change this agreement on a 30 day written notice. Otherwise it will remain in effect until a different agreement is recorded. However this does not mean that the patient will be forced to remain in the nursing home against his/her will for any length of time. -- The agreement did not state that the facility must not require a third party guarantee of payment to the facility as a condition of admission or expedited admission, or continued stay in the facility, or that the facility may require an individual who has legal access to a resident's income or resources available to pay for facility care to sign a contract, without incurring personal financial liability, to provide facility payment from the resident's income or resources. -- When reviewing the admission policy with the administrator on 07/26/11 at 02:30 p.m., the administrator said the facility did not expect someone other than the resident to be personally at risk for payment to the facility, except for bed hold expenses. She agreed the admission agreement did not specify that the resident's responsible party would not be held personally liable for the resident's expenses.",2016-03-01
4461,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2016-05-12,221,D,0,1,UTVK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of the facility's restraint policy, the facility failed to ensure a resident's right to be free from physical restraints not required to treat the resident's medical symptoms. Resident #108 and Resident #30 wore lap belts while in their wheeled chairs. There was no physician's order for use of a lap belt for Resident #108. Neither resident had an assessment to determine the least restrictive restraint and/or alternatives to physical restraints. There was no evidence the resident and/or responsible party were informed of the risks and benefits of physical restraint use. This affected two (2) of twenty-three (23) sampled residents. Resident identifiers: #108 and #30. Facility census: 108. Findings include: a) Resident #108 On 05/02/16, observations of Resident #108 for over an hour before, during, and after the lunch meal found she sat in the dining room slightly reclined in a specialty chair. She wore a fastened lap belt across her abdomen the entire time she sat in the dining room, including time spent while a nursing student sat beside her and spoon fed her meal to her. Review of the resident's medical record on 05/09/16 at 11:00 a.m., found the absence of physician's orders for the use of a lap belt. The medical record contained no restraint assessment for use of a lap belt, and no informed consent from the responsible party for the risks and benefits of its use. Additionally, there were no staff directives of when and how often to use the lap belt, or when and how often to release the lap belt used on this resident. The resident's care plan contained no mention of lap belt use. Further review of physician's orders found an order for [REDACTED]. Review of the most recent quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/07/16, identified that a trunk restraint was not used when up in the chair. It also assessed that the chair did not prevent rising. Her brief interview for mental status (BIMS) score indicated moderate impairment of cognitive skills. The comprehensive admission MDS, with an ARD 11/07/15, assessed the same. She lacked capacity for medical decision-making. Observation of the lunch meal on 05/09/16, found this resident received her lunch tray at 12:34 p.m. Her lap belt was in place over her abdomen and fastened. Nurse Aide (NA) #81 sat in a chair beside the resident as she spoon fed her one on one. During an interview with NA #81 on 05/09/16 at 12:45 p.m., she said this resident always wore a lap belt while sitting in a chair. She said this was nothing new, as the resident had always used a lap belt when up in a chair. She said staff did not remove the lap belt during a meal or activity while directly supervised. The resident was unable to remove the lap belt when asked if she could remove it. Observation found the resident had contractures of the elbows and wrists. During an interview with the director of nursing (DON) on 05/09/16 at 1:10 p.m., the observations of the fastened lap belt during the meal service that day and last week, and staff reports that she used the seat belt every day when up in the chair were discussed. The DON was informed the resident's medical record contained no physician's order for the lap belt; contained no restraint assessments to ascertain whether the resident required a lap belt some, all, or none of the time; and contained no informed consent by the responsible party, with risks and benefits of lap belt use. It was also brought to the DON's attention that staff applied the lap belt, but had no directives of when to apply the lap belt, or when and how often to release the lap belt that they were using. Also, there was no Kiosk directive for the aides to apply a lap belt. The DON verbalized understanding. She said the Kiosk interventions for the nurse aides' use pulled directly from the care plan for the aide section. Because there was no care plan for the lap belt, the aides would therefore not have mention of the lap belt on their Kiosk. She acknowledged there was no physician's order for the lap belt. She said the lap belt kept the resident positioned in the chair and said the resident's mother told them the resident needed and appreciated a lap belt for safety reasons. The DON provided no further evidence of restraint use assessments, or physician's orders for lap belt use, prior to exit on 05/12/16. b) Resident #30 Observation of the resident during Stage 1 of the Quality Indicator Survey, on 05/02/16 at 11:45 a.m., found the resident was seated in a wheelchair with a seatbelt. The seatbelt continued to be in use during daily observations, including, but not limited to: - 05/03/16 at 11:00 a.m. and 2:55 p.m. - 05/04/16 at 11:30 a.m. - 05/05/16 at 12:15 p.m. - On 05/09/16 the resident was observed with the seatbelt in place continuously from 10:08 a.m. to 12:55 p.m. During these observations, there were no attempts made by the resident to get out of her chair. Medical record review, on 05/09/16 at 9:05 a.m., revealed a physician's order for a seat belt dated 03/09/16. The order stated Seat Belt to w/c for fall prevention, release q2hrs for 30min, and offer to toilet, assist to activities, assist with ROM/exercises. (Seat Belt to wheelchair for fall prevention, release every two hours for 30 minutes, and offer to toilet, assist to activities, assist with range of motion/exercises). On 05/09/16 at 9:15 a.m., review of the resident's admission Annual Minimum Data Set (MDS) with an assessment reference date (ARD) of 03/15/16, found the MDS did not reflect the resident had a physical restraint. The care plan in use at the time of the survey, dated 03/09/16, reviewed on 05/09/16 at 9:28 a.m., did not address the seat belt as a restraint. The care plan included the seat belt as a fall prevention intervention. Further review of the medical record on 05/09/16 at 9:45 a.m. revealed no assessments concerning the seat belt. During an interview on 05/09/16 at 10:00 a.m.,MDS Coordinator-Registered Nurse (MDS RN) #14 stated she did not include the seat belt on the MDS because the Director of Nursing (DON) and Administrator told her it was a positioning device only. The MDS RN stated she was aware the resident had a seat belt when completing the MDS, but had not looked at or completed any assessments concerning the seat belt. The MDS RN stated the seat belt should have been included on the admission MDS considering there was no documentation stating it was not a restraint. An interview with the Director of Nursing (DON) on 05/09/16 at 2:53 p.m. revealed there were no assessments completed concerning the seat belt prior to placing it on the resident. The DON stated the resident's responsible party wanted the seat belt applied so the facility cooperated. The DON stated there should have been an assessment completed before using the seat belt. The DON was unable to provide any documentation, other than a physician's order, for the seat belt. In an interview on 05/10/16 at 8:35 a.m., the Administrator stated the resident's seat belt was used for positioning, so an assessment was not warranted. The Administrator was unable to provide any documentation, other than an order and the care plan, concerning the seat belt. The Administrator stated if the family wanted a seat belt, then the facility would oblige. The Administrator stated she was unaware of the facility's policy requirements concerning restraints. c) Review of the facility's policy on restraints titled Restraints Standard, with a revision date of (MONTH) 2013, reviewed on 05/10/16 at 9:00 a.m., found the policy defined a restraint 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. The policy's process for physical restraint usage includes documenting other non-restrictive alternatives that have been attempted and documentation that they were unsuccessful. The policy includes a Pre-Restraint Assessment will be completed to determine the least restrictive measures. The results of the Pre-Physical Restraint Assessment in (initials of software) shall be conveyed to the physician.",2019-10-01
5680,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2014-12-03,221,D,0,1,GPE511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to ensure one (1) of three (3) Stage 2 residents reviewed for restraints was restrained only as required to treat medical symptoms. The facility used side rails for the resident; however, the resident was not assessed for their use. Resident identifier: #69. Facility census: 93. Findings include: a) Resident #69 Resident #69 was re-admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS), dated [DATE], documented Resident #69 was able to independently move himself in the bed from side to side, but required the assistance of one (1) staff to safely transfer from the bed. This MDS was silent to the resident's use of any type of physical restraint during the assessment period. Review of the current Activities of Daily Living (ADL) care plan, dated 02/22/12, documented Resident #69 had physical and cognitive impairments and required the assistance of staff to perform his ADLs. An intervention was documented for the resident to have bilateral half bed rails on his bed to aid him with independent bed mobility and for safety. The clinical record was silent to an assessment for the use of the bed rails on his bed. Review of the current physician orders, completed on 12/02/14, also revealed an order for [REDACTED]. Observation on 12/02/12 at 9:30 a.m. revealed Resident #69 was in bed with bilateral half rails in the up position on his bed with blue pads around the rails. There was an alarming device noted on the bed to alert staff of his unassisted attempts to exit the bed. On 12/02/14 at 4:15 p.m., while at the nurses station, this surveyor heard Health Service Worker (HSW) #14 state she was told to remove the bed rails on Resident #69's bed, but she was not sure why they were being removed as she stated the resident was able to use the rails to turn himself. During an interview with HSW #14 at this time, she stated Resident #69 is able to get out of the bed on his own but not safely. She also stated he has recently had a decline in health and has not attempted unassisted ambulation for about a week. HSW #14 stated he was able to scoot down in the bed far enough to go around the padded bed rails to get himself into his wheelchair, but due to his current health condition he did not currently attempt to do this. Review of the clinical record revealed it was silent for an assessment documenting the medical symptoms that warranted the use of the physical restraint of bed rails for Resident #69. During an interview with the Second Floor Unit Manager #156, on 12/03/14 at 8:42 a.m., this surveyor requested to see the completed assessment for the use of the bed rails for Resident #69. She stated she thought there was a bed rail assessment for the use of the rails on Resident #69's chart, but she was not sure and stated she would have to look for it. Unit Manager #156 stated she felt all residents on the unit would have an assessment for the use of their bed rails to determine if the rails were safe and if the device was a physical restraint. Further interview with Unit Manager #156, on 12/03/14 at 10:05 a.m., verified they had not completed an assessment for the use of the restraining device of bed rails for Resident #69. During an interview, on 12/03/14 at 2:00 p.m., with the Administrator #10, Director of Nursing (DON) #124, and the Second Floor Unit Manager #156, they verified there was no assessment completed for the bed rails used on Resident #69's bed, and indicated the rails should have been assessed as a potential restraint.",2018-09-01
6159,MONTGOMERY GENERAL ELDERLY CARE,515152,501 ADAMS STREET,MONTGOMERY,WV,25136,2014-08-26,221,D,0,1,6MJ711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure two (2) of two (2) residents reviewed for physical restraints were free from restraints used for staff convenience and not for assessed medical needs. Resident #17 and #56 had EZ release seat belts on while up in their wheelchairs. The facility had not considered these belts as restraints and consequently they were used without assessments for their need. The facility had not completed assessments of the least restrictive type of restraint if a restraint was needed. The facility also did not have plans to systematically and gradually reduce the use of the restraints. Resident identifiers: #17 and #56. Facility census: 55. Findings Include: a) Resident #17 An observation on 08/25/14 at 1:45 p.m. revealed Resident #17 was sitting in her wheelchair in a television lounge. Resident #17 had in place an EZ release seat belt which was attached to her wheelchair in the back and fastened around the resident in the front. The Director of Nursing (DON) asked Resident #17 to remove her seat belt at which time the resident simply laughed at the DON and made no attempt to remove the seat belt which was fastened around her waist. A review of Resident #17's medical record at 3:30 p.m. on 08/25/14 revealed a physician's orders [REDACTED]. Further review of the medical record, on 08/25/14, found the resident's last quarterly minimum data set (MDS) had an assessment reference date (ARD) of 06/13/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. The care plan in use at the time of the survey was reviewed on 08/25/14 at 3:45 p.m. It did not address the seat belt as a restraint. The DON was interviewed at 4:30 p.m. on 08/25/14. She was unable to provide evidence the facility assessed the resident for the medical necessity of the EZ release belt. She stated they had never thought of it as being a restraint, therefore they never assessed it as such. She further stated it was not coded on the MDS as a restraint or addressed on the care plan as a restraint because they had never thought of it as one. She said Resident #17 had dementia and that was why the resident could not remove the seat belt at will. b) Resident #56 An observation on 08/25/14 at 2:00 p.m. revealed Resident #56 was sitting in his wheelchair outside visiting with his family. Resident #56 had in place an EZ release seat belt which was attached to his wheelchair in the back and fastened around the resident in the front. The DON asked Resident #56 to remove his seat belt at which time the resident fumbled with the latch, but was never able to release the seat belt. The DON stated he was just readmitted from the hospital and he must have forgotten how to take it off while he was hospitalized . A review of Resident #56's medical record at 2:30 p.m. on 08/25/14 revealed a physician's orders [REDACTED]. Further review of the medical record, on 08/25/14, found the resident's discharge with return anticipated MDS had an assessment reference date (ARD) of 07/30/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. The care plan in use at the time of the survey was reviewed on 08/25/14 at 3:00 p.m. It did not address the seat belt as a restraint. The DON was interviewed at 3:50 p.m. on 08/25/14. She was unable to provide evidence the facility assessed the resident for the medical necessity of the EZ belt release. She stated they had never thought of it as being a restraint, therefore they never assessed it as such. She further stated it was not coded on the MDS as a restraint or addressed on the care plan as a restraint because they had never thought of it as one. She said Resident #56 had dementia and that was why he could not remove the seat belt at will. She stated sometimes he might remember how to take it off, but not always.",2018-05-01
6378,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,221,E,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed for physical restraints was free from a restraint used for staff convenience not for an assessed medical need. A pelvic restraint was used without an assessment or a plan to systematically and gradually reduce the use of the restraint. Resident identifier: #64. Facility census: 77. Findings include: a) Resident #64 Observation of the resident during Stage 1 of the Quality Indicator Survey, on 06/17/14 at 2:22 p.m., found the resident was seated in a reclining Broda chair (a tilting and reclining positioning chair) with a pelvic sling applied. The sling was tied behind and under the seat of the Broda chair. The pelvic restraint was in use during numerous daily observations, including but not limited to: -- 06/16/14 at 12:15 p.m. -- 06/17/14 at 2:22 p.m. -- 06/18/14 at 12:30 p.m. -- 06/19/14 at 9:00 a.m. -- 06/20/14 at 10:17 a.m. -- 06/23/14 at 1:26 p.m. -- On 06/24/14 the resident was observed with the sling in place continuously from 8:15 a.m. until 9:51 a.m. -- On 06/25/14 the resident was observed from 9:00 a.m. to 9:33 a.m., and at 5:13 p.m. with the sling in place. -- On 06/26/14 at 11:46 a.m. Medical record review, on 06/24/14 at 9:45 a.m., found a physician's orders [REDACTED]. Further review of the medical record, on 06/24/14, found the resident's last annual minimum data set (MDS) had an assessment reference date (ARD) of 03/06/14. Section P of the MDS was not coded to reflect the resident had a physical restraint. The care plan in use at the time of the survey was reviewed on 06/24/14 at 10:30 a.m. It did not address the pelvic sling as a restraint. On 06/24/14 at 1:06 p.m., Employee #2, the registered nurse MDS coordinator, stated the physician told her the pelvic sling was not a restraint, it was a positioning device, so she did not code a restraint on the MDS. Employee #2 verified the care plan did not address the use of a restraint. She stated the resident was unable to remove the pelvic sling and/or reposition herself. The director of nursing was interviewed at 12:37 p.m. on 06/25/14. She was unable to provide evidence the facility assessed the resident for the medical necessity of a pelvic restraint.",2018-04-01
6462,HOLBROOK NURSING HOME,515076,183 HOLBROOK ROAD,BUCKHANNON,WV,26201,2014-05-15,221,D,0,1,8VLA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, record review, and observation, the facility failed to ensure one (1) of three (3) residents reviewed for physical restraints was free from a physical restraint. The facility used a restraint for a resident in the absence of a medical condition requiring the use of the restraint. Resident identifier: #88. Facility census: 90. Resident identifier: #88. Findings include: a) Resident #88 Resident #88 came to the facility on [DATE] with a [DIAGNOSES REDACTED]. A review of the admission Minimum Data Set ((MDS) dated [DATE] found Resident #88 was cognitively impaired and required extensive assist of two (2) staff members for bed mobility and transfers. This MDS also documented Resident #88 had no current physical restraints in place. There was a physician's orders [REDACTED].#88's bed to have bilateral half bed rails on the bed and the rails were to be located in the middle of the bed. Further review of the clinical record revealed the facility completed a bed rail assessment on 04/29/14. This assessment documented the resident needed the bed rails for bed mobility (assist with turning from side to side). This assessment revealed the resident should have half bed rails on her bed, but it failed to document if the rails should be full rails or half rails. The bed rail assessment documented the facility explained to the resident/family the risks and benefits of bed rail use including the risk of significant injury if the resident would fall. Review of the current cognition care plan, dated 04/30/14, found Resident #88 had cognitive impairment related to her [DIAGNOSES REDACTED].#88 was at risk for serious injury for falls, due to dementia, anxiety, [MEDICAL CONDITION], end of life requiring hospice intervention, use of as needed antianxiety and antipsychotic medications, and a history of falls. The fall care plan interventions included: Staff should promote the proper use of her bed rails, keep her bed at the lowest level at night, and assist the resident with all transfers. A review of the activities of daily living care plan revealed Resident #88 required the extensive assistance of two (2) staff members for bed mobility. The care plan also stated staff should remind the resident to grasp the side rail on her bed when turning. A review of the nurses' progress notes revealed on 04/15/14 at 7:56 a.m., Resident #88 sat at the foot of her bed and yelled, I want to get up! The progress notes revealed the resident was repositioned in bed and continued to yell out. She also put her feet on the side rails. Further review of the nurses' progress notes revealed on 05/09/14 at 10:24 a.m., Resident #88 attempted to get out of bed unassisted. On 05/12/15 at 11:21 a.m., 05/14/14 at 2:10 p.m., and 05/15/14 at 9:14 a.m., Resident #88 was observed in her bed with bilateral 1/2 bed rails in the up position in the middle of her bed. An interview with Employee #61 (nurse aide), on 5/15/14 at 9:11 a.m., revealed the resident was to have the rails up on her bed when she was in bed. She stated Resident #88 was able at times to use the rails to adjust herself in bed, but stated the resident would also attempt to use the rails to sit herself on the side of the bed even though she should not get up by herself. She stated the resident often became confused and would attempt to get out of bed on her own with the rails in the up position. Interview with Resident #88's husband, on 5/15/14 at 11:05 a.m., revealed Resident #88 became confused and thought she could do more than she could actually do. He stated she experienced falls at home prior to coming to the facility and would attempt to get up without assistance. There was no evidence the facility used the rails on Resident #88's bed to treat a medical symptom. There was also no evidence the facility attempted to use the least restrictive device or to reassess the use of the bilateral bed bed rails after Resident #88 made two attempts to exit the bed around the rails.",2018-03-01
6676,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-10-01,221,D,0,1,KBHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews, record reviews, and observations, the facility failed to ensure two (2) of the nine (9) residents (Residents #89 and #35) investigated in Stage 2 for physical restraints were free from physical restraints. Both residents were in chairs that prevented them from getting up independently. Additionally, Resident #89 had straps around his legs and pelvic area. There was no evidence the physical restraints were required to treat the residents' medical symptoms. The Stage 2 sample was 36. Resident identifiers: #89 and #35 Facility census: 87. Findings include: a. Resident #89 Review of the clinical record revealed Resident #89 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), dated [DATE], revealed Resident #89 was moderately cognitively impaired, unable to make himself understood and was rarely able to understand others. Resident #89 was documented as requiring the extensive assistance of two (2) staff for bed mobility and transfers, and walking did not occur during this assessment period. The MDS also documented the resident had experienced a fall with injury and a limb restraint was being utilized daily. Review of the current fall care plan dated 07/24/14 documented Resident #89 was at risk for falls and required the use of a Broda chair (a restraining device) that was to be reclined with the resident ' s feet in the up position when he was seated in the chair. The fall care plan also revealed documentation that Resident #89 was to have pelvic straps around both of his legs and his pelvic area when he was up in the Broda chair with an alarming device attached to the chair that would alert staff if the resident was to make any unassisted attempts to ambulate. There was no evidence of a care plan for physical restraints. Review of the physician's orders [REDACTED]. The clinical record for Resident #89 did not contain any type of assessment for the use of the Broda chair to ensure the device was the being utilized to treat the resident's medical symptoms, was the least restrictive device, or if the device was safe for Resident #89 to be placed. The nursing notes revealed an adverse incident occurred on 08/08/14 when Resident #89 was seated in the Broda chair and he tipped the chair over backwards. Review of the nursing notes revealed Resident #89 was placed in the Broda chair daily since it was ordered on [DATE]. Review of the nursing notes on 07/22/14 at 6:07 a.m. revealed Resident #89 was very agitated and aggressive and would not sit still in his Broda chair (a chair with straps around his legs to prevent him from rising). On 07/30/14 at 3:16 a.m., the nurse notes documented Resident #89 was observed to be rising himself up off the back of his Broda chair. On 08/10/14 at 7:30 p.m., Resident #89 was noted to be anxious and attempting to stand up in the Broda chair and was being uncooperative with his care. On 08/20/14 the nursing notes documented Resident #89 was again very anxious, agitated, combative with care and attempting to get out of his Broda chair. Observation on 09/23/14 at 2:20 p.m. revealed Resident #89 was seated in the hallway in the Broda chair with pelvic and legs straps in place. The chair was noted to be in a reclined position. Observation on 09/23/14 at 2:30 p.m. revealed Resident #89 was in the Broda chair in hall and he was in a reclined position with pelvic and legs straps in place. Observation on 09/23/14 at 3:40 p.m. revealed Resident #89 was in the Broda chair in a reclined position with the pelvic and legs straps in place. Interview with Health Service Worker (HSW) #3 on 09/23/14 at 4 p.m. revealed she worked on Unit A-1. She stated Resident #89 was very agitated upon admission to the facility. HSW #3 stated he was placed in the Broda chair with the straps when he was admitted and he would often try and get out of the Broda chair by pulling his legs up through the leg straps. She stated the Broda chair was the chair the resident sat in daily. HSW #3 stated at one point he was able to get out of the chair with the straps in place and they found him walking in the hall unassisted. She said they tried to watch the resident while he was in the Broda chair, but there was no way they could have their eyes on him all the time. HSW #3 said they have residents on the unit that require three (3) staff to provide their care due aggressive behaviors, so they would all be in a room and no one would be able to watch Resident #89 at all times. Interview with Physical Therapy (PT) Employee #98 on 09/24/14 at 9:30 a.m. revealed Resident #89 was placed in the reclining Broda chair on 07/17/14, one day after he was admitted to the facility. PT #98 stated Resident #89 had not been assessed by the physical therapy department to determine if the resident was safe to be restrained in the Broda chair device. She stated he was not assessed for safety for the use of the Broda chair until after he had fallen backwards while sitting in Broda chair in a reclined position. PT #98 stated he fell out of the chair on 08/08/14, but he was not assessed for the use of the Broda chair by physical therapy until 08/17/14, when the licensed therapists returned to work. She stated the Broda chair was deemed to be an appropriate positioning device at that time. Review of the physical therapy notes revealed Resident #89 should not be fully reclined in the Broda chair due to increased instability of the chair in that position which placed the resident at a higher risk for falls. During this interview, PT #98 was asked if they were aware of Resident #89's continued attempts to stand, pull his legs through the straps, and try to exit the Broda chair. She stated they were not aware and stated if they were aware of these actions by the resident, they would not have deemed Resident #89 to be safe to be placed in the Broda chair. On 09/24/14 at 2:55 p.m., an interview with the Assistant Director of Nursing (ADON) #30 revealed the facility currently did not conduct any type of restraint assessments prior to using a restraining device for a resident. She stated the administrator had recently obtained several different assessment forms. ADON #30 stated these forms were a Pre-Restraint Assessment Tool and the other was a Restraint Checklist Tool. These tools were to be used to assess the resident prior to utilizing a physically restraining device. She verified Resident #89 had not been assessed prior to placing him in the Broda chair and placing straps around his pelvis and legs. Interview with Licensed Practical Nurse (LPN) #171 on the Unit A-1 on 09/24/14 at 3:15 p.m. revealed she was not aware of any type of assessment that was required prior to utilizing a restraining device. When asked if she had ever seen a tool called Pre-Restraint Assessment Tool or the Restraint Checklist Tool, LPN #171 searched in the computer for completed ones for Resident #89. She was not able to locate them, nor could she find any blank copies of these forms in the computer that she would be able to fill out for any resident. She stated if she needed to utilize a physical restraint for any resident, she would call the physician to obtain an order for [REDACTED]. Interview with the MDS/Care Plan Nurse #118 on 09/24/14 at 4:20 p.m. revealed she did not have any type of assessment that she was required to conduct prior to utilizing a physical restraint for a resident. MDS/Care Plan Nurse #118 stated she thought physical therapy conducted an assessment of residents for the use of a special chair that might be considered a physical restraint. She stated she was only aware of a tool called a Restraint Reduction form and they would use this to attempt to reduce the restraint to the least restrictive device, but there was nothing done prior to placing them in the restraint other than a physician order. MDS/Care Plan Nurse #118 stated just prior to this interview she had been given copies of the new forms called Pre-Restraint Assessment Tool or the Restraint Checklist Tool and stated she was told to complete these forms for several residents. She was sitting in her office at her desk completing them during this surveyor's interview with her. During an interview on 09/25/14 at 2:55 p.m. with the Director of Nursing (DON) #107, and ADON #30, they both verified residents should be assessed before utilizing a restraining device to ensure the device was safe for the resident. They verified Resident #89 had not been assessed prior to placing him in the Broda chair on 07/17/14. b. Resident #35 Review of Resident #35's clinical record on 09/24/14, revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. Per the resident's admission MDS dated [DATE], the resident scored a 7 on the Brief Interview for Mental Status (BIMS), indicating the resident presented with severely impaired cognition. The resident was further assessed as independent with ambulation. The MDS was silent for the use of physical restraints. The resident's care plan was silent for the use of a physical restraint. Further review of the clinical record found no evidence of an assessment for the use of the reclining chair (Geri chair) and its impact on the resident's functional ability. A physician order [REDACTED]. Review of a nursing notes documented the following: -- On 08/10/13 at 12:30 p.m. revealed the resident was Up in recliner. Slept at intervals. -- On 11/23/13 at 2:34 p.m. Resident remained in a recliner chair unless staff walked with him in the hallway. -- On 11/23/13 at 12:15 a.m. Resident was sitting in a reclining chair in the hallway; he was awake and alert, Resident is not sitting calmly in his seat; he continually likes to get out of his seat; or try to get out of his seat and try to walk around. -- On 3/27/14 9:20 p.m., resident continues to be awake without any sleep resting in recliner chair at nurses station. -- On 03/29/14 at 6:14 a.m., the resident Has rested in reclining chair. -- On 03/29/14 at 6:22 a.m., resident in recliner chair at nursing station. -- On 03/31/14 at 10:34 p.m. Resident is reclining at the nurse's desk. -- On 5/18/2014 at 6:16 a.m. resident is currently in his recliner chair by the nurse's station because he will not stay in bed. -- On 07/14/14 at 9:57 p.m., Kept in Geri chair (reclining chair) most of shift. Crying on and off. Shooting invisible spider webs. -- On 07/16/14 at 9:55 p.m. Kept in Geri chair all shift for safety. -- On 07/17/14 at 4:30 a.m., Resident up to geri chair. -- On 07/17/14 at 1:51 p.m., Resident in recliner chair resting at this time. -- On 07/19/14 at 8:59 p.m., Awake at times. In Geri chair by nurse's station for safety. -- On 08/31/14 at 8:25 p.m., Feed by staff in Geri chair. -- On 09/14/14 at 3:01 p.m. In Geri chair. Review of the Potential for falls due to unsteady gait care plan dated 09/04/13 included the interventions to provide assistance with transfers, ambulation and locomotion as needed when manic he will run in hallways and dance report this to the nurse and Provide recliner prn (as needed). On 09/24/14 at 3:40 p.m. the resident was observed ambulating independently in the hallway. During an interview on 09/24/14 at 3:45 p.m., LPN #65 stated when the resident is in his manic phase we place him in a recliner to prevent him from ambulating due to his unsteady gait. We put him in the chair to keep him still. During an interview on 09/26/14 at 5:35 a.m., HSW #120 stated we sometimes place the resident in a reclined chair to prevent him from falling. She further stated that When the chair is reclined the resident is unable to exit the chair and does at times try to climb out of the chair. During an interview conducted on 09/26/14 at 8:10 a.m., Physical Therapy (PT) Supervisor #98 verified the resident had not been assessed by physical therapy for the use of a reclining (Geri) chair. During an interview conducted on 09/26/14 at 9:26 a.m., HSW #106 stated, We put him in the Geri chair when he gets unsteady. She further stated, He tries to get out of the Geri chair but he can't because the chair is leaned back. During an interview on 09/26/14 at 10:40 a.m., the Care Plan Registered Nurse (RN) #89 who was responsible for the MDS assessment and development of the care plan for Resident #35, verified the use of the recliner (Geri) chair for the resident. He stated he was not aware that a reclined chair could meet the definition of a restraint for this resident.",2017-12-01
8327,WELLSBURG CENTER LLC,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2012-09-20,221,D,0,1,XHRZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, and staff interviews, the facility failed to release a restraint per the care plan and failed to determine the use of a restraint for 2 of 6 residents reviewed of the 26 residents identified to have a potential restraint (Residents #22 and 60). Findings include: 1. Resident #22 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of Resident #22's medical record noted a physician's orders [REDACTED]. Resident #22 had a care plan entry dated 05/11/2012 noting that she was at risk for falls related to having [MEDICAL CONDITION]. Interventions included making her bed low, placing a mat on the floor beside the bed and bolster pads for positioning. A second care plan entry dated 05/11/2012 noted that Resident #22 had a potential for complications from a restraint. The restraint was listed as a lap buddy (padded device placed in front of a resident in a wheelchair to prevent them from moving forward in the chair) in the wheel chair due to poor safety awareness. Bed bolsters were not noted on the care plan as a potential restraint. Interdisciplinary Team (IDT) Physical Restraint Reviews dated 5/24/2012 and 08/16/2012 noted the lap buddy as the restraint in use. There was no documentation about the bed bolsters. An IDT Therapy Data Collection form dated 08/01/2012 noted no change in Resident #22's condition and she was not referred for an evaluation. Review of the Annual Minimum Data Set (MDS) assessment dated [DATE] noted the lap buddy as a chair restraint but did not note a bed restraint. Review of the Plan of Care Kardex for Resident #22 noted a Lap Buddy under the Restraints section, but there was no documentation of the bed bolsters. On 09/20/2012 at 9:25 AM, an interview was done with Therapy Assistant #78. Therapy Assistant #78 confirmed that Resident #22 was not currently on the therapy case load. An interview was completed with the Administrator and Nurse #51 on 09/20/2012 at 9:27 AM. The Administrator and Nurse #51 reported that every restraint identified by the facility is reviewed every quarter by the interdisciplinary team (IDT). If the IDT felt like there was a change in the resident, they would refer the resident to the therapy department for an evaluation. They also said that the therapy department does a quarterly screening of restraints even if the IDT doesn't refer the resident. The decision is made by looking at falls and injuries. If (a resident) has had a decrease in falls that means it's working. Therapy would do the assessment to see if they think the restraint is the least restrictive and appropriate. A follow up interview was completed with Therapy Assistant #78 on 09/20/2012 at 10:00 AM, Therapy Assistant #78 said, During our quarterly screen, we would review for any recent changes (improvement or decline) in any area. If there was a change, there would be an evaluation by PT (physical therapy), TO (occupational therapy) or ST (speech therapy), whatever is appropriate. If there is no change, we mark no change on the quarterly screen and that's it unless there is a change later or until the next quarterly screen. The quarterly screen determines if we do an evaluation (to determine if a resident needs therapy services). During an observation on 09/20/2012 at 11:00 AM, Resident #22 was noted to be in bed. Upper side rails were up and padded. Large padded bolsters were observed along the lower part of the bed beginning at the lower end of the upper side rails. The bolster was higher above the mattress than the elevated upper side rail. On 09/20/2012 at 10:55 AM, an interview was completed with Nursing Assistant #69 (NA #69). NA #69 stated that she was familiar with Resident #22. NA #69 reported that,The bed wedges (bolsters) help keep her in the bed. She moves around in the bed a lot. When she is in the wheel chair, she has a lap buddy. During an interview on 09/20/2012 at 10:56 AM, NA #9 said, If the wedges weren't on the side of the bed, (Resident #22) would fall off. An interview was completed with Nurse #23 on 09/20/2012 at 11:40 AM. Nurse #23 said that she was familiar with Resident #22. Nurse #23 said she was not aware of any falls that Resident #22 may have had. She has a lap buddy and she has a bed alarm and the floor mats on the side of the bed. She has bolster pads on her bed. It keeps her from rolling. I don't think it's a restraint. She could get over it if she really wanted to. I haven't seen her try and get over the mattress. On 09/20/2012 at 1:50 PM, an interview was completed with the Director of Nurses (DON). The DON said, We use the bolsters to help position her. We put the pillow behind her back and against the bolster. The DON acknowledged that Resident #22 can move in the bed and would probably be able to move off the bed if the bolsters were not present. 2. The Use of Restraints Policy dated 10/2007 noted (9) Care plans which include the use of physical restraint for behavior control shall specify the behavior to be eliminated, the method to be used, and the time limit for the use of the method. Resident #60 was admitted to the facility on [DATE]. Review of Resident #60's medical record revealed a physician's orders [REDACTED]. A review of the care plan for Resident #60 noted an entry dated 05/04/2012 for the potential for complications from the use of restraint-alarming seat belt for poor safety and falls. Interventions were to evaluate benefits and alternatives and to check the restraint per protocol. Additionally, the care plan stated to, Offer opportunity to be restraint free. Record review revealed a Restraint Review dated 05/10/2012. The review noted that Resident #60 had a decrease in the number of falls and that she was not able to remove the seat belt. The plan was to continue to use the seat belt. Another Restraint Review was dated 08/16/2012. The review noted that Resident #60 was using the alarming seat belt due to a history of falls. Review of the Plan of Care Kardex noted that Resident #60 had an alarming seatbelt in the wheelchair. Instructions were to check the seat belt every 30 minutes and to release the seat belt every 2 hours and for meals and activities. Occupational Therapy notes dated 09/07/2012 were reviewed. The note revealed that Resident #60 was exercising 15 minutes restraint free. Goal is for resident to be restraint free sitting in C (wheelchair) for 30 min (minutes) with close supervision. On 09/19/2012 at 12:30 PM, Resident #60 was observed in the dining room eating lunch with the seat belt in place. An interview was completed with Nurse #75 on 09/19/2012 at 1:00 PM. Nurse #75 stated that Resident #60 wears the seat belt because she will get up and walk. She can walk, but she falls. An interview was completed with Nursing Assistant #69 (NA #69) on 09/19/2012 at 3:00 PM. NA #69 stated that she was familiar with Resident #69. It's been about a month since she fell . She tries to get out of bed on her own. She has a bed alarm and a seat belt on the chair. She tries to get out of the chair too. There are tippers on the chair. We give her a break from the seat belt about every 2 hours so we can move her. We take it off at meal times. A follow up interview was completed with Nurse #75 on 09/19/2012 at 4:00 PM. Nurse #75 acknowledged that she saw Resident #60 with the seat belt in place during the lunch meal. Who ever takes her in to the dining room should release the belt. I don't know who took her in. On 09/20/2012 at 8:30 AM, an interview was completed with the Administrator. The Administrator stated, The interdisciplinary team does a quarterly review. If the team thinks she needs a change, we refer them to TO (occupational therapy). (Resident #60) is having a care plan meeting today so she will have another restraint evaluation today. An interview was completed with the Administrator and Nurse #51 on 09/20/2012 at 9:27 AM. The Administrator and Nurse #51 reported that every restraint identified by the facility is reviewed every quarter by the interdisciplinary team (IDT). If the IDT felt like there was a change in the resident, they would refer the resident to the therapy department for an evaluation. They also said that the therapy department does a quarterly screening of restraints even if the IDT doesn't refer the resident. The decision is made by looking at falls and injuries. If (a resident) has had a decrease in falls that means it's working. Therapy would do the assessment to see if they think the restraint is the least restrictive and most appropriate device. There was a therapy note in May and therapy did not pick (Resident #60) up for services. A follow up interview was completed with Therapy Assistant #78 on 09/20/2012 at 10:00 AM, Therapy Assistant #78 said, During our quarterly screen, we would review for any recent changes (improvement or decline) in any area. If there was a change, there would be an evaluation by PT (physical therapy), OT (occupational therapy) or ST (speech therapy), whatever is appropriate. If there is no change, we mark no change on the quarterly screen and that's it unless there is a change later or until the next quarterly screen. The quarterly screen determines if we do an evaluation (to determine if a resident needs therapy services). During a follow up interview on 09/20/2012 at 12:05 PM, Therapy Assistant #78 acknowledged that there had been no documented therapy evaluation considering a restraint reduction. On 09/20/2012 at 12:15 PM, Resident #60 was observed being taken into the dining room in her wheelchair by a visitor. Resident #60 was placed up to the dining table. NA#63 set up the meal tray but did not check the seatbelt. Resident #60 started eating her meal with the seatbelt on. On 9/20/2012 at 12:20 PM, NA #63 was asked if Resident #60 still had on the seat belt. NA #63 looked under Resident #60's shirt and said, Yes. We normally take it off. Someone else brought her to the dining room, I didn't.",2016-07-01
8339,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2012-04-27,221,D,0,1,N6W411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview, and medical record review, it was determined the facility failed to ensure that one (1) of twenty-one (21) sampled residents (R35) was free from a physical restraint. Findings include: a) Resident 35 Review of the Census and Condition Form (CMS 672), completed on 04/24/12, revealed the facility documented there were no residents in the facility who were restrained. Observation of R35 during the initial tour, on 04/24/12 at 9:15 a.m., found the resident in bed. The resident's wheelchair was nearby, and was equipped with a seatbelt. Interview with the Director of Nursing (DON), during tour, revealed this was not a restraint, as R35 could release the seatbelt without staff assistance. Observation, on 04/24/12 at 1:05 p.m., revealed R35 was in the wheelchair with the seatbelt fastened. When asked, the resident was unable to release the seatbelt and said, Why is that there? Observation at 1:30 p.m. again revealed the resident could not release the seatbelt upon request. R35 could not release the seatbelt until Licensed Practical Nurse (LPN) 123 cued the resident by providing instructions (verbally and physically) to push the red button on the seatbelt. Interview with LPN123 confirmed the resident required cuing to remove the seatbelt, and was unable to release it upon request. Review of the clinical record revealed R35 was admitted on [DATE], with no restraints. R35's [DIAGNOSES REDACTED]. A Significant Change Minimum Data Set, on 01/16/12, revealed R35 continued to have no restraints. The resident was identified at risk for falls, required extensive assistance with transfers/ambulation, and was unsteady in balance. Review of the clinical record revealed on 01/29/2012, the resident was found on the floor, with a chair alarm sounding. That same day, nursing progress notes documented Resident's family wants to talk to social worker about what kinds of restraints they could use to restrain resident so staff could do care. Nurse explained to them we cannot restrain resident. However, on 01/30/12, an order was obtained for a self-release alarming seat belt. Review of the Pre-Restraining Assessment Evaluation form, completed on 01/30/12, by the therapy director (OT) revealed no evidence that a full interdisciplinary team (IDT) assessment had been made prior to restraining R35. Multiple portions of the form were not complete. Under Physical and Mental Considerations, staff had not completed information about the resident's vision, muscle control, or potential medical factors affecting behavior. Staff documented that environmental factors such as poor lighting and the resident's need to go to the bathroom could be contributing behavioral factors. R35 also had other factors, such as recent medication changes, according to social services notes of 01/25/12. However, there was no evidence staff had attempted to address these factors prior to restraining the resident. Under the Referral/Recommendation section of the form, the OT listed the recommendation of a seatbelt. The section regarding alternatives to restraints had not been completed, and there was no evidence an IDT had assessed less restrictive measures prior to restraining the resident. Review of the form revealed no evidence of a medical symptom for which the restraint was being used to treat. Review of the 01/30/12, Informed Consent - Physical Restraint form reflecting information provided to the family, revealed, The specific medical symptom that requires the use of a restraint is dementia. There was no evidence of an assessment as to why R35, whose admission [DIAGNOSES REDACTED]. Further review of the Informed Consent form revealed that Opportunities for the reduction or discontinuation of the physical restraint will be part of the facility's care planning process. Review of the Care Plan Team Meeting Summary of 04/19/12, revealed the resident: Continues use of self-release seatbelt when up in wheelchair. However, review of R35's comprehensive care plan revealed the problem of restraint use was not included and a plan for restraint reduction/removal had not been developed. Interview on 04/25/12 at 10:20 p.m. with the OT revealed the recommendation for an alarming seat belt was made to give staff more time to get to the resident to prevent falls/injuries. The OT related the resident had dementia and the facility was using the restraint as a last resort. The OT related that she was not in the habit of documenting less restrictive measures prior to restraint use, even though the facility's Pre-Restraining Assessment form called for this information to be assessed. The OT further stated that although she had been thinking about the need for restraint reduction, no plan had yet been developed.",2016-07-01
8469,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2012-05-11,221,E,0,1,HIO211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review the facility failed to ensure that 6 of 19 sampled residents (#R14, R33, R40, R49, R54, and R66) were free from restraints, unless they were needed to treat an assessed medical symptom. Cognitively intact residents were restrained against their will. Residents were restrained prior to a thorough assessment of their needs. Restraints were applied without evidence of attempts at less-restrictive measures. Plans for restraint reduction were not developed. Findings include: Review of the Census and Condition Form completed by the facility on 05/08/12 revealed they identified 20 of 92 residents in the facility as being restrained. 1. Observation during initial tour on 05/08/12 at 10:00am revealed R14's bed had four ? side rails (SR) attached to it. Interview with the Activity Director providing information during initial tour revealed there were no residents on the unit who used restraints, and staff only put 3 of the 4 SR on R14's bed up, ensuring that it did not restrain the resident. Observation on 05/09/12 at 10:15am, 11:15am, 2:45pm, 3:45pm, and 4:00pm revealed the resident asleep in bed. During each observation, all four ? side rails were in the up position, restraining the resident. Observation revealed that when the head of the bed was lowered, there was a gap of up to 7 inches between the two ? SR on the right side of the bed. (Refer to F323.) Interview on 05/09/12 at 3:15pm with CNA21 (Certified Nursing Assistant) revealed staff was using the SR to, Keep him from getting out of bed. CNA21 related that although the resident did not try to climb over the SR, there had been instances where R14's leg was up and over the rails. Interview with LPN18 (Licensed Practical Nurse) on 05/09/12 revealed the resident was being restrained because R14, was trying to get up unassisted, and was falling out of bed. Interview with LPN17 on 05/09/12 at 4:50 pm revealed R14 had purposeful movement and would attempt to stand/rise from a chair. Review of the clinical record of R14 revealed [DIAGNOSES REDACTED]. Upon admission on 04/19/11, the resident had no restraints. Nurses notes on 05/10/11, document, Late entry: noted the resident was grabbing, wanting to hold something while staff were repositioning him. A physician's orders [REDACTED]. There was no explanation as to why the need of staff assist when getting out of bed (which had been present upon admission) now required the resident to be restrained. As the clinical record did not contain evidence the resident was assessed prior to restraint use, a request was made for the Director of Nursing (DON) to produce any other information for review. Observation revealed the DON provided multiple conflicting pieces of documentation, including two Pre-Restraining Evaluation forms, both allegedly completed on 05/11/11. Review of these form revealed conflicting reasons for the reason a restraint was needed. The first form provided showed that side rails were for rolling in bed. However, a second copy of this form, listed the medical symptom warranting restraint use as, signs/symptoms (s/s) of fear when repositioning self; requiring staff assist when getting out of bed. Review of the 2 Pre-Restraining Assessment forms revealed conflicting information regarding the resident's mental status, hearing, need for repositioning, understanding of what is said, history of falls, vision, and sitting ability. Review of the second form provided by the DON revealed staff had noted the resident (who was assessed as severely cognitively impaired) was requesting something to help position self. Review of these 2 forms also revealed conflicting information about alternatives to restraint use. The section of the form for an Interdisciplinary (IDT) Team Evaluation was not completed on one of the two forms, while the other form used this section to list, use 2 SR when in bed. Neither form showed evidence of assessment as to why the resident needed to be restrained, evaluated possible root causes of R14's fear, or identified and explained the multiple discrepancies between the two forms. Other forms also revealed conflicting information. For example, review of the Consent for Use of Safety Devices and Release of Physician and Nursing Home form, completed by the facility on 05/11/11, revealed that staff had listed Dementia as the reason side rails were needed when in bed. However, review of the resident's record revealed that R14 also had dementia upon admission, when it was determined that no restraints were needed. Review of current physician orders, dated 05/05/12 revealed the resident continued to have an order for [REDACTED]. Observation of a label attached to the top right ? SR revealed, Warning: Patient Entrapment with Bed Side Rails may result in entrapment or death. Use only with coherent patients capable of avoiding entrapment. Patients at risk of entrapment include those with pre-existing conditions such as confusion, restlessness, lack of muscle control, Alzheimer ' s, dementia, altered mental state or those prone to [MEDICAL CONDITION]. Review of a Charge Nurse Restraint Assessment form revealed that on each shift, the charge nurse was to assure the resident had been assessed for safety and security. Review of the forms for February, March, and April revealed at least 22 facility nurses, including the DON, had signed off as having assessed the use of the SR (restraint) as safe. Review of the monthly forms and the clinical record revealed no evidence that any of the nurses had observed the warning label printed clearly on the side rail. Review of the Charge Nurse Restraint Assessment form also revealed that the nurses' signature indicated the restraint was applied as ordered and the need for the device continues to exist. However, interview with the Director of Nursing on 05/10/12 revealed the nurses signing off on the form had not actually assessed the continuing need of the device each shift. Interview with LPN17 on 05/09/12 at 4:50pm revealed that therapy staff was to complete quarterly restraint reduction screens. LPN17 indicated that a plan for restraint reduction is not made in an interdisciplinary manner, as the person completing the restraint screen determines if a reduction attempt should be tried. Review of quarterly restraint screens completed on 01/16/12 and 04/04/12 by the Physical Therapist Assistant (PTA) revealed no attempts at restraint reduction. Each screen was a copy of the previous report, repeating, Resident has had no change in status that would necessitate a change in restraint. There was no rationale as to why a restraint reduction could not be attempted, as the PTA made the decision to Continue 2 side rails when in bed. Review of these screens revealed the PTA had not identified that staff were restraining the resident with a device other than that ordered by the physician (four ? side rails.) After being asked for any information showing attempts at restraint reduction, the DON provided a Patient Health Care Plan dated 11/15/11 on which the DON documented, attempted to lowers SRs. Per resident request he asks for rails to help turn himself. On 02/15/12, another nurse documented, asked resident if we could attempt to reduce SRs - Resident replied, No. However, review of the clinical record revealed the resident did not have capacity to make decisions, and quarterly assessments documented the resident was severely impaired in cognition and required extensive assistance in bed mobility. The DON also provided a Physical Restraint Elimination Review form, allegedly completed on 11/15/12 (refer to F514) and 02/15/12. Review of both forms revealed that on Page 2, staff marked the resident was not a candidate for restraint reduction or elimination. However, review of the forms revealed that no assessment as to why restraint reduction could not be attempted. The form stated that if the resident was not a candidate for reduction/elimination, staff must, state specific reason/behavior below. However on both the November and February forms, this section was left blank. 2. Observation on 05/08/12 at 10:00am revealed that R33 was in bed with side rails that were as long as the bed. The resident appeared pleasantly confused. The side rails had black pipe insulation covering the top bar. Black netting extended from the head to the foot of the bed and the top of rail to the bed frame. The netting was thick and black as to impede vision from a person lying in the bed. The height of the rail was approximately 1 foot from the top of the mattress. Observation on 05/09/12 at 2:30pm revealed R33 lying in bed on her side with a pillow to the back. Both full-length rails were in the up position. The head of the bed was elevated 20? and a tray table was placed across the bed. The resident was not able to see the top of the table on which were placed several snack cakes wrapped in plastic. Review of a record titled Pre-Restraining Evaluation dated 01/10/11 indicated that R33 had medical considerations of history of [MEDICAL CONDITION] (dizziness), [MEDICAL CONDITION] (low blood pressure), and [MEDICAL CONDITION]. However, review of the resident's clinical record for January, 2011 revealed that she was being treated for [REDACTED]. Per the medical record, the resident did not have [MEDICAL CONDITION]. On the form, staff had marked the only device attempted as a restraint alternative was a wheelchair. There was no evidence of evaluation as to why a wheelchair would have been an appropriate intervention for the resident while in bed. The document has a written statement at the bottom that the resident had, SR (side rails) x2 (times 2) when in bed to enhance mobility while in bed. However, review of the annual Minimum Data Set ((MDS) dated [DATE] revealed that the resident was dependent on staff for bed mobility and transfers. Review of Quarterly Restraint screens dated 04/04/12 and 01/06/12 performed by the PTA revealed that both documents were exactly the same. Resident was screened this date for restraint usage. Last restraint screen on (each had a different date). At the time she had a physician order [REDACTED].Continue side rails when in bed. Review of the Quarterly Restraint screens revealed no evidence the facility had evaluated why the resident was being restrained, per family request. Interview on 05/09/12 at 4:10pm with the PTA revealed she makes her recommendations based on whether she, feels that the resident needs a different restraint. Surveyor requested and never received documentation that alternatives to side rails while in bed were tried and evaluated for this resident. 3. Observation on 05/08/12 at 10:00am revealed R40 resident was lying in bed with full-length side rails covered in black netting and black pipe insulation. She was turned to her side with a pillow to her back. The call light was attached to the top of the bed, her water pitcher was on a chest at the foot of her bed where she could see it but not reach it. Observation on 05/08/12 at 2:10pm revealed the resident was in her room unsupervised, tied to a wheelchair with a belt restraint that was crossed in the back and tied to the bottom frame of the chair. (The belt was loose enough for a person to slide out of the chair from the bottom.) The resident was jerking and pulling on the belt and making angry noises. Observations on 05/09/12 revealed that at 8:40am she was in the dining room tied to the wheelchair with soft belt that crossed. At 9:20am she in the bed with the full-length side rails pulled up. She was flat in the bed and the water remained on the chest at the foot of the bed. At 12:22pm, the resident was unsupervised in her room, up in the wheelchair with the restraint in place. Resident was noted to be jerking on the restraint. Review of resident admission documents revealed that she was originally admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of document titled Pre-Restraining Evaluation dated 01/10/11 and given to surveyor on 05/10/12 indicated that the back of the document was not filled out or signed by evaluator. On 05/11/12 the DON presented surveyor with another copy of the same form, unsigned, but the back had now been filled out to indicate that the resident requires soft belt for falls and side rails due to her tardive dyskinesia. Review of informed consent for physical restraints revealed that the document was signed and dated on 05/18/10 before the Pre-Restraining Evaluation was done. Review of a document titled, Physical Restraint Elimination Review revealed that on 01/02/12 the resident attempts to ambulate and transfer without assistance and slides down in chair. Asked if resident wanted 2 side rails resident stated yes they help me. On the same document under the date 03/31/12 resident uses side rails as an enabler to move in bed and requests them to be up. Both entries were signed by LPN34. Review of a document titled Determination of Capacity dated and signed on 06/15/06 revealed the resident lacks capacity to make her own decisions. Review of annual MDS dated [DATE] assessed the resident as having unclear slurred speech, who is rarely understood. Resident is totally dependent on staff for bed mobility, transfers, and eating. Interview with LPN49 on 05/10/12 at 5:20pm she indicated that the facility had attempted to place R40 in a lap buddy, geri-chair, pommel cushion, and she takes them off or pulls them out. She stated the resident fell and cracked her head several times. She stated that the last attempt at restraint reduction on R40 had been over a year ago. The LPN admitted that the resident could walk with the assistance of 2 people but the resident would probably be restrained for the rest of her life. The LPN stated that she had not been to an in-service on restraints for 5-[AGE] years. Surveyor asked for but never received the documentation that the attempts to reduce the restraints had been done 4. R49 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During initial tour of the facility on 05/08/12 at 9:30am, LPN 73 indicated that R49 was alert, oriented, and interviewable. A review of the medical record revealed that a Determination of Capacity form was signed and dated 04/18/11 by the physician, documenting R49 demonstrates capacity to make decisions. R49 was observed in bed with two ? side rails up on 05/10/12 at 11am and 9:40pm. R49 was interviewed on 05/10/12 at 11:00am and stated, They always put these rails up when I ' m in bed. I don't want them, I even signed a paper telling them I didn't want them or that pad they wanted to put on my bed. A review of the medical record revealed that R49 signed a form titled Informed Consent for the use of Physical Restraints. The form indicates the need for two ? side rails due to history of [MEDICAL CONDITION], falls, and above the knee amputation (right leg). The facility presented the survey team with a list of residents requiring side rails, R49 is listed as needing two ? rails. The facility also produced a Charge Nurse Restraint Assessment form on 05/11/2012 at 10am, which according to the Director of Nursing (DON) indicates that the charge nurse assesses the resident to ensure that the restraint is applied as ordered and the need continues to exist. This form was signed every day for the months of February, March, April, and May 1-10 2012. A review of the Care Plan indicated the following: (3) Self care deficit - approach Side rail (1) as enabler to turn/reposition self or assist staff (7) Falls risk r/t (related to) [MEDICAL CONDITION] and falls - approaches listed do not include the use of side rails (16) risk for trauma r/t [MEDICAL CONDITION] - approaches listed do not include the use of side rails The DON could not explain why the facility was using 2 side rails, although R49 was care planned for 1 side rail and R49 is alert, oriented and requested the use of no side rails. 5. Observation on 05/08/12 at 10:00am revealed R54 was sitting in a wheelchair in the dining room. R54 was independently moving about the facility in the wheelchair. The resident was noted to be alert, oriented and participating in activities. Observation on 05/10/12 at 9:20pm revealed the resident was in bed with full length side rails that were covered with black netting and black pipe insulation. Review of Quarterly restraint documents, dated 01/06/12 and 04/04/12, revealed the PTA wrote Resident was screened this date for restraint usage. Last restraint screen (date.) At that time she had a physician's orders [REDACTED]. Resident requested 2 side rails for safety and mobility. Resident has no change in status that would necessitate change in restraint. Continue 2 side rails when in bed, staff to reposition every 2 hours and as needed. Although staff documented the use of side rails was per resident request, interview on 05/11/12 at 10:40am revealed R54, did not like the side rails and did not want them. Interview with R54 revealed she could not see over or through them. When the rails are up she cannot reach any of her personal property or get a drink of water. R54 indicated she never requested them. Review of a quarterly MDS dated [DATE] resident was coded with a BIMS score of 15 (no cognitive impairment) and had no behaviors. Fall Risk Assessments for 04/26/11, 08/11/11, 11/11/11, and 02/11/12 revealed that the resident was not a falls risk. 6. Observation of R66 on 05/08/12 at 10:08am revealed the resident was in bed with 2 full-length side rails covered in netting. The Nurse Supervisor, LPN59, stated the resident required total care and was immobile. She also stated he was suffering from [MEDICAL CONDITION] and had been a resident for approximately 2 years. The resident appeared to be alert and oriented and was able to introduce himself. When asked if he knew what the purpose of the net covered bed rails was, he responded, No Ma'am, I don't . LPN59 stated, Most of the residents need side rails as 'enablers'. However, she could not explain why the residents needed to be restrained with full length side rails covered in netting. Review of the Use of Restraints policy revealed restraints shall only be used, After other alternatives have been tried unsuccessfully. The policy noted the definition of a restraint is based on the functional status of the resident and not the device. If a resident cannot remove a device in the same manner in which the staff applied it, given that resident's condition (i.e. side rails are put back down rather than climbed over) and this restricts ability to change position or place, that device is considered a restraint. Further review of the policy revealed that, Prior to placing a resident in restraints, there shall be a pre-restraining assessment .The assessment shall be used to determine possible underlying causes of the problematic medical symptom and to determine if there are less restrictive interventions that may improve the symptoms. The policy also noted care plans for residents in restraints, shall also include the measures taken to systematically reduce or eliminate the need for restraint use. The policy provided multiple pieces of documentation that were required, including, How the restraint use benefits the resident by addressing their medical symptom.",2016-06-01
8598,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,221,D,1,0,BVS711,"Based on medical record review and staff interview, the facility failed to ensure one (1) of eight (8) sampled residents had the right to be free from a physical restraint which was not required to treat a medical symptom. Resident #16's care plan contained an intervention for a physical restraint. This restraint was for staff convenience, in that the restraint was an action to control the resident's behavior with a lesser amount of effort by the facility. Resident identifier: #16 Facility census: 78 Findings include: a) Resident #16 A medical record review was conducted 05/30/13 at 2:00 p.m. The resident's care plan revealed an intervention related to the resident's wandering that stated, If unable to redirect Resident #16 and it is not safe for him to be wandering (for example if he is going into other resident's room) Use a sheet to wrap him up in to administer IM medications when needed. Medical record review revealed no evaluation for the need of a restraint.Assessment and Care Planning for Restraint Use There are instances where, after assessment and care planning, a least restrictive restraint may be deemed appropriate for an individual resident to attain or maintain his or her highest practicable physical and psychosocial well-being. This does not alter the facility's responsibility to assess and care plan restraint use on an ongoing basis. Before using a device for mobility or transfer, assessment should include a review or the resident's: o Bed mobility (e.g., would the use of the bed rail assist the resident to turn from side to side? Or, is the resident totally immobile and cannot shift without assistance?); and o Ability to transfer between positions, to and from bed or chair, to stand and toilet (e.g., does the raised bed rail add risk to the resident's ability to transfer?). The facility must design its interventions not only to minimize or eliminate the medical symptom, but also to identify and address any underlying problems causing the medical symptom. The interventions that the facility might incorporate in care planning might include: o Providing restorative care to enhance abilities to stand, transfer, and walk safely; o Providing a device such as a trapeze to increase a resident's mobility in bed; o Placing the bed lower to the floor and surrounding the bed with a soft mat; o Equipping the resident with a device that monitors his/her attempts to arise; o Providing frequent monitoring by staff with periodic assisted toileting for residents who attempt to arise to use the bathroom; o Furnishing visual and verbal reminders to use the call bell for residents who are able to comprehend this information and are able to use the call bell device; and/or o Providing exercise and therapeutic interventions, based on individual assessment and care planning, that may assist the resident in achieving proper body position, balance and alignment, without the potential negative effects associated with restraint use. Procedures: Determine if the facility follows a systematic process of evaluation and care planning prior to using restraints. Since continued restraint use is associated with a potential decline in functioning if the risk is not addressed, determine if the interdisciplinary team addressed the risk of decline at the time when restraint use was initiated and that the care plan reflected measures to minimize a decline. Also determne if the plan of care was consistently implemented. Determine whether the decline can be attributed to a disease progression and/or inappropriate use of restraints. For sampled residents observed as physically restrained during the survey or whose clinical records show the use of physical restraints within 30 days of the survey, determine the intended use of the restraint for convenience or discipline, or a therapeutic intervention for specified periods to attain and maintain the resident's highest practicable physical, mental or psychosocial well-being. Probes: This systematic approach should answer these questions: 1. What are the medical symptoms that led to the consideration of the use of restraints? 2. Are these symptoms caused by failure to: a. Meet individual needs in accordance with the resident assessments including, but not limited to, MDS 2.0, section AC.Customary Routine, in the context of relevant information in sections AA.Identification Information and AB.Demographic Information? b. Use rehabilitative/restorative care? c. Provide meaningful activities? d. Manipulate the resident's environment, including seating? 3. Can the cause(s) of the medical symptoms be eliminated or reduced? 4. If the cause(s) cannot be eliminated or reduced, then has the facility attempted to use alternatives in order to avoid a decline in physical functioning associated with restraint use? (See Physical Restraints Resident Assessment Protocol (RAP), paragraph I). 5. If alternatives have been tried and deemed unsuccessful does the facility use the least restrictive restraint for the least amount of time? Does the facility monitor and adjust care to reduce the potential for negative outcomes while continually trying to find and use less restrictive alternatives? 6. Did the resident or legal surrogate make an informed choice about the use of restraints? Were risks, benefits, and alternatives explained? 7. Does the facility use the Physical Restraints RAP to evaluate the appropriateness of restraint use? 8. Has the facility re-evaluated the need for the restraint, made efforts to eliminate its use and maintained resident's strength and mobility? The facility had no plan for a systematic and gradual process toward reducing the resident's restraint.s (e.g., gradually increasing the time for ambulation and muscle strengthening activities). This systematic process would also apply to recently admitted residents for whom restraints were used in the previous setting. There was no evidence the r facility must also explain the potential negative outcomes of restraint use which include, but are not limited to, declines in the resident's physical functioning (e.g., ability to ambulate) and muscle condition, contractures, increased incidence re was no evidence the facility care plan Interview with Employee #33, a registered nurse (RN) unit manager, 5/30/13 at 3:00 p.m. regarding the intervention to restrain the resident with a sheet. He stated he was unaware of the intervention ever being used and he stated the intervention had been removed from the resident's care plan.",2016-05-01
8618,"WAR MEMORIAL HOSP, D/P",5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2012-12-07,221,D,0,1,L97I11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure a restraint was used only as required to treat medical symptoms for one (1) of fourteen (14) sample residents. The resident was restrained in a tilt geri-chair. There was no assessment prior to initiating the physical restraint, and no physician's order reflecting the presence of a medical condition to warrant the restraint use. The faciilty also was unable to provide evidence the responsible party was made aware of the potential risks and benefits of restraint use. Additionally, there was no care plan to re-evaluate the need for the restraint and no systematic plan to reduce the use of the restraint. Resident identifier: Resident #1. Facility census 16. Findings include: a) Resident #1 Review of the medical record revealed Resident #1 was admitted to the facility on [DATE]. The resident had been deemed to lack capacity to make her own health care decisions for the past several years. She was alert at times but, was not oriented to person, place and time. A Brief Interview for Mental Status (BIMS) had not been attempted because of rambling incoherent speech. The resident exhibited both short and long term memory loss. She also exhibited repetitive body and limb movements daily. The resident's care plan included the use of a bed alarm, a low bed with floor mats, and the daily use of a chair to prevent rising. This chair was identified as a physical restraint in both the care plan and the minimum data set (MDS) assessments dated 04/22/12, 07/22/12, and 10/22/12. There was no physician's order reflecting the presence of a medical symptom that would necessitate the use of a physical restraint. There was no evidence in the record that the responsible party for Resident #1 was informed of the risks and/or benefits associated with the use of a restraint, and no evidence the resident was assessed for the suitability of this particular restraint. There was no evidence the use of the restraint had been periodically evaluated for elimination or, that alternative measures had been considered in an attempt to reduce the restraint. During a staff interview with Employee #9 (nursing assistant) at 3:50 p.m. on 12/04/12, she agreed the resident could not rise and exit the geri-chair when it was tilted back. She stated the resident was in the geri-chair in a tilted position whenever she was out of bed. The Director of Nurses (DON) and the Social Worker (SW) were interviewed at 8:45 a.m. on 12/06/12. They agreed, after reviewing the record, they failed to secure a physician's statement of a medical symptom necessitating the restraint, and confirmed they could not locate documentation of an assessment for the use of the restraint. They could provide no evidence information had been provided to the responsible party (daughter) prior to use of the tilt chair but, stated she visited almost daily and was aware of the use of the tilt chair. The resident's daughter was not seen at the facility during the survey.",2016-05-01
8875,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2012-05-25,221,E,0,1,ZX7V11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident and staff interview and clinical record review the facility failed to ensure that 3 of 23 sampled residents (R99, 69, 78,) were free of unnecessary restraints. Restraints were applied without assessments, without attempts at lesser restrictive interventions, and without ongoing assessments for restraint reduction. Findings include: 1. Observation during initial tour on 05/22/12 at 10:05am revealed R99 ' s wheelchair was equipped with a seatbelt. Interview with the Assistant Director of Nursing (ADON) who was present on tour revealed that the seatbelt was not a restraint, as the resident could self-release it. Observation on 05/22/12 at 1:10pm revealed R99 in the dining room, eating lunch. The resident's seatbelt was fastened and she was unable to release it upon request. Observation on 05/23/12 at 6:33am, revealed the resident sitting in a wheelchair at the nurses' station. The seatbelt was fastened, and the resident was unable to release it upon request. At 6:45, QA103 rolled R99 into the dining room. The resident was again requested to remove/release the seatbelt with staff present, but was unable to remove the belt. Interview with R99 revealed she did not know what the belt was for. Interview at 6:55am with LPN43 revealed there were times when the resident was able to release or get out of it when she was agitated and pulled on it. However, LPN43 confirmed, the resident could not consistently remove the seatbelt upon request at all times. When interviewed on 05/23/12 at 3:05pm, LPN26 stated, We are a restraint-free facility. LPN43 continued that because of the type of seatbelt being used, the device was not considered a restraint. The LPN then acknowledged that the resident, cannot remove it on demand - we never know when or if she can get it off. Review of R99's clinical record revealed [DIAGNOSES REDACTED]. The resident had a history of [REDACTED]. Prior to initiation of the restraint, the resident's last fall was on 01/26/12, from the bed. Review of a Health Status Note revealed that on 02/01/12, new orders written for wheelchair with tab alarm release seat belt when up. Review of the clinical record revealed no evidence of an interdisciplinary assessment prior to the initiation of the seatbelt, which constituted a restraint since the resident could not always remove it at will. 2. Observation of R69 on 05/22/12 at 9:30am revealed the resident in bed. Two full padded side rails were in place. Interview with the ADON who was present on tour revealed the side rails were used because the resident had [MEDICAL CONDITION] disorder and did not constitute a restraint for the resident. Observation revealed that throughout all four days of the survey, R69 was in bed, with both full side rails up. When interviewed on 05/23/12 at 3:05pm, LPN26 stated, We are a restraint-free facility. LPN43 continued that the side rails were not a restraint, since the resident had [MEDICAL CONDITION] disorder. The LPN then acknowledged that R69 had voluntary movement in the bed and could not remove or lower the side rails. Review of the clinical record revealed R69's [DIAGNOSES REDACTED]. Review of the clinical record revealed no evidence of an interdisciplinary assessment prior to the use of the full side rails. Current physician orders [REDACTED]. Review of the most recent Resident Assessment Instrument (RAI), an annual assessment completed on 04/25/12, revealed the use of side rails had not been marked in Section P or assessed through this process. Interview on 05/24/12 at 4:00pm with the ADON revealed that an assessment was not completed prior to initiation of the restraint for this resident. The ADON related that the facility had not considered the side rails a restraint because they were needed in response to the resident's [MEDICAL CONDITION] disorder. Review of a Plan of Care Note, dated 04/25/12, revealed the resident, Uses SR x2 for [MEDICAL CONDITION] disorder. The same note continued there was, No recent [MEDICAL CONDITION] activity noted. Interview with the ADON on 05/22/12 at 3:35pm revealed no plans had been developed to reduce or discontinue the use of the side rails. She stated there was no documentation, but this decision was made because the resident's [MEDICATION NAME] ([MEDICAL CONDITION] medication) levels are up and down. Although staff related the restraint was needed and could not be reduced because of his [MEDICAL CONDITION] disorder, observation during medication pass on 05/23/12 revealed R69 was not receiving his ordered [MEDICATION NAME] in a manner to maintain therapeutic levels. (Refer to F332.) 3. On 05/23/12 at 6:55 AM R78 was observed on the East hallway in an upright Geri-chair with a large lap tray attached. Review of the clinical record revealed R78 was admitted on [DATE] for long term care with the following diagnoses; [MEDICAL CONDITION], disorder of plasma protein metabolism, [MEDICAL CONDITION], unspecified debility, [MEDICAL CONDITIONS] disorder, disorders of magnesium metabolism, hypopotassemia, [MEDICAL CONDITION], reflux, and dysphagia. Review of the clinical record revealed no evidence of an interdisciplinary assessment prior to the use of the Geri-chair with the lap tray. Interview with LPN43 revealed R78 could stand with assist, and would attempt to stand without the lap tray. She further indicated the lap tray was in place to promote activities. There was a wooden puzzle observed on the lap tray however, R78 was not engaged in puzzle solving. R78 was observed over a 45 minute period that morning, at no time did R78 engage in the puzzle activity. Review of the most recent comprehensive assessment dated [DATE] revealed he was not coded as having a restraint. His plan of care did not address restraints. Interview on 05/24/12 at 4:00pm with the ADON revealed that no assessments were completed prior to initiation of restraints for the above residents. The ADON related that the facility had not considered the seatbelt, full side rails, or Geri-chairs restraints. The ADON continued that as a result of not considering them restraints, they had not been assessed through the (RAI) process or care planned as a problem, with a goal of restraint reduction. During an interview with the DON on 05/25/12 at 9:20 AM, she stated, We are a restraint free facility. No one has been assessed for restraints or care planned or reassessed for reduction, because we are restraint free. Review of the Physical Restraint Policy revealed, Physical restraints are used as a last resort; the medical record must indicate events leading up to the use restraints, alternative interventions attempted, (and) a comprehensive pre-restraining assessment which included Activities, Rehab Nursing, and Social Service.",2016-03-01
8919,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,221,D,0,1,NP7N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and medical record review, the facility failed to assure one (1) of thirty-eight (38) sample residents was afforded the right to be free from a physical restraint imposed for staff convenience during meals. Additionally, the facility failed to attempt alternative measures to control behaviors in order to reduce or eliminate the restraint. Resident identifier: #35. Facility census: 90. Findings include: a) Resident #35 During observations of the noon meal service, on 11/28/11 at 12:35 p.m., Resident #35 was observed to be seated in a geriatric chair with a locking tray. Her chair was positioned against the wall away from the other residents seated at tables and eating their meals. Continued observation noted the resident remained in the restraint, isolated from the other residents, throughout the entire meal. An interview with the unit manager, registered nurse (RN) #59, could elicit no rationale for the resident being placed in an isolated area away from the other residents. Review of the medical record found a physician's orders [REDACTED]. This physician's orders [REDACTED]. Review of the current care plan found a problem statement, from 08/14/11, which stated, (Resident #35) will attempt to take food off of others trays and eat the food which can cause potential choking. The behavior is inappropriate and dangerous, her diet order is for pureed. She will get angry when redirected by staff. One of the interventions listed for this problem was, If resident does not attempt to grab food from others, evaluate q (every) three months for continued need of restraint. Obtain speech consult prn (as needed). The minimum data set (MDS) coordinator, Employee #21, was asked on 12/06/11 at 5:45 p.m., to provide any evidence the facility had attempted to reduce the restraint. She was unable to give any examples of attempts to reduce the restraint.",2016-03-01
9173,CORTLAND ACRES NURSING HOME,515063,39 CORTLAND ACRES LANE,THOMAS,WV,26292,2011-02-02,221,D,0,1,IEXL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and staff interview, the facility failed to ensure each resident was free from any physical restraints not required to treat the resident's medical symptoms. One (1) of thirty-six (36) Stage II sample residents was placed in a beanbag chair (which prevented him from rising) without a written physician's order for its use to treat a medical symptom. Resident identifier: #62. Facility census: 90. Findings include: a) Resident #62 1. At approximately 3:00 p.m. on 01/24/11, observation found Resident #62 to be sliding out of his positional chair while located in the living room area. Only one (1) aide was present in the room, and she placed a beanbag chair that had been positioned adjacent to his chair under him, so that he slid out of the positional chair and onto the beanbag chair. At 4:30 p.m. on 01/24/11, this surveyor observed the resident still reclining in the beanbag chair receiving one-on-one (1:1) supervision by a nursing assistant (Employee #80) while a licensed practical nurse (LPN - Employee #43) worked nearby. The resident was very confused, making snoring sounds, and hitting out (ineffectively) at staff. During an interview with Employee #43 at this time, she stated they use the beanbag chair when the resident is so agitated that they cannot get him in any other chair without fear that he will throw himself out or turn the chair over. A subsequent review of incident reports verified this behavior. The incident reports indicated the falls were usually from his positional chair with a safety belt harness in place. The resident was strong and would shift his weight to one (1) side and, then, upset chair. He had six (6) reported falls of this type in the last two (2) months (on 01/24/11, 01/18/11, 12/15/10, 12/13/10, 12/05/10, and 12/01/10). A follow-up visit, at 5:45 p.m., revealed Resident #62 was in a positional chair being fed by a nurse aide. When he had finished eating, he was moved away from the other residents and was provided a 1:1 caregiver (Employee #60). He was still very awake and trying to rise, although the nurse (Employee #43) stated he had received [MEDICATION NAME] to help him calm down. -- 2. A review of Resident #62's medical record revealed this [AGE] year old male was admitted to the facility on [DATE], and his [DIAGNOSES REDACTED]. -- 3. During interviews with a nurse (Employee #105) and a nursing assistant (Employee #46) at 11:00 a.m. on 01/25/11, they verified Resident #62 can upset his chair when he becomes agitated, and they stated he even calls out to staff of his intention to do so. The nurse stated that, because of his falls, she and the therapist have been investigating different types of chairs. She also stated that they used a beanbag chair at times and provide 1:1 direct supervision (which he was receiving on this day) when necessary. They both stated staff got the resident up early, and he would spend his day in the positional chair as he was no longer ambulatory, even with assistance. He was toileted by staff and could, at times, support his weight to pivot to the commode. This resident no longer ambulated, even with assistance, and this was evidenced in a note by the physical therapist on 09/29/10, which stated: Mr. (name of Resident #62) is no longer able to ambulate. Can bear wt. but does not do this functionally. -- 4. In an interview with the occupational therapist (Employee #149) at 9:30 a.m. on 02/01/11, she produced a manila envelope of materials about various types of chairs (including BRODA) that she had ordered in an attempt to prevent Resident #62 from overturning his chair. She stated several interventions had been tried without success (including a helmet), but as he was not currently a therapy patient (he was discharged from rehabilitative services on 11/01/10), she had kept no record of these actions and had no input into his current care plan. When asked about the use of the beanbag chair for Resident #62, Employee #149 stated beanbag chairs were used for extremely agitated residents who were thrashing about, to prevent their harming themselves by hitting the chair or turning over. Employee #149 further stated the use of this chair had been considered for Resident #62 and was ruled out, because of the curvature of his back from an old injury (which meant he needed extra support). When she was told of the surveyor's observations of Resident #62 in a beanbag chair, she expressed surprise and stated there was only one (1) resident in the facility with an order for [REDACTED]. -- 5. Review of the facility's Operational Policy and Procedure Manual for Restraints found: Policy Interpretation and Implementation 1. '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 restricts normal access to one's body. 7.d. The Director of Nursing Services or designee has the authority to order the use of emergency restraints. The Attending Physician must be notified of such use and the reason for the order. 7.e. Orders for emergency restraints may be received by telephone, and shall be signed by the physician within forty eight 48) hours. 9. Restraints shall only be used upon the written order of a physician and after obtaining consent from the resident and/or representative (sponsor). 17. Care plans for residents in restraints will reflect interventions that address not only the immediate medical symptom(s), but the underlying problems that may be causing the symptom(s). 18. Care plans shall also include the measures taken to systematically reduce or eliminate the need for restraint use. -- 6. Review of Resident #62's current care plan revealed an entry, dated 07/02/10, stating, Belt restraint in chair for safety. Also has PRN (as needed) order for Velcro postural vest. This same information was also on the Life Skill Sheet (caregiver instruction sheet). The belt restraint was noted to be in place while he was in the positional chair, on several observations during the survey. -- 7. A review of the physician's orders for Resident #62 revealed the following restraint orders: Resident to be up in blue positioning chair with safety belt (in upright position) when out of bed. Check Q (every) 30 min for positioning and breathing checks. Q 2 hr (every 2 hours) releases for ambulation, bathroom, meals, skin inspection etc. NOC AM PM (night, morning, and evening). Notify Staff. Dx: resident with dementia causing him to be unaware of risk of injury by getting up unassisted, tipping chair and falling from chair. There was no physician's order or care plan for the use of the beanbag chair. There was no PRN order for the use of [REDACTED]. While the care plan recognized the use of the positional chair and the belt restraint and established a goal related to restraint use, there were no interventions for the use of restraints with this resident, as required by the facility policy. -- 8. During an interview with the director of nurses (DON), the administrator, and a registered nurse (RN) supervisor (Employee #28) at 4:20 p.m. on 02/01/11, the above findings were reviewed, and the DON expressed surprise that there were no restraint orders or care plan for Resident #62, stating she would review his record and follow-up with this surveyor. The administrator stated that beanbag chairs are never used without a physician's order. No additional information had been presented prior to this surveyor's exit on 02/02/11.",2016-01-01
9550,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,221,D,0,1,5V2011,"Based on random observation and staff interview, the facility failed to assure each resident was free from physical restraints imposed for staff convenience. Facility personnel allowed a chair alarm to become a physical restraint for one (1) resident of random opportunity. Resident identifier: #32. Facility census: 157. Findings include: a) Resident #32 On 11/17/09 at 4:25 p.m., this resident was observed seated in front of Building 2's nursing station. At 4:26 p.m., the resident began rising from the wheelchair, and an alarm sounded. Employee #7 ( a licensed practical nurse - LPN) immediately looked up and across the nursing station. She loudly said, Ah! Ah! Sit back in your chair! Employee #7 did not attempt to ascertain why the resident wanted up and did not direct anyone else to attempt to determine his needs. Directing the resident to sit down, instead of ascertaining the resident's needs when an alarm sounds, results in that alarm becoming a restraining device for that resident. This information was provided to the director of nursing (DON - Employee #165) at 4:35 p.m. on 11/17/09. At that time, the DON confirmed that staff should have asked the resident what he needed instead of telling the resident to sit back down.",2015-10-01
10226,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,221,D,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to assure residents were free from physical restraints imposed for the convenience of staff and not to treat a medical condition for one (1) of twenty-nine (29) Stage II sample residents. Resident #53 was admitted to the facility on [DATE]. On 04/17/10, staff applied four (4) half side rails to Resident #53's bed, with full-length side rail pads over each set of half rails on either side of Resident #53's mattress. On 04/20/10, Resident #53 was found on the floor after having climbed over the side rails. Subsequently, Resident #53 was noted to attempt on multiple occasions to exit the bed and/or throw his legs over the side rails. The facility failed to identify the use of these sets of half side rails with full-length pads as a physical restraint, failed to develop a plan for the systematic and gradual reduction of the use of these devices as a physical restraint (to ensure the resident's safety), and failed to re-evaluate the use of these devices once they presented a safety hazard to Resident #53. Facility census: 48. Findings include: a) Resident #53 Observation, at 8:00 a.m. on 06/03/10, found Resident #53 in bed with two (2) half rails up on each side of his bed. He also utilized full-length pads that covered both sets of half rails on either side of his mattress running from the head to the foot of the bed. His bed was in the lowest position possible, but this was not a ""low bed"" near the floor. There were no safety mats on the floor on either side of the bed. -- Record review revealed this resident was admitted to the facility on [DATE]. A bed safety assessment, completed on the day of admission, indicated the need for two (2) upper half rails for bed mobility. On the following day (04/17/10), a pre-restraint assessment stated, ""A telephone consent was obtained from the responsible party for 4 half rails with 2 long pads since this was considered a restraint."" There was no evidence to reflect the facility had considered the risks and benefits associated with the use of these devices (including the risk for injury or death) for a resident who attempts to exit the bed by climbing over the side rails. Documentation on the pre-restraint assessment identified no members of the interdisciplinary team (IDT) were present at that time the assessment was completed, because it was Saturday. There was no evidence that the IDT reviewed this issue when they returned on Monday. A nursing note, dated 04/20/10, stated, ""Resident found in floor in room had crawled over bed rails, no injuries noted. ..."" Staff identified that the bed alarm also in use at that time was not working properly, but the IDT did not address the issue of the resident climbing over the side rails. -- Review of the resident's care plan, dated 04/29/10, found the side rails were listed as an intervention to prevent falls. The care plan did not identify the use of these sets of half rails with full-length pads as a physical restraint. There was no evidence to reflect the IDT had discussed, or addressed in his care plan, the issue of this resident having climbed over the side rails on 04/20/10 (several days before the care plan meeting was held), nor was there evidence to reflect efforts by the IDT to identify the reason(s) why the resident was attempting to exit the bed. There was also no plan for the systematic and gradual reduction of the use of these devices (which functioned as physical restraints) as required. -- Further review of Resident #53's medical record found he continued to attempt to exit his bed over the side rails. A nursing note, dated 05/30/10, indicated the resident had frequent episodes of staying awake on night shift (11:00 p.m. to 7:00 a.m.). This note also indicated the resident was attempting to climb out of bed, noting that he would pull himself close to the side rails when he was in bed and put his legs over the side rails. -- During an interview with the assessment nurse (Employee #16) at 3:00 p.m. on 06/03/10, she reported Resident #53 had used side rails since his admission. She stated he was due for a re-evaluation, and they would look at them (the side rails) again, because he was walking better now. When questioned at that time about other safety interventions to prevent falls from bed or to lessen injuries related to falls (e.g., a bed lower to floor level, a different type of mattress, pads on the floor beside the bed, etc.), she could not provide evidence that alternatives to the side rails had been attempted. When asked about the use of low beds close to the floor, she stated they had tried these in the past, but the families did not like them. She was aware of the resident climbing over the bed rails, but she reported he had only climbed over the rails and fallen one (1) time. -- On 06/04/10, Employee #16 produced evidence of a re-assessment for the use of side rails. This documentation identified that the family was notified and agreed with the recommendation to use only the upper half rails and to put Resident #53 on an exercise plan. .",2015-06-01
10430,NELLA'S INC.,51A010,399 FERGUSON ROAD,ELKINS,WV,26241,2010-01-20,221,E,0,1,Z0GS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, observation, and record review, the facility failed to assure physical restraints were being used only for treatment of [REDACTED]. Resident identifiers: #87, #59, #48, #79, #32, and #3. Facility census: 93. Findings include: a) Resident #87 A review of Resident #87's medical record revealed an [AGE] year old male with [DIAGNOSES REDACTED]. The medical record also contained a physician's orders [REDACTED]. During an interview with a licensed practical nurse (LPN - Employee #49) at 3:00 p.m. on 01/13/10, she stated the resident was restless, rocked back and forth in the wheelchair even when it was still, and liked to keep moving. She stated the seatbelt restraint did keep him from getting out of the chair. She did not recall that any other type of restraint had ever been tried. The restraint had been in use since 10/03/08. A review of the record failed to disclose that an assessment had been completed prior to the use of the restraint, to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint was to treat a medical symptom. The resident was observed in his wheelchair with the seatbelt in place at 3:00 p.m. on 01/13/10 and at 1:00 p.m. on 01/19/10. A review of the fourteen (14) page care plan, which was last reviewed and revised by the facility on 01/06/10, failed to reveal any plan, goal, or nursing interventions to ensure the appropriate use of the seatbelt restraint to maintain the resident's highest practicable physical and psychosocial well-being. During an interview with the director of nursing (DON), the social worker, and a nurse (Employee #16) at 10:25 a.m. on 01/20/10, Employee #16 acknowledged that restraint use had been left out of the care plan and stated they would attempt to locate an assessment done prior to the use of the restraint, but at the time of exit, none had been presented. b) Resident #59 A review of Resident #59's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. At present, the resident had a ""soft belt"" when up in the wheelchair, because she attempted to stand and/or ambulate without staff assistance. The use of this device was addressed in the care plan last reviewed and revised by the facility on 01/15/10. The care plan indicated that, in the past, both a trunk restraint and a Merry Walker were tried without success, but there was no evidence in the record that an assessment was made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #16 and #41 (both nurses) at 10:25 a.m. on 01/20/10, the social worker stated an assessment was described in the care plan, but no specific assessment was completed when the physician ordered a restraint. Employee #41 stated their risk management consultants, who had been present in the facility earlier in the week, had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. c) Resident #48 A review of Resident #48's medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. She had a history in the facility of falls and wandering. Resident #48 was observed at 11:00 a.m. on 01/14/10, at 1:30 p.m. on 01/19/10, and at other times during the survey, in her wheelchair with a seatbelt in place, moving herself about in the facility. A review of the record revealed no evidence that an assessment had been made prior to restraint use to determine the presence of a specific medical symptom requiring the restraint, and there was no indication in the record of how the restraint would treat a medical symptom. During an interview with the DON, the social worker, and Employees #41 and #16 at 10:25 a.m. on 01/20/10, they acknowledged Resident #48 did have a seatbelt and that the facility had not been doing assessments prior to restraint use, but they related their risk management consultants had recommended they do monitoring of the residents with restraints, and they had already begun this and presented examples of this monitoring. The monitoring did not include a prior assessment. d) Resident #79 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the minimum data set (MDS) assessments dated 07/07/07, 10/07/09, and 01/07/09. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. It was dated 04/23/08. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated, ""He is confused and unable to understand. He does not know to stop fiddling with his belt."" The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint resident assessment protocol (RAP) did not trigger for further assessment. e) Resident #32 Observation, at 2:30 p.m. on 01/11/10, revealed this resident was wearing a self-release belt while in his wheelchair. This device was observed attached to the resident, while in the wheelchair, throughout the survey. Medical record review, on 01/19/10, revealed the resident was ordered the device as a safety device. The device was not identified as a restraint in the medical record and was not identified as a restraint on the significant change MDS dated [DATE], or the quarterly MDS dated [DATE]. A document entitled ""Release of Physician and Nursing Home"" was in the medical record. This document was signed by the responsible party and released the facility from responsibility regarding the use of the device. It was not a consent for the use of the device. In addition, this document did not describe the specific device and/or its risks and benefits for the resident. Interview with the restorative nurse, at 1:00 p.m. on 01/19/10, revealed the facility did not consider the device a restraint, because it was a self-releasing device. The nurse stated the resident was confused and did not understand the use of the belt. The resident's confusion was confirmed during medical record review. There was no identification of a specific medical symptom that would require the use of a restraint and /or how the use of a restraint would best treat a medical symptom, protect the resident's safety, and assist the resident in attaining or maintaining his highest practicable level of physical and psychosocial well being. There was no evidence of interventions prior to the use of a restraint, no evaluation for the need for the restraint, no evidence the type of restraint the resident might require was assessed, and no care planning regarding restraint reduction. Since the facility did not consider the device a restraint, it was not identified as such on the MDS. Therefore, the physical restraint RAP did not trigger when the significant change MDS was completed on 09/26/09. f) Resident #3 Review of the medical record for Resident #3 revealed no evidence of a consent for use of a physical restraint which described the potential risks and benefits of restraint options under consideration and potential negative outcomes. Review of the medical record found no evidence of specific pre-restraint assessment. Review of the physical restraint RAP, dated 01/22/09, revealed no mention of the use of bilateral full length siderails which this resident used daily while in bed, although it did note the use of a trunk restraint, specifically a soft belt restraint when up in the wheelchair. Although a physical therapy evaluation was ordered by the physician, with a subsequent order dated 01/12/10 for occupational therapy (OT) five (5) times per week for four (4) weeks, the current care plan (as copied by facility staff and provided to the surveyor on 01/20/10) did not reflect the physician's orders [REDACTED]. During an interview with the DON and other facility staff on 01/20/10 at 10:30 a.m., findings related to restraint use were discussed. At this time, it was found that new forms related to restraint use were recently ordered by the facility and may soon be utilized. .",2015-04-01
10493,MILETREE  CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2011-11-23,221,D,1,0,BCGW11,"Based on medical record review, staff interview, and facility policy review, the facility failed to assure a physician's order to restrain Resident #57 contained clear and specific parameters for the use of the restraint. The order was also in conflict with the facility's own restraint policy. This was true for one (1) of nine (9) sampled residents reviewed for the complaint survey conducted on 11/21/11. Resident identifier: #57. Facility census: 60. Findings include: a) Resident #57 Medical record review revealed a physician's order on 09/16/11 for, ""intermittent soft limb restraints during procedures when resident is combative with risk of injury to self or others in the presence of a licensed nurse."" Review of the nurses' notes found only one (1) entry, written on 09/16/11, ""Received signed understanding restraint use form from MPOA (medical power of attorney). Spoke with Dr. (name of physician) and new order obtained to use intermittent soft limb restraints. MPOA in agreement with new order."" Further review of the nurses' notes found a note from the resident's care plan meeting held on 09/14/11. The note contained the following quoted documentation: "". . . During this meeting the IDT (interdisciplinary team) contacted MPOA regarding resident's weight, skin, behaviors, combative and aggressiveness. Explained resident's kicking, scratching, biting, etc. which resident does when care is provided as well as medication vs. (verses) soft restraint use during these times. Risk vs. benefit of each type of intervention (medication, soft restraints etc.) were explained to MPOA. MPOA in agreement with the use of soft restraints as medications have caused sedation in the past when trialed (sic). Consent form to be faxed to MPOA for signature and fax back to facility today. Upon receipt of consent MD (doctors) order will be obtained for the use of intermittent soft restrains during procedures in which resident is combative with risk of injury to self or others. Will continue to observe."" Further review of the medical record found soft limb restraints were used to straight catheterize the resident for the purpose of obtaining an urine culture on three (3) occasions: 10/21/11, 10/26/11 and 11/20/11. The director of nursing was interviewed on the morning of 11/22/11 and stated the soft restraints were only used to obtain urine cultures when the resident exhibited signs and symptoms of an urinary tract infection. She further stated the restraint was the only means to obtain the urine as the resident is incontinent of urine and uncooperative when being catheterized. At 4:30 p.m. on 11/22/11, Employee #28, a registered nurse on the resident's unit, was asked about the physician's order to use soft limb restraints. She stated the restraints were, ""Just for the things that absolutely have to be done."" When ask for specific examples of what has to be done, she replied, ""catheterize and brief changes."" Review of the facility's policy and procedure for the use of restraints found: -- the physician's order must specify the specific medical symptom present for the use of a restraint and the frequency of use and release time, and -- ""...PRN (as needed) or transfer orders are not acceptable."" It is true restraints can be used for brief periods to permit medical treatment as a last resort to protect the safety of the resident. However, before a resident is restrained, the facility must determine the presence of a specific medical symptom that would require the use of a restraint and how the use of the restraint would treat the medical symptom and protect the resident's safety. The current physician's order did not specify the specific, ""procedures,"" for which a restraint could be used for this resident. The order violated the facility's policy and procedure by directing the intermittent use of the restraint, the failure to specify the medical symptom for the use of the restraint, and the frequency of use and release time.",2015-03-01
10648,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2009-08-27,221,D,0,1,W65Z11,"Based on observation, record review and staff interview, the facility failed to assure side rails were used on residents only after being properly assessed for the necessity of these devices. A staff member was observed putting up full length side rails when Resident #4 was sleeping. It was indicated in the medical record that this resident did not require the use of bed rails on her bed. Applying these devices for a resident when there is no indication for their use was observed for one (1) of fifteen (15) sampled residents. Resident identifier: #4. Facility census: 59. Finding include: a) Resident #4 During an observation of Resident #4 on 08/26/09 at 4:00 p.m., Employee #34 put up bilateral full length side rails on the bed of this resident. Review of the medical record revealed a physician's order for a lateral support when the resident was up in the chair because she had a tendency to lean to the side. However, there was no physician's order to utilize side rails for this resident. Further review of the medical record found a bed safety assessment completed on 12/14/08. This assessment indicated no rails were present on this bed and there was no indication for side rail use for this resident. The director of nursing (DON), when questioned about the use of side rails for this resident on 08/26/09 at 5:00 p.m., confirmed there was no indication for this resident to utilize side rails. .",2015-01-01
11113,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2011-04-01,221,D,1,0,0DKH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, medical record review, staff interviews, and review of the State Operations Manual (Appendix PP - Guidance to Surveyors), the facility failed to assure one (1) of three (3) sampled residents was free from physical restraints imposed for the purpose of convenience and not required to treat the resident's medical symptoms. Resident identifier: #65. Facility census: 84. Findings include: a) Resident #65 Review of facility documents found a former quality aide (QA - Employee #0) reported Resident #65 had been restrained in her bed by the use a of tightly tucked blanket / sheet at approximately 9:00 p.m. on 03/10/11. Review of Resident #65's medical record found no evidence the treating physician ordered the resident to be restrained while in the bed. Further review of the medical record found a minimum data set (MDS) with an assessment reference date (ARD) of 01/17/11. Review of this MDS revealed this [AGE] year old resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She was assessed as having long and short term memory problems and difficulty focusing attention with disorganized thinking, and she displayed moderately impaired cognitive skills for daily decision making with noted delusions. She is always incontinent of bowel and bladder. She required one person physical assistance with bed mobility, transfers, dressing, eating, personal hygiene and total assistance with bathing. -- The following interviews were conducted with former and current staff: 1. Employee #0 (a QA) Employee #0 was interviewed at 9:59 a.m. on 04/01/11. She stated she was working the evening shift on 03/10/11 at approximately 9:00 p.m., when she walked past Resident #65's room and heard her call out ""Baby Doll"". Employee #0 stated she entered the resident's room to determine if the resident was trying to get up or had fallen. She noticed Resident #65 was lying on her back and was trying to raise her upper body but could only lift up about a foot. When she looked closer, she saw the resident's sheet and blanket was ""really tight"" across her abdomen. She reported this to Employee #65, a medical records clerk. 2. Employee #65 (medical records clerk) Employee #65 was interviewed at 3:19 p.m. on 03/30/11. She stated she worked late on the evening of 03/10/11 when, at about 9:30 p.m., Employee #0 approached her and told her she needed to check Resident #65, as the QA believed the resident was being restrained. Employee #65 went into Resident #65's room and noticed the resident was lying on her back on the bed. Employee #65 described walking over to the resident's bed and pulling on the blanket beneath her breast area, which appeared to be tight. She stated she was only able to move the blanket about an inch from the resident's body. She stated she reported the resident's condition to the charge nurse, a licensed practical nurse (LPN - Employee #93). 3. Employee #93 (an LPN) Employee #93 was interviewed at 8:45 a.m. on 03/31/11. She stated that, at approximately 9:15 p.m., Employee #65 requested her to come and look at Resident #65, that she was tied to her bed. Employee #93 described that, when she entered the resident's room, she noted a thin white blanket was tucked tightly under the resident's mattress. She left the room to get assistance from Employee #22, a certified nursing assistant (CNA). She stated both she and Employee #22 had to rip the blanket to get it off the resident. 4. Employee #4 (a QA) Employee #4 was interviewed at 4:43 p.m. on 03/30/11. She stated that, two or three days before 03/10/11, she and another QA were in Resident #65's room with a CNA (Employee #25). She stated Employee #25 showed them that the resident's sheet was tucked between the mattress and the bed frame. She relayed that Employee #25 stated, ""This is why (Resident #65) isn't getting up."" Employee #4 stated the QAs were required to watch Resident #65, because she would try to stand up / get up when she is in her bed and would fall. She stated it was really hard to pass ice and snacks and also have to watch this resident. 5. Employee #47 (the social worker) Employee #47, the social worker for the facility, was interviewed on the afternoon of 03/31/11. She stated she saw the blanket that had been removed from Resident #65's bed. She described two (2) jagged tears on two (2) of the corners of the resident's blanket. 6. Employee #25 (a CNA) Employee #25 was the CNA assigned to care for Resident #65 on the evening shift on 03/30/11. He was the only aide assigned to the resident's hallway. He was interviewed at 5:04 p.m. on 03/31/11. He denied restraining the resident by tightly tucking the blanket or sheet under the resident's mattress. 7. Employee #68 (a CNA) An interview with Employee #68 was conducted at 6:54 p.m. on 03/30/11. She stated that, on the evening shift on 03/30/11 after the 9:00 p.m. bedcheck, Employee #22 told them they were not to ""tie nobody up, restrain nobody, tie the covers or tuck them in until they can't move"". When Employee #68 asked Employee #22 why they were being told this, she stated Employee #22 informed her they had to rip the two (2) corners of the sheets to get Resident #65's covers loose. -- The facility obtained a statement from Employee #22, a CNA who worked night shift aide on 03/11/11. Her statement concurred that Resident #65's sheet was tucked tightly under the mattress. (This individual was not available to be interviewed by the surveyor.) -- Review of the State Operations Manual, Guidance to Surveyors, F221, found examples of restraints included, ""... Tucking in or using Velcro to hold a sheet, fabric, or clothing tightly so that a resident's movement is restricted..."". .",2014-08-01
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
1509,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2017-10-13,222,D,0,1,UMXO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review, the facility failed to ensure residents were free from chemical restraints imposed for purposes of discipline or convenience, and not required to treat the resident's medical symptoms for one (Resident #1) of five ( 5) residents reviewed for the care area of unnecessary medication during Stage 2 of the Quality Indicator Survey (QIS). The use of an [MEDICAL CONDITION] ([MEDICATION NAME]), used to treat anxiety, to be given two (2) times a week prior to showers was for staff convenience and not to treat Resident #1 medical condition. Resident identifier: #1. Facility census: 32. Findings include: a) Resident #1 Review of Resident #1's medical record, on 10/11/17 at 10:05 a.m., revealed she was a [AGE] year old female admitted on [DATE] with the following Diagnoses: [REDACTED]. Record review of Resident #1's quarterly MDS 3.0 (Minimum Data Set), dated 08/24/17, revealed she was unable to complete the interview for the BIMS (Brief Interview for Mental Status), indicating severe cognitive impairment. Record review of Resident #1's care plan with a revision date of 11/30/16 revealed a Focus for the Resident to receive: --[MEDICAL CONDITION] medication for [MEDICAL CONDITION] and obsessive behavior as evidenced by demanding, pushing, hitting, yelling, agitation with bathing, hoarding, social withdrawal and shoving; --[MEDICATION NAME] for depression as evidenced by social withdrawal; --[MEDICATION NAME] for physical agitation; and --[MEDICATION NAME] for agitation during showers. The care plan (dated 11/30/16) revealed a Goal for the Resident's use this medication will result in maintenance in the residents functional status as evidenced by no known increase in behaviors. The care plan (dated 11/30/16) revealed the following Interventions: --[MEDICATION NAME] one (1) milligram (mg) on Tuesdays and Fridays one (1) to two (2) hours prior to bathing (showers); hold if lethargic. --Assess and record effectiveness of drug treatment. --Monitor and report signs of sedation, [MEDICATION NAME] and/or extrapyramidal symptoms. --Attempt non-pharmalogical interventions for negative behaviors (family phone calls, music, reading, crafts, etc.). --Monitor for negative medication side effects (constipation, [MEDICAL CONDITIONS], sleepiness and dizziness). --Monitor residents behaviors and response to medication and document on behavior monitoring sheets. Monitor resident's functional status. --Pharmacy consultant review. Review of Resident #1's computerized Physician order, reveals an order dated 12/07/16, [MEDICATION NAME] 1 mg tablet by mouth. Give one (1) hour before bathing (hold if lethargic. Bath (shower) days are Mondays and Thursdays, re: to decrease physical agitation associated with bathing (showers) causing risk of injury to self and others. Review of Resident #1's Nurses' Notes from 02/16/17 through 03/21/17, found no documentation concerning behaviors. No nurse's notes from 03/21/17. On 09/21/17 at 12:00 p.m. the note read: Small surface cut noted on resident's chin, hospice nursing assistant stated that it happened when she had her in the shower that resident was hitting at her and hit the razor. No further nurse's notes noted after 09/21/17. Resident #1's Behavior/Intervention Monthly Flow Record completed by the licensed nurses from 01/01/17 through 10/11/17, found no behaviors documented. Additionally, review of the nursing assistants documentation on the Activities of Daily Living sheets from 01/17/17 through 10/11/17, found it was marked with a 0; which indicates no behaviors occurred. Observations from 10/09/17 through 10/12/17, found resident lying in bed with eyes closed: --10/09/17 at 3:15 p.m. --10/10/17 at 11:05 a.m. --10/10/17 at 11:20 a.m. --10/10/17 at 2:15 p.m. --10/11/17 at 10:30 a.m. --10/11/17 at 2:00 p.m. --10/12/17 at 1:05 p.m. In an interview on 10/12/17 at 1:15 PM with the Director of Nursing (DON), confirmed the [MEDICATION NAME] was being used twice weekly due to the residents severe agitation during showers. Review of the nurses' notes, nurse aide documentation and the behavior/intervention flow record with the DON found no behaviors noted from 01/01/17 through 10/11/17, except on 09/21/17 when Resident #1 was being given a shower by the hospice nursing assistant. No further information was provided.",2020-09-01
6677,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2014-10-01,222,D,0,1,KBHF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and record review, the facility failed to ensure one (1) resident (#89) was free from a chemical restraint imposed for purpose of staff convenience. The resident was given [MEDICATION NAME] when he exhibited behaviors, without non-pharmacological interventions being attempted first. This affected one (1) of five (5) residents investigated for the use of unnecessary medications. The Stage 2 sample was 36. Resident identifier: #89. Facility census: 87. Findings include: a) Resident #89 Review of the clinical record revealed Resident #89 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS) assessment, dated 07/29/14, revealed Resident #89 was moderately cognitively impaired, unable to make himself understood and was rarely able to understand others. Resident #89 was documented as requiring the extensive assistance of two staff for bed mobility, transfers and walking had not occurred during the assessment period. The MDS documented the resident had experienced a fall with injury and a limb restraint was being utilized daily. This MDS also documented Resident #89 had exhibited behaviors such as hitting, kicking, pushing, or grabbing 1-3 days a week and rejected care 1-3 days a week during the assessment period. Review of the admission physician orders [REDACTED]. The current care plan, dated 07/24/14, was silent to the behaviors noted on the MDS dated [DATE] that were exhibited by Resident #89 since his admission on 07/16/14 such as hitting, kicking, pushing, or grabbing at staff. This care plan was also silent to use of any anti-anxiety medication to be used as needed for Resident #89 when he exhibited anxious behavior. Review of the nursing notes revealed the following interventions for Resident #89: -- On 07/22/14 at 6:07 a.m., Resident #89 was very agitated and aggressive and would not sit still in his Broda chair (a chair with straps around his legs to prevent him from rising). The nursing notes revealed the nurse administered [MEDICATION NAME] 5 milligrams at that time. There was no evidence the staff attempted any non-pharmacological interventions prior to administering the anti-anxiety medication. -- On 07/30/14 at 3:16 a.m., Resident #89 was observed to be raising himself up off of his Broda chair and again [MEDICATION NAME] 5 milligrams was administered. There were no non-pharmacological interventions attempted prior to administering the anti-anxiety medication. -- On 08/10/14 at 7:30 p.m., Resident #89 was noted to be anxious and attempting to stand up in the Broda chair and was being uncooperative with his care. The nursing notes documented the nurse administered [MEDICATION NAME] 5 milligrams at that time with no non-pharmacological interventions attempted. -- On 08/20/14, Resident #89 was again very anxious, agitated, combative with care and attempting to get out of his Broda chair. The nursing notes revealed [MEDICATION NAME] 5 milligrams was given with no non-pharmacological interventions attempted prior to giving the resident this anti-anxiety medication. An interview with Licensed Practical Nurse (LPN) #2 on 09/25/14 at 2:00 p.m., revealed Resident #89 was often very restless in the Broda chair and would often attempt to get up out of the chair. She stated he was a big eater and when he became restless, the first thing she did was to attempt to calm him with a snack. LPN #2 stated he would often calm down for her with this intervention and no medication was required. She stated there was a form in the computer the nurses were required to document on when residents exhibited disruptive behavior. Review of this form revealed a list of things that should be tried before administering an anti-anxiety medication. These interventions included things such as conducting a pain assessment, provide hydration or nutrition, ambulation, positioning, and verbal calming. There was no evidence any of these interventions were attempted prior to the administration of the anti-anxiety medication [MEDICATION NAME] on 07/22/14, 07/30/14, 08/10/14, and 08/20/14 when Resident #89 was attempting to exit the restraint of the Broda chair. During an interview on 09/25/14 at 2:55 p.m. with Director of Nursing (DON) #107 and Assistant Director of Nursing (ADON) #30, they both verified staff should not be utilizing anti-anxiety medication as an intervention to attempt to keep Resident #89 in his chair and that prior to the administration of an as needed anti-anxiety medication, the nurses were required to assess the resident and attempt non-pharmacological interventions.",2017-12-01
10609,"MONTGOMERY GENERAL HOSP., D/P",515081,WASHINGTON STREET AND 6TH AVENUE,MONTGOMERY,WV,25136,2011-09-30,222,D,1,0,0VZD11,"**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 eight (8) sampled residents had the right to be free from chemical restraints. This resident was given a medication to control behaviors for staff convenience and not to treat identified medical symptoms. The medication was used without assessing possible causes for the resident's behavior and/or without first attempting non-pharmacological interventions. The medication was used as a means of managing the resident's behaviors with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. Resident identifier: #41. Facility census: 38. Findings include: a) Resident #41 Closed medical record review, on 09/28/11, revealed this resident was admitted to the facility on [DATE]. The resident was determined to possess the capacity to understand and make informed health care decisions in May 2011. According to the medical record, the resident was very upset on 06/06/11, because a nurse cleaned her dresser drawers, threw away some newspapers, and sent some soiled clothing to the laundry. There was no evidence that staff had obtained her permission to go through the resident's personal belongings when cleaning her room. Instead, all evidence suggested the resident was told, after the fact, why it was done. On 06/07/11, nurse's notes described the resident continued to be upset about her room being cleaned and her possessions being thrown away. Additionally, nurse's notes indicated the resident continued to be angry and agitated up to and including 06/10/11. On 06/10/11, nurse's notes described the resident was agitated about the change in her medications and refused to take them. At 20:00 (8:00 p.m.), a telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". At 20:10 (8:10 p.m.), when staff attempted to give the injection to this resident, the resident screamed, ""You're not giving me no shot."" The resident was walked to her room, all the while screaming ""No, no, no."" Nurse's notes described the resident as ""shaking all over"" and continued to scream as two (2) nurses assisted each other in giving the resident the injection in her left hip. According to the social worker's notes dated 06/07/11, the resident stated she did not like to take her medications because ""she does not like how it makes her feel."" It should be noted that [MEDICATION NAME] was one (1) of the medications the resident had refused to take by mouth. Nurse's notes, on 06/13/11 at 05:55 (5:55 a.m.) revealed another telephone order was obtained for ""[MEDICATION NAME] 1 mg IM now"". Nurse's notes continued with, ""... Unable to give resident shot. Became very agitated and belligerent and defensive. Not enough staff available @ this time to assist. She refuses to have [MEDICATION NAME]."" This resident was given [MEDICATION NAME] for staff convenience. It was used without assessing possible causes for the resident's behavior and without evidence of attempts at planned and individualized non-pharmacological interventions, prior to the decision to use a medication. The facility used medication as a means of managing the resident's behavior with a lesser amount of effort by facility staff, and not because the medication was in the resident's best interest. As such, this resident was chemically restrained. Interview with the acting director of nursing (DON - Employee #171), at 10:30 a.m. on 09/29/11, confirmed this resident should have been afforded the right to refuse the [MEDICATION NAME], and staff violated the resident's rights when they did not allow the resident to refuse the injection of [MEDICATION NAME] on 06/10/11. Employee #171 also confirmed staff should have tried non-pharmacological interventions, and she confirmed there was no evidence that staff had attempted any non-pharmacological approaches prior to the decision to use a medication to control the resident's behaviors. .",2015-01-01
10829,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2011-08-16,222,D,1,0,XG6O11,"**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 six (6) sampled residents was free of chemical restraints. Staff administered to Resident #67 an antipsychotic medication ([MEDICATION NAME]) via intramuscular injection (IM) for agitation without evidence of having first ruled out causal factors (e.g., pain, other sources of discomfort, environmental factors, etc.). [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for being uncooperative with staff and cursing. [MEDICATION NAME] 5 mg IM was given again on 03/26/11 at 11:42 p.m. for yelling ""Help"", cursing, and being physically abusive toward staff. The resident had physician's orders [REDACTED]. The [MEDICATION NAME] IM was used to control the resident's behavior, which required a lesser amount of effort by the staff and was not in the resident's best interest. Resident identifier: #67. Facility census: 66. Findings include: a) Resident #67 Medical record review disclosed this [AGE] year old male resident, who was initially admitted to this facility on 02/21/11, had medical diagnoses that included multiple [MEDICAL CONDITION] with [MEDICAL CONDITIONS], diabetes, hypertension, [MEDICAL CONDITION] of the prostate with metastasis, dementia, gangrenous changes in his extremities, Stage 2 pressure ulcer on the coccyx, and recent bouts with pneumonia. Review of the multidisciplinary notes disclosed the resident had been sent out to the hospital for acute medical problems and returned to the facility on [DATE]. The notes revealed that, shortly after returning to the facility, the resident began exhibiting behaviors of verbal and physical abuse toward staff and other residents at times. The notes also disclosed the resident was confused, non-ambulatory, and required assistance for most activities of daily living. Review of physician's orders [REDACTED]. In addition, [MEDICATION NAME] 0.5 mg PO (by mouth)/IM BID (twice daily) had been given on 03/16/11. Further review of multidisciplinary notes found [MEDICATION NAME] 5 mg IM was given on 03/26/11 at 12:58 a.m. for the resident being uncooperative with staff and cursing. The multidisciplinary note stated (quoted as written): ""Resident has been uncooperative cursing and call staff names and slapping at staff, tried to talk and redirect him to no avail. Gave syrexia 1ml. injection, into lt. gluteus.at 12:05AM.at 1:05AM resident calm asleep.will continue to check and monitor."" [MEDICATION NAME] IM was given again on 03/26/11 at 11:42 p.m. for yelling ""Help"", cursing, and being physically abusive toward staff. The multidisciplinary note stated (quoted as written): ""Resident yelling at top of his voice 'HELP' went to room he started calling this nurse names and cusing at me explained it was night time he did nt have to yell others were tring to sleep 'Hell they are they arent asleep you .....' started to kick and hitting this nurse about face and kicked me in the stomack. gave syprexa 5 mg. injection into RT. gluteus at 11:30 p.m."" Review of the March 2011 Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Review of the resident's care plan, developed on 03/15/11, found it addressed the resident's behaviors of cursing at staff and combative / threatening behaviors. Interventions included to always ask for help if the resident became abusive / resistive and remove from public area when behavior was unacceptable. Review of multidisciplinary notes found no documentation indicating these interventions in the care plan were used before giving the resident antipsychotic drugs for which he had no diagnosis. There was also no intervention to assess the resident for pain or discomfort as a possible underlying cause of the behaviors. In an interview on 08/15/11 at 3:30 p.m., the director of nursing (Employee #6) confirmed the use of [MEDICATION NAME] IM was not appropriate. .",2014-12-01
165,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-06-20,223,E,1,0,HCKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of reported allegations, resident interview, staff interview, family interview, staffing records, policy review, and personnel record review; the facility failed to protect residents after an allegation of abuse for one (1) of five (5) allegations reviewed. This practice affected one (1) resident but had the potential to affect more than a limited number of residents. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., had verbalized the facility completed annual training in-services, and had one scheduled for Wednesday, 06/21/17, related to abuse and neglect. The nurse said the LPN's role was to tell the director of nursing (DON) and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. LPN #66 said if the alleged perpetrator was an employee, the person would not be allowed to work with the involved resident. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked day shift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured Resident #1 was placed back in bed. NA #79 verbalized during the interview, that she went back into the room and apologized for what had happened. The nurse aide said Resident #1 did not exhibit behaviors, was very sweet person. The NA said the resident's routine was to toilet and lay down. The resident would get up fifteen (15) minutes before meals. The NA voiced she thought the family member had talked to the facility about it. The Kardex report noted Resident #1 required assistance of two (2) persons for all transfers. The care plan indicated the resident required extensive assistance (weight bearing assistance) from staff for toileting. The care plan also indicated Resident #1 was at risk for chronic pain related to the [DIAGNOSES REDACTED]. The interventions section noted the resident was able to call for assistance when in pain, ask for medication, and tell staff how much pain was experienced. Resident #1, interviewed on 06/20/17 at about 12:30 p.m. ,was in bed, lying on left side, awake and alert. The resident verbalized that staff sometimes puts her down too hard when putting her back in bed. Resident #1 said when she had a concern she told her daughter and the daughter talked to the facility. Family Member (FM) #1, interviewed at 12:48 p.m., verbalized she had not made a formal complaint because her mother was confused as to dates and times, FM #1 said the resident told someone said, Well, that was totally unnecessary to another staff person when performing care. She said she informed RN#73 last week about Resident #1's concerns, but did not file a formal complaint because she did not know if it was true. The minimum data set (MDS) with an assessment reference date (ARD) of 04/28/17 indicated Resident #1 had a brief interview for mental status (BIMS) score of 08 which indicated moderate cognitive impairment. During another interview with the assistant administrator, at 1:10 p.m., she voiced the LPN started the investigative process, filled out forms, notified the charge nurse called the social worker so there was no lag time. The administrator verbalized that she, the director of nursing, and the social worker were out of the building last week. When asked who was in charge, she said Administrator #10, whatever charge nurse, and RN #71. RN #71, interviewed at 1:17 p.m., voiced FM #1 had spoken to her on Monday (06/19/17) about an incident that happened concerning one of the aides, but did not know whether or not it was truthful. The nurse said the FM did not say what happened. The RN voiced everything was brought to the attention of the DON on Monday morning, around 11:00 a.m., but she already knew about it. The DON, entered the office shared with RN #71 at 1:18 p.m. she said NA #79 told her yesterday morning (06/19/17) , and reported the NA thought she had told the med (medication) cart nurse. The DON said it was still being investigated. The abuse, neglect and exploitation policy, with an implementation date of 11/15/16, was reviewed on 06/20/17 at 11:47 a.m. The policy defined verbal abuse as follows: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The definition of abuse was noted as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Policy number eight (8) noted the facility would make efforts to protect all residents after alleged abuse, neglect, .Examples of ways to protect the residents included h.) time off for nursing staff and increased supervision of staff and/or residents. -Number nine (9) required the nurse respond to the needs of the resident and protect them from further incident, -notify the DON and administrator, -initiate an investigation immediately and call the social worker and administrator to assist, -notify the attending physician, resident's family/legal representative and medical director -Suspend the accused employee pending completion of the investigation. Remove the employee from the resident care areas immediately . The schedule, reviewed on 06/20/17 at 12:30 p.m., indicated NA #22 worked on 06/14/17, 06/15/17, 06/16/17 and 06/19/17 on the 3:00 - 11:00 shift. The time card indicated the nurse aide worked: 06/14/17 from 2:57 p.m. to 11:23 p.m. 06/15/17 from 2:57 p.m. to 11:23 p.m. 06/16/17 from 2:57 p.m. to 11:23 p.m. and 06/19/17 from 2:59 p.m. to 6:00 p.m. Assignment sheets noted NA #22 provided care to residents as follows: 06/14/17: Resident #1, #4, #5, #15, #27, #30, #32, #37, #52, #53 and #54 06/15/17: Resident #1, #3, #6, #7, #11, #17, #20, #25, #31, #34, #39, #48, #49 and #56 (discharged ) 06/16/17: Resident #8, #9, #14, #17, #20, #24, #29, #35, #38, #40, #44, #45, 06/19/17: The assignment sheet did not reflect NA #22 had worked. The assignment list reflected NA #22 had worked on two (2) of two (2) hallways. During a follow-up interview with AA #2, at 1:45 p.m., she verbalized she had spoken with Administrator #1, and expressed she understood the facility failed to protect the residents by allowing NA #22 to continue working from 06/14/17 to 06/19/17.",2020-09-01
1563,WHITE SULPHUR SPRINGS CENTER,515100,345 POCAHONTAS TRAIL,WHITE SULPHUR SPRING,WV,24986,2016-12-15,223,J,0,1,32NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, State and Federal guidelines, and policy review, the facility failed to implement policies and procedures to protect one (1) of thirty-five (35) Stage 2 residents from potential abuse. The hospital transfer information recorded the resident alleged rape by a male perpetrator; the physician identified a history of possible sexual abuse by the father; the resident had a history of [REDACTED]. On 12/05/16 the physician assessed the resident as incapacitated, and the father was recorded as the responsible party. The Clinical Admission Director (CAD) had noted on 12/01/16 she had been informed the resident became agitated after speaking with the father on the telephone. The father was noted as the only emergency contact, and the facility notified him of the resident's location on 12/05/16. On 12/07/16 at 6:15 p.m., the administrator was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. No deficient practice remained for this requirement after the immediate jeopardy was removed. Resident identifier: #128. Facility census: 63. Findings include: a) Resident #128 During a Stage 1 interview on 12/06/16 at 10:55 a.m., Resident #128 voiced she was scared of her father and that he was mean. The medical record, reviewed on 12/06/16, indicated the father was Resident #128's emergency contact and authorized Health Insurance Portability and Accountability Act (HIPAA) contact. A discussion with the administrator on 12/06/16 at 7:00 p.m. revealed he had no awareness Resident #128 was fearful of her father or had any other concerns, and called the social worker (SW) to the office. SW #72 said she had been notified by Unit Manager (UM) #5 of an issue of alleged sexual abuse by the father, about two (2) hours earlier. She indicated the physician had noted possible history of sexual abuse by the father. The social worker stated she had not yet completed a resident assessment, and that she had not discussed it with the administrator. During a follow-up interview on 12/07/16/16 at about 9:30 a.m., SW #72 stated she had not yet completed a social service assessment for Resident #128. Unit Manager (UM) #5, interviewed on 12/07/16 at 9:45 a.m., stated the facility had been informed on the morning of 12/05/16 by the director of the previous nursing home placement (prior to hospitalization ), that, As long as her father doesn't find her you'll be okay. The UM verbalized the facility had notified the father on 12/05/16 of the resident's location. Upon inquiry, UM #5 stated she was notified on the morning of 12/05/16 by the director of nursing, and was not aware of any action plan in place to protect the resident. A hospital behavioral health note, dated as faxed on 12/01/16, recorded Resident #128 verbalized an allegation of being raped him. A physician's history and physical dated 12/05/16 noted the chief complaint as a, History of [MEDICAL CONDITION] and was sexually abused by father as a child? The physician's plan of care included, No male attendants, and indicated the plan of care was discussed with staff and the resident. Additionally, on 12/05/16 at 12:09 p.m., a physician ordered, No male nurse aides (NA). A progress note dated 12/05/16 also noted male NA's were not to provide care. The physician's statement of capacity noted Resident #128 lacked capacity due to [MEDICAL CONDITION], cognitive loss, disoriented to person, place, and time, inappropriate answers to questions, and long-term care indicated. The form noted the resident was notified the father would be making health care decisions during the period of incapacity. Further review of the record on 12/07/16 revealed Resident #128 signed a consent for treatment and release of information on12/03/16. The form contained names allowing permission for the facility to discuss information with family members or friends about her condition. The Quick PAR (Patient Assessment Review) form, dated 12/01/16 and signed by the CAD, noted, the social worker had stated, Patient did get upset after her father called her. The care plan was silent related to the resident's history of alleged sexual abuse or relationship with her father. An interview with Licensed Practical Nurse (LPN) #15 on 12/07/16 at 4:21 p.m., revealed Resident #128's father called the facility on 12/06/16 requesting information about her care. Nurse Aide (NA) #51 stated she was not aware of any concerns related to visitation and nothing had been reported to her from other shifts. On 12/07/16 at 6:15 p.m., the facility was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. During a discussion with the administrator and Center Nurse Executive (CNE) on 12/07/16, between 8:10 p.m. and 8:43 p.m. regarding admission practices, the CNE said a hospital nurse determined Resident #128 was appropriate for admission to the facility. Upon inquiry, the director said the registered nurse was a corporate employee and referred to her as a CAD (Clinical Admission Director). Upon inquiry as to how the facility ensured services were in place for the resident, the CNE said the hospital called report to the floor nurse. The CNS did not know who took the report, and had just found out about twenty (20) minutes prior to the discussion related to the immediate jeopardy, that there was a concern related to an allegation of possible sexual abuse. She related no information was available to the facility to indicate the resident had expressed fear or an allegation of sexual abuse. The medical record, reviewed with the CNE, included the hospital note dated 11/30/16, which had been faxed to the facility on [DATE], prior to Resident #128's admission and recorded raped him. She further added, the CAD would notify the facility of any pertinent information and denied she had been informed of any concerns. The CNE stated the facility did not address the resident's mental/psychosocial issues prior to admission, and had not reviewed the information although she was being discharged from a psychiatric location. During clarification of the admission process, at 10:06 p.m. on 12/07/16, the CNE said the CAD determined if the resident was acceptable, the information was placed on the care line, passed to the center, and the admission director (AD) at the facility printed it from the care line. She said if the CAD told them they were getting an admission, the facility did not routinely review the information, as it came from the CAD. Upon inquiry as to what happened to the information once the AD received it, the nurse said it was given to the floor nurse at the time of admission and the nurse only reviewed medications. The CNE denied she had received the referral information. The admission director (AD), interviewed on the morning of 12/08/16, verbalized her responsibility with the admission process was to obtain the referral from the care line. Upon inquiry as to what she did with the information, the AD said she gave it to the CNE. The director acknowledged she had obtained Resident #128's referral on 12/01/16 and said she had given it to the CNE on 12/02/16. The resident was admitted on [DATE]. Upon request, the CNE joined the meeting. She related she only reviewed medications, and did not look at any additional information including behavioral health/psychiatric notes. The Admission Criteria: General policy with a revision date of 08/01/16, reviewed on 12/07/16, included, .the scope of service provided must meet the level of health care needs of the patient upon admission .The Clinical Admissions Director (CAD) or employee reviewed admission criteria, a medication watch list to discuss need, potential alternatives . and noted guardianship was subject to review by the regional office. The purpose was to ensure a center preparedness for admission. The form indicated that if a clinical condition was not on the Center Clinical Capabilities, the CAD would .discuss the referral with the Center Nurse Executive (CNE) or designee prior to acceptance . The administrator and CNE voiced they did not understand the facility's responsibility related to Resident #128's past history of alleged sexual abuse and her stay at the facility. They denied adult protective services had been contacted related to the physician's findings, to the history of allegation of rape voiced by the resident at the hospital, or the previous nursing facility's report that they would be fine as long as the father did not find her. They also said the physician's orders [REDACTED]. Both denied the information created a question of concern about the resident's safety or psychosocial and emotional well-being. Additionally, the staffing assignment sheets, reviewed on 12/08/16, recorded a male NA assigned to Resident #128's care for the dates of: 12/06/16 on 7:00 a.m. - 3:00 p.m. shift 12/06/16 on 2:00 p.m. - 10:00 p.m. shift 12/07/16 on 2:00 p.m. - 10:00 p.m. shift When asked about the visitation protocol, the administrator said visitors did not sign in or out, and the facility did not track who entered the building. The administrator called SW #72 to the room at 8:42 p.m. The social worker said she had contacted APS at 10:30 a.m. or so on 12/07/16 and was told they were Resident #128's representative for ten (10) days during an investigation in (YEAR), but it was not substantiated and representation was returned to the father. Further review of the medical record revealed social service notes, dated 12/07/16 recorded at: -- 8:52 a.m., Resident states she is afraid of her father due to some sexual issues. States that she does not want him coming to the facility. SW called (Nursing Facility), past facility .They also stated that when her father came to visit, she would become agitated and throw herself in the floor, hence causing her admission to the hospital -- 13:12 (1:12 p.m.) Spoke with SW at (previous Nursing Home) regarding her stay . and was informed Resident #128's father was verbally abusive on the phone, calling names and cursing. SW #72 recorded she had spoken with a case worker who reported the father had told them there was some sexual abuse and Resident #128 did not want to be around him. -- At 14:50 (2:50 p.m.) a social service note indicated the ombudsman said the facility should contact adult protective services due to the resident did not want her father as representative. When asked what the facility did to protect Resident #128, the administrator related he had called the father and directed him not to come to the facility. Upon inquiry as to the process for alerting staff, the administrator said he would alert staff to be aware of someone who was about [AGE] years old; may ask for identification if asked about the resident, but did not have a plan in place. The Checklist for Surrogate Selection form, completed 12/07/16 at 12:55 p.m., noted the resident was deemed incapacitated by the physician on 12/05/16, and did not have a court appointed guardian, or medical power of attorney (MPOA). The form noted the Resident does not wish father to be involved in her care due to alleged sexual abuse, and he was notified at 5:30 p.m. on 12/07/16. The physician signed the form on 12/08/16 indicating the Department of Health and Human Resources (DHHR) would be designated as the resident's representative due to Resident does not wish father to be involved. The WV Abuse Prohibition policy, with a revision date of 11/28/16 was reviewed on 12/07/16. It noted the facility would identify possible incidents or allegations which needed investigated, and protect the resident(s) during the investigative process. 7.1 noted the facility would Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. 7.2 noted the facility would Assign a representative from social services or a designee to monitor the patient's feelings concerning the incident, as well as the patient's involvement in the investigation. The Reporting of Suspected Crimes under the Elder Justice Act (EJA) dated 08/08/11 noted, All covered individuals will be notified by the Corporate Law/Compliance of their reporting obligations under the EJA to report a suspicion of a crime to the state survey agency and local law enforcement for the political subdivision in which the Center is located. A covered individual was defined as anyone who was an owner, operator, employee, manager, agent, or contractor of the Long Term Care (LTC) Center. Serious bodily injury was noted as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. During the interview with the administrator on 12/07/16 at 8:10 p.m., he acknowledged both the physician and the CAD were required to report any allegation and/or suspicion of abuse and protect the resident from potential harm. b) On 12/07/16 at 6:15 p.m., the administrator was notified of an immediate jeopardy related to the facility's failure to identify and act upon Resident #128's allegation of a history of sexual abuse, an allegation of rape from an unknown male perpetrator, and fear of her father and to protect the resident from potential abuse, sexual and/or psychosocial, or another other resident who might have been at risk. The facility provided a plan of correction to the State agency which was reviewed and accepted at 10:55 p.m. The plan of correction was reviewed for implementation and the immediacy abated at 11:00 p.m. on 12/07/16. No deficient practice remained for this requirement after the immediate jeopardy was removed. c) Plan of Correction for the Immediate Jeopardy The Center Executive Director (CED) and Center Nurse Executive (CNE) reported the allegation related to the resident #126 expressed fear of her father to the appropriate state entities on 12/7/16. The police was notified by CED on 12/7/16 at 7:05 PM of the allegation and arrived at the center and is in process of interviewing the resident. APS at 8:52AM and the Ombudsman 2:50PM were made aware by phone of the allegation by the Social Services on 12/7/16. It was recommended that APS be made temporary guardian until an appropriate surrogate is identified. The APS worker to fax form for Medical Director to complete the required form requesting APS to act as surrogate until an appropriate surrogate is determined. SS interviewed the resident at 7:15 PM of the actions taken. All residents of the facility have the potential to be affected. The CED interviewed SS at 7:55PM regarding any other residents who have statement regarding fear of responsible party and none were identified. CED and CNE will immediately reeducate Assistant Director of Nurses of the Unit and Medical Director who on 12/5/16 and SS on 12/6/16 that were aware of the allegation regarding need to identify an allegation of abuse and protect the resident and to implement the policy and procedure for abuse and immediately report to the appropriate State agencies. The Clinical Admission Director who faxed the information to the center regarding the resident's course in the hospital on [DATE] will be provided reeducation by CED/designee on 12/8/16 regarding the need to notify the center in advance of an allegation of abuse, need to protect the resident and need to implement the policy and procedure for abuse. The CAD/RN will review records for any potential allegations of abuse and neglect prior to admission. Hospital paperwork will be reviewed by CNE/designee prior to admission. SS contacted the father 12/7/16 at 5:48 PM regarding SS had spoken with DHHR about being guardian for resident due to resident wishing father not to be involved and requested he not visit. Resident #126 will be placed on 15 minute checks for 7 days and then to be determined by QIC to ensure protection, will have supervised visits from any visitors, and arrangements will be made for the physician visit on 12/12/16 to have EMS provide female attendants to remain with the resident while out of the center. The CED/designee will begin immediate reeducation of staff regarding need to identify an allegation of abuse and protect the resident and to implement the policy and procedure for abuse staff on duty 12/7/16 and continue at beginning of each shift until all employees are reinserviced. A posttest will be completed to validate understanding. Staff not available during this timeframe will be provided reeducation including posttest the first shift upon return to work. All residents/legal representatives will be interviewed for alleged abuse by SS/designee by 12/8/16 to ensure no additional findings with corrective action upon discovery. Staff interviews regarding alleged abuse investigation will start 12/7/16 by Nurse Practice Educator/management designee and will be completed by 12/8/16 or on the next shift worked. Trends identified will be reviewed monthly at the Quality Improvement Committee by CED/designee for any additional follow up and/or inservicing needs until the issue is resolved and randomly thereafter.",2020-09-01
1666,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2017-10-10,223,J,1,1,UKRP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, clinical record review, review of facility records and review of facility policy and procedures, the facility failed to ensure the safety of residents from physical and verbal abuse. Resident #1 reported on [DATE] that Registered Nurse (RN) #10 had verbally and physically abused her roommate Resident #22 on [DATE]. Resident #1 reported incident to Social Worker (SW) #39 on [DATE]. The facility initiated an investigation regarding verbal abuse but did not investigate the allegation of physical abuse. On [DATE] RN #10 verbally abused Resident #51. The incident was witnessed by an anonymous family member, Nurse Aide (NA) #23. NA #23 attempted to report the incident on [DATE] to the Director of Nursing (DON) #35. The facility failed to protect the resident or conduct any investigation. Resident #51 expired on [DATE]. On [DATE] Resident #86 reported NA #26 had verbally abused him on [DATE]. Resident #26 reported the incident to NA #23. NA #23 reported allegation to RN #80. The facility failed to protect the resident or conduct any investigation of the allegation. On [DATE] at 4:45 PM, the Administrator was notified of Immediate jeopardy (IJ) related to based on the center's failure to identify and report allegations of physical and verbal abuse in a timely manner; to protect residents from potential harm during the investigative process; and to implement the facility policy and procedures regarding abuse. On [DATE] at 8:40 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. The P[NAME] included: At the time that the allegation of verbal abuse was brought to the attention of the Administrator and DON, Resident #22 was assessed by Assistant Director of Nursing (ADON) on [DATE] (date of the allegation) and no signs or symptoms were identified. The involved nurse was suspended at the time of the allegation [DATE] per phone by the Administrator, center initiated an investigation and was unable to substantiate verbal abuse and the nurse was returned to work on [DATE] at 6:59 AM. The nurse was again suspended regarding the allegation of physical abuse on [DATE] at 1:59 PM with the investigation initiated by the Administrator. Resident #22 was reassessed by a licensed Social Worker to ensure the resident was not exhibiting signs of fearfulness, guarding or tearfulness on [DATE] at 6:15 PM and no signs or symptoms were noted. Resident #51 no longer resides in the center. Resident #86 was interviewed by a licensed Social Worker on [DATE] at 5:30 PM. He stated to the Social Worker that he did not feel abused by the Rehab Transport person per Interview, One day I can't remember which initials of NA,( NA #23) walked by 3 times, and said I don't see you doing your finger exercises, if you did them you might be able better feed yourself He doesn ' t ' ' believe she was the one who actually fed him later that shift, so the social worker asked, How does that make you feel, and the resident responded she's a good girl, I think she was just being a smart ass. The Rehab Transport Person (RTP) who is a CNA was suspended pending investigation on [DATE] at 10:40 AM regarding an unrelated event. The RTP remains on suspension at this time. The Administrator spoke to the OHFLAC surveyors on [DATE] requesting the names of the persons reporting the allegations of abuse to the surveyors so that the facility can initiate the center's policies and procedures regarding abuse prohibition. The Regional Vice President of Operations (RVPO) and Vice President Clinical Operations (VPCO) provided reeducation to the Administrator and DON on [DATE] regarding abuse prohibition policies and procedures, including reporting to state entities, identifying abuse and/or neglect and initiating a thorough investigation. A posttest was completed to validate understanding. Reeducation of all staff on duty regarding abuse prohibition policies and procedures, including reporting to state entities, identifying abuse and/or neglect and initiating a through investigation began on [DATE] at 6:00 PM by Regional Educator/designee and will be conducted with all employees prior to beginning work on the next scheduled shift. A posttest will be completed to validate understanding. New staff during orientation will receive education and completed posttest on abuse prohibition. Staff interviews regarding alleged abuse and/or neglect allegations have been initiated by the Regional Educator and Social Services on [DATE] following completion of reeducation and will be continued shift to shift until all staff have received reeducation at the beginning of shift prior to taking an assignment to validate understanding. All interviewable residents will be interviewed by Nurse Practice Educator and/or designee regarding any concerns of abuse and/or neglect starting [DATE]. All non-interviewable residents will have body audits completed by the licensed staff to ensure no signs or symptoms of abuse have occurred starting [DATE]. RVPO and/or Clinical Quality Specialist/designee will review each abuse and/or neglect allegation x 4 weeks then monthly x 3 months to ensure reporting to state entities, identifying abuse and/or neglect and initiating a thorough investigation has occurred. Trends identified will be reported monthly by the Administrator/designee to the Quality Improvement Committee until the issue has resolved and randomly thereafter as determined by the Quality Improvement Committee. After the plan of correction for immediate jeopardy was implemented, a deficient practice at a scope and severity of D remains for the failure of the staff to immediately initiate a thorough investigation of the allegations, and the failure of the facility to implement its policies and procedures. This deficient practice affected three (3) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #22, #51 and #86. Facility census 48. Findings include: a.) Resident #22 Clinical record review revealed a [DATE] care plan for behaviors. Interventions include: explain all care, including procedures (one step at a time), and the reason for performing the care before initiating, observe for non-verbal signs of aggression, e.g. rigid body position, clenched fists etc, approach the resident in a calm, unhurried manner, reassure as needed, if resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure. A [DATE]:48 AM nurses note (written by RN #10) stated resident refused to swallow these pill, she was hitting and scratching. behaviors are very bad this morning. MD is aware of resident's behaviors. Review of facility documents revealed Resident #1 reported to SW #39 on [DATE] that RN #10 had threatened her roommate. The [DATE] 12:45 PM typed statement signed by administrator and DON on [DATE] stated that on Saturday around 12 noon She indicated that Nurse (RN #10) entered the room with (Resident #22's) medications. She stated something about (resident #22) still being in bed at this time of day. (NA #8) was present during the exchange. Resident #1 stated NA #8 asked RN #10 to wait until she got Resident #22 up in the chair, RN #10 did not, she got a cloth and wiped Resident #22 eyes, which Resident #22 made and got her riled up. Resident #22 was then hitting RN #10. RN #10 was holding her hands and trying to get Resident #22 to take her medications. Resident #22 keep resisting. RN #10 then said 'you have to take these behavior meds or they will take you out of here to----(name of psychiatric hospital). The statement written by NA #8 stated she asked RN #10 to wait to give Resident #22 her meds until she got her out of bed. RN #10 got a washcloth and washed Resident #22's face and made her mad and then she tried to give her meds she spit her meds out and she yelled at Resident #22 telling her to take her meds. She only got some of her meds in her she was a little harder to get up. The initial 24 hr report on [DATE] to the state entities was for verbal threatening comments. The report did not include any allegation of physical abuse. The final [DATE] report substantiated conversation but not in a threatening manner. RN #10 was reeducated and returned to duty. The investigation included a statement from RN #10 (alleged perpetrator), NA #8 and LPN #83. The investigation did not include any evidence of investigation of physical abuse, no physical examination of Resident #22. No other interviewable residents were interviewed. During an interview with DON #35, ADON #2, Administrator #38 and SW #39, at [DATE] at 6:30 PM, SW #39 stated she completed the initial and final reports to OHFLAC, APS and Ombudsman. SW #39 stated she did not interview other interviewable residents. SW #39 only interviewed Resident #1 the roommate. The Administrator stated the file contained no evidence of any physical examination of Resident #22. DON #35 stated he did not examine resident #22. The ADON #2 made no comment. The Administrator after reviewing Resident #1's statement of RN #10 holding Resident #22's hands down, the facility should have reported an allegation of physical abuse and conducted an examination of the resident at the time of the allegation. The Administrator stated the facilities expectation is for staff to attempt other measures than forcing residents to take their medications. Administrator stated I cannot state why the nurse didn't get the resident out of bed before giving the medications. During an interview with Administrator, DON #35, ADON #2 and Clinical Quality Specialist (CQS) #94, on [DATE] at 3:50 PM, the Administrator stated we have not further investigated the aspects of physical abuse, involving Resident #22, because we would not be able to see evidence of physical abuse. b) Resident #51 On [DATE] at 8:15 p.m., during a confidential interview, the interviewee said one (1) night last week there was only one (1) nurse for the whole nursing home. The interviewee said, A nurse was so disrespectful to (Resident #51's name) and his aunt. I have never seen anything like it. She was screaming over top of (Resident #51), and he was suffering. When asked, Who was the nurse screaming at? The resident? The interviewee replied, No, (Registered Nurse #10) was screaming at his aunt. (Resident #51) was in so much pain and agony, and his aunt just wanted them to send him to the hospital to get him help, so he wouldn't be hurting like he was. I felt so sorry for the aunt and (Resident #51). No one should be treated like that. It was just awful. When asked, Did you report it to anyone? The interviewee stated when she had told the administrator about things before, the administrator had told her to mind her own business. I didn't know who I could tell, that's why I wanted to tell you. It was awful no one deserves to be treated like that. On [DATE] at 9:27 a.m. review of records revealed Resident #51 first entered the facility on [DATE]. The resident had multiple health issues, including but not limited to [MEDICAL CONDITIONS] also known as a stoke, [MEDICAL CONDITION] (loss or impairment of the power to use or comprehend words), dysphagia (difficulty in swallowing), occlusion and stenosis of bi-lateral Carotid Artery, [MEDICAL CONDITIONS], left above the knee amputation (AKA), right eye [MEDICAL CONDITIONS] a liver disease with ascites/ [MEDICAL CONDITION], inoperable kidney abscess, perineal abscess, Opiod dependent with withdrawal, [MEDICAL CONDITIONS], and convulsions. Death occurred in the facility on [DATE]. On [DATE] at 10:54 a.m., review of Licensed Practical Nurse (LPN) #19's nurse's progress note dated [DATE] at 7:16 a.m. revealed a physician visit to resident with new orders for [MEDICATION NAME] ([MEDICATION NAME]), and a [MEDICATION NAME]. order sent to pharmacy. On [DATE] at 9:36 a.m., review of the physician's orders [REDACTED]. Review of physician orders [REDACTED].>-- An order dated [DATE] for [MEDICATION NAME] HCl Tablet 10 milligrams (mg) give one (1) tablet by mouth every six (6) hours as needed for pain. -- An order dated [DATE] was noted for [MEDICATION NAME] 72 hour 12 MCG/hr (micrograms/hour) apply one (1) patch [MEDICATION NAME] one (1) time a day every three (3) days for pain and remove per schedule. -- An order dated [DATE] for [MEDICATION NAME] (Concentrate) Solution, 20 mg/ml (milligram per milliliter) Give 10 mg (0.5 ml) by mouth every one (1) hour as needed for pain. -- On [DATE] at , the [MEDICATION NAME] (Concentrate) Solution 20 mg/ml was increased from 10 mg/0.5 ml to 20 mg/1 ml by mouth every one (1) hour as needed for pain. Review of Medication Administration Record [REDACTED] - [MEDICATION NAME] HCl Tablet 10 mg at 3:09 a.m. and 11:03 a.m., the resident could have one (1) tablet by mouth every six (6) hours as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) at 3:47 p.m., 7:20 p.m., 9:02 p.m.,10:30 p.m., the resident could have this every hour as needed for pain. Review of Medication Administration Record [REDACTED] - No [MEDICATION NAME] was given to the resident on [DATE] according to the MAR. - According to the MAR [MEDICATION NAME] (Concentrate) Solution 0.5 ml (10 mg) was given at 12:41 a.m. and 1:45 a.m., the resident could have 0.5 ml (10 mg) every hour as needed for pain. - [MEDICATION NAME] (Concentrate) Solution 1 ml (20 mg) was given at 4:02 a.m., the resident may have every hour as needed for pain. - The MAR indicated [REDACTED]. On [DATE] at 10:54 a.m., review of nurse's progress note (written LPN#19) dated [DATE] at 18:22 (6:22 p.m.), (typed as written), Was called back to room by residents aunt (aunt's name), went into room and she started to question me on what I had done this afternoon. told her I would be glad to speak with her if she asked the other residents to leave the room or she came out into the hall way, (Aunt's name) came in to the hall and asked me about the new orders, told her that I heard (doctor's name) speak with resident about new orders for pain and if he wanted to go to the hospital I heard resident tell (doctor's name) he did not want to go out to the hospital that he knew he was dying and he was ready to die. I also told her what time I administered the pain meds, told her what time then she asked me to take his temp. (temperature) it was 98.4. she began crying and wanted to know if I thought he needed to go out to the hospital I told her it was not my decision it was a decision made by (Resident's name) and as a nurse I have to respect his wishes. she began to cry and walked away from me. On [DATE] at 11:17 a.m., review of nurse's progress note (written by RN #10) dated [DATE] at 18:47 (6:47 p.m.), revealed the following: (typed as written) At about 540 pm (Aunt's name) resident's Aunt came to the nurses station demanding he be sent to the ER (emergency room ) now, Explained to her that (Resident) has capacity and his wishes were to be kept in the facility and be made comfortable. (Resident #74 ) and (roommate's visitor) were in the resident's room at the bedside when I went into talk with (Resident #51) and would not leave the room. I asked (Resident #51) 4 times if he wanted sent to the Hospital and all 4 times he said NO, (Resident's aunt) was angry that I would not send him to the ER, I tried to explain the end of life process to (Aunt's name) and she told me to just get the hell out of the room. I walked out of the room and called (Doctor's name) at 550 pm, (Doctor's name) said he spoke with the resident this morning about 8 am himself and the resident did not wish to be sent to the Hospital unless we can not keep him comfortable in house. Also given a verbal order to start D5 ,[DATE] NSS at 75 ml/hr again for 3 days for hydration. This morning (LPN #19's name) LPN received scripts from (Doctor's name) for [MEDICATION NAME] and Fent(anyl) Patch and (Resident's name) was aware of the medication prescribed. She also called (Resident's aunt's name) and told her about the new orders. (Resident's aunt) was demanding copies of the medication record this evening and (LPN #19's name) and I told her medical records is the only one who can print and give her copies of the medical records. I took the IV (intravenous) fluids into the room and started them in Left Upper Arm .(Resident's aunt and Resident's name) were both notified of the order for IV fluids Review of nurse's progress note dated [DATE] at 2:28 a.m. (written by LPN #14), on [DATE] at 10:06 a.m., revealed the resident was showing signs and symptoms of shortness of breath, gasping for air, upper quad lungs sound gurgling .trying to cough but unable. MPOA agreed to take him off fluids, got verbal order ok from (doctor's name) and disconnected intravenous fluids per request. Resident showing signs and symptoms of pain such as wincing, blinking and saying yes when asked if he is in pain, resident unable to verbally say what is hurting him or verbalize a numbered pain scale, [MEDICATION NAME] as ordered every hour .continuing to monitor. When asked whether Confidential Interviewee #1 knew Resident #51, the interviewee started crying and became very emotional. The interviewee said, When I came into work that day I went in to check on him because they said he was dying. I have been a (staff position and how long in that position) and have never seen anyone die like that, suffering in that way. He was begging for help. The resident was groaning, and kept saying over and over, 'Please help me. Please help me' and groaning 'Oh God.' When asked whether RN #10 was aware of the situation and the resident's suffering, the interviewee said, Yes, and added RN was aware, because I saw her go into the resident's room and saw it herself. The aunt was standing by the bed, on the side of the window, holding the resident's hand. You could clearly see the resident suffering, he was groaning non-stop and begging for help. The NA said she heard the aunt ask RN #10 to send the resident to the hospital. The NA said the RN was on the opposite side of the bed leaning over the resident with one hand on the resident's stomach, and with the other hand pointing her finger at the aunt and loudly said, No! He knows he is dying, you have to accept it. He is dying. The interviewee said RN #10 was getting louder and louder as she told the aunt. The entire time the resident was non-stop begging for help. When asked whether she saw the RN do anything for the resident's pain, the interviewee stated, I think she put a pain patch on him. I know when I went back by the nurse's station (RN #10) had called (doctor's name), because I heard (RN #10's name) say, I am covering myself. When asked if she reported the situation to anyone, she said the next morning I asked to talk to the DON, but he said he was too busy right then. The DON said he was aware of the situation, and if he needed a statement he would get one from her. The interviewee did not give a statement. At the time she witnessed RN #10 talking to the aunt, another resident and a resident's wife were in the room. The interviewee was crying during the entire interview concerning Resident #51, and at times sobbing. After composing herself, the interviewee said, It was the most horrible thing I have ever seen, to see someone die suffering like that. During a confidential interview, Interviewee #2 said they had one nurse that got loud when she was upset and if you did not know her it would seem she was inappropriate - she is not a people person -its more her demeanor. During the interview, the interviewee said, I heard a loud commotion coming from his room, but I could not make out what was being said I was down at the other end of a hall. [DATE] at 8:20 a.m., during an interview, the resident's doctor said, I talked to him that morning and he agreed he wanted to stay here .if I had known he was in that kind of pain I would have either increased his medication or sent him to the hospital . (Resident's name) had capacity. We had a discussion earlier in the day that unless his pain was unable to be control, he agreed stayed in facility - I only became aware of how much pain he was in since this survey investigation. (Resident's name) had an inoperable kidney abscess and history of [MEDICAL CONDITION] [MEDICAL CONDITION] in the past. (Resident #51) had capacity could have changed his mind to be sent to the hospital or if he was in enough pain, he could have changed his mind. The doctor expressed surprised that no one had notified him about the amount of pain the resident was in. On [DATE] at 11:30 a.m. surveyors met and discussed identified pain management issues concerning Resident #51 with the Administrator, Clinical Nurse Executive (CNE) (formerly called Director of Nursing (DON)), the Assistant Director of Nursing (ADON), the Clinical Quality Specialist, and the Clinical Education Specialist. Identified issues and concerns included the resident's pain management the evening prior to the resident's death at 4:45 a.m. on [DATE]. It appeared the resident had worsening pain. It was determined the physician ordered a [MEDICATION NAME] for pain. The Physician was contacted at 3:00 a.m. and the resident's 0.5 milligram (mg) of [MEDICATION NAME] solution was increased to one (1) mg at 4:00 a.m. on [DATE], and the resident died at 4:45 a.m. on [DATE]. The resident's pain worsened and he was not given his pain medication on an hourly basis as ordered, starting at 7:30 p.m. on [DATE] until 4:00 a.m. on [DATE]. The opportunities to give the medication have gaps in when he could have had pain medication, there was 1 1/2 hour gap between 7:30 p.m. and 9:00 p.m., 1 1/2 hour gap between 9:00 p.m. and 10:30 p.m., 2 hour gap between 10:30 p.m. and 12:40 a.m., and then between 1:45 a.m. and 4:00 a.m. another 2 hour gap. There was documentation at 2:30 a.m. the resident was unable to describe his pain and at 3:30 a.m. the Physician was notified. When asked, Is it your expectation staff administer medication according to orders? The DON nodded his head in affirmation. The administrator replied, Yes, it is. The expectation would have been if the resident would have continued in pain the staff would have called the physician. We will check on that. The surveyors informed the facility that they had spoken with the physician, and were told he was unaware of the level of the resident's pain, that if he had been aware, he may have done more or something different. c.) Resident #86 Clinical record review revealed Resident #86 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The [DATE] physician determined the resident had capacity to make health care decisions. The [DATE] nursing admission assessment revealed he was alert and oriented. During an interview, on [DATE] at 1:45 PM, NA #23 had told her on [DATE], during the evening shift, that NA #26 had told him you should just use your fingers then we wouldn't have to feed you. NA #23 considered this comment to be abusive since the resident couldn't use his arms and had to be fed by staff. NA #23 stated she reported the incident to RN #80 during that same shift. During a phone interview, on [DATE] at 2:10 PM, RN #80 stated Resident #86 is totally dependent for eating due to problems with both his arms. RN #80 stated the resident is in the facility for therapy. RN #80 denied being informed of any incident of verbal abuse or Resident being told to use his fingers to eat. During an interview, on [DATE] at 3:42 PM, Resident #86 stated he was at the facility for rehab. He stated he had [MEDICAL CONDITION] arthritis and was unable to use his arms. Resident #86 stated that 2 days ago NA #26 had an attitude problem. She told me If I would use my fingers, they wouldn't have to feed me. It upset me at the time He stated I don't want anyone to loose their job. Resident #86 stated he reported the statements to NA #23 when he was upset. During an interview with Administrator, DON #35, ADON #2 and CQS #94, at [DATE] at 3:50 PM, the Administrator stated she would consider the comments made to Resident #86 to be verbal abuse. The Administrator stated she had not been informed about the incident. d.) Review of facility's policy and procedure entitled Abuse Prohibition revised [DATE] was conducted on [DATE] at 6:00 PM. The policy stated .Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of property .report the incident to his/her supervisor immediately. The policy also states initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated . The policy also states the investigation will be thoroughly documented The Center will protect patients from further harm during the investigation.",2020-09-01
2127,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2016-08-30,223,G,0,1,6MCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure two (2) of three (3) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. Resident #40 expressed fear of Resident #75 who had grabbed her and kissed her on the cheek. Resident #75 allegedly struck Resident #51 in the face with his fist and on another occasion struck the resident multiple times with a metal object. Resident identifiers: #40, #51, and #75. Facility census: 53. Findings include: a) Resident #40 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 expressed fear of Resident #75. She said the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. She added that he had struck (name of Resident #51) several times with a metal object. The Director of Nursing (DON) identified Resident #40 was referring to Resident #75. Resident #40's medical record, reviewed on 08/24/16 at 9:17 a.m., found the resident's [DIAGNOSES REDACTED]. Her minimum data set (MDS) assessment with an assessment reference date of 08/03/16, identified the resident scored 14 on The Brief Interview for Mental Status (BIMS) indicating Resident #40 was cognitively intact. A progress note, dated 06/12/16, indicated Resident 40 had expressed a concern regarding Resident #75 and she was told by the nurse to stay away from him. During an interview on 08/24/16 at 4:07 p.m., with the DON and current administrator, the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The DON said she did not know it was actually sexual behavior because the resident (#75) had dementia. During another interview, on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40, when asked again to describe the incident between herself and Resident #75, said she was in the hallway and Resident #75 grabbed her and kissed her on the cheek. She repeated that she did not know why Resident #75 kissed her, but it scared her and she told the nurse, who told her to stay away from him. Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75, and again voiced he had hit (Resident #51's name) with a metal object. Observations of transfers on 08/23/16, 08/24/16 and 08/25/16, revealed Resident #40 transferred with the use of a mechanical lift and was totally dependent on staff. Once in the wheelchair, the resident was able to propel herself, but moved very, very slowly. Review of Resident #75's medical record, on 08/24/16 at 9:17 a.m., found he was able to walk without assistance. The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. The administrator agreed the facility should have addressed Resident #40's fears. b) Resident #51 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 voiced that Resident #75 had exhibited violent behaviors and had been physically abusive prior to his discharge. The resident said The mean man hit (Resident #51) on the head - he was dangerous and they knew it and kept him knowing. The resident further added, He had already hit her (Resident #51) in the head with his fist. Resident #40 reported she saw Resident #75 pushing a table down the hallway, and he hit Resident #51 four (4) for five (5) times with the metal leg from off the table. She added, We all was panicking, scared to death. I couldn't (could not) sleep. They took him out and brought him back the same night. Reportable allegations, reviewed on 08/23/16 at 4:09 p.m., noted an allegation of resident to resident abuse with Resident #75 as the alleged perpetrator. The report, dated 06/20/16, indicated the incident occurred on 06/19/16 at about 8:50 p.m. The nurse noted that while administering medications she heard the alleged victim screaming for help, and when nursing staff arrived, Resident #75 was using a metal object to strike the victim in the head and upper back. Both residents were transferred to the hospital for evaluation and treatment. The five (5) day follow-up report indicated Resident #75 had obtained a bedside table from the therapy room with a piece of equipment on it, picked up the piece of equipment, slammed it to the floor, breaking a leg off the equipment, which he picked up and used to hit Resident #51 repeatedly. Resident #51's statement indicated Resident #75 came down the hallway pushing the bedside table with the exercise equipment on it. The resident said she told him she did not think he was allowed to do that. She said as he got closer to her he picked up the equipment and threw it in the floor, and after it broke he picked up a piece of it and hit her repeatedly in the head. She related she screamed, and staff came to help her. Resident #51 said she thought he was going to kill her, and only felt safe after he was put on one on one (1:1) supervision with a staff member. Resident #40's witness statement in the reportable allegation indicated she saw Resident #75 standing up in the hall. He was staring and pointing at Resident #40 and she told another resident He is going to do something, he is up to something .I seen him coming with the table, he started walking slow then he started walking faster and ran into (Resident #51's name). He was hitting her back with the table repeatedly hard. He took the metal leg, I don't know where he got it from, but he hit (Resident #51) on the head four to five (4-5) times really hard. I still can't (can not) get it out of my head. We were all really afraid. We couldn't do anything to help her. We were all yelling for help. Witness statements provided by staff indicated the LPN on red hall heard someone screaming and ran toward the sound. When the nurse approached the area, she observed Resident #75 striking Resident #51 repeatedly with an object. She indicated the object used to strike Resident #51 was broken off of a bicycle exercise equipment. Another LPN said she heard screams in the hall and ran toward the screams. She indicated Resident #51 had her hands over her head to protect herself. One nurse aide (NA) reported she was outside on break and did not witness any of the event and one resident related he/she was in a room providing direct care and did not see what actually happened, but assisted the LPN to keep Resident #75 away from Resident #51 with one-on-one monitoring. Another NA related using the restroom, and when finished, saw Resident #75 lowering his hands with the therapy equipment, and staff had intervened. The hospital discharge summary, dated 06/19/16 indicated Resident #51 had a mild closed head injury, and contusions to the vertex/occipital scalp due to an alleged assault. Another emergency department note indicated the Registered Nurse from the facility indicated the chief complaint was that Resident #51 was struck to the back of the head multiple times and another note in the section indicated Resident #51 was struck to the left side of the jaw the previous day. The hospital preliminary report from the ambulance service indicated Resident #51 informed them the same resident had struck her in the left side of the jaw the previous day. Follow-up interviews with the DON and ADON on 08/30/16 between 8:30 a.m. and 10:30 a.m., indicated they were not aware of the alleged incident voiced by Resident #51 indicating Resident #75 had hit her in the jaw. They confirmed no reports were available to indicate the facility had identified and/or intervened on behalf of Resident #51. c) Resident #75 Progress notes, reviewed at 9:43 a.m. indicated Resident #75 arrived by private car with family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. The admission information indicated Resident #75 had a [DIAGNOSES REDACTED]. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m., Resident #75 was admitted from another facility -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. indicated the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door. Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.) and had said he was leaving and did not care what happened to him. -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual obviators (sic) to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m., indicated the resident wandered in the hallways and into several other residents' rooms, was exit seeking and was redirected with moderate redirection. -- 06/14/16 at 2:25 p.m., a note by Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. a social history and assessment noted a Brief Interview for Mental Status with a score of 5.0, which indicated the resident was severely cognitively impaired. -- 06/15/16 .Resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways -- 06/17/16 at 11:21 a.m., an interdisciplinary note by the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents' rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. indicated the resident wanders all over the facility and into other rooms Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor . gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- 06/19/16 at 2:02 p.m., .wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m., a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying You just don't (do not) know, you just don't know. The daughter had informed them the resident threatened to just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m., discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger An order was received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m., indicated an order was received for medication administration, no entry as to what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and was transferred via private vehicle with his daughter to another facility at 3:33 p.m. One to one (1:1 ) intervention continued until he left the building. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., voiced she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied - he was sometimes pleasant and sometimes very short. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual obviators, the administrator reviewed the progress note dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. Further discussion at 2:54 p.m. with the administrator and director of nursing (DON), the DON said the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). The care plan, reviewed on 08/24/16 at 9:17 a.m. included a problem statement of cognitive impairment and interventions included: monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address anxiety for which the resident received [MEDICATION NAME], sexual behaviors, elopement attempts, or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Licensed Practical Nurse (LPN) #45 interviewed on 08/24/16 at 10:48 a.m., stated Resident #75 did not like people who were black, was always looking for a way to get out of the building, and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual obviators. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received the [MEDICAL CONDITION] medication [MEDICATION NAME], an antianxiety medication, from the time of admission on 06/10/16. The RN confirmed the care plan did not address the use of the anxiety, or of sexual behaviors toward female residents. Additionally, the care plan did not address the resident's anxiety for which he received [MEDICATION NAME], or the possible emotional connection to Resident #40 (thought she looked like/or was his daughter) or aversion to Resident #51 (who staff said Resident #75 identified as a black male.) The care plan indicated staff would monitor for behaviors, but did not identify what behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. Nurse #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, or how frequently the behaviors occurred. When asked which diversion interventions were successful and which interventions were not successful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and were successful or failed. e) The abuse policy indicated the facility staff would do what was within their control to prevent occurrences of abuse and neglect and prevention included identifying, correcting, and intervening in situations in which abuse was more likely to occur and included patient to patient abuse. The policy also noted a representative from social services or designee would monitor the resident's feelings concerning the incident, as well as the resident's involvement in the investigation. f) No evidence was provided to indicate the facility had adequately intervened and monitored Resident #75 to ensure the safety of residents. No evidence was present to indicate which interventions the facility had tried and found ineffective when or how frequently Resident #75 exhibited signs/symptoms of agitation and what those signs and symptoms included, or that a plan was developed related to sexual behaviors, his possible dislike of black individuals, and his perceived need to protect Resident #40 from Resident #51. No evidence was presented to indicate the facility monitored for changes that would trigger abusive behavior or ensured that staff assigned had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16 and 06/19/16 noted the resident had several episodes of agitated behavior and did not like to be directed. There was no evidence found to indicate the facility had actively sought a resolution prior to the assault on Resident #51. The administrator, interviewed on 08/30/16 at 1:22 p.m., acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. Additionally, the facility provided no evidence to indicate Resident #40's fear had been address during the perpetrators stay at the facility. There was no evidence the facility identified Resident #75's behaviors were escalating and attempted to identify and address causal factors, and/or sought medical interventions while evaluating the resident. This failure culminated in actual harm to Resident #51 who sustained injuries to her head when Resident #75 hit her with a metal object, and residents, who like Resident #40, were afraid of Resident #75.",2020-09-01
3915,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,223,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure one (1) of one (1) residents reviewed for abuse, were free from physical, emotional, mental and/or sexual abuse. A male resident allegedly grabbed Resident #164's arm and tried to push her hand down toward his private area. This practice had the potential to affect more than a limited number of residents. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): --Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/16 at 9:36 a.m. revealed Resident #164 was admitted in (MONTH) (YEAR), her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent.",2020-04-01
3966,FAIRMONT HEALTHCARE AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2017-06-30,223,D,0,1,25Q611,"Based on observation, staff interview, family interview, and policy review, the facility failed to ensure residents were free from verbal abuse. Resident #44, a mentally challenged individual with documented communication deficits demonstrated increased agitation and fearful facial expressions after a nurse aide yelled at him in the hall. Resident identifier: #44. Facility census: 115. Findings include: a) Resident #44 A random observation on 06/27/17 at 9:38 a.m., found Nurse Aide (NA) #61 in the hall across from the nurses' station, loudly say, Don't punch me! as she backed away from Resident #44. Resident #44, who sat in his wheelchair, exhibited tight facial muscles, clenched fists, and held his right arm across his at chest as though to strike out. Licensed Practical Nurse (LPN) #142 was standing near the nurses' desk during this incident. When interviewed on 06/27/17 at 9:40 a.m., he agreed NA #61 raised her voice at Resident #44. When asked if he would consider this verbal abuse he stated, I will talk to her. LPN #142 reported this incident to the Risk Manager after this interview. During an interview on 06/27/17 at 9:45 a.m., NA #61 stated, I am a loud talker, and denied raising her voice or yelling at Resident #44. Review of the resident's medical record on 06/27/17 at 2:10 p.m., revealed Resident #44 was alert, mentally challenged individual with a severe intellectual disability since birth, and had unclear speech with limited verbalization skills. He resided in an assisted living home for several years, but after a hospitalization , he was not eligible to return to his previous home because of his need for total care. The resident's care plan, dated 05/03/17, identified behaviors as a problem and included verbal outbursts and Potential/shows aggression towards staff and other residents. The care plan for mood, depression, and anxiety included the interventions of, Speak softly, clearly & stand/sit directly in front when communicating (Don't want misinterpretation). In an interview on 06/29/17 at 10:28 a.m., the staff development coordinator Registered Nurse (RN) #110 reported she just reviewed verbal abuse with the staff last month. She said verbal abuse was talking in an unkind manner, screaming, raising your voice, or yelling at the resident. Anything that made him feel threatened was considered verbal abuse.",2020-04-01
4007,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,223,K,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, incident/accident reports review, facility reportable allegation(s) of abuse review, policy and procedure review, and staff interviews, the facility failed to ensure residents were free from sexual abuse. This was true for seven (7) residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s), who received nonconsensual sexual contact by Residents #10, #11, and/or #62 which were reviewed during the Quality Indicator Survey (QIS) and complaint investigation. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficient practice may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance.) A reasonable person, if touched inappropriately by another person putting hands his down ones pants, touching breasts, and/or rubbing genital area without consent in one's resident home, would feel fear, humiliation, anger, anxiety, and/or stress. These findings had the potential to affect more than a limited number of residents. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, and #20. Alleged perpetrators: #10, #11, and #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them bene",2020-03-01
4022,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2017-03-29,223,G,1,0,CMPK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation of a facility video, clinical record review, review of facility staffing sheets, resident interview, staff interviews, and review of facility investigations, the facility failed to prevent resident abuse by a Health Service Worker (HSW). A staff member yelled at, cursed at, and slapped Resident #58's hand, then removed the resident from the dining room just as her meal arrived. Resident #6 was seated at the same table as Resident #58 and remained upset and distressed more than three (3) weeks after the occurrence. This occurrence resulted in actual harm to Resident #58 and Resident #6. Resident identifiers: #58 and #6. Facility census: 57. Findings include: a) Resident #58 Resident #58 had [DIAGNOSES REDACTED]. The 02/15/17 annual Minimum Data Set assessment indicated the resident had physical behaviors directed at others and rejected care 1-3 days and had severe cognitive impairment. She was non-ambulatory, used a wheelchair, and had limited range of motion on one side. She required setup assistance for eating. Her 02/20/17 care plan interventions included: - Due to limited verbal communication, staff are encouraged to ask simple questions which require yes/no answers. - observe facial expressions (smile or frown) - she has been known to become anxious in crowded and noisy areas, staff are recommended to ask if she would like to go to her room or a calmer location - Staff are recommended to avoid grabbing and holding down her left arm or hand when she is agitated. Review of the facility's investigation revealed on 03/02/17 at 5:20 p.m., Health Service Worker (HSW) #30 had physically, emotionally, and psychologically abused Resident #58. HSW #30 was initially suspended pending an investigation on 03/02/17 at 7:02 p.m. The investigation was completed, after requesting 2 extensions to complete the investigation, and submitted to the State agency on 03/15/17. The facility substantiated verbal, mental and physical abuse based on review of video footage of the incident, resident interviews, and staff interviews. Review of facility staffing assignments showed HSW #30 returned to work on 03/06/17 at 6:00 p.m. until 10:30 p.m. on the same hall that Resident #58 resided. HSW #30 again worked on Resident #58's hall on 03/07/17 from 2:00 p.m. until 5:45 p.m During an interview, on 03/21/17 at 3:06 p.m., Assistant Administrator (AA) #102 stated on 03/06/17 he and the administrator made the decision to bring HSW #30 back to work 03/06/17 since the investigation did not show the resident was physically harmed. AA #102 stated HSW #30 worked back on the floor for one and 1/2 shifts. AA #102 stated he had reviewed the video footage prior to making the decision to bring HSW #30 back to work. During an interview on 03/21/17 at 3:13 p.m., Recreation Specialist (RS) #52 stated she had witnessed HSW #30 abuse Resident #58 on 03/02/17 in the dining room during the evening meal. RS #52 stated HSW #30 yelled at Resident #58 telling her she was tired of her s---. Resident #58 kept saying, No, no, my god no. Resident #58 was frowning, shaking her head no, and trying to push herself away from the table. Resident #6, who was also sitting at the table, asked HSW #30 to leave Resident #58 alone. HSW #30 yelled at Resident #6 to mind her own business. Resident #6 stated, I am not going to stay in a place where they treat us like dogs. RS #52 stated when Resident #58's dinner tray arrived and HSW #30 stated, I guess you are out of here now and removed the resident from the dining room. I reported the incident to Social Work Supervisor (SWS) immediately. RS #52 stated she had never seen a resident abused like that before in 9 years. During an interview on 03/21/17 at 3:45 p.m., Administrator #90 and AA #102 stated after bringing HSW #30 back to work on 03/06/17, they determined they needed to further investigate the incident on 03/07/17 and sent HSW #30 home. We then brought her back to work in the dietary department on 03/08/17. During an interview on 03/21/17 at 4:33 p.m., HSW #30 stated she had received training regarding resident abuse and neglect. HSW #30 stated Resident #58 was agitated on 03/02/17 in the dining room and complained of the clothing protector being too tight around her neck. HSW #30 stated Resident #58 would not calm down so she took her back to her room. HSW #30 stated she returned to work on Resident #58's hall on 03/06/17 from 6:30 p.m. until 10:30 p.m. and on 03/07/17 from 2:30 p.m. until 3:30 p.m. when I was re-suspended. On 03/27/17 at 11:51 a.m., review of the facility's video with Administrator #90 and Psychological Assistant (PA) #7, noted HSW #30 took Resident #58 into the dining room on 03/02/17 at 5:21 p.m. The HSW double knotted a clothing protector around resident's neck. Resident #58 frowned, shook her head no, and pulled at clothing protector. HSW #30 pushed Resident #58 back to the table 4 times and locked her wheelchair. HSW #30 slapped Resident #58's left hand 5 times and held her hand down under the table. Resident #58 withdrew her hand and frowned and shook her head no when HSW #30 slapped her hand. When the meal arrived at the table, HSW #30 removed Resident from the dining room at 5:27 p.m. (30 seconds after the meal arrived). During the video review, the administrator stated, We should have not brought her back to work until we completed our investigation. He further stated HSW #30 was again suspended after an interview on 03/21/17. During an interview on 03/27/17 at 2:22 p.m., Social Work Supervisor (SWS) #32 stated she became aware of the abuse allegation on 03/02/17 from RS #52 and Resident #6. SWS #23 stated her investigation was not complete when HSW #30 was brought back to work on 03/06/17. SWS #32 stated she had only been able to work on the investigation for one day. During an interview on 03/29/17 at 10:50 am, Food Service Worker (FSW) #48 stated he had witnessed an incident between HSW #30 and Resident #58 in the dining room on 03/02/17. FSW #48 stated HSW #30 was aggressive, and yelled and cursed at Resident #58. HSW #30 slapped Resident #58's left hand and held it down. HSW #30 would not let Resident #58 move away from the table. Although the resident had severe cognitive impairment, a reasonable cognitively intact person would have been humiliated and demeaned by the treatment Resident #58 received. Therefore, this was determined to constitute actual harm for Resident #58. b) Resident #6 During an interview on 03/27/17 at 10:00 am, Resident #6 confirmed she was at the dining room table on 03/02/17 at 5:20 p.m. with Resident #58. Resident #6 stated that HSW #30 was mean to Resident #58. The resident continued, stating, I got very upset and wanted to cry . I got shaky and upset when (name of HSW #30) told me we could take it outside . No one should be treated like she did to (Resident #58's name). She (HSW #30) treated her worse than like a dog. I didn't want to stay in a place where people are yelled at and pushed around. (HSW #30) told, (Resident #58's name) 'Well I guess you are not going to get any dinner tonight.' She (HSW #30) took her out of the dining room. (Resident #58's name) was just trying to get her to fix her bread and setup her meal in the way she likes. (Resident #58's name) just can't talk for herself. During the interview, Resident #6 was visibly upset cried and her hands were shaky in describing the incident involving Resident #58 and HSW #30. Resident #6 continued to be upset and distressed by the occurrence on 03/02/17, which was more than three (3) weeks after the event. This was determined to constitute actual harm to Resident #6.",2020-03-01
4136,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,223,D,0,1,JLJC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, staff interview, and policy review, the facility failed to ensure one (1) of one (1) resident reviewed for abuse, was free from verbal abuse. Resident #8 had a documented allegation that a Health Service Worker (HSW) had yelled during care. Resident identifier: #8. Facility census: 29 Findings include: a) Resident #8 A review of the clinical record for Resident #8 at 2:00 p.m. on 11/02/16 revealed she was a [AGE] year old female. Her brief interview for mental status (BIMS) was 15; which indicates she was cognitively intact. She had been determined by a physician to have the capacity to make medical decisions. Additionally, a review of the nurse's notes found a note written by Employee #77, licensed practical nurse (LPN) on 10/05/16. This note read, At approximately 5 a.m., resident rang her call bell. When answered, she replied, Am I not allowed to take a bowel movement in there anymore and pointed to her bathroom. When asked what she meant, she stated that the HSW had screamed like a maniac because I had a bowel movement didn't you hear it? When this nurse answered, No, I did not hear anyone yelling, she got visibly upset and stated, Of course, you would take her side. The HSW was not heard yelling at her and the resident was upset because she said, And she had to clean my bottom, too. When it was explained that the HSW was only trying to help her, she got even more upset and staff left the room so as not to upset her further. Resident was checked on around 6:00 a.m., and she was sleeping in her bed, with the call bell in place. Interview with Resident #8, on 11/02/16 at 3:30 p.m., found when asked if anyone had abused her mentally, physically, verbally and sexually. She replied, Yes, the aides (HSW) verbally yell at me especially when I have accidents (bladder and/or bowel incontinence). On 11/02/16 at 4:15 p.m., an interview with the Director of Nursing (DON), found that she was not aware of this reported allegation of verbal abuse. She was aware LPN, #77 had told them the resident was upset with a HSW, but had not mentioned she had yelled at her. On 11/03/16 at 1:24 p.m., an interview with Social Worker (SW) #42, Social Worker, found she had spoken with Resident #8 on 10/05/16 at 1:43 p.m. She further stated, I did not report it to the appropriate State agencies due to I was unaware of the HSW yelling at the resident. Review of the abuse and neglect policy found the following: The resident has the right to be from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Our hospital will ensure that residents are not subjected to abuse by anyone, including, but not limited to, hospital staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals.",2020-02-01
4259,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,223,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents were protected from incidents of repeated inappropriate sexual contact and language displayed by a cognitively impaired resident. This involved discharged and current male residents, and had the potential to affect more than a limited number of residents in the facility. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed five (5) incidents of sexually inappropriate behavior by Resident #103 towards other residents: --On 10/29/15, Resident #103 was witnessed by staff putting his hand in the pants of a cognitively impaired resident. --On 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was reported to have rubbed the resident's leg toward the resident's groin area. --On 01/28/16, Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . During that incident Resident #103 was noted rubbing the back of the resident's neck. --On 09/18/16, Resident #103's roommate reported the resident was playing with his toes and attempt to get into bed with him. --On 09/29/16, Resident #103 kissed the back of another resident's hand, stroked his beard and asked him to come to his room later for a kiss. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103 had a current care plan dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. The Administrator and DON verified Resident #103 had a history of [REDACTED]. The Administrator confirmed the incidents of inappropriate resident to resident physical contact were not reported to the State agency. During an interview on 10/05/16 at 11:33 a.m., Social Worker (SW) #31 stated she was working on 09/18/16 when she was informed by a Nurse Aide (NA) (she did not recall name) that Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get in his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs! The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. Review of General Notes, dated 01/29/16 at 2:26 p.m., revealed Resident #103 followed another male resident around the facility and wanted to know if he could be roommates with that resident. The notes stated Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was re-directed four times that shift. Review of General Notes, dated 01/29/16 at 2:52 p.m., revealed Resident #103 was sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident (noted in the General Notes on 01/29/16 at 2:26 p.m.) and Resident #103 was redirected. Review of the Physician Determination of Capacity, dated 05/10/16, revealed Resident #103 was assessed to lack sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Review of General Notes by Social Worker #31, dated 09/18/16 at 3:08 p.m., revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings revealed Resident #103 was having sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. Review of another psychiatric consultation log by the licensed social worker (LSW) from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is, over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings Resident #103 stated he could control his feelings. Review of a Physician Determination of Capacity form, dated 09/27/16, revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacity was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment was completed for Resident #103 for behaviors of sexual inappropriateness with previous roommate and nursing staff since last review on 08/11/16. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and the DON spoke with Resident #103 regarding these allegations. SW #31 documented Resident #103 did not deny or admit to the allegations. SW #31 documented they explained to Resident #103 his behavior wasn't appropriate and advised him to refrain from touching and propositioning other residents. Review of General Notes, dated 09/29/16 at 6:30 p.m., revealed Resident #103 was noted to be alone in his room with his roommate while his daughters were present in facility but visiting another resident in their room at that time. The notes documented Resident #103 was noted to be holding/patting his roommate's left hand and his roommate told him to, go visit with your daughters and repeatedly told Resident #103, thank you, ok, goodbye. The notes documented Resident #103's due to a medical condition the roommate was unable to remove his left hand from Resident #103's reach. The notes documented Resident #103 was redirected to the restorative dining room with both his daughters. The DON and administrator notified at that time with recommendations to move Resident #103 to another room. According to facility documentation of Resident #103's activity and whereabouts on 09/29/16, Resident #103 was in the dining room with family at 6:00 p.m., in his room alone holding his roommate's hand at 6:15 p.m. and in the restorative dining room with family at 6:30 p.m. There was no evidence the resident's level of supervision was increased beyond the every 30 minute checks after he was again noted displaying unwanted resident to resident physical contact. Review of General Notes, dated 09/29/16 at 6:45 p.m., revealed RN #40 spoke with Resident #103's family inquiring if they were aware of Resident #103's behavior that day related to him being inappropriate with two alert and oriented residents. The notes stated that during this meeting a nurse came to staff and the family that Resident #103 was asking his roommate at that very moment about the size of his penis. Review of General Notes, dated 09/29/16 at 7:20 p.m., revealed Resident #103's roommate reported to a NA that Resident #103 asked him, how big is his penis and if, he could see it. The note revealed the roommate was interviewed at that time and he reported, (Resident #103's name) always asks me how big ' it ' is and if he can see it. Review of the Change in Condition Notes, dated 09/29/16 at 11:04 p.m., revealed Resident #103 had a change in condition or behavior. The notes indicated onset and duration as the Resident had increased episodes of inappropriate sexual behavior. A nurse witnessed him rubbing on his roommate's arm and body. The roommate also stated that Resident #103 asked him, how big it was and can he see it. The previous night, another resident complained Resident #103 attempted to kiss him on the mouth. The notes documented the roommate was moved to another room, and Resident #103 was by himself in his room and being monitored every 30 minutes around the clock for his behaviors. The note further revealed Resident #103's level of consciousness as alert, the same as previous state and orientation to person, place, and time. Review of the facility's abuse prohibition policy, with a revision date of 9/01/16, provided by the Administrator, revealed sexual abuse includes but not limited to, sexual harassment, sexual coercion or sexual assault. The policy further revealed the definition of mental abuse is includes but not limited to humiliation, harassment, threats of punishment or deprivation. The policy indicated upon receiving information concerning a report of suspected or alleged abuse the Center Executive Director (CED) or designee would enter the allegation into the Risk Management System (RMS) and report to OHFLAC Long Term Care Department of Health and Human Resources using the Immediate Reporting Allegations form.",2020-02-01
4442,GUARDIAN ELDER CARE AT WHEELING,515002,20 HOMESTEAD AVENUE,WHEELING,WV,26003,2015-12-17,223,G,0,1,HB4W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, family interview, resident interview, observations, and review of Appendix P of the State Operations Manual (SOM), the facility failed to ensure Resident #104, a cognitively impaired resident, was not inappropriately touched by Resident #147, who had a history of [REDACTED]. There are circumstances in which the survey team may apply the reasonable person concept to determine severity of the deficiency. To apply the reasonable person concept, the survey team should determine the severity of the psychosocial outcome or potential outcome the deficiency may have had on a reasonable person in the resident's position (i.e., what degree of actual or potential harm would one expect a reasonable person in a similar situation to suffer as a result of the noncompliance). Based on the application of the reasonable person concept as identified in Appendix P of the SOM, a determination of actual harm was made for Resident #104, a cognitively impaired resident. A reasonable person, if touched inappropriately, fondled, and/or kissed without consent in one's residence, would feel fear, humiliation, anxiety, and/or stress. This affected one (1) of three (3) residents reviewed for abuse. Resident identifiers: #104 and #147. Facility census: 128. Findings include: a) Resident #104 Review of the clinical record for Resident #104, on 12/17/15 at 2:05 p.m., revealed the resident was severely impaired in cognition, required extensive assistance of two (2) staff members for activities of daily living, and the use of wheelchair. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. On 12/16/2015 at approximately 9:00 a.m., review of a progress noted dated 12/15/2015 at 7:13 p.m., revealed Social Service Supervisor #107 documented attempted to reach the resident's daughter to inform her of an incident with happened at approximately 6:10 p.m. this evening in the lounge, where Resident #147 put his hand down Resident #104's shirt. Social Service Supervisor #107 did speak with Resident #104 who did not appear upset or concerned in any way after the incident took place. Resident #104 stated they were always hungry and just wanted to eat all the time. They discussed the resident's feelings and the resident did not indicate any feelings of distress or worry. Reassurance and support provided. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. b) Resident #147 Review of the clinical record for Resident #147, on 12/15/15 at 6:40 p.m., revealed an admission date of [DATE]. The resident's [DIAGNOSES REDACTED]. A progress note, dated 05/31/15 at 10:03 p.m., included, . observed patient touching women patients on wing inappropriately, also kissing female patients, patient was asked to stop and to stay away from the female patients but he continues to touch them inappropriately. reported to charge nurse. Section C1000 of the significant change Minimum Data Set (MDS) assessment, dated 11/01/15, revealed Resident #147 had moderately impaired cognition, and was oriented to location, and staff names and faces. Section [NAME] of the MDS indicated behavioral symptoms were not exhibited. Section G0400 of the MDS indicated the resident had upper extremity impairment on one side, and no lower extremity impairment. The care plan initiated, on 10/03/14, included the following focus/problem: --Resident has mood and behavior deficits. --Behavior symptoms: Behavior intrudes on the privacy or activity of others. --Staff have noted that the resident is making sexual advances toward confused female patients. --On 05/20/15, staff have not reported this to be a problem at this time. The goal of the care plan, initiated on 10/03/14, and revised on 11/23/15, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: -- (Resident ' s first name) episodes of behavioral occurrences will not increase through the next review. The interventions of the care plan, initiated on 10/24/14, for the focus/problem of Resident #147 making sexual advances toward confused female patients included: --Refer to task (date initiated 01/23/15) --Behavior Occurrences: Did you observe any unusual behavior for this resident? (You MUST notify the charge nurse of any unusual behavior observations.) Any sexual advances toward female patients. (date initiated 10/24/15) The care plan did not include interventions to prevent the known behavior of being sexually inappropriate with female residents. Interview with Care Plan Nurse #27, on 12/17/15 at 3:07 p.m., revealed she did not know why the care plan was initiated on 10/03/14. She further verified the clinical record did not contain documentation to support the development of the care plan at that time. A progress note, dated 12/12/15 at 11:14 a.m., included the resident, propels self throughout facility in wc (wheelchair). On 12/15/15 at 5:55 p.m., a family member alerted Nurse Aide (NA) #95 and this surveyor that Resident #147 placed his hand down the front of the shirt of Resident #104. The residents were in the lounge at the end of the hall. No staff members were present in the lounge at that time. NA #95 went into the lounge and found Resident #147 sitting beside Resident #104. Resident #147's hand was not down the other resident's shirt at that time. NA #95 moved Resident #147 to another table across the hallway, and reported the incident. On 12/15/2015 at 6:00 p.m., attempts to interview Resident #104 were unsuccessful due to the resident's cognitive status. The resident placed her hand up in front of her face when this surveyor tried to assess her physical/emotional status. During an interview, on 12/15/15 at 6:15 p.m., NA #95 stated he/she was not aware of Resident #147 exhibiting this type of behavior and was not aware of any behavioral interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:20 p.m., Licensed Practical Nurse (LPN) #105 stated he/she was not aware of the resident exhibiting such behaviors and was not aware of any interventions in place to prevent this type of occurrence. During an interview, on 12/15/15 at 6:45 p.m., the family member who reported the inappropriate action of Resident #147, stated this was not the first time he/she had observed Resident #147 put his hand down the front of Resident #104's shirt. Approximately 6 months ago (05/31/15), this family member observed Resident #147 put his hand down the front of Resident #104's shirt, and stated it was reported to staff at that time. The family member further stated Resident #147 seemed to always place himself close to Resident #104. Review of Complaint/Grievance Report, dated 12/17/15, found, Social worker spoke to resident about behavior that took place in Dayroom Wing 8, called resident's wife, and notified her of behavior. Following the 12/15/15 incident, the facility put the following interventions in place from 12/15/15 through 12/16/15: --A one on one staffing ratio for the resident until 11:00 p.m. --After 11:00 p.m. observation every hour during bedtime hours. Additional interventions were: --Resident #147 ' s care plan was updated on 12/15/15. --A care conference scheduled for 12/16/15, including the resident and his wife. --A behavior plan developed and scheduled for implementation on 12/17/15. Review of Resident #147's Behavior Management Support Plan, dated 12/17/15, revealed the following current issues: -- Resident #147 has been in his room since the fall and [MEDICAL CONDITION] at the end of October. -- The resident recently is up and in his wheelchair and ambulating freely throughout the second floor environment. -- The resident's spouse is a good support for the resident and visits the resident frequently, taking the resident to, and participating with, the resident in activities. -- Due to the history [MEDICAL CONDITION] and the resident's [MEDICAL CONDITION], it is difficult to determine the resident's cognitive ability concerning right from wrong along with the resident's brain damage as it relates to his impulse control. -- Due to these reasons and the resident's most recent incident of inappropriate touching of a female resident this plan was initiated. Proactive intervention strategies for Resident #147, include: -- Continue to encourage spouse to visit and participate with Resident #147 in the resident's life in the facility. -- Provide time alone time for Resident #147 and his spouse, if this is to be in the facility or on an outing. -- Resident #147 should never be left alone in any of the day rooms. -- Staff should be aware of Resident #147's whereabouts at all times, making sure he is not alone. The resident should be either with his spouse or involved in a social gathering or activity. Reactive intervention strategies for Resident #147 include: -- The resident should never be left alone with female residents. -- In social settings do not isolate the resident, but staff should try their best to have the resident around other male residents. -- In a social setting, participating in a facility activity, staff should be aware of his presence and if the resident makes any gestures of inappropriate touching toward a resident, staff are to without saying anything to the resident remove them from the immediate area. Once out of the area let him know the reason he was taken out of the area. Escort them back to his wing and inform the wing nurse. The wing nurse should inform the charge nurse and the incident should be documented and investigated. Interview with Nurse Aide (NA) #71, on 12/16/15 at 6:15 a.m., revealed she was aware of the 12/15/15 incident between Resident #147 and Resident #104. NA #71 stated he/she was aware of Resident #147 inappropriately touching other residents and the need to monitor the resident for such behaviors a month or so ago, but was unaware of interventions to prevent such occurrences. During an interview on 12/16/15 at 8:00 p.m., Licensed Practical Nurse (LPN) #51 said she had not observed Resident #147 engage in inappropriate behavior in the past, however they had been suspicious of the resident being inappropriate with other female residents due to the resident propelling himself in order to be in close proximity of the female residents. She stated the resident was able to propel himself when up his wheelchair. Observation of Resident #147, on 12/16/15 at 8:35 a.m., revealed him propelling himself in a wheelchair in the lounge at the end of the hallway. The resident was under the direct supervision of a staff member seated in the lounge. During an interview with Registered Nurse (RN) #132 and Care Plan Nurse #27, on 12/16/15 at 9:15 a.m., they verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. They both stated they were not aware of the documented occurrence on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with Licensed Social Worker (LSW) #107, on 12/16/15 at 9:20 a.m., verified the care plan in place at the time of the 12/15/15 incident did not include interventions to prevent the behavior of being sexually inappropriate with female residents. She further verified she was not made aware of the documented incident on 05/31/15 where Resident #147 was sexually inappropriate with a confused female resident and verified the care plan was not updated at that time. Interview with LPN #38, on 12/16/15 at 4:00 p.m., verified she documented the incident that occurred on 05/31/15. She stated, on 05/31/15 at 10:03 p.m., Resident #147 was in the day room with his hand down the shirt of Resident #104. At that time, Resident #104 was removed from the day room and did not present in any distress at that time. After removing Resident #104, LPN #38 stated Resident #147 was informed that Resident #104 did not give permission to be touched in a sexual manner. When queried further LPN #38 stated to her knowledge Resident #147 had not exhibited this type of behavior before or after the 05/31/15 incident. At that time, she reported the inappropriate touching to the charge nurse. LPN #38 could not remember the name of the charge nurse. Review of progress notes from 04/01/15 to date, on 12/16/15 at 10:00 a.m., did not include documentation indicating the 05/31/15 incident as reported by the family member. LPN #38 stated she observed Resident #147 propel his wheelchair up to female residents and stopping, and once the resident realized someone was watching, the resident would move away from the female residents. LPN #38 stated she believe Resident #147 was aware of what he was doing when approaching the female residents. In addition, LPN #38 stated she never read Resident #147 ' s care plan. Licensed Practical Nurse #38 further clarified the progress note, dated 05/31/15 at 10:03 p.m., did not pertain to any other female residents other than Resident #104.",2019-10-01
4480,GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2016-06-09,223,D,0,1,ENC511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and staff interview, the facility failed to identify an allegation of physical abuse for one (1) of three (3) residents (Resident #34) reviewed for abuse. Resident #34 reported a nurse aide did not stop giving her a shower or adjust the water temperature when she complained of the shower water being too cold. Resident identifier: #34. Facility census: 48. Findings include: a) Resident #34 On 06/06/16 at 3:14 p.m., review of the resident's medical record found the Resident #34, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #34 did have capacity to make health care decisions. In addition, according to the quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 04/16/16, Resident #27 had a score of 15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was cognitively intact. On 06/07/16 at 11:26 a.m., Resident #34 was heard in a loud, angry voice telling a Restorative Nurse Aide (RNA) #4, They gave me a cold shower. I kept telling (name) NA #34 the water was cold but she didn't stop. Resident #34 stated she asked the NA #34 to feel the water and when she did the NA #34 agreed the water was cold. In an interview with NA #4, on 06/07/16 at 11:32 a.m., she stated the resident (Resident #34) did allege she was given a cold shower. RNA #4 stated this was a form of neglect and she would need to report to her supervisor. On 06/07/16 at 1:41 p.m., during an additional interview with Resident #34, when asked if she received a cold shower that morning, she said Yes. When asked if she knew the name of the NA, she said NA #16's name. Resident #34 stated she told NA #16 that the water was cold and the NA #16 responded by stating, No, it is not cold. Resident #34 asked her to feel the water and when NA #16 felt the water, she stated the water was cold and continued to give the resident her shower without attempting to adjust the water temperature. Resident #34 stated the water did start to warm up towards the end of the shower.",2019-10-01
4786,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,223,D,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, Centers for Disease Control and Prevention interview, State Epidemiology interview, and policy review the facility did not ensure one (1) of nine (9) residents, reviewed for abuse allegations in Stage 2 of the quality indicator survey (QIS), was free of abuse. Resident #14 was involuntarily secluded due to a history of a multi-drug resistant organism. Resident identifier: #14. Facility census: 81. Findings include: a) Resident #14 During a Stage 1 interview, on 01/11/16 at 12:55 p.m., Resident #14 related he only participated in activities in his room. The resident related he was told he had an infection and could not go outside of his room for activities. A physician's orders [REDACTED]. Review of the care plan, on 01/12/16, at 4:00 p.m. revealed a focus, initiated on 06/19/14 related to isolation precautions due to Resident #14 had a history of [REDACTED]. Interventions indicated gloves would be worn upon entry of the room, and other PPE (personal protective equipment) would only be required if substantial contact with resident expected. The Carbapenem Resistant [MEDICATION NAME] (CRE) policy, reviewed on 01/12/16 at 2:59 p.m., revealed the purpose was to prevent transmission ., and to ensure compliance with federal and state regulations .according to centers for disease control (CDC) guidelines. The policy also indicated isolation would be discontinued after completion of antibiotic therapy, then in thirty (30) days if three (3) consecutive cultures obtained from the source of infection were negative, unless otherwise advised the isolation would remain discontinued. An interview with the infection control preventionist, Licensed Practical Nurse (LPN #106), on 01/13/16 at 10:02 a.m., revealed she utilized the CRE toolkit and the CDC had been contacted when Resident #14 was admitted to the facility. The nurse related one infectious disease specialist indicated the resident should be kept in isolation indefinitely; and the other specialist indicated the resident could be removed from isolation in (MONTH) of (YEAR). LPN #106 related Resident #14 would sometimes have a home pass, had a catheter, and knew how to wash his hands. She related the medical director did not feel comfortable allowing the resident out of his room, and had continued contact precautions, including segregation from other residents. LPN #106 related Resident #14 had acquired CRE prior to admission, and contact precautions were implemented immediately, LPN #106 said the resident had never been out of isolation, since admission on 06/17/2014. The nurse related the infectious disease specialist was contacted and had told the facility, There was no reason for the resident to return to his office. Progress notes, reviewed from admission to current, revealed the following notes: -06/19/14 .Contact isolation precautions continue d/t (due to) CRE in urine . New orders to schedule appointment with infectious disease specialist for further treatment instructions of CRE. Resident to remain in isolation until cleared by the infectious disease doctor per the medical director. -07/14/14 progress note indicated the resident was out of facility with EMS (emergency medical service) to an appointment with Infectious Disease Specialist #1 (IDS#1). The resident returned to the facility with an order for [REDACTED].#1. -07/16/14 progress note indicated the physician had spoken with IDS#1 and the specialist had recommended the resident remain in isolation while in the facility due to his history of CRE, VRE and [MEDICAL CONDITION]. -07/30/14 progress note indicated Resident #14 attended an appointment scheduled with IDS#2 for a second opinion, and indicated IDS#2 recommended the resident continue contact isolation for six (6) more months. -08/05/14 note indicated the LPN #106 contacted the CDC for recommendations, to no fruition, and a note dated 08/06/14 indicated the facility received an email from the CDC noting, No recommendation can be made regarding when to discontinue contact precautions. -11/14/14 a physician's orders [REDACTED]. -01/23/15 a health status note indicated Resident #14 had an appointment with IDS#2, who recommended the resident remain in isolation until (MONTH) (YEAR), and follow up as needed. -03/25/15 plan of care note indicated the social worker was to monitor Resident #14's adjustment to being placed in isolation and not having enough social contact. Resident will remain in isolation until 06/01/15. -06/17/15 nursing note indicated the facility physician was notified of the IDS#2 recommendation for the resident to be removed from isolation, but the facility physician related he decided to go with IDS#1 .and leave the resident in isolation indefinitely. Urinalysis with culture and sensitivity, obtained on 08/31/15, 11/25/15, and 12/18/15 failed to isolate CRE and/or noted No CRE or VRE isolated. Review of the Facility Guidance for Control of Carbapenem-resistant [MEDICATION NAME] (CRE) (MONTH) (YEAR) Update - CRE Toolkit, indicated, residents with CRE at lower risk for transmission .do not need to be restricted from common gatherings in the facility (e.g. meals, group activities .) An observation and interview, on 01/20/2016 at 8:46:55 AM, with Resident #14 revealed the resident lying in bed, supine position, watching television. A cart was placed outside the door of the room and contained, gowns, gloves, booties, hairnets, upon inquiry as to how the resident felt about staying in his room, he related he sometime left his room in the evenings when no one else was in the hallway but not very often. Related he could not go out anytime he wanted. He said he did get showers. Resident #14 said it made him, feel bad that he could not go out of his room during times of activities. Further inquiry revealed the resident did not touch his catheter and knew how to wash his hands. An interview with Nurse Aide #27(NA) on 01/201/6 at 8:49 a.m., revealed the resident left his room, once in a while, late at night. The NA indicated the resident used to go outside when no one else was out there, but did not believe he had been out since summer, and said activities were done in his room. The NA related the catheter seldom leaked and the resident knew how to wash his hands. She further added, He is very good at that. An interview with the centers for disease control, on 01/20/16 at 10:42 a.m., indicated residents who were colonized with CRE, and were low risk for transmission, required standard precautions. Upon inquiry, the CDC consultant related it was not necessary for the resident to be confined to his room and referred to CDC guidelines for multi-drug resistant organisms. The consultant also suggested guidance from the state health department for more stringent guidelines imposed by state regulations. An interview with the epidemiologist, on 01/20/16 at 11:16 a.m., also revealed the resident did not require segregation from other residents. He related as long as the resident was negative for CRE, and the secretions were contained, he should not be isolated from other residents. Upon inquiry as to incontinence, the epidemiologist related, if the stool was contained in the brief, the resident should be able to leave his room. Further inquiry revealed a stool culture was not necessary. Another interview with the infection control preventionist, and the administrator, on 01/20/16 at 11:52 a.m., again revealed LPN #106 had referred Resident #14 to the physician/medical director in (MONTH) (YEAR), requesting the resident be allowed to leave his room, but the doctor did not feel comfortable. She again related IDS#1 had indicated the resident remain in isolation indefinitely and IDS#2 had related the isolation could be stopped in six to twelve (6-12) months, which ended (MONTH) (YEAR). LPN #106 related the physician was notified of ongoing negative urine cultures, which the physician had reviewed and signed. Upon inquiry, the LPN related the resident had no un-contained fluids. She related the resident utilized a catheter for urine and a brief for stool. An interview with the physician/medical director, on 01/20/16 at 11:58 a.m., confirmed he had not contacted IDS#1 after the urine cultures returned negative. The physician related the specialist had previously related, Not enough was known about the disease, and related the resident should remain isolated indefinitely. Upon inquiry, the physician related he had not reviewed the (MONTH) (YEAR) CRE update provided by the CDC, and would confer with specialists again.",2019-07-01
4796,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2015-11-04,223,E,0,1,KC5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, accident/incident report review, facility policy and procedure review, and staff interview, the facility failed to ensure each resident had the right to be free from physical abuse. Two (2) residents alleged physical abuse by the same resident (Resident #83). The facility did not thoroughly investigate or address the allegations to ensure the prevention of additional abuse to these residents and/or other residents. Residents #9 and #28 were affected; however, this practice had the potential to affect more than an isolated number of other residents. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #28. This resident was originally admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #28's score on the BIMS, on the annual MDS, with an ARD of 06/02/15, was 14, indicating cognition was intact. A review of incident/accident reports, on 11/04/15 at 9:12 a.m., revealed Resident #28 reported to nursing assistant (NA) #95 that she was in her wheelchair in the hallway when Resident #83 walked by and struck her in the right upper arm. A concurrent review of the accident/incident report for Resident #83 revealed the resident was ambulating on the Hilltop hallway and hit Resident #28 in the face. The incident/accident further stated, The next time she (Resident #28) stated that he (Resident #83) had hit her in the right arm. This resident could not give history of event. The event section of Resident #28's report indicated the incident was a resident-to-resident altercation with alleged abuse. The event section of Resident #83's report indicated the incident was a resident-to-resident altercation and Resident #83 was the alleged abuse/aggressor. c) On 11/04/15 at 9:15 a.m., the facility's policy and procedure titled Abuse Prohibition was reviewed. The Process section stated: 5. Staff will identify events --- such as suspicious bruising of patients, occurrences, patterns, and trends that constitute abuse --- and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.2 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. 5.2.3 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. d) An interview was conducted with the Social Worker (SW) on 11/04/15 at 10:11 a.m When asked about the resident-to-resident altercations instigated by Resident #83 toward Residents #9 and #28, the SW stated because Residents #9 and #28 did not experience physical injury, nothing further was done related to the incidents. The SW stated This is how we look at them. When asked if the incidents constituted abuse, the SW did not reply to the question. The SW again stated, This is how we look at them. An additional question was asked regarding the fact the incident/accident reports indicated the incidents were each called resident-to-resident altercation with alleged abuse-victim, The SW stated this was probably assessed in error. The SW stated there was a drop down box for recording information, and the wrong information was indicated on each of the reports.",2019-07-01
4872,NELLA'S NURSING HOME,5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2016-03-16,223,D,0,1,6KMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, accident/incident report review, and staff interview, the facility failed to protect two (2) of four (4) residents (#6, #17) reviewed during Stage 2 of the survey from being physically abused by another resident (#77). Resident identifiers: #6, #17, and #77. Facility census: 75. Findings include: a) Resident #6 On 03/09/16 at 1:37 p.m., review of the resident's medical record found the resident, admitted on [DATE], had [DIAGNOSES REDACTED]. A continuing review of the medical record revealed Resident #6 did not have capacity to make health care decisions. In addition, according to the annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/04/15, Resident #6 had a score of 11 on the Brief Interview for Mental Status (BIMS). This score indicated the resident was moderately cognitively impaired. A concurrent review of incident/accident reports revealed, on 12/12/15 at 7:10 p.m., Resident #6 asked Resident #77 to not follow her down the hallway and not to enter her room. Resident #77 then struck Resident #6 in the nose causing a nose bleed. First aid was provided by nursing staff to Resident #6. No physician intervention was needed at the time of the incident; however, the physician ordered an x-ray of Resident 6's nose the following morning (12/13/15) when Resident #6 complained of nose pain. b) Resident #17 On 03/09/16 at 2:03 p.m., medical record review for Resident #17 found this resident, admitted on [DATE], had [DIAGNOSES REDACTED]. The MDS with an ARD of 12/28/15, identified Resident #17 had a score of one (1) on the BIMS, indicting the resident was severely cognitively impaired. A concurrent review of incident/accident reports, revealed on 12/20/15 at 7:00 p.m., Resident #17 was struck on the right cheek by Resident #77. As stated in the incident report, Resident #17 yelled at Resident #77 after which Resident #77 hit Resident #17 on the right side of her face. The assessment noted a 2.5 centimeter (cm) bruise on the right cheek of Resident #17. According to the accident/incident report investigation in the section titled Victim's account of what happened, Resident #17 stated Resident #77 hit her in the face. c) Resident #77 On 03/09/16 at 3:10 p.m., medical record review found this resident, admitted on [DATE], had [DIAGNOSES REDACTED]. According to the resident's admission MDS with an ARD of 09/16/15, Resident #7 had no BIMS score because of the inability to understand the questions. The quarterly MDS with an ARD of 12/04/15, indicated no change in the BIMS score. Both MDSs indicated this resident wandered daily. A concurrent review of an untitled form listing acute problems and approaches (interventions) indicated: -- on 09/16/15, Resident #77 pulled the fire alarm; -- on 09/30/15, the resident exhibited sexually inappropriate behavior toward staff; -- on 10/11/15, he tossed trash cans through the air in the dining room; -- on 10/24/15, he was cursing, yelling at staff while they redirected him out of other resident rooms and was combative by swinging at staff; -- on 11/01/15, he argued with other resident in the dining room and became combative when directed away from other residents; -- on 12/12/15, struck Resident #6 causing a nose bleed; and -- on 12/20/15, he hit Resident #17 on the cheek causing a bruise. In an interview with the Social Worker (SW) on 03/09/16 at 4:29 p.m., when asked what the facility's procedure was for preventing and protecting residents from injury from other residents, she stated that nursing would separate the residents and continue to monitor the residents. After reviewing the accident/incident reports for Resident #17 with the social worker, the social worker was asked if this was physical abuse. She stated it was a resident to resident altercation requiring no physician intervention and therefore was not reportable. When asked again if these incidents were physical abuse by Resident #77, the social worker did not reply.",2019-07-01
5147,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,223,K,0,1,PDA311,"Based on observation, resident interviews, staff interviews, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure the safety of residents after an allegation of resident to resident sexual abuse. Resident #72 alleged Resident #79 touched her inappropriately. She reported it to a licensed practical nurse (LPN) on 06/13/15; however, the nurse did not report the allegation and an investigation was not immediately initiated. In addition, no efforts were made to protect other facility residents from sexual abuse from Resident #79, who was able to move freely throughout the facility. Investigation during the survey revealed the allegation was brought to the facility's attention in a morning meeting on 06/15/15. Although the facility initiated an investigation at that time, the facility did not put measures in place to protect the residents from sexual abuse by Resident #79. As of 06/16/15, during the survey, measures to protect the residents had not been put into place. Another resident, Resident #2, stated she was made aware of the situation by Resident #79 (the perpetrator). She said she was afraid Resident #79 would do something to her also. On 06/16/15 at 6:58 p.m., the Administrator and Director of nursing (DON) were notified of an Immediate Jeopardy (IJ) situation as the result of the facility's failure to protect residents during the investigation of an allegation of abuse. On 06/16/15 at 8:43 p.m., the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated. The P[NAME] included: Immediate Jeopardy has been identified based on failure to report an allegation of sexual abuse in a timely manner; to protect residents from potential harm during the investigative process; and, to implement the facility policy and procedure regarding abuse. On 06/15/15 at approximately 9:15 AM, the Director of Nursing informed Administrator of a progress note written on 6/13/15 by LPN stating that a female resident had reported to her that a male resident had touched her breast. Social Worker immediately interviewed resident and resident reported that it had happened on 06/13/15 at approximately 6:30 PM. After Social Worker confirmed the resident's statement, Social Worker reported this allegation to state agencies at approximately 11 AM. Shortly after reporting the initial reportable, female resident told Social Worker that same male resident had come into her room on the night of 06/14/15 at approximately 11 PM and touched her vagina. Social Worker then called the police and spoke to dispatch about the allegation and (name of) County dispatch said they would send an officer right away. After waiting approximately 45 minutes for the officer to come, Administrator phoned (county name) dispatch to see if they had dispatched an officer and they confirmed they had. Shortly after Administrator phoned the dispatch, Officer #1 arrived at the facility to interview the residents involved in the allegation. Officer #1 took female resident ' s statement and came back 2-3 hours later to complete male resident ' s statement with another officer, Officer #2. While the officer was out of the facility, female resident was under constant supervision and male resident stayed in his room. Female resident was then sent to (name of hospital) for a sexual assault medical examination. Licensed nurse who failed to report allegation of abuse immediately to supervisor was suspended pending investigation on 06/16/15 by Director of Nursing. Social Worker who failed to properly report allegation to the appropriate state agencies was reeducated on 06/16/15 by Administrator. Reeducation of all staff on abuse reporting has started on 06/16/15 by Nurse Practice Educator and/or designee and will be completed by 06/17/15 or prior to working next shift. Staff interviews regarding alleged abuse investigation have started on 06/16/15 by Nurse Practice Educator/management designee and will be completed by 06/17/15 or prior to working next shift. All interviewable residents were interviewed on 06/16/15 by Nurse Practice Educator and/or designee with no additional findings. Male resident involved in allegation was moved to a private room and different hall on 06/16/15 at 5:30 p.m Male resident involved in allegation will be placed on one-on-one supervision beginning on 06/16/15 at 8:48 p.m. and will be on one-on-one supervision until the sexual assault medical investigation results are received by the facility. On 06/17/15 at 9:45 p.m., Resident #79 was observed in a private room on a different unit. A staff member was sitting outside the room. After the plan of correction for the immediate jeopardy was implemented, a deficient practice at a scope and severity of D remained for failure of staff to immediately report the allegation, and failure of the facility to implement its policies. This deficit affected two (2) residents, but had the potential to affect more than a limited number of residents. Resident identifiers: #72, #2, and #79. Facility census: 55 Findings include: a) Resident #72 The resident's clinical record review, on 06/16/15 at 4:00 p.m., revealed an 08/27/14 physician's determination the resident had capacity to make health care decisions. According to the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/29/15, Resident #72 had a score of 15 on the Brief Interview for Mental Status (BIMS). A score of 15, the highest possible score on the BIMS, indicated the resident was cognitively intact. Review of a nurse's note, dated 06/13/15 8:42 p.m., revealed Resident #72, . told me also this morning that another resident touched her boob. She said it was not the first. I educated her to please stay away from that resident. The nurse's note was written by Licensed Practical Nurse (LPN) #64. In an interview on 06/16/15 at 3:38 p.m., Social Worker (SW) #8 stated she became aware of the abuse allegation on 06/15/15 at the morning meeting. SW #8 stated Resident #72 reported to her during an interview, that Resident #79 touched her left breast on 06/13/15. The SW said Resident #72 stated she reported the incident to LPN #64 that same day. SW #8 stated she had not completed any further investigation with any residents or staff regarding the allegation. b) Resident #2 The resident's clinical record review was conducted on 06/16/15 at 4:00 p.m. An 04/25/15 quarterly MDS indicated the resident had a BIMS score of 15, identifying the resident was assessed as cognitively intact. During an interview, on 06/16/15 at 3:34 p.m., Resident #2 stated Resident #79 told her he touched Resident #72 inappropriately and raped her. Resident #2 stated, I am afraid to sleep, because he might do something to me. c) Resident #79 On 06/16/15 at 3:42 p.m., Resident #79 was observed lying on his bed in his room. Review of the resident's medical record on 06/15/15 at 3:30 p.m., found his admission MDS, with an ARD of 05/07/15, identified his BIMS score was 15, indicating he was cognitively intact. It also identified he was independently mobile. At 4:08 p.m., on 06/16/15, the Director of Nursing (DON) stated the facility instructed Resident #79 to stay away from Resident #72. The DON confirmed Resident #79 resided on the same hall as Residents #72 and #2. Upon inquiry, the DON stated she became aware of the abuse allegation on 06/15/15 in the morning. She said she informed the day nurse of the allegation, but provided no instruction to staff for protection of residents during the investigation. During an interview on 06/16/15 at 4:20 p.m., the Administrator and DON stated they became aware of the abuse allegation on 06/15/15 in the morning. They confirmed LPN #64 should have reported the allegation immediately on 06/13/15. The Administrator stated Resident #72 was sent to the hospital for evaluation and police were notified of the allegation. The Administrator and DON confirmed Resident #2 was ambulatory both in and out of the facility. They confirmed they put no protective measures in place for residents during the facility's investigation. d) Review of the facility's policy and procedure entitled Abuse Prohibition, dated as revised on 07/16/13, was conducted on 06/16/15 at 6:25 p.m. The policy stated . 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. Options for room changes will be provided based on the situation. The policy also stated the center would . conduct an immediate and thorough investigation. According to the policy, The Center will protect patients from further harm during the investigation. Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. e) In a follow-up interview on 06/17/15 at 10:40 a.m., SW #8 indicated she would now interview the victim immediately and then wait for further instruction from the administrator. SW #8 stated she reported Resident #72's allegation against Resident #79 to OHFLAC on 06/16/15 in the evening. Review of facility records revealed a fax receipt to OHFLAC on 06/16/15 at 5:06 p.m. f) During an interview, on 06/17/15 at 11:15 a.m., Assistant Director of Nursing (ADON) #16 stated she was on call the weekend of Resident #72's allegation on 06/13/15. ADON #16 stated LPN #64 did not report the allegation to her as required by facility policy. g) On 6/17/15 at 11:29 a.m., Nurse Practice Educator (NPE) #65 stated she provided new education for staff regarding abuse and neglect starting 06/16/15. NPE #65 stated she conducted interviews of staff and residents since 06/16/15, but did not identify any new allegations of resident abuse. h) Review of in-service records on 06/17/15 at 1:40 p.m., revealed 43 staff members had completed in-service training regarding abuse and neglect since 06/15/15. i) On 06/17/15 at 1:40 p.m., 42 staff statements conducted by the facility were reviewed. No additional concerns of resident abuse or neglect were indicated. j) During an interview on 06/17/15 at 12:36 p.m., LPN #64 indicated she had been trained to immediately report any allegation of resident abuse to the supervisor or other management staff. At that time, the LPN confirmed she had written the 06/13/15 at 8:43 p.m. nurse's note in Resident #72's clinical record. LPN #64 stated, When you think of abuse, I think staff to resident and didn't think about residents with capacity not so much as abuse. I should have reported it immediately.",2019-03-01
5544,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2015-10-14,223,E,1,0,9SYM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to ensure residents were free from resident-to-resident verbal and physical abuse. One (1) of six (6) sample residents displayed abusive behaviors toward multiple residents in the facility. The facility failed to develop individualized interventions to protect the other residents from verbal and physical abuse by the resident. This had the potential to affect more than an isolated number of residents. Resident identifier: #40. Facility census: 58. Findings include: a) Resident #40 The CMS 802, Roster/Sample Matrix, reviewed on 10/12/15 at 2:00 p.m., indicated Resident #40 exhibited behavioral symptoms which affected others. An observation, on 10/12/15 at 2:15 p.m., revealed Resident #40 yelling at staff, demanding to leave the facility, and threatening to break through the front door. The resident kicked the door. Review of the medical record, on 10/13/15 at 4:45 a.m., found [DIAGNOSES REDACTED]. The record indicated there were scheduled appointments with an online psychiatry and neurology group. Additionally, the resident was sent to a psychiatric hospital for evaluation and treatment on 10/03/15. Progress notes, dated 04/08/15 through 10/13/15, were reviewed at 5:00 p.m. on 10/13/15. The notes indicated the resident was admitted to the facility because his wife had apparently left him somewhere because she could no longer take care of him. Progress notes, dated 04/08/15 through 10/13/15, were reviewed at 5:00 p.m. on 10/13/15. They revealed numerous notations regarding the resident's aggressive and/or abusive behaviors toward other residents: 1. A note, dated 05/09/15, indicated the resident was . becoming increasingly uncooperative . and pilfering through another resident's belongings. 2. On 05/15/15, a note indicated Resident #40 was . being combative and showing agitation, is yelling out at other residents . An interdisciplinary note indicated, Behaviors noted with resident verbally threatening other residents, cursing staff, and slapped another female resident today .verbally aggressive with male resident and pulled roommate by his shirt collar pulling him backwards . 3. Notes dated 05/21/15 indicated Resident #40 had . several episodes of yelling and grabbing other residents this shift picked up his cloth napkin and threw it in the face of another resident. A note also indicated Resident #40 threw a remote control at his roommate. 4, On 05/22/15, a note indicated Resident #40 was pointing his fork at another resident and telling her, in a loud voice, not to talk with her mouth full. The note indicated, He appeared very threatening. 5. Behaviors were again noted on 05/24/15. The facility consulted a gerl-psych unit for an inpatient evaluation. The resident was readmitted to the nursing facility on 06/02/15. 6. A note dated 06/06/15 indicated Resident #40 threatened to hit a resident, but staff intervened. 7. The resident exhibited aggression toward others on 06/09/15. 8. A note indicated the resident exhibited episodes of aggression on 07/01/15 in room [ROOM NUMBER]. 9. Progress notes, dated 07/16/15 and 07/27/15, indicated Resident #40 exhibited behaviors of aggression toward other residents. 10. According to progress notes, the resident exhibited verbally aggressive behaviors toward staff when they intervened to prevent Resident #40 from attempting to provide care to other residents. For example, Resident #40 tried to put other residents to bed on 07/01/15, 07/20/15, 07/27/15, and 08/01/15. 11. Behaviors toward other residents were noted on 08/07/15, 08/09/15, 08/11/15. 12. On 08/18/15, While in the dining room for lunch, resident began yelling at another resident stating, If you don't shut your mouth I am going to put my fist in it and shut you up. A staff member attempted to intervene, and asked Resident #40 to walk down the hall with her; however, Resident #40 refused to leave the dining room. 13. Progress notes indicated behaviors toward other continued on 09/03/15, 09/09/15, 09/10/15, and 09/12/15. On 09/03/15 at 6:38 p.m., the progress note indicated the nurse aide stepped between Resident #40 and another resident and said, You don't (do not) talk to him like that. 14. Resident #40 received a new roommate (Resident #61). The progress note, dated 09/12/15 indicated, Resident exhibiting combative behaviors. Resident heard yelling, stop that quit hitting my chair, and upon entering the resident's room, Resident #40 was pushing Resident #61's chair. 15. On 09/25/15, Resident #40 is noted to be aggressively speaking to his roommate. Resident is threatening bodily harm to his roommate. Resident's roommate has been removed from the room and assisted to the nursing station at this time. 16. On 09/26/15 a note indicated, Resident's roommate's (Resident #61) cherry wood cane was found under his (Resident #40) mattress along with red box cutters . There was a plan for staff to provide redirection; however, there were no specific interventions identified to use to redirect Resident #40. The medical record indicated staff attempted to redirect the resident during periods of aggression on 07/20/15, 07/27/15, 07/29/15, 09/28/15 at 11:35 p.m., on 09/28/15 at 4:43 p.m., on 09/29/15 at 11:42 p.m., and on 10/13/15 at 2:30 p.m. The specific interventions used to redirect the resident were not identified. The care plan, reviewed on 10/13/15 at 5:00 p.m., identified the resident had combative and aggressive behaviors due to [MEDICAL CONDITION]. The interventions included medications as prescribed and psychiatry appointments and inpatient hospital evaluation. Another focus problem related to behaviors, was can be verbally and physically aggressive. The interventions for this problem were assess and manage unmet needs such as pain, toileting, fatigue and hunger, encourage to attend activities, familiarize resident with own belongings and surroundings, and one on one to monitor behaviors (initiated 09/29/15). A mood status care plan indicated staff should observe for changes in mood (absence of emotion in resident action and facial expression), behavior, and overall functioning and document. The facility had no specific individualized interventions to implement when Resident #40 exhibited behaviors toward other residents.",2018-10-01
6379,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,223,D,0,1,35BV11,"Based on review of allegations reported to the State, family interview, resident interview, staff interview, and medical record review, the facility failed to ensure (2) of three (3) residents, reviewed for the care area of abuse during Stage 2 of the Quality Indicator Survey (QIS), were afforded the right to be free from physical abuse. Residents #100 and #95 both alleged staff had treated them rough during care. The facility failed to recognize the abuse and failed to address the allegations of physical abuse. Resident identifiers: #100 and #95. Facility census: 77. Findings include: a) Resident #100 On 06/16/14 at 6:32 p.m., the family member of Resident #100 stated staff had been rough with the resident during care. The family member said the incident was reported to the facility staff during a care plan meeting about two (2) weeks ago. The facility assured them the incident would be investigated, but the family member did not know the outcome of the investigation. Review of the medical record found the resident's last care plan meeting was held on 06/03/14. The care plan note identified the family member attended the conference, but there was no discussion of any concerns reported by the family. Review of the allegations of abuse and neglect the facility had reported to the State, found no evidence of a report or investigation of any concerns related to Resident #100. This was further evidence the facility did not recognize alleged abuse. Employee #3, a registered nurse, who attended the care plan meeting on 06/03/14, was interviewed on 06/19/14 at 11:06 a.m. Employee #3 stated she remembered the meeting when the resident's family told the care plan team a staff member had been rough with the resident during care. Employee #3 said she believed the social worker investigated the situation. The social worker, Employee #63, who attended the care plan meeting on 06/03/14, was interviewed at 12:58 p.m. on 06/19/14. She stated the resident's wife told her, Someone had been rough with him. At the same time, the resident told her it was One of those girls. The social worker did not report the incident because she said she was not able to Confirm the who, what, where and when. I took this upon myself not to report it because some people are just rougher than others. She explained she normally discussed all accusations of abuse and neglect with the administrator, but this time she did not because she did not think it was abuse. b) Resident #95 During an interview with Resident #95, at 3:55 p.m. on 06/17/14, she reported a CNA (certified nursing assistant) was rough with her when taking her to the commode, bruising her wrist and making her ribs sore. She reported that she thought it was about one year ago and said, The CNA was mad. During an interview with the son of Resident #95, on 06/19/14 at 1:45 p.m., he reported his mom told him someone had been rough with her. He reported this to Employee #61 (social worker). When interviewed on 06/19/14 at 2:20 p.m., Employee #61 stated she was not notified of the resident's allegations for a long time. Employee #61 provided a copy of a facility In House Concern dated 01/14/14. Review of the document revealed Employee #61 was made aware of the alleged incident, and interviewed the resident, but failed to report the allegation to the required agencies. She reported she did not feel the allegations were substantiated. Review of the facility's reportable allegations, on 06/19/14 at 3:00 p.m., revealed no record the allegations were reported to the required agencies. This was further evidence the facility did not recognize alleged abuse. The review also revealed no internal investigation was completed, nor were staff interviews conducted.",2018-04-01
6733,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2013-11-13,223,K,0,1,IQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy review, the facility failed to ensure residents were free from verbal, mental and/or physical abuse by another resident. Residents were fearful of harm to themselves or others related to Resident #145's behaviors. In addition, the resident's foul language was upsetting to some of the residents. Three (3) sample residents and one (1) resident identified through a random opportunity for identification were affected; however, the situation had the potential to affect more than an isolated number of residents. At the time of of the resident's admission, the facility had knowledge the resident had a severe mental disorder, was disoriented, displayed inappropriate social behavior, had seriously impaired judgment, and was verbally abusive. There was no evidence the facility developed a plan of care or implemented interventions, when the resident was admitted , to protect other residents and ensure a safe living environment. Between 10/18/13 and the date of review on 11/06/13 (nineteen (19) days), the resident exhibited aggressive behaviors affecting others. These included cursing, threatening behaviors, physical aggression with staff, intrusions on the privacy of others, and significant disruption of resident care and the living environment. The facility failed to identify the impact this resident's behaviors had on other residents. The resident's comprehensive minimum data set (MDS) assessment did not accurately reflect and assess the behaviors. The care plan did not contain interventions related to preventing harm to himself or others, or interventions to protect other residents' privacy. Resident #145 created an environment which four (4) residents interviewed believed was unsafe. No actual harm had occurred at the time this was identified; however the potential existed for this resident to cause harm to more than an isolated number of residents. The administrator was notified an immediate jeopardy situation existed on 11/06/13 at 1:40 p.m., as the residents had the potential to suffer from harm if interventions were not immediately implemented to protect the other residents from Resident #145. The administrator presented an Immediate Plan of Action, in which Resident #145 would receive one-on-one 24 hour supervision. It was also confirmed this would be a daily assignment. This plan was immediately put in to action and was observed by the surveyor. The plan was relayed to the Office of Health Facility Licensure and Certification. The immediate jeopardy at F223 was removed at 2:30 p.m. on 11/06/13. The scope and severity was reduced from a K to an E at that time. Resident identifiers: #5, # 87, #66, and #83. Facility Census: 107. Findings include: a) Resident #5 During an interview with the Resident Council President (Resident #5) on 11/06/13 at 10:00 a.m., he immediately stated to the surveyor upon entering his room, I guess you know about the big problems we have here. When told the survey team was not aware of a big problem, he said, Well everyone knows about it. The resident stated there was a resident (he named Resident #145) of whom people were afraid. Resident #5 said, He is beating people up. He said he was not aware of anyone being hurt yet, but Resident #145 had grabbed him and other people. He stated if something was not done about this man, he was afraid one of the helpless residents who can't defend themselves would be hurt. Resident #5 said Resident #145 was admitted after the last council meeting, but everyone had been talking about it and something needs to be done. When asked if he had talked to any of the staff, he stated, Yes, the administrator and the nurses. He stated the resident wandered into everyone's rooms at night and used cuss words that you should not have to listen to. Resident #5 reiterated he was afraid if something was not done, Resident #145 was going to hurt someone. He said the ladies got upset with Resident #145's language and they should not have to be exposed to the things he said to them. Resident #5 said he rings his light when he (Resident #145) comes in his room, but worries about the residents who are helpless and not able to yell for help. He stated Resident #145 Was walking and grabbed him from behind while he was in his wheelchair and twisted his arm. b) Resident #87 During an interview on 11/06/13 at 11:05 a.m., Resident #87 stated Resident #145 was inappropriate. When asked if she felt afraid, she stated, Yes, everyone is. Resident #87 referred to Resident #145 as mean. She said he came in her room one night and sat on her bed and it scared her. She said none of the residents want him around because they are afraid of him. Resident #87 said there were three (3) ladies who have a snack together every night whom the resident bothers. She said, Something should be done. When asked if Resident #145 made her feel her environment was not safe, she stated Yes. c) Resident #83 During an interview with Resident #83, on 11/05/13 at 1:00 p.m., he said, A resident on C hall is mean. The girls are afraid of him. He identified girls as staff. The resident said he did not know the individual's name, but knew the resident resided on C hall. He said the resident would Push people up the hall, and when the staff tried to stop him, he threw staff against the wall and twisted their arms. Resident #83 said the resident had put a staff member in the bathroom, locked the door and would not let him out. He added, It isn't right. He is mean and someone could get hurt. During another interview on 11/06/13 at 11:00 a.m., Resident #83 identified the resident he described as Resident #145. d) Resident #66 An interview with Resident #66, on 11/05/13 at 8:30 a.m., revealed Resident #145 had entered her room, grabbed her foot, and asked, Do you want to do it? She said when she responded, Do it?, Resident #145 said, Do you want to f_ _ _? Resident #66 denied abuse, but said she was fearful for other residents who could not protect themselves. During another interview on 11/06/13 at 11:05 a.m., Resident #66 said she could not remember the date or time of that incident because time runs together here. She reiterated the resident had grabbed her foot while she was in bed and it startled her. She added, I don't like that dirty talk. e) Resident #145 A review of the medical record for Resident #145 revealed he was an [AGE] year old male admitted to the facility on [DATE]. His pre-admission screening (PAS) revealed his mental disorder was severe. The data on his PAS stated he had been disoriented, displayed inappropriate social behavior, had seriously impaired judgment, was verbally abusive, and had [MEDICAL CONDITION]. This information was on the resident's PAS prior to admission to the nursing home, confirming the facility was made aware of the resident's condition and behaviors prior to his admission. The admission minimum data set (MDS), with an assessment reference date (ARD) of 10/29/13 was reviewed. -- Item E0200B noted, This resident had verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others) -- Item E0200C noted, Other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual act, disrobing in public, throwing or smearing food or bodily wastes, or verbal/vocal symptoms like screaming , disruptive sounds). Both E0200B and E0200C were coded 1, indicating the behaviors of this type occurred one (1) to three (3) days during the seven (7) day look back period. -- Section E0300 stated if there were any behavioral symptoms in questions E0300 coded one (1), two (2) or three (3), considering all of the behavioral symptoms, answer E0500 and E0600. -- E0500 was coded as follows: E0500.A Did the identified symptoms put the resident at significant risk for physical illness or injury? This was coded zero (0) to reflect no. E0500.B Significantly interfere with the resident's care? This was coded 1 to reflect yes. E0500.C Significantly interfere with resident's participation in activities or social interactions? This was coded 1 to reflect yes. -- Section E0600 asks questions to identify the impact on others the resident's behaviors have. The questions were as follows: Did any of the identified symptoms put others at significant risk for physical injury? The answer to this question was coded as No . Significantly intrude on the privacy or activity of others? This question was answered No. Significantly disrupt care or living environment? The answer to this question was No. f) The Care Area Assessment (CAA) notes for behavioral symptoms, which are intended to be a detailed assessment of the problem identified, contained a section titled analysis of findings. In this section, the behavioral symptoms were not determined to be an immediate threat to self or to others. The care plan considerations stated the care plan would be to minimize risk. The CAA note stated, Care plan will be developed to minimize injury to self and others as well as increase compliance with daily care. The interdisciplinary care plan was dated as last revised 10/25/13. This care plan was written prior to the comprehensive assessment date. There was no evidence the facility utilized the CAA to develop a care plan to minimize injury to self and others as stated. This care plan was written as follows: Problem/focus: Wandering/Behavior - The resident is an elopement risk/wanderer, has potential for physically verbally disruptive behaviors as evidenced by decreased personal safety awareness, wandering, episodes of physical/verbal aggression. (Has history of farming, coal mining, and electrician at (name of entity) working night shift, and has a known history of frequent fighting as a boy). Goals: The resident will not leave the facility unattended daily and through the review date. The resident will demonstrate happiness with daily routine through the review date as evidenced by no more than one physical/verbal outburst per week. The resident's safety will be maintained daily and through the review date. Interventions included: document episodes of leaving facility unattended, notify doctor of aggressive behaviors, offer redirection (snack, drink, activity of choice) to quiet area during episodes of physical aggression, offer redirection during episodes of exiting unattended, picture on file, report to the nurse episodes of physical / verbal aggression, wander guard to body. There were no care plan interventions to address the risk of injury to self and others as described in the CAA note. In addition, there were no interventions to protect other residents or keep Resident #145 from intruding in other residents' rooms. g) The facility's nursing notes were reviewed. These notes identified the resident was admitted in the evening at 17:45 (5:45 p.m.) on 10/18/13. It was noted the behaviors started the day after his admission. The notes were as follows: -- 10/19/13 - 04:40 - Resident pushing another resident in wheelchair into his room. Staff attempted to get resident and wheelchair from room. Resident began to get agitated and yell at staff. Staff members were able to get resident in wheelchair out of room. Neither resident or staff was injured. -- 10/19/13 - 05:41 - Staff members attempted to assist resident with toileting and resident became aggressive. Resident grabbed male CNA (certified nursing assistant) by the arm and wrist while yelling at him. After convincing resident to let the CNA go the resident then came out of the restroom and shut the door trying to hold the bathroom door shut with the CNA inside. Redirected the resident and took him for a walk with this nurse. Staff member denies any injuries. Will continue to observe. -- 10/19/13 - 16:33 - Resident has been wandering within facility. No attempt to exit noted. He has been generally pleasant but becomes agitated easily. Cursing and swearing at times. CNA report that resident went over to roommate in room and showed him his fist, saying 'I'll hit you!' then walked away. Will monitor closely. -- 10/19/13 - 18:45 Dr. In to see resident with new order noted for [MEDICATION NAME] 5 mg po (by mouth) daily for dementia. -- 10/20/13 - 16:12 - Night shift staff reported that resident was up during the night wandering in and out of rooms, pushing other residents in w/c (wheelchairs), yelling at other residents/staff etc. Resident has been resting in bed quietly much of the day. His wife sat with him at lunch. Resident appeared pleasantly confused. Will continue to monitor. -- 10/21/13 - 01:17 - Resident awake at this time. Standing by roommates bed yelling at him stating go to sleep! Assisted resident back to his bed. Will continue to observe. -- 10/21/13 - 18:42 - Resident exhibited wandering for most of the shift. Resident was redirected easily out of others rooms. -- 10/21/13 - 19:44 - Resident being very aggressive this evening. He grabbed a guests arm and attempted to pull her down the hall. RN (registered nurse) intervened and redirected resident. Resident has attempted to close the door when LPN (license practical nurse) was in the room and told her to get into his bed. He also attempted to get another resident into his room. Staff is monitoring frequently. -- 10/22/13 - 01:50 - Resident continues to be awake ambulating in the hallways. He is easily agitated with staff and other residents. Continuing to monitor. -- 10/22/13 - 05:17 - Resident has been awake all night. Physically aggressive behaviors noted. He has pushed staff and yelled down the hallways. He walks into other residents rooms trying to lay in other bed. Resident has been shown his bed and assisted to bed but gets back up in a few minutes yelling at staff. He attempted to pull his roommate out of the bed. Frequent monitoring continues. -- 10/22/13 - 07:16 - Resident very combative and refused medication. -- 10/22/13 13:21 - Resident refused a.m. care until 12:30 p.m. Resident has wandered all shift and he has been easy to redirect. Resident does get agitated around other residents at times. -- 10/22/13 - 14:51 - Attending physician notified via fax regarding behaviors since admission and current meds. Awaiting response -- 10/22/13 - 18:11 - Medication administration Note - Resident refused. I do not need a d_ _ _ shot. -- 10/22/13 - 22:50 - Resident very agitated and aggressive this evening. He continues to attempt to uncover his room mate and stated 'lets tear him apart'. He sneezed in the hallway and CNA (certified nursing assistant) said 'bless you' and resident responded with 'F_ _ _ you'. He has sexually inappropriate behaviors with staff. He has yelled out in the hallways and attempted to enter other rooms becomes very angry when staff is attempting to redirect. -- 10/23/13 - 06:56 Resident was assisted to bed around 2:00 a.m. and has slept well throughout the night. -- 10/23/13 - 12:04 - Resident has exhibited sexually inappropriate behaviors towards staff several times so far this shift. While CNA assisted resident with his a.m. care resident stated to CNA 'you want this. Come on touch it.' Resident was pointing to his penis while talking. The resident was educated about behavior. CNA was walking resident to the dining room for lunch. As resident walked by me at my med cart he grabbed my buttock and stated 'woo hoo'. I educated resident about behavior. Resident has made several comments when female staff entered his room. 'Come get in bed with me good looking. I wished you were in my bed. I can't wait to get you in my bed.' Will continue to observe. -- 10/24/13 - 02:04 - CNA assisted resident in to bed and resident stated 'You better not come in here with your pants off. I will stick it in you then feel you up and you will float like a balloon.' Spoke with resident about behaviors. Will continue to observe. -- 10/25/13 - 04:18 - Resident has made sexually inappropriate comments to the CNA this shift. Resident stated 'come on baby lay down with me.' Resident also has been trying to go into other female resident's rooms. Resident gets very agitated when staff tries to redirect him out of other resident's rooms and combative at times. This nurse tried to offer snack or to sit down this seems to help some with behaviors. -- 10/25/13 -16:17 - Resident has spent much of the day sitting near nurses desk calling out to staff and other residents saying 'Hey come here! You need some help? I got what you need' etc. No combativeness notes so far this shift. Will continue to monitor. -- 10/25/14 - 20:25 - Resident was in a female resident's room. When CNA went to try and get resident out of room resident jumped out of the wheelchair and begin to hit CNA. Wheelchair was in between resident and CNA. CNA denies any injuries. -- 10/26/13 - 05:12 - Resident entered the hall way and voided in the hall way. Staff guided him check him and lead him back to bed. The LPN (licensed practical nurse) mopped the floor. -- 10/26/13 - 12:49 - Resident exhibited verbal and physical aggression with staff during care. Resident refused his shower and all a.m. care. I knocked on residents door because his room mate had his call light on. As I knocked on the door the resident screamed out 'Don't be beating on my d_ _ _ door.' I explained to the resident I was knocking before entering out of courtesy. Resident yelled 'Get the h_ _ _ out of here before I knock your d_ _ _ head off.' When the staff took resident to the shower CNA started to assist resident remove his shirt and resident stated 'Don't take my p_ _ _ _ _ off. CNA tried to explain she was trying to assist him in taking a shower. Resident pushed CNA and stated 'you let me out of here or I will kill myself and you too.' Will continue to monitor. -- 10/27/13 - 05:29 - Resident wandered from room to room disturbing several residents until staff was able to get him in to bed. -- 10/27/13 - 10:59 - Medication administration note - Resident refused. 'Get those d_ _ _ things out of here. I don't take medicine.' -- 10/27/13 18:32 - Resident has exhibited wandering into other residents rooms, verbally and physically aggressive when staff attempt to redirect resident from other resident's rooms, sexually inappropriate by making comments to female staff during care 'You want to f_ _ _ me?' Resident has been educated throughout the shift regarding behaviors. Resident has also voided in roommates clothes hamper, and a plant in the front lobby and in his hallway. -- 10/28/13 - 01:50 - Resident stated 'I' d like to pat that a_ _ for 30 min . Your pretty, I really like to pat your a_ _ .' ' I got something I like you to massage' 'boy let me tell you what I'd like to pat that b_ _ _ Won't you let me pat it?' Staff politely declined. -- 10/28/13 -14:30 - Fax sent to Dr.(name) re: increased behaviors and review of home medications with resident previously on [MEDICATION NAME] 23 mg (milligrams) new order to increase [MEDICATION NAME] to 10 mg po (by mouth) daily. Call placed to MPOA (medical power of attorney). aware and agreeable to changes. -- 10/28/13 - 21:31 - Resident entered another resident's room this evening and family members were in there. Staff observed resident enter room and then observed resident attempt to grab a family member. Resident became very physically aggressive with staff when redirection was attempted. Staff attempted several times to calm resident down without success. Resident was in the hallway and walked past another resident in a chair and placed his hand on her forehead and shoved her had back. Resident was yelling and cursing at staff. Dr. was paged and a new order received for [MEDICATION NAME] 1 mg po (by mouth) times one dose. -- 10/29/13 - 01:24 - One time dose for [MEDICATION NAME] effective. Resident calmed down and was very pleasant after the medication administration. -- 10/29/13 08:42 - Resident exhibiting worsening behaviors at night with wife informing staff that he was [MEDICATION NAME] home due to his inability to sleep. Noted that the resident has increased aggression, inappropriate sexual behaviors, wandering, and exit seeking after he has been awake all day and worsens throughout the evening as he may become increasingly tired. fax sent Dr. (name) requesting trial dose of Ambien. Awaiting response. -- 10/29/13 - 20:55 - Resident had a bowel movement in roommates trash can and voided in the floor at his roommates bedside. -- 10/29/13 - 22:57 - Fax received from Dr. (name) to [MEDICATION NAME] mg by mouth at bedtime as needed. -- 10/29/13 - 22:57 - Resident was wandering throughout the facility this evening entering resident's rooms. He entered a resident's room on D-Hall and voided in his trash can at his bedside. Resident becomes very aggressive and agitated when staff attempted to redirect. Resident was refusing to lay down for the night and continued wandering. New order [MEDICATION NAME] bedtime noted and administered to resident. Resident assisted to bed shortly after and is currently resting in bed quietly with eyes closed. Call light within reach. Routine toileting and safety checks continue. -- 10/30/13 - 17:46 - multiple episodes of inappropriate sexual behavior this shift i.e., following staff into rooms making sexual comments. No physically aggressive or combative behaviors noted. -- 10/30/13 - 20:05 - Resident grabbed another resident's wheelchair from behind. When the resident turned to see who had hold of his chair resident cursed him, grabbed his wrist and attempted to hit resident without success. -- 10/30/13 e 23:09 - Received order per Dr. (name) for [MEDICATION NAME] 0.5 mg po (by mouth) for behaviors. Pharmacy noticed. POA (power of attorney) to be notified in the a.m. -- 10/31/13 e 15:15 - Care Plan Meeting Note - Initial Review: Current weight is 187. Is on LCS (low concentrated sweets) Is in use of wander guard for resident's safety. Has had noted physical and verbally aggressive behaviors. At times difficult to redirect. Wife visits often. Has notified staff that he has had increased trouble sleeping over the past few years. At this time resident is expected to have long term placement in facility. -- 10/31/13 - 18:06 - yelling at roommate. Wandering in rooms. -- 11/01/13 - 11:05 - Social Service Note - Resident is in-capacitated. No plans for discharge and resident remains appropriate for placement. His family is supportive and visits on a regular basis. Resident's wife was appointed Health Care Surrogate. Care plan developed regarding resident impaired cognition, wandering and disruptive behaviors. Continue to follow up as needed. -- 11/01/13 - 14:16 - Refused a.m. care, verbally aggressive with care, wandering. -- 11/01/13 - 10:04 - Resident exhibited refusing a.m. care, wandering into other residents rooms, verbally aggressive with staff when staff attempts to divert resident from other residents rooms. -- 11/02/13 - 5:47 a.m. - Resident aggressive with staff members, attempted numerous times to hit staff. Resident went into female residents rooms and became aggressive when staff attempted to redirect. -- 11/02/13 - 17:07 - yelling at staff and other residents. Resident attempted to wheel a female resident into his room. This nurse was able to remove female. Will continue to observe. -- 11/03/13 - 00:03 - Resident went in to every resident and staff trying to sell a box of tissues. When they wouldn't buy them he would cuss and move on some times becoming difficult. After he gave up on the tissues he patted the lpn (Licensed Practical Nurse) on the back side and stated I would pat that for an hour. Do you like that? The staff told him no and removed his hand from their bottom. -- 11/03/13 - 19:49 -[MEDICATION NAME] mg by mouth administered per order. 1/2 Tablet. -- 11/03/13 - 20:12 - Family member of residents in another room (named room number) came to this nurse and said this resident was in room (named room) trying to get into the bathroom to use the toilet. Upon entering room, found resident sitting on the trash can in the room (not in the bathroom) having a bowel movement. Attempted to assist the resident by offering my hand to help him stand. Told the resident we needed to go to his room to get cleaned up et (and) resident started swinging his fist yelling saying 'I am trying to s_ _ _ '. Explained to the resident that he needed to go to his room and use his toilet and not the trash can and the resident stated 'I don't give a d_ _ _ what you say. I have to s_ _ _ and I am S _ _ _ _ _ _ _ right here.' This nurse went to side 2 (two) to get the CNAs who work with this resident to see if they could assist him back to his room. CNAs X's (times) 2 (two) came to the room and ask resident if they could help him get cleaned up. Resident was compliant with CNAs letting them assist him back to his room. Room (number named) was cleaned up at this time. -- 11/03/13 - 23:05 - Resident attempting to get into female resident's room. When CNA attempted to redirect resident, resident told CNA 'I am going to knock you on you a _ _ .' -- 11/04/13 - 08:40 - [MEDICAL CONDITION] med (medication) assessment [MEDICATION NAME] 0.5 mg BID (twice a day). Comments: Resident was started on the medication r/t (related to) inappropriate behaviors. See behavior notes in behavior folder. Will observe for adverse effects and effectiveness of medication. -- 11/04/13 - 14:03 - Verbal aggressive with care. -- 11/04/13 - 22:40 - Resident being sexually inappropriate towards staff and other residents. Threatening to hit staff and other residents. Cussing -- 11/05/13 - 13:35 Verbally aggressive with staff during care, wandering into other residents rooms. -- 11/05/13 - 18:46 - Resident exhibited verbal aggression towards staff during care. 'If you don't get out of here I will kill you. I will kill myself too with an axe and a knife' .CNA (certified nursing assistant) waited aprox. 30 min for resident to calm down then performed a.m. care. -- 11/06/13 - 00:34 - Resident was wandering within the facility this evening. He was entering other residents rooms and became aggravated when staff attempted to redirect. Resident is physically aggressive with staff. h) Employee #34 (nursing assistant) was interviewed at 11:00 a.m. on 11/06/13. It was verified she was the regular caregiver for Resident #145. She also verified most of his behaviors happened in the evenings after she was gone but the resident was combative with them sometimes. She was asked if she had ever heard other residents on that hall verbalize concerns of being afraid of Resident #145. Employee #34 said she heard some of the ladies talk about being concerned with Resident #145. When asked for the names of female residents on that hall who voiced concerns, she identified Residents #87 and #66. i) During an interview with the director of nursing (DON) at 11:30 a.m. 11/06/13, she was asked for the facility's incident and accident reports. The DON provided three (3) months of reports, and verified these were all of the reports. She was asked if there were any incident reports for the incidents identified in the notes (as listed above) of Resident #145. She verified there was only one (1) report for him, and it was dated 10/28/13. Review of the incident report revealed it was related to a fall on 10/28/13. There were no other incident reports Resident #145. The DON verified there were some incidents that required an incident report, but were not completed. When asked about Psychiatric Services for this resident, the DON verified Resident #145 had not had a Psychiatric evaluation since his admission. j) The facility's policy and procedure titled, Abuse Prevention Policy and Procedure, dated 2012, was provided by the DON on 11/06/13 at 2:30 p.m. Review of the policy revealed the following: 1. Policy Statement This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies service the residents, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences. The facility did not take preventative steps for the occurrences of verbal, sexual, mental, and potential physical abuse of residents by Resident E145. There was no evidence the facility identified the abusive behaviors Resident #145 inflicted on others, or established a plan to protect others from the abuse. Even though this resident was confused and did not have capacity, the other residents in the facility suffered from his abusive behaviors. The facility failed to identify the negative impact this had on the residents and their environment. On 11/07/2013 at 8:35 a.m., after an immediate jeopardy was called on 11/06/13 at 1:40 p.m. related to the behaviors of Resident #145, the resident was sent out to the hospital for a psychiatric evaluation due to [MEDICAL CONDITION] and disruptive behaviors. It was verified the resident was admitted for treatment and remained at the hospital as of the time of exit on 11/13/13.",2017-11-01
6862,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2014-03-07,223,D,0,1,JZ4X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, staff interview, and resident interview, the facility failed to ensure two (2) of five (5) residents reviewed for the care area of abuse during Stage 2 of the survey were free from abuse by other residents. Resident #53 exhibited abusive behaviors toward other residents. The facility did not implement measures to protect the residents in the facility from abuse. Actual harm resulted when Resident #53 hit Resident #65 causing a laceration which required physician intervention. Resident #53 also kicked Resident #83 in the back resulting in a bruise to her back. Resident identifiers: #83, #65 and #53 . Facility Census: 62. Findings include: a) Resident #65 An incident and accident report, dated on 01/05/14 at 7:00 p.m., revealed Resident #53 went into Resident #65's room and hit her on the right arm. According to the incident report, Resident #65 was yelling at the resident for being in her room. The incident report stated in the section titled, Nature of Injury, the resident received a laceration. A physician's orders [REDACTED]. Apply [MEDICATION NAME] ointment and apply dermagel wrap with kling qd (daily) prn (as needed). Resident #65 was interviewed 03/06/14 at 3:00 p.m. She verified a resident came in her room. Resident #65 said when she tried to get the other resident out, the resident hit her, injuring Resident #65's arm. b) Resident # 83 During an interview at 2:00 p.m. on 03/05/14 with Resident #83, she stated Resident #53 (she called her by name) came in her room a few days ago and kicked her really hard in the back. She said she did not have her wheelchair locked and she rolled across the floor to the other side of the room and stopped herself with her foot before she hit the wall. She said she was not afraid of her but she is afraid for the other residents because she tries to hurt people. She stated the only time Resident #53 hurt her was when she came up behind her and she was not ready for it and did not see it coming. She stated she has seen Resident #53 try to hit others and she gets in between them and stops her. The facility incident and accident reports were reviewed. On 02/18/14 at 12:00 p.m., documentation indicated Resident #83 reported to the nurse that Resident #53 came into her room on 02/17/14. She said the resident kicked her in the back while she was in her wheelchair. The nurse instructed the resident to inform staff immediately of any incidents. The nurse assessed the resident and recorded she had a bruise on her back. c) Resident #53 The facility's incident and accident reports, dated 02/18/14, revealed Resident #53 went in Resident #83's room and kicked her in the back causing a bruise to her back. Another incident report noted Resident #53 went in Resident #65's room on 01/05/14 and hit her right arm causing a laceration. During a review of the medical record for Resident #53, there was no care plan to address this resident's abusive behaviors toward other residents. There were no interventions to protect others from her aggressive behaviors and prevent further injuries. The facility's abuse files were reviewed for the last six (6) months. The files did not contain information regarding the incidents involving Residents #53, #65 and #83. In addition, there was no evidence an investigation was conducted to assess the abusive behaviors in an attempt to prevent these from occurring again, or to prevent injury to other residents. A review of the facility's policy titled OPS327-WV Abuse Prohibition effective 06/01/96 and last revised 07/16/13, revealed physical abuse was described as hitting, slapping, pinching, and kicking . The abuse policy stated in section 4. 4.2, The actions to prevent abuse will include identifying, correcting, and intervening . Section 6.2 of the policy stated the facility will conduct an immediate and thorough investigation. There was no evidence of an investigation nor evidence of attempts to identify causative factors, and/or interventions to prevent further injury. During an interview with the Administrator, on 03/06/13 at 10:00 a.m. , she was made aware of the documents reviewed and the abuse files reviewed. She stated all of the abuse investigations and complaints were included in the abuse records provided. She said if there was nothing in there, then they did not do an abuse investigation.",2017-11-01
6890,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,223,G,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review, and staff interview, the facility failed to ensure three (3) of three (3) residents reviewed for the care area of Abuse during Stage 2 of the survey were free from mental abuse and/or involuntary seclusion. -- Resident #125 was not free from involuntary seclusion and mental abuse. When she was admitted to the facility, she did not have capacity to make medical decisions. After she regained this capacity, and voiced a desire to go home, the facility made no effort toward discharging the resident. This alert and oriented individual resided on the Lighthouse Unit, a locked dementia care unit. The resident's Medical Power of Attorney, not the resident, made the decision for the resident to be on dementia unit. The resident suffered harm, beginning 08/30/13, when she became capable of making her own health care decisions, but was not afforded that opportunity by the facility. -- Residents #77 was not free from mental abuse. She was not assisted in toileting as requested. Staff insisted she go to the bathroom when she wanted to use a bedpan. This resulted in an episode of incontinence. -- Resident #18 was not free from mental abuse. She was not assisted in using the bed pan as requested. Staff informed her she could not be assisted until she, her roommate, and all other residents on her hall were finished eating. Resident Identifiers: #125, #77, and #18. Facility Census: 85. Findings Include: a) Resident #125 Employee #116, a physician, was interviewed at 1:45 p.m. on 01/20/14. He stated Resident #125 did not belong on a locked unit. Resident #125's medical record was reviewed at 8:22 a.m. on 01/21/14. This review revealed the resident was admitted to the Lighthouse Unit (Dementia Care Locked Unit) on 07/30/13. Upon her admission to the facility, the resident lacked capacity to make medical decisions. She had a determination of incapacity for medical decision-making completed on 07/25/13 at a local area acute care hospital. This determination was in effect until 08/30/13, when a facility physician reviewed the resident for capacity and determined the resident had regained capacity to make medical decisions. As of 08/30/13, the resident should have been afforded the right to make her own heath care decisions. Further review of the medical record revealed a from titled, Special Care Unit Consent. This form contained the following text: I give my consent for (Resident #125's Name) to be placed on a Special Care Unit for his/her safety and security due to his/her present status with dementia. I understand that he/she will be evaluated Quarterly according to facility policy for continued stay. If the evaluation team finds that continued stay on the unit is no longer appropriate, the resident and/or the resident representative will be informed. This form was signed by the resident's Medical Power of Attorney (MPOA) on 07/30/13. The form was also signed by Employee #28, the Lighthouse Unit director. There was no evidence this consent for placement on the Special Care Unit was reviewed with, or discussed with, the resident after the resident was deemed capable of making medical decisions. At 10:41 a.m. on 01/21/14, Resident #125 was interviewed in her room on the Lighthouse Unit. The resident stated being in the facility, Makes me feel like I am confined to some place I can't get out of. The resident stated, I am angry about how I am being treated. When asked if it was her intention to remain in the facility she stated, No I am locked in and can't go anywhere or do anything without someone being with me. She stated, It has been my intention from day one to go home. I never agreed to stay here long term. She further stated, I do not want to be here. I do not belong here. The doctor came in here the other day and told me I did not belong here. When asked how long she has wanted to go home, she replied, I have wanted to go home from the beginning. I know I needed some therapy, but I have been done with that for months now. I want to go to somewhere like assisted living. It will only cost me $4,000 a month instead of $8,000 a month plus I will have more freedom and independence. I hate it here. I am sad and angry I am still here. The resident stated the facility staff only recently began talking to her about going home. She stated, I understand I don't have the home I had before I came in here, but I do not belong here. I don't know why they waited so long to start talking to me about this. Finally the resident stated, I am fed up with being here and I want to be out of here before I have to give them another dime of my money. The following progress notes, written by Employee #28, the Lighthouse Unit Director, were in the resident's medical record: Note dated 07/31/13: Resident's daughter came to talk to me and is worried about her Mom. She said (Resident Name) told her that she is unhappy here, and she wanted to go home . Note dated 08/14/13: . She does believe she is going home soon, and states she is going to work hard to get there . Note dated 09/04/13: (Resident Name) son and daughter requested to this staff member that we have a meeting with (Resident Name) to discuss her long term plan because she continues to ask them when she gets to go home. Meeting was held with (Resident Name) and family, and options were discussed. She stated that it bothers her to live here with the other people because it makes her sad to see what could happen to her. She states she understands that she has dementia, and she realizes she can not safely live by herself. She would prefer to move to an assisted living situation where she would have her own room, or go home with caregivers, (Resident Name) son explained to resident that her financial status would prevent this from being a long term plan, and they would prefer she stay in the Lighthouse Unit. (Resident Name) responded by saying she just wanted to way (sic) her options, and see what she could do. Her family stated that a decision did not have to be made at this time, and they would inquire at a couple of places to what cost was, and they would talk about it with her. She seemed to accept that. Not in (Resident Name) presence, the MPOA (Medical Power of Attorney), (name of resident's son) stated that their wishes remain that she continues to be a resident on the Lighthouse Unit. Note dated 11/05/13 (Quarterly review): .She wants to go home, but currently understands her financial situation, and that there is no one to live {with} her. She show minimal deficits at this time with no behaviors. Her children visit often, and she does go out of the facility with them to shop, eat, etc. She does cooperate well with care, and is very independent with activities of daily living. Note dated 01/07/14: (Resident Name) has been very upset yesterday and today crying. This staff member spoke with her regarding what is wrong, and she states she is unhappy here, and wants to have her own place. She has been doing well overall until right around Christmas time, which is the first anniversary of the death of her husband. She feels like her children has 'abandoned her and don't give a damn.' She stated that she has some friends looking for her an apartment in (town and state). She currently retains capacity, but her son (name) holds Durable Power of Attorney. He lives in (town and state) and her daughter also lives away from here. (Name of son) takes care of her finances currently. Spoke with (name of son) regarding her feelings. He stated, 'I understand, but being home by herself is what put her in the hospital. She is doing so much better now.' This staff member explained that we could make a referral to (a specialized program), just to see what options are available. He was in agreement, though voiced reservation because he would prefer she stay here. She is currently staged at a 4, and does display memory deficit. This staff member spoke with social worker and (Resident Name) and discussed the plan. (Resident Name) seemed pleased, and stated 'My husband and I worked hard all of our lives for our money and I want to be at home.' Staff will continue to monitor. Note dated 01/16/14: (Resident Name) asked this morning if the ombudsman was going to visit with her today, (Resident Name) stated that the ombudsman has told her she would check back in with her today. This staff member stated that I hadn't heard from the ombudsman yet today, but if she doesn't come we will call her. She stated that would be fine. She will wait and see if she comes today. She has been very social this week, and is enjoying her new kindle that she got for Christmas. She plays a game called Candy Crush that she enjoys very much. She reads a lot, and bought several books on her last outing. Note dated 01/21/14: (Resident Name) has voiced being upset today about the meeting from yesterday with her children, granddaughter, myself, and Social Services. The meeting was discussing (Resident Name) desire to leave the facility. She states she wants more freedom, and doesn't feel like she belongs here. Her son told her he had moved to (town and state) and she was previously unaware of that. He also told her he had sold most of her things. She stated, All of my clothes too? He stated that the clothes that were there were too large for her anyway, and she could just buy new clothes if she wanted. There was obvious tension between (Resident Name) and her family, and both (Resident Name), (son), and (daughter) raised their voices during the meeting. (Resident Name) does not believe she has any deficits, and her children are concerned with her long term safety, as they both live away, as well as long term financial plan. It was concluded in the meeting that Social Services would contact some assisted living facilities to check availability, and also find out prices. (Resident Name) showed a specific interest in (local assisted living facility). Her family stated they would go with her to tour some facilities On 01/21/14 at 10:00 a.m., the Lighthouse Unit Director, Employee #28, was interviewed. She confirmed Resident #125 was not appropriate for the Lighthouse unit. Employee #28 stated this was a recent change. She stated Resident #125 was not allowed to have the code to get out off the unit because she was giving it to other residents. Employee #28 stated she explained this to Resident #125. She stated they did not give Resident #125 the code to get off the unit after they spoke to her about giving other residents the code. She said to her knowledge, anytime Resident #125 wanted off the unit,staff opened the door and let her leave the unit. When asked about the, Special Care Unit Consent, Employee #28 stated, I never thought about having her sign the consent when she regained her capacity to make medical decisions. At 2:54 p.m. on 01/21/14, Employee #88, the Social Service Director, was interviewed. The Social Service Director agreed Resident #125 was not appropriate for the Alzheimer's Unit. She agreed if a resident who had capacity was not allowed to leave the Lighthouse unit as they chose, she were involuntarily secluded from the rest of the facility. Employee #88 said she began discharge planning for the resident on 01/07/14. The Social Service Director stated, This was when her strong vocalizations about going home began. She said the resident had been upset and crying for two (2) days over her desire to go home. The Social Service Director said she was not aware of Residents #125's vocalizations about wanting to go home, despite the fact they were noted in the medical record, by Employee #28, the Lighthouse unit Director, on 07/31/13, 08/14/13, 09/04/13 and 11/05/13. Social Service Note dated 08/06/13: SW (social worker) also completed the social services initial history on this date. The resident reported she wants to return home but her MPOA plans for her to remain in long term care. Social Service Note dated 01/07/14: Social Work (SW) has been advised by the Lighthouse Unit director that (Resident Name) has recently became (sic) verbal about wanting to leave (facility name) and move into her own residence. Resident lived independently in her own residence before her placement at (facility name) in July of last year. SW made referral to the regional office of (name of agency) today to see if they could be of assistance. SW spoke with (agency representative) at this agency who reported the resident does not qualify for (name of program) because she is not on Medicaid. They have no other assistance program to offer as the Medicaid Wavier program remains frozen for new referrals. SW has learned that the the resident is paying privately for her care and should have the means to move back into a residence of her own or assisted placement if she would be agreeable. (Resident Name) is noted to still have decision making per MD (medical doctor) evaluation shortly after her admission to (name of facility). She is reported to be a high functioning dementia patient but to have some memory deficit. A full-time supervised living situation would be ideal for her but she has the right to leave if she wishes. SW met with the resident at length this afternoon to discuss her situation and options. She was adamant that she wants to leave and verbalized she does not feel the Lighthouse unit is the appropriate place for her at this time. She also verbalized that she is unhappy that she does not have control of her finances. Her son (name) is her DPOA (durable power of attorney) and assumed responsibility for her checkbook and paying her bills after she was placed at (name of facility). SW inquired if she might be able to live with any family but she is opposed to this idea and verbalized 'they have their own lives.' She has some close friends in (town) (friends last name) whom she reported would be willing to help her find a suitable place to rent. SW spoke with the her about the need to work out all the practical details before she is discharged from (facility name). The main issue may be her resuming control of her finances. The resident may need outside advocacy and SW made a consult to the Regional NH (nursing home) ombudsman to consult with the resident. Social Service Note dated 01/17/14: The regional nursing home ombudsman, (Name), met with the resident last week and again today to discuss her request for discharge to the community and to provide (Resident Name) with options regarding local assisted living facilities. Social Work (SW) spoke with the ombudsman today regarding her consultations and she reported she believes the resident would be very appropriate for assisted living placement. She also reported (Resident Name) has identified, (the names of three (3) separate local assisted living facilities) as her preferences for placement. (Resident Name) verbalized she would like to tour the facilities. SW spoke with the ombudsman about the need to involve the resident's son in the planning since he currently controls her finances. SW contacted resident's son (Name) to discuss the situation. He is opposed to the plan and questions that his mother is mentally competent. SW explained to him that his mother has been determined to have decision making capacity and that she has the right to make her own decisions. He agreed to attend a meeting with his mother and this has been scheduled for Monday, 01/20, at 11 am. SW has left message for the ombudsman about the time because she has requested to attend. The resident verbalized to (ombudsman) that she would like to leave by the end of the month. Social Service Note dated 01/21/14: SW made a follow up call to the regional ombudsman office to relay the outcome of yesterday's family meeting. (Ombudsman) was out of the office and SW left a voice message for her requesting a return call. The LHU (Lighthouse Unit) Director and the undersigned social worker met with the resident and family (son, daughter, and granddaughter) at length yesterday to discuss (name of resident) desire to return to the community. The family voiced opposition to the plan, particularly the son who is concerned his mother's safety needs will not be met away from secure dementia unit. He also questioned the doctor's decision about his mother's competence. Both SW and LHU director emphasized with the family that (name) has been determined to have decision making capacity and that she has the right to determine where she lives. (Name) is independent with ambulation and ADL's (activities of daily living) but does have some cognitive deficits related to early stage dementia, primarily memory loss. Both SW and LHU director verbalized to the family that (name) would be a good candidate for assisted living. She would have more privacy and freedoms in the type of setting. (Name) is agreeable to this plan and her daughter reported she would be available next week to take her mother to tour some facilities. SW has contacted two assisted living facilities the resident has expressed interest for placement b) Resident #77 On 01/16/14 at 12:40 p.m., a Licensed Nurse (Employee #68) was observed administering medications to Resident #77. Upon entering the room to administer the medications, the resident's call light was observed on and the resident was calling out for assistance. When the nurse entered the room, the resident asked the nurse, could you get me the bedpan? The nurse informed the resident she had not been using the bedpan, and had been getting up and going to the bathroom. The resident said, I do not want to get up and go to the bathroom, I want the bedpan. The nurse informed Resident #77 she was going to give her medications and then she would get someone to come and take her to the bathroom. The resident again stated, I do not want to go to the bathroom, I want the bedpan. The nurse then said, Your daughter wants you to get up and go to the bathroom, and does not want you to use the bedpan. The resident replied, I will just use my Depends then. Employee #68 then administered the medication to Resident # 77. This took seven (7) minutes. After the nurse was finished, she told the resident, I will go get someone to take you the bathroom now. Resident #77 said, You can forget it. I do not need to go now. I just used my diaper. A nursing assistant (Employee #65) came into the resident's room at 12:55 p.m. She said, I will take you to the bathroom before you eat. The resident stated, I do not need to go, I just used my diaper. You can just change it now. The resident said they have told her before to just use her diaper, so it should not matter. The nursing assistant told Resident #77 the other nursing assistants probably just told her that because they did not want her to suffer. The nursing assistant said Your daughter does not want you to use the bedpan. She wants you to go to the bathroom. Resident #77 replied, My daughter is not my boss and can not tell me when and where to p_ _ _. Employee #65 then told the resident she would change her. The resident was interviewed at 1:00 p.m. on 01/16/14. When questioned about the amount of toileting assistance she required, she stated she had a hurt foot. She said she did not want to get back up after she laid down just to use the bathroom, because it was a lot of trouble. The resident said she knew when she needed to go to the bathroom, but getting someone to take you was Another story. She stated, They do not care anyway, because they tell you to just go ahead and use your diaper. c) Resident #18 Review of the resident's medical record, on 01/16/14, revealed a nursing note, dated 09/11/13 at 6:31 p.m. (Typed as written), Resident asked CNA (certified nursing assistant) for place her on bedpan during dinnertime when dinner trays were still on the floor and staff was still assisting residents that required assistance to eat, CNA asked resident if she was finished with her dinner, resident stated that she was not finished with dinner, but needed the bedpan anyway. CNA explained to resident that she could not stop assisting other residents at this time to place her on bedpan. CNA came to this nurse for advise, and this nurse agreed that since it was [MEDICATION NAME], and she did use the bedpan approximately thirty minutes prior to dinner, that CNA should wait until she finished her dinner, and other residents, including her roommate, was finished with dinner. According to a physician's determination of capacity, dated 11/02/12, the resident demonstrated capacity to make medical decisions. The resident was not provided the code to get out of the door, and had to ask to leave the unit. Staff did not always open the door for her. This practice resulted in psychological harm to the resident. Further review of the medical record [MEDICATION NAME] mg. (milligrams) was prescribed on 09/12/13 for seven (7) days for treatment of [REDACTED]. During an interview with the director of nursing (DON), on 01/16/14 at 12:31 p.m., she verified she was unaware of the nursing note. The DON stated the staff member should have toileted the resident when the resident asked. She said the information provided to the nursing assistant by the nurse was incorrect. The social services director, Employee #88, verified on 01/20/13 at 12:34 p.m., she was unaware of the nursing note. The social worker stated the information given to the nursing assistant was incorrect. Employee #88 said, Residents should be taken to the bathroom anytime they ask.",2017-11-01
7284,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2014-06-04,223,E,1,0,0VPW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure eleven (11) residents, which included five (5) of eight (8) sample residents and six (6) residents who were identified through random opportunities for discovery, were free from abuse by Resident #56. The facility failed to initiate 1:1 supervised care, as ordered by the physician, to deter a resident who exhibited sexual and physical abuse toward others. Resident identifiers: #56, #55, #57, #28, #21, #8, #30, #24, #27, #20, #52, and #53. Facility census: 55. Findings include: a) Resident #56 Review of the medical record for Resident #56 revealed he was a [AGE] year old male admitted to the facility on [DATE], for skilled wound care of healing 2nd and 3rd degree burns. His [DIAGNOSES REDACTED]. The resident's speech was very hard to understand. He had been living at home his entire life, and had never been exposed to a group environment until his present nursing home admission. Review of incident reports, since Resident #56's admission on 02/07/14, revealed incidents which involved him and 11 other residents (Residents #8, #20, #21, #24, #27, #28, #30, #52, #53, #55, and #57). Several of the residents were involved in multiple episodes with Resident #56. Since his admission, there were 14 reported incidents of aggression by Resident #56 concerning various other residents due to his behaviors. On 04/30/14, an incident report revealed Resident #56 was hit in the arm by another resident when he attempted to touch the resident. The resident's behaviors in the facility began in late February as his physical status improved and he became mobile, self-propelling himself in a wheelchair. These behaviors included: wandering in and out of other resident rooms, taking other residents personal property, running into residents with his wheelchair, hitting himself, and refusing medications, food, and/or care from staff. By April 2014, his behaviors were almost daily and had progressed to sexual touching of female residents, staff, and visitors. The nurse's note, dated 04/29/14, revealed the resident, while up in his wheelchair in the hallway, began grabbing the breasts of female staff. He was redirected several times without success and then began to kick and hit staff, other residents, and students who were present on that day. This behavior continued throughout the afternoon. His physician was present to witness those behaviors. The physician ordered changes in medications and male 1 on 1 supervision. The nurse's notes acknowledged the medication changes and plans for a psychiatric consult, but said nothing about initiating the 1:1 supervision. Nurses' notes, incident reports, and reports to State agencies revealed sexually oriented incidents including kissing, touching breasts through clothing, and groping underneath clothing of various residents on almost a daily basis. The notes and other reports contained no evidence of 1:1 supervision until 05/04/14, after the facility received a complaint from another resident's family, who witnessed the sexual groping. When implemented on 05/04/14, the 1:1 supervision was documented as successful in preventing any incidents for the rest of the day. There was no evidence of 1:1 supervision used again until 05/06/14, following sexual groping of 2 separate female residents that morning. The nurses' notes, on 05/07/14 (night shift ending at 7:00 a.m.), stated, Monitored frequently by staff and the day shift nurse wrote, Res (resident) has been one - on - one with a C.N.A. (certified nursing assistant) all day. 0 (no) inappropriate behavior noted. On 05/09/14, after an incident of sexual groping of a female resident, Employee #13 (registered nurse) initiated 1:1 supervision. Employee #13 notified the nurse manager (Employee #89). At that time, the order written on 04/29/14 was implemented and full time supervision was started. This was verified during an interview with Employee #13 at 9:00 a.m. on 06/03/14. She also stated the supervision had continued to the present, and was successful in preventing any further resident to resident events. During an interview with Employee #16 (licensed practical nurse) at 3:35 p.m. on 06/03/14, she stated she was present during the incident on 5/04/14. She said staff were trying to check on Resident #56 often at that time. The nurse acknowledged it was not continuous as it was now. She added there had been no additional resident to resident incidents since the 1:1 supervision was implemented as ordered. There were 10 reported incidents of resident-to-resident abuse involving Resident #56 between 04/29/14, when the 1:1 supervision was ordered, and 05/09/14, when the 1:1 supervision order was actually implemented as ordered. During an interview with the director of nursing (DON), at 4:00 p.m. on 06/03/14, she stated she was aware of the 1:1 supervision order on the day it was written (04/29/14). She stated there was confusion about the order which was not clarified until 05/09/14, when the order was changed to Close supervision of the resident at all times. The DON stated, after reviewing the record, there was no evidence the 1:1 supervision was initiated full time until 05/09/14, although it was done for limited periods at times after an incident. b) On 06/02/14 at 12:00 p.m., review of incident/accident reports, and the facility's documentation of incidents reported to State agencies as allegations of abuse, found the following occurrences involving Resident #56. 1. Resident #55 According to the facility's investigation notes, Resident #56 wheeled himself into the room of Resident #55 on 05/03/14 at 9:30 a.m. Resident #55's shirt was pulled up, and Resident #56 was seen touching her breast. Staff removed him from her room. The corrective action was to keep these two (2) residents away from each other, provide 1:1 with Resident #56 as needed, and continue to provide redirection. Medical record review on 06/03/14 at 8:00 a.m. revealed Resident #55's speech was inappropriate. She was unable to make her needs and wants known. The resident required total care for activities of daily living (ADLs). She was non-ambulatory, and required lifting to and from the bed. This resident was observed on 06/04/14 at 10:00 a.m. She did not respond appropriately to verbal stimulation. She spoke words that were not in context with anything being said, or that was going on around her. 2. Resident #57 According to the facility's investigation notes, Resident #57 was sitting in her geri-chair in the hallway on 05/03/14. At 10:00 a.m. on 05/03/14, Resident #56 leaned over her geri-chair and was seen with his hand beneath her blouse and on her breast. He was removed from the area of Resident #57 in the hallway. The corrective action was to keep these two (2) residents separated from each other, provide 1:1 with Resident #56 as needed, and continue to redirect as needed. Incident/accident reports, and reporting of incidents of abuse sent to the State, were reviewed on 06/02/14 at 12:00 p.m. According to the facility's investigation notes, Resident #56 wheeled himself into the room of Resident #57 on 05/09/14 at 3:30 p.m. His hands were touching around her waist and were in the top of her pants. Her abdomen was exposed. Staff removed him from her room. The corrective action included 1:1 with Resident #56 when he was up in the facility. This was the second incident with Resident #57 in a six (6) day period. Medical record review on 06/03/14 at 8:30 a.m. revealed Resident #57 required total care for all ADLs. She was immobile and aphasic (lacked speech). She had a [DIAGNOSES REDACTED]. This resident was observed on 06/04/14 at 10:05 a.m. She did not speak in response to verbal stimulation. 3. Resident #28 According to the facility's investigation notes, Resident #28 was sitting in her chair in the activity room on 05/03/14. At 10:30 a.m. on 05/03/14, staff heard her yelling for help and crying. Resident #56 was seen with his hand beneath her shirt, and he was touching her breast. Resident #28 told him to stop several times, but he did not listen. Staff removed Resident #56 from the activity room. The corrective action was to keep these two (2) residents away from each other, provide 1:1 with Resident #56 as needed, and continue to redirect as needed. Medical record review on 06/03/14 at 9:00 a.m. revealed Resident #28 lacked capacity for health care decision making, but was able to make her needs and wants known. Multiple observations of this resident between 06/02/14 and 06/04/14 found her self-ambulating as she desired. Many of her words were difficult to understand. 4. Resident #21 According to the facility's investigation notes, Resident #21 was sitting in the dining room on 05/03/14. At 1:00 p.m. on 05/03/14, Resident #56 was seen leaning over Resident #21, and had his hand beneath her shirt while rubbing her breast. Staff removed Resident #56 from the dining room. The corrective action was to keep these two (2) residents apart, provide 1:1 to Resident #56 as needed, and provide redirection as needed. Medical record review on 06/03/14 at 9:30 a.m. revealed Resident #21 had a [DIAGNOSES REDACTED]. She was lifted to the geri-chair which was used when she was out of bed due to having no trunk control. This resident was observed on 06/04/14 at 10:10 a.m She did not verbalize in response to verbal stimulation. 5. Resident #8 An incident reported to the State for this resident included at 2:00 p.m. on 05/03/14, Resident #56 was seen leaning over Resident #8's geri-chair as she sat in the hall. He had her shirt pulled up and both of his hands were on her breast. Staff removed her from the hallway and took her back to her room. The corrective action was to keep these two (2) residents away from each other, provide 1:1 to Resident #56 as needed, and provide redirection as needed. Medical record review on 06/03/14 at 10:00 a.m. revealed Resident #8 had a [DIAGNOSES REDACTED]. She was non-ambulatory and required the assistance of two (2) staff persons for transfers. This resident was observed on 06/04/14 at 10:20 a.m. She did not speak in response to verbal stimulation. 6. Resident #30 According to the facility's investigation notes, Resident #30 was in the hallway on 05/03/14. At 4:30 p.m. on 05/03/14, Resident #56 was seen in the hallway with his hand up Resident #30's shirt, touching her breast. A few minutes later, Resident #56 was observed putting his hand down Resident #30's pants. Resident #56 was removed from Resident #30. The corrective action was to keep these two (2) residents away from each other, provide 1:1 to Resident #56 as needed, and provide redirection as needed. Medical record review on 06/03/14 at 10:30 a.m. revealed Resident #30 had a [DIAGNOSES REDACTED]. This resident was observed on 06/04/14 at 10:30 a.m. She did not speak in response to verbal stimulation. 7. Resident #24 On 06/02/14 at 12:00 p.m., a review was conducted of the incident/accident reports, and reported incidents of abuse sent to the State. Investigation notes regarding Resident #24 revealed at 5:30 p.m. on 05/03/14, Resident #56 was noted standing over Resident #24 in the dining room, kissing her on the lips. He had both hands beneath her shirt while touching her breast. A family member notified staff of this incident. Staff removed Resident #24 from the dining room. The corrective action was to keep these two (2) residents separated from each other, provide 1:1 to Resident #56 as needed, and provide redirection as needed. Medical record review on 06/03/14 at 11:00 a.m. revealed Resident #24 had a [DIAGNOSES REDACTED]. She required extensive to total care for ADLs. She could answer simple Yes or No questions. This resident was observed on 06/04/14 at 10:40 a.m. in her room. She spoke, but her speech was rambling. Her verbal replies did not match screening questions posed. 8. Resident #27 Review of the incident/accident reports, and reported of incidents of abuse sent to the State, were reviewed on 06/02/14 at 12:00 p.m. According to the facility's investigation notes, at 12:30 p.m. on 05/04/14, Resident #56 went up to the resident in the hallway and grabbed her breast. Staff removed Resident #56 from the resident. The corrective action was to keep these two (2) residents away from each other, and provide 1:1 to Resident #56 as needed. Medical record review on 06/03/14 at 11:30 a.m. revealed Resident #27 was able to make only a few simple needs and wants known at times. She often looked at staff, then turns away and stares. The resident had a history of [REDACTED]. This resident was observed on 06/04/14 at 10:50 a.m. She did not respond to verbal stimulation and eye contact. c) An interview was conducted with the Director of Nursing on 06/04/14 at 9:30 a.m. She said staff were now doing 1:1 with Resident #56 all the time, until his transfer from the facility was completed.",2017-06-01
8174,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2013-09-05,223,F,1,0,54LC11,"Based on record review and staff interview, the facility failed to ensure residents were free from physical and/or verbal abuse from other residents. Twenty-one (21) of thirty-four (34) reported episodes of resident-to-resident altercations in June, July, and August 2013 were identified as abuse directed at seventeen (17) residents (#53, #9, #3, #66, #24, #40, #86, #57, #34, #25, #8, #69, #11, #26, #68, #55, and #60). Ten (10) residents (#89, #3, #9, #40, #44, #68, #11, #22, #25, and #10) were the perpetrators who slapped, punched, grabbed, shoved, screamed at, hit, and/or cursed one (1) or more of the residents identified as abused. It should be noted, some of the residents who were abused were also the ones that abused other residents. The perpetrators were capable of roaming throughout the facility. This created a potential for abuse of all residents who resided in the facility. Resident identifiers: #8, #68, #55, #69, #53, #9, #3, #34, #25, #24, #57, #40, #60, #86, #26, #66, #11, #70, #89, and #22. Facility census: 91. Findings include: a) A review of the thirty-four (34) episodes of reported actual and/or possible resident-to-resident aggressions during June, July, and August 2013 was completed on 08/21/13. The investigations completed and documented by the facility revealed seventeen (17) residents were physically and/or verbally abused during the resident-to-resident aggressions. Ten (10) residents were identified as the perpetrators of abuse. The abused and their abusers were as follows: 1) On 06/07/13, Resident #89 slapped Resident #53 on the head in the main bathroom. 2) On 06/06/13, Resident #3 struck Resident #9 on the head when he threw a cup of coffee. 3) On 06/06/13, Resident #9 struck Resident #3 on the shoulder after a confrontation in the dining room. 4) On 06/05/13, Resident #40 hit Resident #66 on the right arm. 5) On 06/16/13, Resident #34 cursed, grabbed, and hit Resident #24. 6) On 06/18/13, Resident #68 hit Resident #40. 7) On 06/18/13, Resident #40 cursed and hit Resident #68. 8) On 07/31/13, Resident #11 hit Resident #40. 9) On 06/23/13, Resident #40 cursed at and hit Resident #86 several times on the arm and shoulder. 10) On 06/26/13, Resident #22 hit Resident #57 three (3) times while sitting in the solarium. 11) On 06/29/13, Resident #25 slapped Resident #34 while in the dining room. 12) On 06/29/13, Resident #34 slapped Resident #25 while in the dining room. 13) On 07/06/13, Resident #68 hit Resident #8 in the face causing two (2) cuts to his inner lower lip and redness to his right eye. 14) On 07/14/13, Resident #40 hit Resident #24 on the left side of his head. 15) On 07/16/13, Resident #89 hit Resident #69 with a washcloth more than once while in the hallway. 16) On 07/21/13, Resident #11 punched Resident #40 in the arm. 17) On 07/21/13, Resident #40 cussed, yelled at, hit, shoved, and punched Resident #11. 18) On 07/25/13, Resident #40 yelled at, screamed at, and hit Resident #26 on the left shoulder. 19) On 08/20/13, Resident #34 cursed and kicked Resident #40 20) On 08/08/13, Resident #70 struck Resident #55 in the groin as he passed her in the hall. 21) On 08/16/13, Resident #40 hit Resident #60. b) Review of reports submitted to the Office of Health Facility Licensure and Certification (OHFLAC) for occurrences between 06/06/13 and 08/20/13 found fifty-five (55) of seventy-two (72) incidents reported (this number includes the examples listed in finding a)) involved some type of resident to resident abuse. In the fifty-five (55) reports submitted there were twenty (20) different residents identified as perpetrators and thirty-five (35) different residents identified as victims. c) During an interview with a Social Worker, Employee #161, at 11:55 a.m. on 08/22/13, she verified resident aggression was an ongoing problem which the facility addressed weekly in care plan meetings with social services and nursing. Employee #161 explained there were also weekly psychology meetings with the psychologist, psychology technician, and psychology students. She said the full-time psychological assistant (Employee #159) reviewed all aggression incidents and presented them to the psychologist. The psychiatrist was included in the team as necessary. She reviewed and verified the files as records of aggression incidents and stated none of them had resulted in harm requiring hospitalization . The Quality Assurance nurse (Employee #122) verified the above practices independently at 3:30 p.m. on 08/22/13. Employee #122 also stated results and suggestions were added to the care plans and were reviewed by quality assurance. At 12:40 p.m. on 08/22/13, another Social Worker, Employee #160, who works three (3) days a week was interviewed. She stated the facility had hired a full-time resident advocate and her primary responsibility was reviewing and investigating resident aggression, complaints, and allegations. During an interview with the Interim Administrator (Employee #2), at 4:50 p.m. on 08/22/13, he acknowledged there were a high number of episodes of aggression. He stated, based on his short period of time at the facility, he did not have anything to add to the investigations.",2016-09-01
9973,HAMPSHIRE CENTER,515176,260 SUNRISE BOULEVARD,ROMNEY,WV,26757,2012-07-13,223,J,1,0,KH3412,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interviews, resident interviews, and policy review, the facility failed to prevent four (4) residents from being mentally and physically abused by another resident (Resident #29); five (5) residents from experiencing verbal abuse by the same resident; and two (2) visitors from being abused verbally by the same resident. The facility failed to complete incident reports for three (3) of the four (4) physical abuse incidents and/or to investigate them. Although physical harm could not be substantiated, the residents involved and other residents are afraid of Resident #29, as evidenced by documentation in the records, confidential resident interviews, and staff interviews. The administrator was notified of the immediate jeopardy at 12:10 p.m. on 07/10/12. The administrator presented an Immediate Plan of Action, at 12:35 p.m. on 07/10/12, that stated Resident #29 would receive one on one 24 hour observation until the facility could secure appropriate discharge. This plan was immediately put into action and was observed by this surveyor. The plan was relayed to the OHFLAC office. Findings include: A review of the medical record for Resident #29 revealed that he was a [AGE] year old male admitted to the facility on [DATE], for therapy after severe multiple traumas related to a motorcycle accident. His [DIAGNOSES REDACTED]. On admission, the resident was ambulating well, alert but confused at times, and had short term memory loss. The Admission minimum data set (MDS), with an assessment reference date (ARD) of 09/15/1,1 indicated in section E0900 that the resident did NOT wander and his only behavior was ""physical abuse"", which was modified to include ""refusal of care"". When the Quarterly MDS was done on 12/06/11, this resident had been assessed to have the behaviors of ""verbal abuse""; ""other behavioral symptoms not directed toward others""; ""refusal of care"" and now was ""wandering. "" The Quarterly MDS on 06/02/12, indicated under Behavioral Symptom (section E0200) that Resident #29 exhibited physical, verbal, and other behaviors 1 - 3 days of the assessment period. He also rejected care 1 - 3 days and wandered daily. A review of the Mood Monitoring Forms for June and July 2012, revealed the following incidents of Resident to Resident aggression initiated by Resident #29: 06/01/12 "" Resident went into other residents rooms; resident smacked C.N.A. ' s hands; Resident cussed a lot. "" 06/06/12 "" Resident yelled at another resident ' You are overweight ' . "" 06/08/12 "" Making inappropriate comments to other residents. "" 06/22/12 "" Yelling out making inappropriate remarks and comments to others. "" 06/25/12 "" Resident refused care several times, hit aid several times, threatened staff several times. "" 06/26/12 "" Resident pushing another resident up hall yelling and hooping, while resident being pushed YELLING ' Help me ' . (frightened). "" 07/01/12 "" Resident shoved another resident (in w/c) (in wheelchair) down hall fast, let go, yelled and laughing ' Look at her go ' . "" This was the only incident that was reported on an incident report. The affected resident was a [AGE] year old female (Resident #54). She was pushed into the back of another wheelchair striking her knees, although no injury was reported. The nurses notes stated: "" Resident pushed elderly resident up hallway while in w/c hard and stated, ' Look at her go ' . No injury occurred, but resident was upset. "" 07/01/12 "" Resident kicked another resident in back "" She was sitting in front of him in w/c. "" The nurses ' notes identified this resident as Resident #42 and stated, "" Resident pushed resident #42 from back of w/c with his ft (feet) while he was in sitted position in chair at nurses ' station. "" 07/01/12 "" Pulled out privates in front of another resident. Making inappropriate comments. "" 07/04/12 "" Resident was arguing with another resident trying to pick a fight with him ... "" Nurses ' notes stated, "" ...resident verbally aggressive and threatening other residents, hard to redirect at times. "" 07/05/12 "" grabbing private area, laughing told visitor in D. Room (dining room) that he had two nuts he ' d give him. Making sexual comments to C.N.A. ' s and nurses ... "" 07/09/12 During a confidential interview, on 07/10/12, a staff member stated that on the prior day the resident had yelled at a child visiting Resident #58 and it had taken two aides to deter him. The resident is also an exit - seeker and had exited the building 36 times from 06/01/12-07/09/12, although he was on visual checks every ? hour around the clock. He had a psychiatric consult on 06/28/12 and his [MEDICATION NAME] dosage was increased. During an interview with the director of nurses and the social worker. at 9:15 a.m. on 07/09/12, they agreed that his behaviors were increasing and that the interventions do not deter them. This was verified by confidential interviews with four (4) staff members. The social worker stated that she had met with the resident ' s wife and sister recently and that they were concerned that he was still wandering about. The sister had demanded one to one care 24 hours daily. The facility had told them this was beyond their scope of care and suggested they consider other types of facilities, but they refused and nothing further was done. In interviews with six (6) alert residents, all of them identified the resident by description and/or name as a resident who: comes and goes as he wants, sets off alarms, scares people, argues loudly, shoves wheelchairs and people out on his way, and goes in and out of rooms. Four (4) of the six (6) stated that when he was in a mood or loud they avoided being out of their rooms. During the interview with the administrator, at 12:10 p.m. on 07/10/12, she stated that they (staff) had discussed the resident ' s increasing needs several times, but as the wife would not consider transfer, they had continued trying to care for him. She stated her understanding that there was a safety risk to the resident when he eloped from the building. At the end of the facility drive-way is a busy highway as the hospital entrance is directly across from the nursing home entrance. The administrator stated that she was unaware of the increase in the resident to resident conflicts being initiated by Resident #29, and agreed that it was a problem that must be addressed. .",2015-08-01
9984,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2012-06-15,223,K,1,0,WQ7R11,"Based on record review, staff interview, review of incident reports, resident interview, observation, and confidential staff interview, the facility failed to protect six (6) of ninety-six (96) residents from physical abuse by a resident known to have a history of aggressive behavior. The failure to prevent assaults and to effectively prevent further assaults resulted in a determination of an immediate jeopardy. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising or skin tears. The most recent battery occurred on 05/28/12, during an unprovoked attack on Resident #60. This incident caused a skin tear above her eye, a bruise to her temple, and broke her eye glasses. Resident #45 was on a 15 minute watch to check his whereabouts, at the time of this attack. Facility staff did not make a decision to send the resident for inpatient evaluation and medication management, due to his aggressive behaviors, until 05/29/12, although the physical abuse happened frequently since 12/16/11. As of 06/01/12, he was still residing in the facility, and the only intervention related to his aggressive behavior was 15 minute watches to check his whereabouts. Confidential staff interviews with twelve (12) employees, who were familiar with Resident #45, revealed they believed he was a threat to others and could seriously harm someone. The employees described the resident had quick mood changes, making the planned 15 minute watches improbable of preventing physical assaults and battery on elderly female residents whom he targeted. A Resident identifiers: #45, #60, #81, #40, #82, #30, and #64. Facility census: 96. Findings include: a) Resident #60 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/16/11, revealed Resident #60 cried, and reported that Resident #45 hit her across the face and eye glasses. The type of injury was redness and a laceration/skin tear. The discussion/plan, on 12/21/12, noted Resident #60 usually knew to avoid others that were aggressive. The report noted ""QA"" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 05/28/12, revealed Resident #45 wheeled up to Resident #60 and stopped. He then hit her in the face, punched her in the right eye breaking her glasses. He also punched her in the nose and twice on the right side of her head. Both residents were brought to the floor/unit. The type of injury was redness, bruise, and a small laceration/skin tear. Resident #60 was screaming and crying, very frightened, and stated she was very frightened of Resident #45 and of her face being bruised. The plan was the facility was working on placement at the hospital for Resident #45. The report noted ""QA"" was done by the DON, a social worker, and the administrator. 3) Observation of Resident #60, on 06/01/12, at approximately 12:00 p.m., revealed a fading bruise to her right temple approximately an inch and a half in length, and less than half an inch in width. When asked about her injury, she said she was hit by a male resident when they were outside. She said it hurt, and her glasses were broken from the hit. When asked, she said she was afraid of him, and she moves away from him when she sees him coming down the hall. She said she did not want to move to another room elsewhere. b) Resident #81 1) Review of an incident/accident report on 06/01/12, with an incident date of 12/28/11, revealed Resident #81 was hit by Resident #45 twice to the head, and once to the right upper cheek and glasses area. The resident stated, ""He hit me I was just sitting in my W/C (wheelchair)."" The type of injury was redness and an abrasion to the right cheekbone at the site of the glasses rim. The report noted ""QA"" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 01/30/12, revealed Resident #81 was hit by Resident #45 on the top left side of her head, and Tylenol was administered for a headache. The discussion/plan on 02/01/12 noted staff would prompt her due to getting too close to the aggressor. The report noted ""QA"" was done by the DON, a social worker, and the administrator. c) Resident #40 Review of an incident/accident report on 06/01/12, with an incident date of 03/03/12, revealed Resident #45 hit this resident, causing her to fall and hit the back of her head. The type of injury was redness ""at base of head (back area)."" The report noted ""QA"" was done by the DON, the social service supervisor, and the administrator. The discussion plan noted the unit social worker would provide counseling. d) Resident #82 1) Review of an incident/accident report on 06/01/12, with an incident date of 03/13/12, revealed Resident #82 reported Resident #45 hit her with a hairbrush. The type of injury was a 1/2 centimeter sized fresh bruise on the right occipital area of her head. The discussion plan noted the team would monitor. Also, the psychology assistant provided counseling, and Resident #45 was re-directed from the area. The report noted ""QA"" was done by the DON, a social worker, and the administrator. 2) Review of an incident/accident report on 06/01/12, with an incident date of 03/19/12, revealed Resident #45 was observed hitting Resident #82 on the head with his fist, and Resident #82 was yelling, crying, and cursing. The type of injury was redness. The report noted ""QA"" was done by the DON, a social worker, and the administrator. Resident #45 was counseled on not hitting residents. 3) Review of an incident/accident report on 06/01/12, with an incident date of 05/02/12, revealed Resident #45 punched Resident #82 on the nose, and hit her twice on the left forearm. Resident #82 was crying, and her eyes were red. The type of injury was a laceration/skin tear 0.5 centimeter on the bridge of her nose. e) Resident #30 Review of an incident/accident report on 06/01/12, with an incident date of 05/16/12, revealed Resident #30 became verbally aggressive with Resident #45. As Resident #45 was passing by, Resident #30 put out her arm as if to hit the other resident, but did not make contact. Resident #45 came in contact with her and repeatedly hit her on the top of her head and the right side of her head. She cried for hours. The type of injury was redness, but the report did not list the site. Resident #30 was moved to another unit at the time of the incident. A care plan meeting was held, and the team agreed to put the resident back in her former room and place her on 15 minutes checks for her safety. The report noted ""QA"" was done by the DON, a social worker, and the administrator. f) Resident #64 Review of an incident/accident report on 06/01/12, with an incident date of 05/22/12, revealed Resident #45 went up to Resident #64 and began hitting her on the left side of her face and the left upper arm. The report noted ""QA"" was done by the DON, a social worker, and the administrator. The discussion plan noted counseling was provided to Resident #45, they talked with this resident about the incident, and Resident #45 was to be seen by the psychiatrist. The report noted ""QA"" was done by the DON, a social worker, and the administrator. During an interview on 06/01/12, at approximately 12:30 p.m., Resident #64 pointed to Resident #45 when asked if anyone in the facility hit others. She stated Resident #45 pulled her out of her wheelchair and hit her in the head with his hand and it hurt. She said she was afraid of him. When asked what she does when she sees him, she said she moves far away from him and gets by the wall. g) Although not directed toward another resident, review of an incident/accident report on 06/01/12, with an incident date of 02/25/12, revealed Resident #45 chased a Health Service Worker (HSW) down the hall, rammed his wheelchair into the nurses' station door, then rammed his right knee into the sub wall of the nurses' station, before putting himself to bed. This was another indicator the resident had the potential to harm others. h) Resident #45 Confidential interviews with nursing employees, on 06/01/12, in the morning and afternoon, and on 06/11/12 through 06/13/12, found twelve (12) randomly chosen employees stated their belief Resident #45 was a threat to other residents, was physically strong and able to hurt someone if he wished, and was unpredictable. They stated he was habitually physically aggressive, and he targeted elderly females who could not fend for themselves. Those interviewed reported 15 minute watches did not deter him from hitting others, and staff were not always present in the hallways or in the solarium to observe him at all times. When asked about injuries, they reported he had caused bruising and skin tears to elderly females. They reported he sometimes showed warning signs of escalation, but not always. Record review revealed Resident #45 struck elderly female residents a known total of ten (10) times since 12/16/11, sometimes causing injury such as bruising and skin tears. The most recent physical assaults occurred in May 2012. He punched an elderly female resident (Resident #82) in the nose and forearm on 05/02/12. This was his third assault on Resident #82 since 03/13/12. Subsequently, she was moved to another floor and unit. On 05/16/12, a female resident (Resident #30) allegedly was verbally abusive to Resident #45, and raised her arm as if to hit him, but did not. Resident #45 hit her repeatedly about the top of her head and right side of her face. After first moving the resident (Resident #30) to another unit overnight, the care plan team agreed to put her back in her former room on 05/17/12, and placed her on 15 minutes checks for safety. Next, on 05/22/12, Resident #45 subjected a female resident (Resident #64) to an unprovoked physical assault. She was seated in her wheelchair in the hallway having a drink, when Resident #45 began hitting her on the left side of her face and upper arm. She was taken to the third floor dining area for separation, while Resident #45 was counseled, and he was placed on 15 minute checks due to aggression. She was offered a room change, but refused. Then, on 05/28/12 during an outside event, while still on 15 minute watches, Resident #45 wheeled up to an elderly resident (Resident #60), stopped, and hit her repeatedly in the face and head. According to the incident report dated 05/28/12, Resident #45 (sic) ""hit her in the face, punched her in the R (symbol for right) eye breaking her glasses, in the nose & twice in the R side of the head."" Resident #45 was (sic) ""screaming and crying."" The incident report described the resident was very frightened and stated she was very frightened of Resident (#45) and of her face being bruised. She was offered a room change, but refused. There was no evidence the facility sought professional assistance regarding Resident #45's aggressive behaviors until they contacted a hospital, on 05/29/12, concerning a transfer of the resident. At the time of the investigation, the facility had made no progress in transferring the resident. During interviews with a former social worker, Employee #169, and the social service director, Employee #106, on 06/01/12, at approximately 1:00 p.m., Employee #169 stated they could not come up with any way to transfer Resident #45 to the hospital, as the hospital required signed consent from the resident's health care surrogate (HCS), who lived in another town. Employee #169 said the required paperwork was mailed to the HCS on 05/30/12. However, the decision the resident needed to be transferred was made on 05/29/12, and contact was made with the hospital at that time. An interview was conducted, by telephone, with the hospital's intake worker, on 06/01/12 at 1:34 p.m. The intake worker stated the hospital typically faxed the consent information to the power of attorney at a convenient location, such as the local emergency room in the community, where it would be signed and faxed back to the hospital. On 06/01/12, at approximately 2:00 p.m., an interview with Employees #169 and #106 revealed Employee #169 had just spoken with the HCS, and was informed the papers had not yet arrived. At that time, the information provided by the hospital intake worker was shared with Employees #169 and #106. This was not something the facility had explored until surveyor intervention. At approximately 3:10 p.m., on 06/01/12, an interview was conducted with the director of nursing and the administrator. At that time, it was communicated that facility staff knew Resident #45 had aggressive behaviors, and had recently, on 05/22/12 and 05/28/12, physically assaulted residents without provocation. This was while he was on 15 minutes watches due to his aggressive behaviors. It was apparent the 15 minute watches did not prevent him from assaulting again. In view of these findings, and with consideration of multiple confidential staff interviews who reported their concerns that Resident #45 was a threat to others, and could potentially harm other residents, it was determined the resident's behaviors toward other residents was an immediate jeopardy to the other residents in the facility. During an interview with the administrator on 06/01/12, at approximately 4:15 p.m., and a confirmation from a nursing assistant, Employee #76, at approximately 4:30 p.m., the facility began, and will continue to provide, 1:1 monitoring with Resident #45 until he can be sent to the hospital for evaluation and medication adjustment. The immediate jeopardy was removed at 4:30 p.m. on 06/01/12. With the implementation of the 1:1 monitoring, no deficient practice in this area remained. Another interview was conducted with the administrator, on 06/01/12, at approximately 5:00 p.m. She stated she spoke with the HCS and found that she has a daughter close by, but because the daughter is working at present, is unable to take her to a community location today to receive and send faxes. When the HCS was asked, by the administrator, if she believed she was the best person to look after Resident #45's affairs, and the availability of the DHHR to do so if she desired, the HCS allegedly spoke positively about the DHHR being able to take over this duty for her. During this interview, the administrator stated she had authorized 1:1 staffing with Resident #45 all weekend, or until such time that he was placed at a hospital. A psychology assistant, Employee #164, was interviewed on 06/11/12 at 3:31 p.m. She said Resident #45 had busied residents ""a couple of times."" She stated that in the past few weeks, Resident #45 had not been sending warning signals he was becoming agitated before he struck. Employee #164 stated this was new for him. She stated he received 1:1 services on 06/01/12 in the evening. When asked, she did not recall him having 1:1 services in May. During an interview with the administrator on 06/11/12 at 4:45 p.m., she said Resident #45 had never hurt anyone. When asked about bruises, she stated there has been no bruising to others by Resident #45, to her knowledge, and if there were, "" ...somebody had better be documenting them."" Several incident/accident reports, reviewed on 06/01/12 described injuries, including bruising, as well as physical and emotional pain experienced by the residents who had been assaulted by Resident #45. All but one (1) of the incident/accident reports noted ""QA"" was done by the DON, a social worker, and the administrator. .",2015-08-01
10240,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2010-06-04,223,G,0,1,5XSR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review, staff interview, review of the facility's infection control policies, resident interview, and review of the Centers for Disease Control and Prevention (CDC) 2007 Guideline for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, the facility failed to assure one (1) of twenty-nine (29) Stage II sample residents was not placed in involuntary seclusion against her will due to the inappropriate application of isolation procedures. The facility's infection control policies and procedures for isolation precautions were not consistent with current standards of professional practice for long-term care facilities established by CDC, which ""recommended that psychosocial needs be balanced with infection control needs"". Resident #45 was required to remain alone in an isolation room with the door closed with no planned in-room activities or other interventions to prevent the resident from being socially isolated from other residents who were important to her (to include a male resident whom she stated must be ""worrying his brains out"", because he did not know where she was). As a result, Resident #45 suffered confusion related to her relocation and psychological harm and mental distress during this period of involuntary seclusion due to the facility's failure to provide for her need for social interaction. Resident identifier: #45. Facility census: 48. Findings include: a) Resident #45 Observations, conducted from 05/24/10 through 05/27/10, noted Resident #45 to be out of her room ambulating in the hallways, participating in activities, and dining with other residents. On the return visit the following week, beginning on 06/01/10, observation found Resident #45 had been moved to a single occupancy isolation room with the door closed and was not observed to leave her room throughout the day. Review of Resident #45's medical record found a physician's orders [REDACTED]. -- Review of her most current resident assessment instrument, an abbreviated quarterly assessment with an assessment reference date of 04/28/10, revealed this [AGE] year old female was alert and oriented to season, location of her own room, staff names / faces, and to the fact that she was in a nursing facility. The assessor noted the resident had problems with her short-term memory but no problems with her long-term memory, and that her cognitive skills for daily decision-making were moderately impaired. Her [DIAGNOSES REDACTED]. She was independent with the self-performance of all activities of daily living and required staff supervision only with locomotion when off the unit. She had no indicators of [MEDICAL CONDITION] and no indicators of depression, anxiety, or sad mood. -- Review of the resident's current care plan, effective through 08/25/10, found the following, ""Has a special friendship / relationship with a male resident. Thinks of him as her boyfriend."" Review of the planned interventions included, ""Provide activities that res (resident) and friend can attend together, such as parties, movies, singings, outings... Provide private space for physical relations if both residents desire."" Review of an activities progress note, dated, 02/01/10, found the following, ""Resident enjoys all activities, loves to talk to staff and residents. She does her own AM (morning) care. Is able to feed, and dress self. She enjoys singing, and all socials. Will go out on field trips. Loves to talk about her family, mother, father, brothers. Enjoys walking around drinking her coffee. She is out of her room most of the day. She is a joy. Will continue with her care plans. Will keep her encouraged."" -- Review of the May 2010 activity attendance record for Resident #45 found she participated in church services, current events, Bingo, group exercise, ice cream socials, trivia time, etc., until she was placed in isolation on 05/27/10. Other than two (2) in-room activities (which were documented after inquiry by surveyor on 06/01/10), her activity participation was marked with an ""I"", indicating she was in ""isolation"". A nursing note, dated 05/27/10 at 2:25 p.m., documented that the resident continued in respiratory isolation per order. ""Client (resident) continues to be reoriented, confusion noted in regards to isolation room. Client continues to attempt to leave. Staff continues to redirect back to room..."". -- An interview with the individual responsible for the day-to-day planning and organization of the activities department (Employee #1) was conducted at 4:14 p.m. on 06/01/10. She was asked what planned activities had been developed to address Resident #45's activity needs while she was alone and confined in the isolation room. Employee #1 stated she had not initiated a plan of activities related to the resident being confined to her room. When asked if she had visited the resident at all that day to provide in-room activities, Employee #1 stated she had not. Employee #1 reported the resident wanted to come out, stating, ""I let her know that she can't come out. Her boyfriend (Resident #20) thinks she's dead. (Resident #45) likes to do anything and everything we do, parties, snacks, music, church, and bluegrass the other night. She don't (sic) like it; she don't (sic) like to be in her room. She likes to be with (Resident #20). She does not like being away from him at all."" -- Observations of the medication administration pass were conducted with a licensed practical nurse (LPN - Employee #44) at 10:00 a.m. on 06/02/10. Resident #45 stated to the nurse that she wanted to go home, that there wasn't anything wrong with her chest. Employee #44 related that the resident referred to her room (prior to isolation room) as ""home"". The resident was interviewed following Employee #44's departure. When asked how she liked her new room, she stated that there wasn't anything to do and there wasn't even a clock in her room. Observation confirmed there was no clock nor any activity items (such as magazines, books, etc.) in her room. The resident stated her boyfriend must be ""worrying his brains out"", because he did not know where she was. (Note that 06/02/10 was Day 7 of this resident's isolation.) -- An interview with the assessment nurse (Employee #36) was conducted at 4:30 p.m. on 06/01/10. Upon review of Resident #45's current care plan, Employee #36 agreed that it had not been updated to reflect interventions related to the resident being confined to her room due to [MEDICAL CONDITION] infection. Employee #36 stated it was her understanding that Resident #45 was not allowed out of her room. -- Review of the facility's infection control policy and procedures titled ""Protocol for Patients [MEDICAL CONDITION] Infection or Colonization"" found: ""1. All patients with [MEDICAL CONDITION] cultures will be placed in contact isolation immediately upon discovery of the infection or colonization."" The policy was devoid of procedures for implementing ""contact isolation"". (See citation at F441.) -- Review of CDC's 2007 Guidelines for Isolation Precautions: Preventing Transmission of Infectious Agents in Healthcare Settings, on page 34, Section I.D.2.a. for long term care facilities (LTCFs), found the following language: ""LTCFs are different from other healthcare settings in that elderly patients at increased risk for infection are brought together in one setting and remain in the facility for extended periods of time; for most residents, it is their home... it has been recommended that psychosocial needs be balanced with infection control needs in the LTCF setting..."". Resident #45 was required to remain alone in a single occupancy isolation room with the door closed with no planned in-room activities or interventions to prevent the resident from being socially isolated from other residents who were important to her, which caused her psychosocial and emotional distress. Relocation of Resident #45 to this isolation room resulted in confusion with attempts to leave the isolation room. -- Following inquiries concerning the stringent infection control practices of the facility and the lack of a care plan in accordance with accepted standards of practice for LTCFs to address contact isolation, the facility developed, on 06/02/10, a care plan which included allowing the resident to attend out-of-the-room activities. -- A nursing note, written at 3:52 p.m. on 06/02/10, documented that the resident was taken outside for gathering in Sunshine Park with mask on for approximately thirty-five (35) minutes with no attempts to remove the mask. .",2015-06-01
10848,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2010-02-11,223,D,0,1,ZHEQ11,". Based on medical record review and staff interview, the facility failed to ensure each resident was free from involuntary seclusion for one (1) of thirty-two (32) Stage II sampled residents. Staff developed a progressive behavior modification plan which included confining Resident #29 to his room. This plan required staff to document antecedents to the target behavior, staff's response to he behavior, what consequence was applied, and the resident's response to the consequence. The imposition of involuntary seclusion was not implemented in accordance with the behavior modification plan. Facility census: 95 Findings include: a) Resident #29 Record review revealed a problem statement within Resident #29's care plan, dated 11/24/09, stating: ""Behavior Protocol: Episodes of inappropriate behavior as demonstrated by voiding on multiple sets of his clothing throughout the day...also has a behavior plan that addresses instances where he voids on his clothing."" Interventions associated with this care plan included a ""Psychosocial Program"". According to this program, on each shift, ""the first time that (Resident #29) voids on his clothing, he will be provided with a change of clean clothes. Staff are to inform that the next time he voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids on his clothing, he will be put in a hospital gown. If during the same shift (Resident #29) voids inappropriately for the second time on his clothes, he will be dressed in a gown. Hospital policy stated that if a resident is wearing a gown, they must stay in their room until properly dress. (Resident #29) will be given a clean set of clothes at the start of the next shift."" On the mid-afternoon of 02/09/10, interview with the psychological assistant revealed this resident's behavior was tracked on behavior monitoring sheets. She indicated the resident had a behavior management plan now in place to reward positive behaviors, and the psychological assistant related the behavior protocol described above originated on 05/28/07 and was discontinued on 10/17/07. She said the resident again began voiding on his clothing purposefully around November 2009, and the behavior protocol was put back into place. Additional information was requested at this time. On the early afternoon of 02/11/10, the psychological assistant presented tracking sheets for Resident #29. On the sheet, instructions stated, ""What was the negative behavior? What brought it on? How did your respond?"" Review of the tracking sheets from 11/02/09 through 02/11/10 found descriptions of the resident's behavior, but there was no discussion of what brought on the behaviors and/or how staff responded when the resident removed his clothing and urinated on it. Also not noted were the resident's responses to staff interventions. A psychological behavior plan note, dated 11/24/09, stated, ""Informed (Resident #29) that a new behavior protocol would be started for his inappropriate voiding behaviors. I explained to him that if he voided on his clothes he would get one clean set and after that he would be in a gown. I also told him that once he was in a gown he needed to stay on the unit and would have his meals on the floor and miss any activity going on at that time. Once the new shift came on he would receive new set of clothes. He asked me questions and I answered... Later on this evening staff informed this writer that (Resident #29) became upset because he said that I told him he was to eat on the floor. Staff tried to tell (Resident #29) that was only if he was in a gown. He continued to argue with staff and went to bed."" Confidential staff interviews, on 02/09/10 at 4:00 p.m. and 02/09/10 at 10:00 a.m., found that, if the resident inappropriately voided once, he was supposed to get another set of clothing. If the resident voided a second time, he would then be put into a hospital gown and brief and placed in his room until the next shift came on. He would not be allowed out of his room until the next shift, at which time he would receive another set of clothing. Both the staff members interviewed reported this protocol was implemented at least once since November 2009. Review of the behavior tracking sheets failed to find any evidence of the resident's reaction to the implementation of the behavior protocol. Review of the psychological assistant's notes for the time period from 11/24/09 through 02/11/10 did not find any description of the resident's response to the behavior protocol when implemented. An attempt to interview Resident #29, on the late afternoon of 02/09/10, was unsuccessful. Psychological notes, dated 11/24/09, 12/04/09, 12/11/09, 01/08/10, 01/22/10, and 02/05/10, documented how many episodes of inappropriate voiding occurred, but there was no mention of how staff intervened and/or how the resident responded to the interventions. The resident also had a behavior management plan that rewarded the resident for good behavior, but the tracking sheets, when reviewed, did not indicate the resident's response when he was not rewarded. The behavior management plan indicated the resident voided inappropriately, but it did not include the behavior protocol that isolated the resident. On the mid-morning of 02/11/10, staff provided a plan of care evaluation, dated 02/10/10, which stated, ""Behavior of inappropriate voiding was brought up at the care plan meeting and staff reported that it has not been a problem recently. Team decided and agreed that it would be appropriate to resolve plan of care for this behavior."" .",2014-12-01
10997,"WAYNE NURSING AND REHABILITATION CENTER, LLC",515168,6999 ROUTE 152,WAYNE,WV,25570,2011-06-09,223,G,1,0,2TQ311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on a review of the facility's self-reported allegations of resident mistreatment / abuse / neglect, medical record review, review of the facility's abuse prohibition policy and procedures, and staff interview, the facility failed to ensure residents were free from abuse. Eight (8) residents were identified, in statements collected from staff, as having been subjected to mistreatment / abuse / neglect by Employee #81, a licensed practical nurse (LPN). Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected residents to involuntary seclusion by restraining them with inappropriate devices and in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others (beyond Resident #12), and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy and procedures. Resident identifiers: #12, #15, #30, #59, #60, #61, #62, and ""X"". Facility census: 58. Findings include: a) Residents #12, #15, #30, #59, #60, #61, #62, and ""X"" 1. On 06/06/11 at approximately 4:00 p.m., a review of the facility's records of allegations of resident mistreatment / abuse / neglect (which had been self-reported to State agencies by the facility) revealed thirteen (13) allegations against Employee #81 - a licensed practical nurse (LPN) who worked on the night shift - were self-reported by the facility to the State survey agency as follows: - ""Employee was alleged to have audiotaped a resident (#12) cursing on her cellular phone."" (This was reported to the State survey agency on 01/25/10; date of incident was not known.) - ""Employee was alleged to have squirted water on resident (#62). ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""Employee was alleged to have pushed resident (#15) quickly down the hallway in wheelchair. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee tied resident's (#30) wheelchair to side rail. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#61) to yell and cuss. ..."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that employee encouraged resident (#12) to yell and cuss and allegedly gave medications in an inappropriate manner."" (This was reported to the State survey agency on 01/26/10; date of incident was not known.) - ""It was alleged that this employee placed cold water on the resident's face (#62). ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee was verbally inappropriate to residents."" (No residents were named.) (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee put resident (#60) to bed in a rough manner. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that this employee cursed in front of a resident and the resident repeated this. Resident unknown at this time. ..."" (This was reported to the State survey agency on 01/27/10; date of incident was not known.) - ""It was alleged that the employee gave laxatives without physician's order and mixed medications and did not give to residents."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #30)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - ""It was alleged that employee used inappropriate restraints (on Resident #12)."" (This was reported to the State survey agency on 01/28/10; date of incident was not known.) - Review of the facility's internal investigations into allegations of mistreatment / abuse / neglect by Employee #81 found the facility substantiated five (5) of the thirteen (13) allegations: - Recording on her cellular phone Resident #12 cursing - Administering laxatives without a physician's order - Encouraging Resident #61 to yell and curse - Tying Resident #30's wheelchair to a side rail - Being verbally inappropriate to residents - Encouraging Resident #12 to yell and curse and administering medications in an inappropriate manner -- 2. Upon review of the witness statements obtained during the facility's internal investigation, the following allegations were reported by staff to administrative personnel at the facility regarding Employee #81's actions towards residents (all are quoted as they were written): (Note: The statements were variously dated as having been written by the witnesses on 01/22/10, 01/23/10, and 01/15/10. Additional responses to pre-determined sets of questions were recorded for employees and signed by each witness and co-signed by either the administrator, director of nursing, and/or social worker, but these statements were not dated.) In a statement dated 01/22/10 by Employee #74 (an LPN): ""This UCN (unit charge nurse) has witnessed UCN (Employee #81) allowing CNA's (certified nursing assistants), to take blood sugars, give insulin, IV (intravenous) treatment & administer meds. Also witnessed a voice recording on cellular phone of a resident having a fecal impaction removed. Resident screams, curses, and makes several other noises. When allowing CNA's to do med, witnessed CNA pry jaws of resident's mouth open shoved crushed pill in mouth & held mouth shut for approximately 15 seconds."" In a separate statement (undated) signed by Employee #74 were the following handwritten responses to a pre-determined set of questions: ""Yes. Ive heard her yell @ (at) residents. Ive seen her hold residents noses & pry mouths open to give medications. She goes in residents rooms and slams door and yells. Ive heard her ask residents 'What the hell do you want?' I have seen her give too much laxitives to residents. She calls this a 'Ashlanta'. It is (4 [MEDICATION NAME] - 30ccs [MEDICATION NAME] & 30 ccs MOM (milk of magnesia). I have seen her put H2O in residents when they have called out. Yes. I heard a recording on (Employee #81's first name)'s cell phone of (Resident #12) yelling & cursing while having stool digitally removed. She played this for staff while laughing. Yes. (Employee #81) gave (Employee #78) CNA insulin and had her give the injection. I don't know which resident. (Employee #81's first name) has asked CNAs to do blood sugar sticks. I seen her give (Employee #78) CNA pills to give residents. Note: Ive been scared of her ..."" - In a statement dated 01/22/10 by Employee #50 (a CNA): ""I have seen (Employee #81) putting (first name of Resident #12) up to singing and getting her to yell an cuss. She has also got (Resident #61) to yell an cuss. ..."" In a separate statement (undated) signed by Employee #50 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed things I do not think is appropriate from (Employee #81's first name) such as riling them up, encouraging cussing & yelling. (First name of Resident #12) (First name of Resident #61)"" - In a statement dated 01/22/10 by Employee #58 (an LPN): ""This LPN has had CNA make verbal statements to me regarding (first name / last initial of Employee #81) and her inappropriate remarks made to residents. They state to me that she'll aggravated and yell at them. ... CNAs state to me that she gets some of the residents ""rowled"" up and laugh about it. ... Some of the CNAs have told me that they have seen her let a couple of the midnite CNAs pass some of her meds and check blood sugars for her. ... I think people are afraid to 'tattle' on her for what she will do to get back at them."" - In a statement dated 01/23/10 by Employee #73 (an LPN): ""I have heard a recording on a cell phone owned by (first name / last initial of Employee #81) and (first name / last initial of Employee #78) of what I believed to be (first name / last initial of Resident #12). It was the sounds made while she was being dug out from impaction. I have witnessed (first name / last initial of Employee #81) holding (first name of Resident #12)'s nose to give meds when she would not take them. I called her on it and have not seen it since. I have had others come to me and tell me that (first name / last initial of Employee #81) throw ice water in (Resident #59) face to make her be quiet. I went to look and could not prove, but pillow as wet. I witnessed (first name / last initial of Employee #81) tie up (Resident #30)'s wheel chair to a hand rail ... I heard (first name / last initial of Employee #81) got mad at (Resident #62) one night and took her to the shower turned on the cold water and held it in her face. (Resident #62) is scared of water ..."" In another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""Yes. I have seen her (Employee #81) hold a residents nose to get her to swallow. I have heard her be verbally inapprop. i.e. 'Youll get your meds when Im ready' 'Youll eat when I eat' I have heard her yell in residents room but done know what she was yelling about. Ive seen her squirt H2O on multiple residents with a syringe just because she thought it was funny. I seen her tie a resident chair to the hand rail to prevent the resident from roaming around. I have seen her give too much [MEDICATION NAME] (laxative) to residents. She calls it a 'Ashlanta' Too many pills w/ liquid [MEDICATION NAME]. She also goes into residents rooms and slams doors. She targets certain residents. I have also witnessed her not giving medication but initialing that she gave them. ... (Employee #81) is inappropriate and we have been afraid to say anything."" In yet another separate statement (undated) signed by Employee #73 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she held a resident's nose and covered mouth until they took their medications. I have also seen her mix medications and not give them to residents. ..."" - In a statement dated 01/23/10 by Employee #59 (an LPN): ""I have heard an audio recording of (Resident #12) having an impaction removed. I heard from a CNA that cold water was poured on (Resident #59) one night while she was screaming. I heard that (Resident #60) was picked up and thrown into bed and hit the wall. The above was done by (Employee #81)."" In a separate statement (undated) signed by Employee #59 were the following handwritten responses to a pre-determined set of questions: ""...Yes. (Resident #12) - yelling while being digitally removed by LPN. (Employee #81) played this for this LPN and other staff. ..."" - In a statement dated 01/23/10 by Employee #51 (an LPN): ""I have heard audio of (first name of Resident #12) hollering & cursing. (First name of Employee #81) recorded when resident was impacted. Resident was upset. ..."" In a separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... Yes, she (Employee #81) held a resident's nose to give juice to (illegible) to get sugar up. ... Yes. I saw her (Employee #81) squirt saline at a resident. ..."" In yet another separate statement (undated) signed by Employee #51 were the following handwritten responses to a pre-determined set of questions: ""... - Witnessed her (Employee #81) pinching (Resident #12) nose to get her to eat, drink - (residents sugar was low) - Resident was acting out & she (Employee #81) squirted her (Resident #62) w/ (with) syringe ..."" - In a statement dated 01/23/10 by Employee #76 (a CNA): ""I do not witnessed or heard any miss conduct other than (first name / last initial of Employee #81) cursed in front of a resident and the resident repeated."" - In a statement dated 01/23/10 by Employee #5 (a CNA): ""I have only heard by another CNA that Nurses was getting a Resident upset."" - In a statement dated 01/23/10 by Employee #79 (a CNA): ""I am aware of no misconduct in this facility over 6 months ago. I was asked to change out oxygen parts by midnight shift."" - In a statement dated 01/25/10 by Employee #75 (a CNA): ""(Employee #81) has know to get people started yelling and such things as (Resident #15) in wc (wheelchair) took to showered later driving the w/c up down hallway say whooo like a cris cross pattern. Getting (Resident #12) start yelling by messing with her and recording it on cell phone. Has made residents upset at times just to hear them yell or see how they react."" In a separate statement (undated) signed by Employee #75 were the following handwritten responses to a pre-determined set of questions: ""I have witnessed her (Employee #81) being inappropriate. Zigzagging her (Resident #15) in wc (wheelchair) quickly down hallway. Yes - (Employee #81's first name) played audio form her phone of (Resident #12's first name) yelling & cussing (Whoo! Oh s***!). Said she taped it the other night w/ a CNA in the room while they were changing her. ..."" In an undated statement signed by Employee #80 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... (Employee #81) encourages (Resident #12's first name) to cuss."" - In an undated statement signed by Employee #67 (a CNA) were the following handwritten responses to a pre-determined set of questions: ""... It's been a couple of months ago - (Employee #81 was) aggrevating (first name of Resident #12). ... she tied a garbage bag & tied it around (first name of Resident X) & first name of Resident #12) to keep them from falling (because they kept falling). ... squirting w/ syringe - aggrevate (first name of Resident #12). ... (first name / last initial of Resident #61) & (first name / last initial of Resident #12) - mocking what they say."" -- 3. Failure to Meet Reporting Requirements Although the witness statements did not identify when each of these alleged events occurred, it was evident that these events were not immediately reported after they occurred by the employees to the facility's administrator as required by this regulation. Additionally, the earliest statements containing allegations of resident abuse / neglect by Employee #81 were dated 01/22/10, but the first self-report of an allegation of abuse was not sent to the State survey agency until 01/25/10. The initial reporting of allegations of abuse / neglect against Employee #81 were not made within no more than twenty-four (24) hours after they were received by the facility as required by this regulation. Furthermore, not all of the events alleged by the employees in their witness statements were reported to the State survey agency as required by this regulation, including the following allegations: - Employee #81 pinched Resident #12's nose to get her to take medications, food, and fluids - Employee #81 poured cold water on Resident #59 to get her to quiet down - Employee #81 initialed residents' medical records to indicate medications were administered when they were not given - Employee #81 allowed unqualified non-licensed personnel to perform tasks outside of their ""scope of practice"", such as administer medications / treatments, perform invasive procedures (to include giving fingersticks and insulin injections), etc. - Employee #81 tied garbage bags around Resident #12 and Resident ""X"" to keep them from falling -- Review of minimum data set assessments (MDSs) for each of the residents identified in the employees' statements above, all with assessment reference dates (ARDs) prior to 01/22/10 (the date of the first witness statement alleging abuse of residents by Employee #81), revealed the following: - According to her 12/15/09 MDS, Resident #12, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/16/09 MDS, Resident #15, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/02/09 MDS, Resident #30, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/13/09 MDS, Resident #59, at that time, was a [AGE] year old female who was admitted to the facility on [DATE] and re-admitted on [DATE]; her [DIAGNOSES REDACTED]. - According to his 11/11/09 MDS, Resident #60, at that time, was a [AGE] year old male who was admitted to the facility on [DATE]; his [DIAGNOSES REDACTED]. - According to her 01/14/10 MDS, Resident #61, at that time, was a [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - According to her 12/30/09 MDS, Resident #62, at that time, was an [AGE] year old female who was admitted to the facility on [DATE]; her [DIAGNOSES REDACTED]. - A review of Resident #12's medical record revealed she have a [DIAGNOSES REDACTED]. Further review of Resident #12's medical record, including nursing notes, medication administration records (MARs), and physician's orders for December 2009 and January 2010, found no physician's order to digitally remove stool from the resident's rectum (an invasive procedure which cannot be performed by an LPN without a physician's order), no nursing note entries by Employee #81 describing the resident's health status necessitating this procedure (including signs / symptoms of the presence of a fecal impaction), and no nursing note entries detailing the performance of this procedure (including the resident's response to the procedure). There was no evidence in the resident's record to indicate digital removal of stool from her rectum was either medically necessary or approved by the physician. The director of nursing and the registered nurse consultant, when interviewed on the afternoon of 06/09/11, agreed the medical record contained no documentation regarding why Employee #81 digitally removed stool from Resident #12. - Employee #81's willful act of digitally removing stool from Resident #12's rectum (causing Resident #12 physical discomfort and/or emotional distress as evidenced by her screaming / cursing during the procedure, which Employee #81 recorded on her cell phone and played for others to hear) constituted abuse. The facility reported to the State survey agency the allegation that Employee #81 audio-recorded Resident #12 screaming and cursing, but the facility failed to report that the cause of the resident's distress was an invasive procedure that was performed by Employee #81 without a physician's order and without evidence of medical necessity. (See also citation at F225.) - Employee #81 physically abused Resident #12 by performing an invasive medical procedure without a physician's order, which resulted in physical discomfort and/or emotional distress as witnessed by multiple employees who reported having heard an audio-recording on Employee #81's cellular phone of Resident #12 screaming and cursing during the procedure. Employee #81 also physically abused a number of unidentified residents by giving them a combination of laxative medications that were not ordered by a physician. Employee #81 threw or squirted water on residents (including a resident known to be afraid of water) and allowed nursing assistants to perform tasks that should not be delegated to unlicensed assistive personnel in a nursing home. Employee #81 subjected three (3) residents to involuntary seclusion by restraining them with inappropriate devices in the absence of a medical necessity. In addition, Employee #81 incited residents to yell and curse. All of the residents identified in the employees' statements had a [DIAGNOSES REDACTED]. The period of time, the extent of harm to others, and the number of residents affected by the behaviors of Employee #81 could not be ascertained, as staff failed to immediately report Employee #81's actions to superiors and/or outside agencies. This failure to immediately report resulted from a failure of the facility to operationalize the abuse prohibition program outlined in the facility's policy titled ""Abuse, Neglect and Misappropriation Of Resident Property: Protection of Residents / Reporting and Investigation"" (effective 01/09/09). (See also citations at F225 and F226.) .",2014-10-01
11305,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2011-02-11,223,G,1,0,3UQL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of the facility's self-reported allegations of resident abuse / neglect and staff interview, the facility failed to ensure one (1) of three (3) residents were free from abuse. One (1) resident suffered mental anguish after staff members intentionally deprived him of free access to his bed. The facility staff did not allow this resident (who was physically able to get into his bed on his own) to access his bed freely. Staff kept the bed elevated with side rails up so as to prevent him from accessing his bed without staff assistance, and then failed to assist him to bed for a period of approximately five (5) during which time he begged staff members to put him in his bed. Resident identifier: #8. Facility census: 43. Findings include: a) Resident #8 1. On 02/11/11 at approximately 11:00 a.m., review of the facility's self-reported allegations of resident abuse / neglect revealed a report dated 01/05/11, which was submitted to the Office of Health Facility Licensure and Certification (OHFLAC) Nurse Aide Registry. The report identified Employee #33 (a nurse aide) as the alleged perpetrator and Resident #8 as the alleged victim. The allegation was: ""(Employee #33) states she elevated the resident's bed so that he would not get into the bed. She states this was done in an attempt to prevent the resident from choking on tobacco, as he refuses to remove the tobacco from his mouth prior to getting in bed. This information was obtained during a counseling session with (Employee #33) on 01/04/11."" -- 2. The five (5) day follow-up report dated 01/12/11 (an extension was granted by OHFLAC due to an employee being on sick leave) stated: ""(Employee #33) states she elevated the resident's bed so he could not get into bed by himself. Done to prevent resident from getting into bed with tobacco in his mouth and possibly choking (sic). DON (director of nursing - Employee #141) stated it was okay to raise the bed for safety purposes. However, there was no order to raise the bed and this was not a part of the resident's care plan."" The facility substantiated the allegation against Employees #33 and #141; however, the facility identified the issue as neglect as opposed to abuse. -- 3. The facility's internal investigation into this incident (titled ""Long Term Care Investigation"") was completed by the facility ' s administrator (Employee #139). The allegation was stated as follows: ""Resident (name of Resident #8)'s bed was elevated so that he could not get into bed by himself. This was allegedly done so that the resident would not get into bed with tobacco in his mouth, putting him at risk for choking and/or aspiration."" The investigative report included summaries of interviews conducted by the administrator with various staff members by the administrator on 01/06/11, 01/10/11, and 01/11/11, including the following: - Employee #68 (housekeeping), interviewed on 01/06/11 - ""(Employee #68) states that one evening while he was working the resident asked for a 'chew.' He states it was probably around five or six o'clock. (Employee #68) states the resident spit the tobacco out and said he would like to go to bed. He states this went on for approximately four hours. ""(Employee #68) states he went in at 21:30 (9:30 p.m.) to pull the trash and the resident was still asking to go to bed. He states that at 22:30 (10:30 p.m.), 'the (sic) man still wanted to go to bed.' (Employee #68) states the resident begged to go to bed. He states the resident's bed was 'in the air' the whole time. (Employee #68) states the resident asked him to put his bed down, but (Employee#68) told the resident he could not put the bed down. (Employee #68) states he reported the incident to (Employee #99), CNO (chief nursing officer)."" - Employee #10 (licensed practical nurse - LPN), interviewed on 01/10/11 - ""(Employee #10) states she was doing a medication pass on December 14, 2010 at approximately 17:30 (5:30 p.m.). She states she was returning to the medication room when (Resident #8) asked her for 'a chew and a pop.' (Employee #10) states that at 19:30 (7:30 p.m.) the resident was at the gate at the nurse's station saying, 'Honey, put me in the bed. My bed is raised up.' (Employee #10) states she informed the resident that 'they' didn't want him to get in bed with a chew. (Employee #10) states (Resident #8) gave her his tobacco. She states she told the resident's nurse, (Employee #30) (LPN) that he wanted to go to bed. ""(Employee #10) states she personally did not see the resident's bed up because she was 'not allowed' to go on that side of the unit. She states (Employee #68) told her it was true, that the resident's bed was up. (Employee #10) states she told the resident to follow (Employee #33 - a nurse aide) and that she would put him to bed. ""(Employee #10) states that at 21:50 (9:50 p.m.) the resident was following her during a medication pass and said he wanted to go to bed. (Employee #10) states that she told (Employee #30 - an LPN), 'If someone doesn't put him in bed, I'm giving him another chew.' (Employee #10) states that (Employee #140 - a registered nurse) came on the unit and she asked (Employee #140) to look and see if the resident's bed was up. (Employee #10) states that (Employee #140) told her the bed was up. (Employee #10) told (Employee #140) not to say anything. ""(Employee #10) states she called (Employee #141), DON, the next morning. (Employee #10) states (Employee #141) asked her, 'What are you doing on that side?' (Employee #10) states she told (Employee #141) that somebody was putting the resident's bed up. She states (Employee #141) replied, 'Day shift does it.' (Employee #10) states she told (Employee #141) that (Employee #68) told her the resident's bed was up. (Employee #10) states that (Employee #141) replied, '(Employee #68) comes behind the desk, too, and he's not supposed to.' (Employee #10) further states that (Employee #39), LPN, told her that (Employee #141) had asked her to write an order to put the bed up, but (Employee #39) said she was not comfortable doing this. ..."" - Employee #17 (a nurse aide), interviewed on 01/06/11 - ""(Employee #17) states that (Employee #33) told her she needed to lock the resident's bed and that (Employee #141) had told her she could put the bed up and lock it. (Employee #17) states that the bed has been put up several times by (Employee #33) and that this has been going on for about a month to a month and a half."" - Employee #142 (physician), interviewed on 01/06/11 - ""(Employee #139) asked (Employee #142) if he had given (Employee #39), LPN, a verbal order to elevate the bed. (Employee #142) states that is not exactly the way it happened. He states that (Employee #141) discussed with him the resident's fall risk, stating that if the resident gets into bed by himself the bed alarm will not be turned on. (Employee #142) states he told (Employee #141) that if it was within the law to raise the bed it was fine. He states he didn't know if that would be like a restraint and also that he did not know if that would keep the resident from falling. He states he does not think that he gave an order for [REDACTED]. -- 4. Included with the facility's investigative report was a typed statement from Employee #141 dated 01/11/11, explaining her why she allowed staff to raise Resident #8's bed up to a point where he could not access it independently. A portion of the letter stated (quoted verbatim), ""... in (Resident #8)'s care plan he is to have at least a one person assist to enter and exit his bed, as he is unable to bear weight on his feet, in his care plan he is to have a bed alarm on at all times, to assure that he does not attempt to exit bed unassisted. (Resident #8) chews tobacco, (Employee #33) C.N.A. came to me expressing her concern that she was unable to comply with (Resident #8's) care plan, nor protect him from aspiration, due to his non compliance. She stated that he would ask the nurses for chewing tobacco, wheel himself back to his room, at which time he would stand on one foot and throw himself into the bed without assistance, the staff unaware of him getting back in bed, his bed alarm would not be on, he would lie in bed with his mouth full of tobacco, falling asleep, the staff would find him asleep, tobacco amber running out of his mouth, his pillow case and bedding covered with tobacco stains, which would be enough fluid that could cause aspiration if the right circumstance presented itself. She told me that she had been raising his bed to the highest level and raising all side rails, so that (Resident #8) would have to ask for assistance to get into bed, which the care plan states that he is to be assisted, at this time she could not assure that he was not going to bed with tobacco in his mouth, this would prevent the chance of aspirating on tobacco, and the bed alarm could be set, to comply with the residents plan of care. At no time was any of the residents' rights denied him, he was never placed in any danger, because with the bed in the highest position and all rails up he could not attempt to enter the bed without assistance. ..."" -- 5. An interview with the administrator and review of the documentation from the facility's internal investigation revealed Resident #8 had the physical ability to get into bed, even though the facility did not want him to do so without staff assistance for safety purposes. Staff had placed a bed alarm on the resident's bed to alert them when he got out of bed, because he was at risk for falls. The investigation by the facility concluded that Employee #141 had given Employee #33 permission to raise the resident's bed up in the air to prevent him from getting into his bed at will. The investigation also showed the resident had gone to his room and saw his bed raised to the point he could not get into it by himself. He had begged Employee #68 to place him in the bed, because he could not do so himself. On 12/14/10, from approximately 5:30 p.m. until at least 10:30 p.m., Resident #8 asked various staff members to put him to bed, because he could not access his bed independently. Staff deprived Resident #8 of the ability to get into his bed on his own. This action caused him to wait several hours, as well as to beg staff members for assistance, before he was assisted into his bed. .",2014-07-01
2128,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2016-08-30,224,G,0,1,6MCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, staff interview, policy review, and facility record review, the facility failed to implement its written policies and procedures to ensure two (2) of four (4) residents reviewed for abuse, were free from abuse by another resident. Resident #40 was afraid of Resident #75, who had kissed her on the cheek and touched her back. Resident #51 was physically assaulted. The facility to develop and implement intervention strategies to prevent occurrences of behaviors, and adequately monitor for changes that would trigger Resident #75's escalating abusive behaviors resulting in actual harm to Residents #40 and #51. Resident identifiers: #40, #51, and #75. Facility census: 53. Findings include: a) Resident #40 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 expressed fear of Resident #75. She said the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. She added that he had struck (name of Resident #51) several times with a metal object. The Director of Nursing (DON) identified Resident #40 was referring to Resident #75. Resident #40's medical record, reviewed on 08/24/16 at 9:17 a.m., found the resident's [DIAGNOSES REDACTED]. Her minimum data set (MDS) assessment with an assessment reference date of 08/03/16, identified the resident scored 14 on The Brief Interview for Mental Status (BIMS) indicating Resident #40 was cognitively intact. A progress note, dated 06/12/16, indicated Resident 40 had expressed a concern regarding Resident #75 and she was told by the nurse to stay away from him. The DON and current administrator, interviewed on 08/24/16 at 2:54 p.m., confirmed no investigation had been completed regarding Resident #40's allegation/concern reported to the nurse regarding Resident #75. During another discussion, at 4:07 p.m., the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The DON said she thought maybe a concern form had been completed, but was not sure. The director said she did not know it was actually sexual behavior because the resident had dementia. Further review of the medical record on 08/25/16 at 11:40 a.m., found no evidence the facility had intervened to ensure Resident #40 was protected or addressed her fear of Resident #75, to ensure her psychological well-being. During another interview on 08/30/16 at 10:47 a.m., in the presence of another surveyor, Resident #40 when asked to describe the incident between herself and Resident #75, she repeated she was in the hallway and Resident #75 grabbed her and kissed her. When asked where he kissed her, she again said her cheek and placed her hand on her face. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. With further inquiry, Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75, and again voiced he had hit (Resident #51's name) prior to the incident with the metal object and staff knew it. Observations of transfers on 08/23/16, 08/24/16 and 08/25/16, revealed Resident #40 transferred with the use of a mechanical lift and was totally dependent on staff. Once in the wheelchair, the resident was able to propel herself, but moved very, very slowly. Review of Resident #75's medical record, on 08/24/16 at 9:17 a.m., indicated the alleged perpetrator was able to walk without assistance. The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. The administrator agreed the facility should have addressed Resident #40's fears. These findings were determined to constitute actual harm to Resident #40. b) Resident #51 During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 voiced that Resident #75 had exhibited violent behaviors and had been physically abusive prior to his discharge. The resident said The mean man hit (Resident #51) on the head - he was dangerous and they knew it and kept him knowing. The resident further added, He had already hit her in the head with his fist. Resident #40 reported she saw Resident #75 pushing a table down the hallway, and he hit Resident #51 four (4) for five (5) times with the metal leg from off the table. She added, We all was panicking, scared to death. I couldn't (could not) sleep. They took him out and brought him back the same night. Reportable allegations, reviewed on 08/23/16 at 4:09 p.m., noted an allegation of resident to resident abuse with Resident #75 as the alleged perpetrator. The report, dated 06/20/16, indicated the incident occurred on 06/19/16 at about 8:50 p.m. The nurse noted that while administering medications, she heard the alleged victim screaming for help, and when nursing staff arrived, Resident #75 was using a metal object to strike the victim in the head and upper back. Both residents were transferred to the hospital for evaluation and treatment. The five (5) day follow-up report indicated Resident #75 had obtained a bedside table from the therapy room with a piece of equipment on it, picked up the piece of equipment, slammed it to the floor, breaking a leg on the piece or equipment, which he picked up and used to hit Resident #51 repeatedly. Resident #51's statement indicated Resident #75 came down the hallway pushing the bedside table with the exercise equipment on it. The resident said she told him she did not think he was allowed to do that. She said as he got closer to her he picked up the equipment and threw it in the floor, and after it broke he picked up a piece of it and hit her repeatedly in the head. She related she screamed and staff came to help her. Resident #51 said she thought he was going to kill her, and only felt safe after he was put on one on one (1:1) monitoring by a staff member. Resident #40's witness statement indicated she saw Resident #75 standing up in the hall. He was staring and pointing at Resident #40 and she told another resident He is going to do something, he is up to something .I seen him coming with the table, he started walking slow then he started walking faster and ran into (Resident #51's name). He was hitting her back with the table repeatedly hard. He took the metal leg, I don't know where he got it from, but he hit (Resident #51) on the head four to five (4-5) times really hard. I still can't (can not) get it out of my head. We were all really afraid. We couldn't do anything to help her. We were all yelling for help. Witness statements provided by staff indicated the LPN on red hall heard someone screaming and ran toward the sound. When the nurse approached the area, she observed Resident #75 striking Resident #51 repeatedly with an object. She indicated the object used to strike Resident #51 was broken off of a bicycle exercise equipment. Another LPN said she heard screams in the hall and ran toward the screams. She indicated Resident #51 had her hands over her head to protect herself. One nurse aide (NA) reported she was outside on break and did not witness any of the event and one resident related he/she was in a room providing direct care and did not see what actually happened, but assisted the LPN to keep Resident #75 away from Resident #51 with one-on-one monitoring. Another NA related using the restroom, and when finished, saw Resident #75 lowering his hands with the therapy equipment, and staff had intervened. The hospital discharge summary, dated 06/19/16 indicated Resident #51 had a mild closed head injury, and contusions to the vertex/occipital scalp due to an alleged assault. Another emergency department note indicated the Registered Nurse from the facility indicated the chief complaint was that Resident #51 was struck to the back of the head multiple times and another note in the section indicated Resident #51 was struck to the left side of the jaw the previous day. The hospital preliminary report from the ambulance service indicated Resident #51 informed them the same resident struck her in the left side of the jaw the previous day. Follow-up interviews with the DON and ADON on 08/30/16 between 8:30 a.m. and 10:30 a.m., indicated they were not aware of the alleged incident voiced by Resident #51 indicating Resident #75 had hit her jaw. They confirmed no reports were available to indicate the facility had identified and/or intervened on behalf of Resident #51. These findings were determined to have constitued actual harm to Resident #51. c) Resident #75 Resident #75's medical record, reviewed on 08/24/16 at 9:07 a.m., noted a discharge transition plan and admission summary which indicated the resident had a [DIAGNOSES REDACTED]. Progress notes, reviewed at 9:43 a.m. indicated Resident #75 arrived by private car with family on 06/10/16. The reason for admission was noted as exacerbation of chronic illness long-term care. The admission information indicated Resident #75 had a [DIAGNOSES REDACTED]. Progress notes, dated 06/10/16 to 06/20/16 revealed the following chain of events: -- 06/10/16 at 12:45 p.m., Resident #75 was admitted from another facility -- 06/11/16 at 6:57 p.m., and 06/12/16 and at 7:49 a.m. indicated the resident was continuously having exit seeking behaviors, stating he needed to go home, staff educated he lived at the facility, the resident verbalized understanding, turned around and pushed on the bar of the door. Staff intervention was to monitor closely. -- 06/12/16 at 7:49 a.m., the note indicated Resident #75 attempted to exit the building at the beginning of the shift (7:00 p.m.) and had said he was leaving and did not what happened to him. -- 06/12/16 at 7:58 a.m., noted Resident #75 was observed making sexual obviators (sic) to female residents, redirected to other activities and closely monitoring for further behaviors. -- 06/13/16 at 1:34 p.m., indicated the resident wandered in the hallways and into several other residents rooms, was exit seeking and redirected with moderate redirection. -- 06/14/16 at 2:25 p.m., A note by Administrator #82 indicated the family was notified of a room transfer from a semi-private to private room, but did not indicate why. -- 06/14/16 at 6:46 p.m. a social history and assessment noted a brief interview for mental status with score of 5.0 which indicated the resident was severely cognitively impaired. -- 06/15/16 .Resident roaming hallways stopping in front of females doorways standing there looking in at them resident difficult with redirecting away from doorways -- 06/17/16 at 11:21 a.m., an interdisciplinary note per the assistant director of nursing (ADON), indicated Resident #75 .ambulates independently in center .does exit seek at times, but is easily redirected .pleasant and appears to be adjusting easily to new environment. -- 06/17/16 at 7:43 p.m., a note indicated Resident #75 continued to wander into other residents rooms, was agitated several times today. -- 06/18/16 at 4:44 a.m. indicated the resident wanders all over the facility and into other rooms .Resident becomes agitated at times and is easily redirected. -- 06/18/16 at 7:00 p.m. indicated Resident #75 exited via the front door with a visitor . gets easily agitated at others when the (they) are accusatory toward him, and noted the resident expressed his desire to leave the facility several times. -- -6/19/16 at 2:02 p.m., wandering all over the facility going into others rooms .does go to exit doors often requesting he needed out. -- 06/19/16 at 2:02 p.m. a progress note indicated his daughter took him out for breakfast and upon return was crying, upset, and had said, He was so mean to me. He told me I was stupid. He kept saying you just don't (do not) know, you just don't know. The daughter had informed them the resident threatened to just take off and go over the hill and get away from here. The nurse noted Resident #75 was very agitated, activity staff took him outside and sat with him, and he was getting more upset about being there. The nurse voiced he had been moved to a private room, but did not know why. -- 06/19/16 at 9:21 p.m., discussed, Patient with increased agitation noted. Called to hallway by screams in hallway. Found resident actively using a wheelchair leg rest to hit another resident to back of the head and upper back. Hard to redirect at this time. Nurse immediately removed wheelchair rest from resident's hands. He was able to be assisted patient back to his room after several attempts. Patient still displays confusion and anger order received for 1:1 supervision and resident transferred to the hospital. -- 06/20/16 at 1:24 p.m. indicated an order was received for medication administration, no entry as to what time the resident returned from the hospital. While out of the facility, resident was determined to have 100 percent coverage of benefits and was transferred via private vehicle with daughter to another facility at 3:33 p.m. One to one (1:1 ) intervention continued until the resident left the building. Nurse Aide #16, interviewed on 08/24/16 at 10:04 a.m., voiced she was unaware Resident #75 had exhibited sexual behaviors of any type, or had thought Resident #40 looked like his daughter and did not like her interacting with Resident #51. The NA was not aware staff were to monitor the resident closely. NA #16 stated Resident #75's mood varied, and was sometimes pleasant and sometimes very short. On 08/24/16 at 1:07 p.m., upon inquiry regarding Resident #75's sexual obviators, the administrator reviewed the progress note dated 06/12/16. The administrator voiced he did not know what was meant by the note and would speak with the director of nursing (DON) as to how the incident was handled and what interventions were implemented. With further discussion at 2:54 p.m., with the administrator and director of nursing (DON), voiced the facility thought Resident #75 petted down Resident #40's back and kissed her because he thought she was his daughter and she looked like his daughter. She further added that Resident #75 did not like Resident #40 talking to the black lady he perceived to be a male (identified by the DON as Resident #51). The care plan, reviewed on 08/24/16 at 9:17 a.m. noted a focus of cognitive impairment and indicated interventions included: monitor for behaviors, underlying causes, monitor for pain, monitor and evaluate types of changes in cognitive status, evaluate behavioral symptoms for underlying causes, evaluate for the need of a behavioral/psychological consult. The care plan did not address the use of [MEDICATION NAME] for anxiety, sexual behaviors, elopement attempts or Resident #75's actual agitated and aggressive behavior. The care plan did not address Resident #75's belief that Resident #40 was his daughter or his dislike of her talking to Resident #51. Licensed Practical Nurse (LPN) #45 interviewed on 08/24/16 at 10:48 a.m., stated that Resident #75 did not like people who were black, was always looking for a way to get out of the facility, and seemed upset with his daughter for bringing him to the facility. The nurse related the resident could hold a good conversation, was aggressive at times, wandered, would go to the doors, curse sometimes, but was not aware of sexual behaviors. LPN #45 said she thought other residents were fearful of him and would say to her, Be careful. Don't (do not) let him hurt you. Upon inquiry as to which residents were fearful, the nurse related she could not remember. The medical record, reviewed with Registered Nurse (RN) #68 at 12:00 p.m. on 08/25/16, confirmed Resident #75 had received [MEDICAL CONDITION] medication from the time of admission on 06/10/16 and included [MEDICATION NAME], an antianxiety medication. The RN confirmed the care plan did not address the use of [MEDICATION NAME] medication, or of sexual behaviors toward female residents. Additionally, the care plan did not indicate the resident had developed an emotional connection to Resident #40 (thought she looked like/or was his daughter) or aversion to Resident #51 (who staff said Resident #75 identified as a black male.) The care plan indicated staff would monitor for behaviors, but did not identify active behaviors. Upon inquiry as to how often or when several occasions occurred, the nurse verified one would not know without asking the nurse. Nurse #68 confirmed the medical record did not provide a clear picture of Resident #75's behaviors, or how frequently the behaviors occurred. When asked which diversion interventions were acted upon and were successful and which interventions were not successful, RN #68 confirmed the medical record did specify how many times the resident was agitated, or which interventions were utilized and successful or failed. The lack of information about the resident's behaviors inhibited the facility's ability to identify the resident's escalating behaviors and provide effective interventions. d) The facility's abuse policy indicated the facility staff would do what was within their control to prevent occurrences of abuse and neglect and prevention included identifying, correcting, and intervening in situations in which abuse was more likely to occur and included patient to patient abuse. The policy required the resident to be protected during the investigation and would provide the resident with a safe environment by identifying persons with whom the resident felt safe and conditions that would be safe. It also noted a representative from social services or designee would monitor the patient's feelings concerning the incident, as well as the resident's involvement in the investigation. e) No evidence was provided to indicate the facility had adequately intervened and monitored Resident #75 to ensure the safety of other residents. No evidence was present to indicate which interventions the facility had tried and found ineffective, when or how frequently Resident #75 exhibited signs/symptoms of agitation and what those signs and symptoms included, or that a plan was developed related to his possible sexual behaviors, or his possible dislike of black individuals. No evidence was provided to indicate the facility monitored for changes that would trigger abusive behavior or ensured that staff had knowledge of Resident #75's behavioral care needs. Progress notes dated 06/17/16, 06/18/16 and 06/19/16 noted the resident had several episodes of agitated behavior and did not like to be directed, but no evidence was presented to indicate the facility had actively sought a resolution prior to the assault on Resident #51. f) The administrator, interviewed on 08/30/16 at 1:22 p.m. acknowledged no evidence was present to indicate the facility actively sought a resolution to Resident #40's concern and that telling Resident #40 to stay away from Resident #75 was not an adequate intervention as she required the use of a wheelchair and Resident #75 was ambulatory. Additionally, the facility provided no evidence to indicate Resident #40's fear had been address during the perpetrator's stay at the facility.",2020-09-01
3255,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2016-12-14,224,D,0,1,467L11,"**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 Resident #56 was transferred in accordance with her care plan and facility policy by staff [MEDICATION NAME] within the scope of their practice. The nurse aide acted out of her scope of practice by stopping and re-starting a continuous feeding for a resident with a gastrostomy tube (a gastrostomy tube is a tube inserted through the abdomen that delivers nutrition directly to the stomach.) This failure by the facility to keep residents free from neglect was discovered during a random opportunity for discovery. Resident identifier: #56. Facility census: 75. Findings include: a) Resident #56 At 9:40 a.m. on 12/07/16, nurse aide (NA) #38 was observed opening the door of Resident #56 ' s room pushing a mechanical lift into the hallway. Resident #56 was observed to be up in her geri-chair. No other staff member were present in the room or with NA #38. Further observation found a private sitter was in the room with Resident #56. NA #38 was asked if she had assistance when using the mechanical lift for Resident #56. NA #38 replied, No, the sitter helped me. At 9:49 a.m. on 12/07/16, the resident's private sitter verified NA #38 had transferred the resident to her geri-chair without any staff assistance. The sitter said she assisted NA #38 by holding the resident's chair for her while NA #38 operated the lift. The sitter said she was a nurse aide at one time but she was no longer certified. The sitter said, That happens a lot, sometimes they have two (2) (referring to staff) sometimes they don't. On 12/07/16, at 10:00 a.m., the director of nursing (DON), confirmed Resident #56 is a full body lift with the assistance of two (2) staff members for transfers. The DON said nurse aides are to look at the care plan to see how the resident should be transferred. The electronic care plan was reviewed with the DON at this time and revealed the following: --The care plan problem was: (Name of resident) requires extensive to total assist with ADL's (activities of daily living) related [MEDICAL CONDITION](cerebral vascular incident) dysphagia, [MEDICAL CONDITION], memory loss, contractures, and muscle weakness. --The goal associated with this problem was: Resident will have daily ADL needs met with extensive to total assist as evidenced by being well groomed, neat and appropriately dressed daily through review. --Approaches included: Transfers dependent of 2. Full body lift for all transfers. The DON confirmed the resident is transferred with a full body lift and the assistance of two (2) staff members is required. The DON said she would immediately investigate this issue. While reviewing the medical record for the issue related to the lift, it was discovered the resident also had a gastrostomy tube with continuous feeding for the following: --Review of the resident's care plan found an additional problem: (Name of resident) is dependent on tube feeding for nutritional support and hydration, with potential for complications, side effects. --The goal associated with this problem is: Will maintain adequate nutritional and hydration statue as evidence by: no signs/symptoms of malnutrition or dehydration through review. An approach associated with this goal was: Prior to toileting resident, stop feeding 30 minutes prior to position changes. At 11:06 a.m. on 12/07/16, licensed practical nurse (LPN), #67 was asked if she had stopped Resident #56's feeding at any time this morning. She replied, No, I will put it on hold at noon when I give her medicine at noon. At 11:30 a.m. on 12/07/16, NA #38, was asked how she managed the Resident's tube feeding during the transfer. NA #38 said, I tied a knot in it and corked it so it wouldn't leak. When asked to explain this procedure, NA #38 said there is a yellow plug you put in the tube which stops the feeding. She said that after the transfer, she started the feeding again. At 11:32 a.m. on 12/07/16, the sitter confirmed the NA stopped the resident's feeding during the transfer to the geri-chair. On 12/07/2016 at 2:30 p.m., the resident's care plan for the feeding tube was reviewed with the DON. The DON confirmed the resident's gastrostomy tube feeding is to be stopped prior to transferring the resident from the bed to a geri-chair. The DON said this would be a position change referred to in the care plan. The DON was made aware of NA #38's statement that she, tied a knot in the tubing and corked it off ., during the Resident's transfer. The DON said NA #38 should have asked the nurse on duty to stop the feeding before transferring the resident. She said she would also investigate this situation because the NA was acting out of her scope of practice. The DON confirmed only a licensed nurse can stop and start a resident's tube feeding. The DON provided a copy of the facility's policy, entitled, Lifting Machine, at 2:30 p.m. on 112/07/16. The policy directs, .The full body requires two staff members to perform the procedure. At 2:00 p.m. on 12/12/16, the DON provided a copy of the facility's completed investigation of the care provided to Resident #56 by NA #38 on 12/07/16. The facility's investigation began on 12/07/16. The facility reported the incident, involving NA #38 to the proper state authorities as directed by State Law. NA #38 was suspended pending investigation. Review of the facility's five (5) day follow up report, completed on 12/10/16, found the facility substantiated NA #38 transferred Resident #56, . by herself which was against facility policy and care plan which calls for assistance of 2. It was substantiated that CNA (certified nursing assistant) did disconnect fed tube which is outside her scope of practice and a violation of facility policy. Attached to the investigation was a hand written statement by NA #38, dated 12/09/16 that read: On Wednesday the 7th, I went into (resident ' s room number) room to do care when I pulled the covers back I seen she had stuff on her. So I got her up with the full body lift by myself which I should have waited for the other aides to get back but I didn't. I know I did wrong by having (name of sitter) help me but I just didn't have the heart to walk away from her and get her later and let her lay there in it. I did ask the nurse to come in (resident ' s room number) to look and was gonna have her help transfer but the nurse didn't hear me. All (name of sitter) did was lower her down while I held the chair and pulled (resident ' s room number) up in it. LPN #67 provided a had written statement, dated 12/09/16, stating NA #38 did not ask for help getting the resident up and the NA did not tell her the feeding machine needed to be unhooked.",2020-09-01
3669,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2017-04-06,224,D,0,1,X3BK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview and dental staff interviews, and resident interview, the facility failed to ensure Resident #84 received dentures the dentist had have made for the resident. The facility made no attempt to try and locate the dentures until surveyor intervention. In addition, the facility failed to identify this occurrence as neglect until after surveyor intervention. This failed practice affected (1) of three (3) residents reviewed for the care area of abuse during a Quality Indicator Survey (QIS) and concurrent complaint investigation. This practice had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 90 Findings include: a) Resident #90 On 04/05/17 at 9:49 a.m. review of the current care plan revealed resident at risk for mouth pain has had dental extractions, awaiting dentures to be made. Review of records revealed no notations or revisions concerning resident ever receiving dentures. On 04/05/17 at 10:55 a.m., during interview and review of records with unit manager RN #105, it was discovered that Resident #84 should have had upper and lower dentures of which the unit manager and the Health Service Workers (HSW) on the unit were not even aware and should have been aware. The current care plan revealed resident at risk for pain has had dental extractions, awaiting dentures to be made. The resident moved to the unit on 12/12/16 from another unit in the facility, and lived on the current unit one hundred fourteen (114) days before it was determined, through surveyor intervention, the resident was supposed to have dentures. Continued interview and record review with RN #105 that began at 10:55 a.m. on 04/05/17, revealed Resident #84 received dental services last year in (YEAR). The resident had his teeth extracted at the dentist's office on 01/15/16, and then on 02/02/16 at the dentist's office alveoplasty was performed (A minor oral surgical procedure to ensure proper fit of dentures, by smoothing and reshaping the jaw bone ridge.). A dental consult dated 04/27/16 noted, I have checked and resident has resources for dentures. Can you please start this process? Thank you. Dental consult dated 05/04/16, revealed, 1st (first) impression for upper and lower dentures next appointment 2nd (second) impression and jaw relation. Dental consult dated 05/18/16, revealed, 2nd and jaw relation next appointment try in. The last dental consult on record, dated 06/08/16, revealed, Try in upper and lower dentures will send to lab and they will return on Monday and if patient has any trouble I will see the next time that I am here. RN #105 stated, I have looked through the records and cannot find anything else about dentures. I was not aware the resident had dentures, or even was supposed to have dentures when he transferred to this unit. I don't know where the dentures are. When asked when the resident moved to the unit, RN #105 looked in the records and replied the resident moved to this unit on 12/12/16 from another unit in the facility. RN #105 said, When the resident came to this unit he did not have any dentures. On 04/05/17 at 11:11 a.m., RN #105 went to the resident's room and asked Resident #84 where his dentures were. RN #105 reported to this surveyor the resident told the nurse he never had any dentures, but they had pulled all his teeth. Interview of Resident #84 by this surveyor, on 04/06/17 at 9:25 a.m., revealed resident had his teeth pulled and had dentures made but never did receive dentures. Resident #84 said, They pulled all my teeth, and I never got any dentures like they said I would. When asked if he ever asked anyone about where or what happen to his new dentures, Resident #84 said he didn't think so. RN #105 told this surveyor, on 04/05/17 at 11:23 a.m., that upon just having called the Dental lab, she was told. (Name of person) delivered the dentures to the facility's front desk switch board on 06/09/16. While trying to determine: where the resident's dentures were; what process was used to ensure residents received dentures once the dentist has the dentures made; how dentures are tracked from the dental lab to the resident; who was aware or should have been aware the dentist was having dentures made for the resident; and when should the resident have received the dentures, the assistant administrator was notified. The assistant administrator was notified about the situation and issues, by this surveyor via phone, on 04/05/17 at 11:29 a.m. The assistant administrator was informed Resident #84, had dentures delivered to the facility on [DATE] according to the dental lab and the facility's Resident Accounts. The assistant administrator was told the resident denies ever having received them, and about the staff's inability to locate the dentures at this time. This surveyor requested information on when something is delivered to the facility for a resident how it is processed and/or tracked. The Assistant Administrator said she would get back to the surveyor with the information. As of the exit date the Assistant Administrator did not provide any further communication or information concerning this issue. On 04/05/17 at 11:33 a.m., this surveyor called the Dentist's office to clarify what the process was of providing dentures to a resident in the facility. Interview of the Dentist's secretary, via phone, revealed the process of getting dentures to a resident in the facility is as follows: (dental lab's name) delivers the denture to the facility; (dental lab's name) places the dentures in the box designated for the floor/unit the resident resides on; then the nurse on that floor/unit gives the resident their dentures. The dentist instructs the facility to place the resident on the dentist's schedule if there are any problems or adjustments that need to done to the dentures. Sometimes the nurses places the resident on the schedule and sometimes they don't. Some resident's do not have any problems and there's no need to. When asked if the Dentist ever does any other follow ups to see how well the resident is doing with their new dentures, the secretary replied No. Interview with Resident Accounts Employee #146 and Employee #157, on 04/05/17 at 12:42 p.m., revealed resident had Medicaid resources that agreed to pay for his dentures. This surveyor was given a copy of the invoice dated 06/09/16 for dentures and a copy of the check, dated 07/12/16, that was used to pay for the dentures. Employee #146 explained the owner of the Dental Lab is the only person that delivers the dentures to the facility. Employee #146 said, (name of person) drops off dentures at the front desk switchboard and walks across the hall to my office and hands me the invoice for them. That's how (name of person from dental lab) does it. The name Employee #146 said, was the same name RN #105, on 04/05/17 at 11:23 a.m., said had delivered the dentures to the facility's front desk switch board on 06/09/16. Based on the dental labs delivery/invoice for dentures dated 06/09/16 and the discovery date of 04/03/17, Resident #84 did not receive or have use of the upper and lower dentures, paid by Medicaid resources, for two hundred ninety nine (299) days. An interview with the DON on 04/06/17 at 11:14 a.m., revealed when asked, What has been done so far concerning Resident #84's missing dentures? The DON said they had looked for the dentures in the resident's room and interviewed the resident last night. The DON stated the resident said he did not get them. The DON also said, We'll start the whole process all over again, starting with another dental consult. We talked to the dentist last night, he said the last thing he knew about the dentures was in his notes. It is just a mystery. We'll get him (Resident #84) taken care of. The DON was asked again, Is there anything else the facility has done concerning Resident #84's missing dentures? The DON replied, No, nothing else I can think of. On 04/06/17 at 11:23 a.m., interview with the Administrator, revealed when asked, What has been done so far concerning Resident #84's missing dentures? The Administrator said the DON and other staff looked for dentures in the resident's room and on all the floors and out front, but could not find them. The staff talked to the resident last night and he said he did not get them. The Administrator also said, We talked to the dentist, he said if he wrote it he did it, and what was in his notes is what he did. We will have to get them for him (dentures for Resident #84). Interview with the administrator, on 04/06/17 at 12:15 p.m. with Surveyor # present, revealed the resident can use their resource once per year, so the facility has plans to start the process all over again and get Resident #84 a set of dentures. The administrator said the facility was going to change the process and procedure of handling deliveries of dentures, so that the dentures and invoice will go to the same facility designated person. .",2020-09-01
4008,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,224,K,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify three (3) male residents who were at risk for sexually abusing female residents, failed to develop interventions to prevent occurrences, and failed to monitor for changes that would trigger sexual behaviors. In addition, the facility failed to implement its written policies and procedures for the prohibition of sexual abuse, verbal abuse and/or neglect. Female residents (#26, #39, #51, #49, #24, #37, and #1) were subjected to repeated nonconsensual sexual contact. In addition, repeated sexual abuse was found for unidentified female residents as evidenced by repeated sexual abuse incidents found in male residents (#10, #11, #62) medical records. This was true for seven (7) of seven (7) residents reviewed for abuse. The facility's failure to protect female residents from repeated nonconsensual sexual contact by male residents resulted in a determination of immediate jeopardy (IJ) The Administrator and Director of Nursing were notified of the IJ on 02/20/17 at 5:28 p.m An acceptable plan of correction (P[NAME]) was received at 6:16 p.m After verifying implementation of the P[NAME], the immediate jeopardy was abated at 7:55 p.m. On 02/21/17 at 4:12 p.m., the facility provided a revised plan of correction with clarifications regarding who would do the training and the resident identifiers added. After removal of the immediate jeopardy, a deficient practice at a scope and severity of G (isolated actual harm) remained. A staff member verbally abused Resident #20, causing the resident to become upset and cry on 02/01/17. The resident remained upset over the incident at the time of the survey. Resident #51 was subjected to neglect when left in a Geri-Chair for twelve (12) hours with no turning and/or repositioning, food and/or fluids, and provided no incontinence care. Resident identifiers: #26, #39, #51, #49, #24, #37, #1, #20, and unidentified female residents. Alleged perpetrators: #10, #11, #62. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #26, originally admitted on [DATE] and readmitted on [DATE], had [DIAGNOSES REDACTED]. She began receiving hospice services on 11/23/16. The significant change Minimum Data Set (MDS) with an assessment reference date (ARD) of 11/25/16 revealed a Brief Interview for Mental Status (BIMS) score of 99, indicating the resident was unable to complete the interview. The cognitive patterns section indicated Resident #26 was severely impaired for daily decision-making and had behaviors of inattention and disorganized thinking. In addition, this resident was assessed as having no problems with hearing or vision, but had unclear speech (slurred or mumbled words). She lacked the ability to make herself understood and rarely/never understood others. Her Activities of Daily Living (ADL) assessment identified she required the extensive assistance of one (1) to two (2) persons for bed mobility, transfers, walking in room, and was totally dependent for dressing, toilet use, and personal hygiene. The resident's care plan included a problem statement, with a start date of 06/04/15, Resident with Alzheimer's Dementia - potential for behavioral/communication/self-care problem/harm. This problem statement was edited on 12/05/16 by the MDS Coordinator. The goal statement, with a target date of 03/05/17, stated Resident will function at optimal level within limitations imposed by Alzheimer's and free from harm. The goal statement was edited on 12/05/16. In addition, an approach statement, dated 09/07/16, stated resident wanders . also at times other residents have touched her inappropriately and she is not able to remove their hands - staff to monitor and intervene and protect her. During a confidential interview (CI #1), CI #1 stated Resident #26 had been targeted by three (3) male residents (#10, #11 and #62) for putting their hands in her crotch. CI #1 stated Resident #26 could not defend herself and staff would separate them when these incidents occurred. When asked how an incident of this type was reported, CI #1 stated they put in the nursing notes and the Social Worker (SW) and Director of Nursing (DON) were informed. In addition, CI #1 stated Resident #26 had to be moved to Second Floor (12/02/16) to get her away from these men. Review of the medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating, Resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (Resident #26's name) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. On 10/06/17 at 10:06 a.m., a nursing entry described Resident #62 was found reaching for the crotch of Resident #26. At 18:47 (6:47 p.m.), Resident #62 again reached for the crotch of Resident #26 and the residents were separated. Staff were to continue to follow. Review of Resident #26's medical record and facility documentation found no additional evidence regarding non-consensual sexual abuse for Resident #26. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 had [DIAGNOSES REDACTED]. Continuing review of the resident's medical record revealed [REDACTED].#39 had no issues with hearing, speaking, and/or vision. In the area of making oneself understood and ability to understanding others were assessed as usually understood and usually able to understand. Her Brief Interview for Mental Status (BIMS) score on the annual MDS was 99, indicating the interview was unable to be completed. BIMS scores of the quarterly MDSs completed on 09/15/16 and 12/15/16 were 01 and 02 respectively. Both BIMS scores indicate severe cognitive impairment. - 09/28/16 at 14:06 (12:06 p.m.) Behavior Monitoring nurse's note stated Alert and orientated . Resident later removed from 29-2 bed (Resident #39). He (Resident #10) states 'I was trying to get a piece of ass.' Resident was redirected and room monitored. - 10/09/16 at 6:46 a.m., the Behavior Monitoring nurse's note stated Alert and oriented . Resident was up adlib (as desires) early this morning via wheelchair. Resident observed to approach resident 29B (Resident #39) as she was resting quietly on couch near nurses station with eyes closed. Resident put his hand on 29s crotch and began rubbing it. She opened her eyes and kicked his wheelchair away from her, pushing him backwards. Resident was redirected by this nurse. He laughed. Resident was relocated by this LPN (licensed practical nurse) away from resident 29B. A review of the nurses' notes found on 10/26/16 at 16:09 (4:09 p.m.), Resident #10 was found in bed with Resident #39. Resident #10 was relocated out of the room. On 02/01/17 at 6:42 p.m., a nurse's note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated then showered. On 02/03/17 at 9:06 a.m., the MDS Coordinator stated in a behavior monitoring nurse's note for Resident #10 that the Social Worker (SW), DON, and Administrator were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. On 02/05/17 at 15:32 (3:32 p.m.) and entry in the CNA/Nurse's Note stated Resident (#10) was in a female resident's room. She (Resident #39) was lying on her bed, the male resident sat on the side of her bed, with her hand in his attempting to have her touch him. She was attempting to pull her hand away from him when the staff member entered the room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. c) Unidentified Female Resident(s) In a continuing review of the medical records for the alleged perpetrators ( Residents #10, #11, #62), the following sexual abuse of unidentified female residents was discovered: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurse's note in Resident #10's medical record stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated, Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) an additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. Noted in Resident #10's medical record. - 10/03/16 Monthly Nurse's Note - continue to need redirection daily due to being sexually inappropriate with other female residents as noted in Resident #62's medical record. - 10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated, He (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times Resident #62 had his hand between unidentified female resident's legs. Redirected both of them. - 11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that . This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. - 11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurse's Note stated, Resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self-propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/05/16 at 11:46 a.m., Activities Daily notes stated Resident (#10) came up behind another female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/11/16 at 2:51 a.m., The Monthly Assessment nurse's notes for Resident #10 stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurses note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women by Resident #62. Redirected when this occurs. - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated, Caught in female residents room trying to uncover her and stick hands down pants by Resident #62. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast by Resident #62. - 01/11/17 at 8:30 a.m. Activities Care Plan Review. Resident #62 cot (sic) touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area by Resident #62. - 02/05/17 7:49 a.m. Hands in female's private parts by Resident #62 - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated a housekeeper reported separating residents for touching female resident inappropriately by Resident #62. d) Alleged Perpetrators: 1. Resident #10 Medical record review on 02/24/17 at 4:30 p.m., revealed Resident #10 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the most recent quarterly MDS with an ARD of 12/22/16 noted a BIMS score of 05, which indicated severe cognitive impairment. In the behavior section, the annual MDS with an ARD of 03/24/16 indicated Resident #10 had no behaviors. The quarterly MDS with an ARD of 12/08/16 noted no behaviors but indicated the rejection of care for 1-3 days of the look back period. The quarterly MDS with an ARD of 12/22/16 identified the resident had physical behaviors directed toward others which includes abusing others sexually for 1-3 days of the look back period. In addition, verbal behaviors directed toward others was assessed as having occurred for 1-3 days of the look back period. A continuing review of the medical record found the following incidents of sexual abuse: - 06/15/16 at 11:30 a.m., Behavior Monitoring nurses note stated sitting on couch beside of female resident with his hands down her pants in vaginal area. Redirected. - 09/01/16 at 16:59 (4:59 p.m.) an amended Psycho-Social note by an unknown writer stated Has inappropriate behavior with female residents at time with redirection needed. In addition at 17:11 (5:11 p.m.) and additional amended noted Per Nurse Fall F/U (follow up) report 06/16/16 re. (regarding) fall on 06/15/16: Had an unwitnessed fall with resident report of attempting to lie down with a female resident. -10/03/16 at 16:36 (4:36 p.m.) Activities Note additional notes stated he (Resident #10) was seen in a female resident room setting on the bed with her. Staff told him he might want to come out for the gospel music which he did. -11/29/16 at 15:00 (3:00 p.m.) Behavior Monitoring nurses notes stated Resident (#10) found by CNAs in solarium with his hand in a female residents crotch area. Hand removed and resident asked not to do that. This nurse instructed aides to try and keep this resident away from other female residents when in common areas. Will observe. -11/29/16 at 15:23 (3:23 p.m.) Resident Care Record CNA/Nurses Notes stated resident (#10) sitting in dining room touching a female resident in personal area. Female resident removed from area. Nurse notified. - 11/29/16 at 23:39 (11:39 p.m.) an amended CNA/nurses stated resident (#10) was refusing to be changed and tore his bag ([MEDICAL CONDITION]) off three (3) times in two (2) hours. The first two (2) times there was nothing in the bag and the last time he had a medium (stool). He had his hand prints on his belly where he had smeared it all over. The resident's [MEDICAL CONDITION] bag was changed. Further stated resident thinks if he keeps tearing bag off and keeps doing bad things he will be sent back to previous residence where he was feeling up women today. The resident was asked why he did this and Resident #10 said because they wanted it. Resident #10 was told no they didn't and he needs to leave the women alone. - 12/05/16 at 11:46 a.m., the Activities Daily notes stated Resident (#10) came up behind a female resident and started putting his hand on her private parts from behind. I told him not to do that and he removed his hand and got his walker and went to the activity room. 12/11/16 at 2:51 a.m., Monthly Assessment nurse's notes stated on 12/02/16 and 11/29/16 Staff to monitor resident he has been inappropriately touching female residents in vaginal area. Staff to redirect and keep residents separated. - 12/16/16 at 14:02 (2:02 p.m.) Behavior Monitoring nurse's note stated Resident (#10) found in female residents room with pants down around his thighs and his shirt pulled up. Sitting next to female on bed. CNA removed resident and brough (sic) female to a common area. Will observe. - On 12/21/16 at 16:00 (4:00 p.m.) Resident #10 was transferred to the Second Floor to get him away from female residents. - 01/12/17 at 16:22 (4:22 p.m.) Social Service Narrative stated, Found (Resident #10) in the hallway with his pants around his ankles in front of female resident who is in wheelchair. Removed female resident and attempted to pull up (Resident #10's) pants. They would not stay up. ( Resident #10) began to shake uncontrollably. Sat him in a wheelchair and the nurse and aides were made aware. - On 01/17/17 at 10:31 a.m., Resident #10 was transferred to the First Floor. - 01/30/17 at 15:32 (3:32 p.m.) Behavior Monitoring nurses note stated resident found in female's room with pants down with her hands on his penis. - 01/30/17 at 15:49 (3:49) CNA/nurse's notes stated 1500 (3:00 p.m.) called to another resident room by on coming staff. Resident sitting on side of female patient's bed, while she was lying on her bed, performing a hand job. Male resident was holding his brief and pants down. Both residents were participating. -02/01/17 at 18:42 (6:42 p.m.) An amended care note stated resident (#10) was cought (sic) by staff on top of female resident with his [MEDICAL CONDITION] bag off anf (sic) bm (bowel movement) was all ovwer (sic) her they were kissing each other on the lips . nurse notified . resident weas (sic) taken out of the room taking to his room and was cleaned up as was the female resident. - 02/03/17 at 9:06 a.m. the Behavior Monitoring nurses notes written by the MDS Coordinator stated Had spoke with social worker, DON, and administrator regarding residents recent sexual behaviors and incident where resident [MEDICAL CONDITION] bag had come off and his stool was all over other resident. This would be a health hazard to other residents. Staff is to deter this resident from going into residents room, careplan updated and nursing staff updated. -02/05/17 at 15:32 (3:32 p.m.) A Resident Care Record CNA/Nurse Notes stated Resident in female residents room, she was lying on her bed, male resident sitting on side of her bed, with her hand in his, attempting to have her touch him, she was attempting to pull her hand away when I entered the room. He said to her 'Oh, come on.' He released her hand after I entered the room and he then went to his room. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were thirteen (13) incidents in which Resident #10 was found to be having non-consensual sexual contact that constituted sexual abuse. b) Resident #11 A medical record review conducted on 02/22/17 at 9:00 p.m., revealed Resident #11 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. Continuing review of the medical record revealed the annual MDS with an ARD of 09/08/16 identified Resident #11 had a BIMS score of five (5) noted on the annual MDS and a BIMS score of two (2) on the quarterly MDS which indicates severe cognitive impairment. The annual MDS indicated Resident #11 had no behaviors. A continuing review of the medical record revealed the following incidents of sexual abuse: - 12/04/16 at 9:00 a.m., the Behavior Monitoring nurses notes for Resident #11 stated Resident self propelled wheelchair to up beside resident who was being coded. Staff assisted resident back away from the coding resident and resident stated 'I know, but I can see her tits and I wanna look.' - 12/19/16 at 16:10 (4:10 p.m.) the Behavior Monitoring nurses notes for Resident #11 stated This past quarter he has been observed with inappropriate behavior when was fondling another female resident in her crotch area - they were separated by the staff. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were two (2) incidents in which Resident #11 was found to be having non-consensual sexual contact that constitutes sexual abuse. c) Resident #62 A medical record review on 02/20/17 at 7:30 p.m., revealed Resident #62 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's admission MDS with an ARD of 03/16/16, identified Resident #62 had a BIMS score of 6, indicating his cognition was severely impaired. Subsequent quarterly MDSs with ARDs of 09/15/16 and 12/08/16 Resident #62 BIMS scored 3 and 5 respectively. This indicated the resident remained severely cognitively impaired. There were no behaviors or rejection of care noted on the admission MDS. Both quarterly MDSs indicated physical behavioral symptoms toward others, which includes abusing others sexually, and rejection of care occurred one (1) to three (3) days of the lookback period. A continuing review of the medical record for Resident #62 revealed the following sexual abuse events: - 10/05/16 at 13:16 (1:16 p.m.) Activities note stated two (2) different times had hand between unidentified female resident's legs. Redirected both of them. - 12/08/16 at 18:20 (6:20 p.m.) Touching female resident's breast by Resident #62. - 12/16/16 at 13:57 (1:57 p.m.) Social Worker notes. Inappropriate sexual advances towards women. Redirected when this occurs. - 12/29/16 at 19:00 (7:00 p.m.) Nurses Note stated caught in female residents room trying to uncover her and stick hands down pants. - 01/10/17 at 18:45 (6:45 p.m.) Hand on female's upper body between arm and breast. - 01/11/17 at 8:30 a.m. Activities Care Plan Review stated cot {sic} touching women and needs redirected. - 02/04/17 at 19:05 (7:05 p.m.) Fondling peri (perineal) area. - 02/05/17 7:49 a.m. Hands in female's private parts. - 02/20/17 at 20:52 (8:52 p.m.) An amended nurse's note stated housekeeper reported separated touching female resident inappropriately. During the period from (MONTH) (YEAR) through (MONTH) (YEAR), there were nine (9) incidents in which Resident #62 was found placing his hands in female residents pants, between their legs, fondling breasts, fondling perineal area, fondling private parts, and inappropriately touching of female residents. On 02/20/17 at 2:08 p.m. a review of the facility's policy and procedure titled Abuse found a section titled Sexual abuse:**Report Immediately**. The policy and procedure stated There are residents who have had bad past experiences and are not fully aware of reality. They may relive a rape or molestation every time that a completely innocent CNA (Certified Nursing Assistant) provides incontinent care. They may scream rape with the utmost conviction. Although these resident need special understanding because their feelings are very real, this is a case of sexual abuse. Staff must put forth every effort to promote the dignity of residents. All reports of sexual abuse will be immediately investigated. A physician must see any resident who is suspected of being a victim of sexual assault immediately. Staff will immediately contact local law enforcement. [NAME] Examples of sexual abuse (not an inclusive list) i. Sexual harassment ii. Sexual coercion iii. Sexual assault On 02/22/17 at 2:06 p.m., an interview with the Director of Nursing (DON) was asked if she could identify the female resident who Resident #10 had put his hands down in her pants based on the documentation in Resident 10's progress notes. The DON stated her best guess would be Resident #26 or #49. The DON then attempted to find information in Resident #26's and #49's charts, but to no avail. When asked if there would or should have been an incident report, she stated if there was no incident report, there should have been. She further stated both residents involved should have been identified in some manner. When asked if the incident was sexual abuse she responded Yes. When asked what type of assessment had been completed for the female resident, she stated None. On 02/24/17 at 11:38 p.m., when asked how she monitored abuse of any type, the Social Worker (SW) stated she monitored incident/accidents on a monthly basis, made rounds on both nursing units and the solarium usually on a daily basis. When asked about reporting the occurrence between Resident #26 and Resident #62 on 08/16/16, when the male had his hand in a female resident's pants, and the female resident was attempting to get away from the male, the SW stated at the time she felt this was a resident to resident incident and did not consider sexual abuse. On 02/27/17 at 4:02 p.m., when interviewed regarding the findings of sexual abuse the Nursing Home Administrator (NHA) agreed incident reports were not completed for both residents when these events occurred, and they should have been reported to the appropriate agencies and the female residents more effectively protected from the male residents. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential interviewees (CI) #3 and CI #4, in separate interviews, both said they have witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and by the physician and the administrator on 01/11/17. During an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. She said staff failed to follow the facility's abuse policy. d) Resident #49 On 02/22/17, review of the resident's medical record found the most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03). This score indicated severely impaired cognitive functioning. This resident lacked capacity for medical decision making. Pertinent [DIAGNOSES REDACTED]. Confidential interviews were obtained with CI #1, CI #2, CI #6, CI #10, and CI #11 in separate interviews. All five (5) said they have witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said that male Resident #11 and male Resident #62 were both removed from Resident #49 on 02/20/17. She said other staff separated the residents, and she did not witness it herself. She said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware that those two (2) male residents were known to touch female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occured. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI #10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI #11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. e) Resident #24 On 02/22/17, review of the resident's most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 01/26/17, found the resident's Brief Interview for Mental Status (MDS) score was four (4), with fluctuation of inattention and disorganized thinking. This score indicated severely impaired cognitive functioning. She lacked capacity to make medical decisions. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents ever since his admission to the facility. She estimated that to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI #11 said that once, over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said the resident's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because he Scared the crap out of her. She said she heard Resident #24 tell him to le",2020-03-01
4357,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2016-06-21,224,D,0,1,2UNV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, facility policy and procedure review, and staff interview, the facility failed to implement its policies and procedures to prevent neglect and abuse of residents. The facility failed to implement its policy when Resident #78 verbalized [MEDICAL CONDITION] and failed to implement its policy to prevent abuse of other residents by Resident #78. Resident identifier: #78. Facility census: 98. Findings include: a) Resident #78 1. On 06/16/16 at 8:34 a.m., reveiw of the medical records for Resident #78 found this resident was admitted on [DATE]. Review of the social services admission note, dated 05/06/16, revealed the resident had [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/11/16, identified the resident had a Brief Interview for Mental Status (BIMS) score of seven (7) of fifteen (15) possible, indicating the resident had severe cognitive impairment. A concurrent review of the care plan dated 05/18/16, found a problem statement of, Resident is new to the faciilty, has dementia, repetitive in speech, verbally assertive. It also noted the resident was able to make her needs known. Interventions included, Assess her comprenhension, attention span and coping abilities when conversing with her, and, monitor for changes in mood/behavior and report to nursing as needed. An additional problem on the care plan dated 05/24/16, was, Cognitive loss with alteration in thought process. Has short and long term memory loss, impaired decision making ability, dementia, [MEDICAL CONDITION], and impaired safety awareness. Interventions included, Approach in a calm manner, using touch carefully, Keep environment calm and organized when resident is trying to concentrate, Remain alert to non-verbal cues that may signal a need. A nursing note dated 06/13/16 at 1:20 a.m., revealed Resident #78 was upset, sitting at the nursing desk and stated, I might as well kill myself. Registered Nurse (RN) #160 on duty when Resident #78 verbalized [MEDICAL CONDITION]. RN #160 stated during an interview on 06/16/16 at 4:08 p.m., she did not initiate the facility's suicidal ideation policy immediately because she did not want to call the director of nursing in the middle of the night and that Resident #78 had verbalized that, all the time, referring to the [MEDICAL CONDITION]. She went on to state she passed the information concerning Resident #78's [MEDICAL CONDITION] on to the next shift. Registered Nurse #7, who worked day shift following Resident #78's verbalization of [MEDICAL CONDITION], stated during an interview on 06/16/16 at 12:31 p.m., she faxed the physician concerning Resident #78's [MEDICAL CONDITION]. The physician's response was to continue monitoring the resident. She also informed Social Worker #2 at approximately 7:30 a.m. on 06/13/16 of Resident #78 verbalizing [MEDICAL CONDITION]. Registered Nurse #7 also explained she had asked for the resident to go to in-patient psychiatric care on this same morning. On 06/16/16 at 10:33 a.m., Social Worker #2 explained she did interview Resident #78 on 06/13/16 and the resident denied the behaviors and statements made during the night shift. The progress note concerning this interview is dated 06/13/16 at 10:11 a.m. An out-patient psychiatric appointment was made for Resident #78 on 06/14/16. Review of the facility suicide precautions policy revealed, The staff is to take any suicide ideation or attempt seriously. Procedures included to, . notify the charge nurse when a Resident expresses [MEDICAL CONDITION] to determine what measures need to be taken, remove the call bell system and replace it with a tap bell, suicide ideations, assess the Resident, notify the physician, administrator, DON, social service director and the Resident's responsible designee to visibly monitor the Resident every fifteen minutes. A physician ordered dated 06/13/16 at 1:00 p.m., indicated to start suicidal precautions including visual checks every fifteen minutes. Documentation of monitoring Resident #78 every fifteen minutes began at 3:00 p.m., on 06/13/16. Resident #78 verbalized [MEDICAL CONDITION] at 1:20 a.m., on 06/13/16, the physician order [REDACTED]. Staff neglected to implement the facility's policy and procedure in a timely manner to ensure the resident's safety. 2. Review of a nursing note dated 05/05/16 at 7:22 a.m., revealed the last shift reported Resident #78 had transferred herself without assist. In addition nursing notes throughout the residents stay revealed the following: --On 05/06/16, The resident is out of bed to wheelchair, disoriented to time and place. Resident propels self in wheelchair. --On 05/08/16, at 9:16 a.m., Resident using inappropriate sexual language multiple times to male CNA --On 05/08/16 at 4:30 p.m., Resident has been reported to be verbally aggressive. --On 05/09/16 at 11:18 a.m., resident yelling at another resident. --On 05/12/16 at 5:23 p.m., reported to be verbally aggressive. --On 05/14/16 at 12:02 p.m., resident suspicious and making statements like 'Why are you looking at me.' --On 05/15/16 at 2:34 p.m., making derogatory impersonation of resident sitting across from her. --On 05/16/16 at 5:09 p.m., resident inappropriate with staff and others. --On 05/17/16 at 9:20 a.m., resident self-transfers and frequently forgets she has a roommate. Previous shift reports resident did not sleep through the night and kept yelling at roommate. --On 05/19/16 at 1:35 p.m., resident is upset because she has a roommate. --On 05/19/16 at 3:45 p.m., resident, continues to be verbally aggressive toward other residents staff and roommate. --On 05/19/16 at 1:35 p.m., resident is upset because she has a roommate. --On 05/19/16 at 3:45 p.m., resident verbally aggressive toward roommate other residents and staff. --On 05/22/16 at 8:30 a.m., resident verbally aggressive with roommate and staff. --On 05/22/16 at 1:04 p.m. the activity staff reported the resident rolled her wheelchair in front of another resident to block the path. --On 05/22/16 at 3:07 p.m., resident continues to be verbally aggressive. --On 05/23/16 at 2:13 a.m., resident argumentative with roommate and staff. --On 05/23/16 at 7:30 a.m., verbally aggressive toward roommate, staff and other residents. --On 05/23/16 at 1:00 p.m., verbally aggressive toward roommate, staff members and other residents. --On 05/24/16 at 1:12 a.m., argumentative with roommate and staff concerning the roommates light. --On 05/25/16 at 1:16 a.m., Argumentative with staff and roommate freq. (frequently) Does not like roommate to have more attention than her and will start complaining of the same problems so she also gets attention. Yells frequently during the night at roommate and also talks to and yells at people who are not there. Will deny yelling and tries to blame it on her roommate. --On 05/29/16 at 8:51 a.m., resident arguing with roommate and shutting off the air conditioner. --On 05/30/16 at 6:10 a.m., agitated with roommate. --On 05/31/16 at 8:46 a.m., argumentative with roommate. --On 06/01/16 at 3:55 a.m., argumentative with roommate. --On 06/02/16 at 1:08 a.m. argumentative with roommate. --On 06/02/16 at 10:09 a.m., argumentative with roommate and threatened to slap the roommate. --On 06/04/16 at 8:15 p.m., nurse notified resident making inappropriate advances to staff by trying to kiss staff on the mouth. Staff will begin working with the resident in pairs. --On 06/05/16 at 1:21 a.m., resident attempted to push a male staff members head into her private area. This was witnessed by a second nursing assistant working in the room. --On 06/13/16 at 12:20 a.m., Resident #78 came out into the hall way and referring to the roommate stated, she needed me to help her, observation by the staff found the roommate with the sheet off of her bed, lying on the bedside stand and the roommate's brief lying on the floor. The nurse then ask Resident #78 if she helped the roommate and Resident #78 stated she did. The nurse went on to explain to to Resident #78 she cannot be bothering or touching other residents. Resident #78 became argumentative and stated I never touched her. Resident #78 was asked to sit at the desk so she could be monitored, for the safety of the room mate (typed as written). --On 06/13/16 at 3:00 a.m., the resident was assisted back to her bed. --On 06/13/16 at 9:52 a.m., Resident #78 was non-compliant with keeping her door open and shuts the door after staff explained the importance of safety and being able to see the roommate. During a telephone interview on 06/16/16 at 4:40 p.m.,Registered Nurse #160 stated she did not assess Resident #176 when found with her blanket off and on the bedside stand and her brief off and on the floor. The nurse said the resident's brief was intact with no soiling. She did have the nursing assistant to put another brief on the resident. During this same interview Registered Nurse #160 stated she did not believe Resident #176 could have placed her sheet on the bedside stand and taken her brief off. She also did not think Resident #78 could have done this behavior due to not being able to stand very long. Registered Nurse #7, during an interview on 06/16/16 at 12:31 p.m., stated she worked day shift on 06/13/16 and informed Social Worker #2 around 7:30 a.m. on 06/13/16 of the events during the night - about Resident #176 being found with her sheet on the bedside stand and her brief on the floor. She went on to state she was told the brief was shredded. Registered Nurse (RN) #7, when asked whether she felt Resident #176 was safe while in the room with Resident #78, replied, referring to Resident #78, I wish she had a roommate that is more mobile. On 06/16/16 at 10:33 a.m., Social Worker #2 explained she did interview Resident #78 on 06/13/16 and the resident denied behaviors and statements made from the incident during the night shift at 12:20 a.m. The social worker stated she did not attempt to interview the roommate, Resident #176. The progress note concerning this interview were dated 06/13/16 at 10:11 a.m. At 11:20 a.m. on 06/16/16, the director of nursing (DON) stated that the twenty-four hour report revealed Resident #176's blanket was off, not that her brief was on the floor. She said during this interview, this was the first time she was made aware of Resident #176's brief being on the floor. On 06/16/16 at 2:50 p.m., when asked about Resident #78 having additional roommates, Minimum Data Set Coordinator #17 provided the following information: --Resident #78 had two (2) previous roommates prior to Resident #176. Resident #170 with whom there were no issues. There was one note in which Resident #78 was mad at this roommate. --Resident #35 who was admitted on [DATE] into the same room with Resident #78 and was moved on 06/02/16 for a more compatible roommate. --Resident #176, was admitted on [DATE] to the same room as Resident #78 with a problem of loss of mobility with weakness to left side. Resident #176 was moved on 06/16/16, after the DON became aware of the brief being found on the floor. Reviewing the facility's abuse policy, neglect is defined as, Failure to take precautionary measures .to protect the health and safety of the resident, and Failure to report observed or suspected abuse, neglect or misappropriation of property.",2019-11-01
4645,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2015-12-18,224,E,0,1,5DCP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medication administration pass observations, medical record review, review of facility policy, review of pharmacy records, review of facility's investigations, and staff interviews, the facility, in coordination with the licensed pharmacist, failed to establish a system of medication records that enabled periodic accurate reconciliation, accounting for, and disposition of all controlled medications. The facility had no formal mechanisms in place to safely handle controlled medications, and to maintain accurate and timely medication records. The facility, in coordination with the pharmacist, failed to establish a means to ensure security and safeguarding of controlled medications. There was no system to account for the receipt, usage, disposition, and reconciliation of all controlled medications. The facility was not conducting periodic reconciliations of records of receipt, disposition, and inventory for controlled medications to prevent or identify loss or diversion of these medications. The facility failed to ensure/prevent misappropriation of controlled substances for 63 residents who resided in the facility for the time period of 09/01/15 through 12/17/15 who received controlled narcotics (pain medication). The facility's failure to follow a systematic approach for receipt and destruction of narcotics resulted in a failure to identify the potential loss of a significant number of narcotic pain medications and placed all residents receiving narcotics at risk for drug diversion and misappropriation of narcotics. This practice affected more than an isolated number of residents. Resident identifiers for all residents who were dispensed and delivered narcotics during 09/01/15 through 12/17/15: #49, #7, #67, #50, #20, #17, #77, #2, #85, #32, #57, #144, #105, #130, #12, #95, #70, #69, #65, #6, #82, #83, #43, #38, #39, #31, #10, #109, #47, #126, #3, #104, #111, #134, #15, #29, #131, #36, #81, #101, #120, #148, #19, #78, #72, #75, #149, #147, #133, #27, #61, #18, #59, #129, #11, #23, #51, #90, #143, #118, #141, #42 and #109. Facility census: 91. Findings include: a) Residents #49, #7, #67, #50, #20, #17, #77, #2, #85, #32, #57, #144, #105, #130, #12, #95, #70, #69, #65, #6, #82, #83, #43, #38, #39, #31, #10, #109, #47, #126, #3, #104, #111, #134, #15, #29, #131, #36, #81, #101, #120, #148, #19, #78, #72, #75, #149, #147, #133, #27, #61, #18, #59, #129, #11, #23, #51, #90, #143, #118, #141, #42 and #109. Review of medical records throughout the afternoon and evening on 12/17/15, found discrepancies in the accounting for controlled narcotics (pain medication) for these 63 residents who resided in the facility for the time period of 09/01/15 through 12/17/15. The following four (4) residents are a representative sample of the findings of the discrepancies in the accounting of controlled pain medication: 1. Resident #32 During observation of the medication administration pass on 12/09/15 at 10:13 a.m., Registered Nurse (RN) #12 administered [MEDICATION NAME] (pain) 7.5/325 mg (milligrams) 1 tablet by mouth to Resident #32. Medication reconciliation on 12/15/15 at 10:00 a.m., found RN #12 failed to document on Resident #32's MAR the [MEDICATION NAME] 7.5/325 mg 1 tablet given on 12/09/15 at 10:13 a.m. On 12/15/15 at 11:15 a.m., RN #12 and the surveyor reviewed the MAR for Resident #32. RN #12 confirmed the medication ([MEDICATION NAME]) was not documented. When asked for the Controlled Substance Accountability Sheet (CSAS) for 12/09/15, RN #12, could not locate the document. At 12:30 p.m. on 12/15/15, Resident #32's CSAS was requested from the director of nursing (DON) and the assistant director of nursing (ADON). On 12/16/15 at 5:00 p.m., the ADON and DON confirmed the CSAS sheet for Resident #32 could not be located. At that time, a request was made for the Monthly Controlled Drug Reports (MCDR) from the pharmacy for all narcotics (pain medications) dispensed and received from the pharmacy for the months of September, October, November, and (MONTH) (YEAR). The MCDR was provided on 12/17/15 at 8:00 a.m. Review of Resident #32's medical record found the Physician's Recapitulation Orders dated (MONTH) (YEAR), included orders for [MEDICATION NAME] (pain medication - same as [MEDICATION NAME]) 7.5/325mg mg (milligram) every eight (8) hours as needed for pain. Review of the Medication Administration Records (MAR) dated September, October, November, and (MONTH) (YEAR) and the MCDRs from the pharmacy found: -- (MONTH) (YEAR) - 120 [MEDICATION NAME] tablets were received from the pharmacy and six (6) doses were documented on the MAR as administered. There were 118 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 130 [MEDICATION NAME] tablets were received from the pharmacy and two (2) doses were documented on the MAR as administered, leaving 128 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 60 [MEDICATION NAME] tablets were received from the pharmacy and zero (0) doses were documented on the MAR as administered, leaving 60 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 60 [MEDICATION NAME] tablets were received from the pharmacy and one (1) dose was documented on the MAR as administered, leaving 59 [MEDICATION NAME] tablets unaccounted for. These findings prompted review of the narcotic medications of three (3) additional residents. 2. Resident #17 Medical record review of the Physician's Recapitulation Orders for Resident #17, dated (MONTH) (YEAR), revealed orders for [MEDICATION NAME] 10/325mg mg (milligram) every four (4) hours as needed for pain. Review of the Medication Administration Records (MAR) dated September, October, November, and (MONTH) (YEAR) and the MCDRs from the pharmacy found: -- (MONTH) (YEAR) - 182 [MEDICATION NAME] tablets were received from the pharmacy and sixteen (16) doses were documented on the resident's MAR as administered. There were 166 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 150 [MEDICATION NAME] tablets were received from the pharmacy and two (2) doses were documented on the MAR as administered, leaving 148 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 120 [MEDICATION NAME] tablets were received from the pharmacy and four (4) doses were documented on the MAR as administered to the resident. That left 116 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 60 [MEDICATION NAME] tablets were received from the pharmacy and six (6) doses were documented on the MAR as administered, leaving 54 [MEDICATION NAME] tablets unaccounted for. 3. Resident #129 Review of Resident #129's medical record found the Physician's Recapitulation Orders dated (MONTH) (YEAR), included an order for [REDACTED]. Review of the Medication Administration Records (MAR) dated September, October, November, and (MONTH) (YEAR) and the MCDRs from the pharmacy found: -- (MONTH) (YEAR) - 50 [MEDICATION NAME] tablets were received from the pharmacy, one (1) dose was documented on the MAR as administered, leaving 49 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 30 [MEDICATION NAME] tablets were received from the pharmacy and nine (9) doses were documented on the MAR as administered. There were 21 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 30 [MEDICATION NAME] tablets were received from the pharmacy and ten (10) doses were documented on the MAR as administered, leaving 20 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 30 [MEDICATION NAME] tablets were received from the pharmacy and three (3) doses were documented on the MAR as administered - 27 [MEDICATION NAME] tablets were unaccounted for. 4. Resident #47 Review of the Physician's Recapitulation Orders for Resident #47, dated (MONTH) (YEAR), revealed orders for [MEDICATION NAME] 5/325mg mg every 6 hours as needed for pain. Review of the Medication Administration Record (MAR) dated October, (MONTH) and (MONTH) (YEAR) and the MCDRs from the pharmacy found: -- (MONTH) (YEAR) - 52 [MEDICATION NAME] tablets were received from the pharmacy and one (1) dose was documented on the MAR as administered. There were 51 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 30 [MEDICATION NAME] tablets were received from the pharmacy and 13 doses were documented on the MAR as administered, leaving 17 [MEDICATION NAME] tablets unaccounted for. -- (MONTH) (YEAR) - 30 [MEDICATION NAME] tablets were received from the pharmacy and 17 doses was documented in the MAR as administered, leaving 13 [MEDICATION NAME] tablets unaccounted for. b) Review of the facility's Medication Storage in the Facility Controlled Substance Storage, dated 05/2012, on 12/17/15 at 8:30 a.m., and revealed: 4.2: CONTROLLED SUBSTANCE STORAGE. Policy: Medications included in the Drug Enforcement Administration (DEA) classification as controlled substances are subject to special handling, storage, disposal and record keeping in the facility in accordance with federal, state, and other applicable laws and regulations. A. The director of nursing, in collaboration with the consultant pharmacist, maintains the facility's compliance with federal and state laws and regulation in the handling of control substances. Only authorized licensed nursing and pharmacy personnel have access to controlled substances. B. Schedule (II-V) medications and other medications subject to abuse or diversion are stored in an errantly affixed, (double-locked) compartment separate from all other medications or per state regulation D. A controlled substance accountability record is prepared by the pharmacy/facility for all Scheduled II, III, IV, and V medications (See 10.12: INDIVIDUAL RESIDENT'S CONTROLLED SUBSTANCE RECORD, although some states require a bound book with numbered pages), including those in the emergency supply. The following information is completed on the accountability form upon dispensing or receipt of a controlled substance or use of a controlled substance from the emergency supply: 1. Name of resident. If applicable. 2. Prescription number, if applicable. 3. Name, strength, and dosage form of medication. 4. Date received. 5. Quality received. 6. Name of person receiving medication supply. E. At each shift change, or when keys are transferred, a physical inventory of all controlled substance, including refrigerated items is conducted by two licensed nurses and is documented. (See 10.14: SHIFT VERIFICATION OF CONTROLLED SUBSTANCES COUNT). The emergency supply may be verified by assuring that the seal on the supply has not been broken. If the seal has been broke to the emergency narcotic supply, then a physical count of the contents must be conducted by two licensed nurses and paperwork must be present to account for any medication removed from the supply ( contents of the emergency narcotic supply is limited by individual state and federal laws). F. Any discrepancy in controlled substance counts is reported to the director of nursing immediately. The director or designee investigates and makes every reasonable effort to reconcile all reported discrepancies. The director of nursing documents irreconcilable discrepancies in a report to the administrator. 1. If a major discrepancy or a pattern of discrepancies occurs, or there is apparent criminal activity, the director of nursing notifies the administrator and consultant pharmacist immediately. 2. The administrator, consultant pharmacist, and/or director of nursing determines whether other action(s) are needed, e.g., notification of police or other enforcement personnel. 3. The medication regimen of residents using medication that have such discrepancies are reviewed to assure the resident has received all medications ordered and the goal of therapy is met (example: a resident receiving a pain medication complains of unrelieved pain). 4. Controlled substance inventory is regularly reconciled to the Medication Administration Record (MAR) and 10:12: INDIVIDUAL RESIDENTS CONTROLLED SUBSTANCE RECORD. G. Current controlled substance accountability records are kept in the MAR, or designated book. Completed accountability records are submitted to the director of nursing and kept on file for (5) years at the facility. H. Controlled substances are not surrendered to anyone, including the resident's physician, other than releasing controlled medication for a resident on pass or therapeutic leave (see 6.1: OUT-ON-PASS MEDICATION/LEAVE OF ABSENCE).to a resident or responsible party upon discharge from the facility (See 5.2: DISCHARGE WITH MEDICATIONS), or to the DEA or other law enforcement officials functioning in a professional capacity in exchange for a receipt documenting the transaction. I. Controlled substances remaining in the facility after the order has been discontinued or the resident has been discharged are retained in a securely locked area with restricted access until destroyed. (See 5:1: CONTROLLED SUBSTANCE DISPOSAL). Accountability records for discontinued are maintained with the unused supply until it is destroyed or disposed of, and then stored for (5) years or as required by applicable law or regulation. The consultant pharmacist or designee routinely monitors control substance storage, records (i.e., change of shift sheets, individual controlled substances accountability sheets, MARs, delivery confirmation sheets), and expiration dates during routine medication storage inspections. On 12/18/15, at approximately 10:00 a.m., review of the facility's investigation of misappropriation of resident's property. The forms were completed on 12/17/15 at 7:30 p.m. for all sixty-three (63) residents (#49, #7, #67, #50, #20, #17, #77, #2, #85, #32, #57, #144, #105, #130, #12, #95, #70, #69, #65, #6, #82, #83, #43, #38, #39, #31, #10, #109, #47, #126, #3, #104, #111, #134, #15, #29, #131, #36, #81, #101, #120, #148, #19, #78, #72, #75, #149, #147, #133, #27, #61, #18, #59, #129, #11, #23, #51, #90, #143, #118, #141, #42 and #109) addressed: -- Brief description of the incident: Misappropriation of Resident Property. Facility unable to reconcile controlled Substance Accountability Sheet with resident medication ordered by physician. Upon review, electronic MAR documentation and controlled substance accountability sheets are unable to confirm what happened to the resident's medication at this time. Interviews with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and the Administrator, on 12/17/15 at 12:00 p.m., confirmed the facility was unable to provide all of the required documentation for the controlled substance for the period of 09/01/15 through 12/17/15. After review of the Monthly Controlled Drug Report provided by the pharmacy by fax, physician orders, and the Medication Administration Records (MAR), and Control Medication Destruction Logs, it was confirmed forty-one (41) residents had discrepancies regarding the residents' controlled medications. (Residents #49, #7, #50, #20, #17, #77, #2, #85, #32, #57, #105, #130, #70, #65, #82, #83, #43, #38, #10, #47, #126, #3, #134, #131, #36, #81, #101, #120, #19, #72, #149, #147, #133, #27, #18, #59, #129, #11, #90, #141, and #42.) Interview with the Consultant Pharmacist on 12/18/15 at 1:00 p.m., found the facility had failed to inform her of any issues with controlled (narcotic) medications. She further confirmed she was informed this that morning by the DON and Administrator and an action plan was being developed immediately.",2019-08-01
4797,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2015-11-04,224,D,0,1,KC5S11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of accident/incident reports, facility policy and procedure review, and staff interview, the facility failed to implement its Abuse Prohibition written policies and procedures to ensure each resident had the right to be free from abuse. Resident #83 allegedly physically abused Residents #9 and #28. The facility had no evidence their abuse policies and procedures to investigate the abuse and to protect residents from abuse were implemented for either resident's alleged abuse. Resident identifiers: #9, #28, and #83. Facility census: 87. Findings include: a) Resident #9 On 11/04/15 at 8:40 a.m., a medical record review was conducted for Resident #9. This resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A continuing review of the medical record revealed this resident had capacity to make health care decisions. In addition, according to the significant change minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/15, Resident #9 had a score of 11 on the Brief Interview for Mental Status (BIMS), indicating the resident was only moderately cognitively impaired. A review of incident/accident reports, on 11/04/15 at 9:00 a.m., revealed on 07/18/15 at 4:40 p.m., Resident #9 was heard yelling while sitting in her wheelchair in the hallway. The report indicated Licensed Practical Nurse (LPN) #102 observed Resident #83 had his hands on the back of Resident #9's neck and was pushing her head forward. The incident/accident report event section indicated this was a resident-to-resident altercation with alleged abuse. The report noted the victim was Resident #9. The event section on Resident #83's incident report also indicated this was a resident-to-resident altercation, with alleged abuse. b) Resident #28 On 11/04/15 at 8:26 a.m., a medical record review was conducted for Resident #28. This resident was originally admitted on [DATE]. [DIAGNOSES REDACTED]. Resident #28's score on the BIMS, on the annual MDS, with an ARD of 06/02/15, was 14, indicating cognition was intact. A review of incident/accident reports, on 11/04/15 at 9:12 a.m., revealed Resident #28 reported to nursing assistant (NA) #95 that she was in her wheelchair in the hallway when Resident #83 walked by and struck her in the right upper arm. A concurrent review of the accident/incident report for Resident #83 revealed the resident was ambulating on the Hilltop hallway and hit Resident #28 in the face. The incident/accident further stated, The next time she (Resident #28) stated that he (Resident #83) had hit her in the right arm. This resident could not give history of event. The event section of Resident #28's report indicated the incident was a resident-to-resident altercation with alleged abuse. The event section of Resident #83's report indicated the incident was a resident-to-resident altercation and Resident #83 was the alleged abuse/aggressor. c) On 11/04/15 at 9:15 a.m., the facility's policy and procedure titled Abuse Prohibition was reviewed. The Process section stated: 5. Staff will identify events --- such as suspicious bruising of patients, occurrences, patterns, and trends that constitute abuse --- and determine the direction of the investigation. This also includes patient-to-patient abuse. 5.2 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. 5.2.3 The Center should seek alternative placement for the patient exhibiting the abusive behavior, if warranted. There was no evidence the facility implemented its Abuse Prohibition policy and procedure regarding the allegations of abuse made by Residents #9 and #28. d) An interview was conducted with the Social Worker (SW) on 11/04/15 at 10:11 a.m When asked about the resident-to-resident altercations instigated by Resident #83 toward Residents #9 and #28, the SW stated because Residents #9 and #28 did not experience physical injury, nothing further was done related to the incidents. The SW stated This is how we look at them. When asked if the incidents constituted abuse, the SW did not reply to the question. The SW again stated, This is how we look at them. An additional question was asked regarding the fact the incident/accident reports indicated the incidents were each called resident-to-resident altercation with alleged abuse-victim, The SW stated this was probably assessed in error. The SW stated there was a drop down box for recording information, and the wrong information was indicated on each of the reports.",2019-07-01
4838,MEADOWVIEW MANOR,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2016-07-20,224,D,1,0,KIXL11,"> Based on observation, staff interview, family interview, policy review, and review of reportable allegations, the facility failed to ensure a resident was free of neglect for one (1) of six (6) sample residents. The facility failed to provide activity of daily living (ADL) care in a timely manner for a dependent resident. Resident identifiers: Resident #53. Facility census: 59. Findings include: a) Resident #53 A random observations on 07/12/16 at 10:55 a.m., revealed Resident #53 sitting in her chair, with the support pillow behind her neck and the cushion in place beneath her heals. During another observation at 1:20 p.m., the resident was observed seated in her chair, in the same position. Subsequent observations revealed the resident seated in her wheelchair. At 4:34 p.m. Nurse Aide (NA) #99 and #102 provided incontinence care for Resident #53. NA #102 reported the resident had been up all day and she hoped Resident #53 was not a mess. The resident's daughter was present during care and related she wanted to observe also. The NA's utilized the lift and transferred Resident #53 to bed. When NA #102 exposed the resident, observation revealed the brief was saturated with urine. Staff turned the resident to her left side for care, exposing a blanchable purple discoloration over the buttocks area. Licensed Practical Nurse (LPN) #51 was notified staff had voiced Resident #53 had been out of bed since 10:30 a.m. without incontinence care. When the LPN observed the brief she exclaimed, Oh, wow! and related she would follow-up. During a conversation with the administrator, on 07/13/16 at 11:30 a.m., she related she had been informed of the incident, and that the director of nursing (DON) had spoken with the dayshift nurse aide who indicated Resident #53 had been transferred to bed at 12:30 p.m., changed and transferred back to her chair. Upon inquiry, at 4:00 p.m., as to whether the incident had been reported to the appropriate State agencies, the administrator related it had not, because Resident #53 had been changed at 12:30 p.m. and did not realize the delay in care applied to the afternoon. The resident's care plan, indicated Resident #53 would be checked and changed every two (2) hours. Family Member (FM) #1, interviewed on 07/13/16 at 3:45 p.m., related staff had expressed they were unable to change Resident #53 when requested, prior to the music activity at 2:00 p.m., and she transported the resident to the activity. The resident had returned to her room at about 3:30 p.m., with no intervention by staff throughout the time she was in the facility. FM #1 said she left about 4:00 p.m. on 07/12/16. Another observation, on 07/20/16 revealed Resident #53 up in her chair at 11:15 a.m., 12:30 p.m., 1:15 p.m. and 2:15 p.m. An interview with Nurse Aide (NA) #126 at 2:15 p.m., confirmed the NA had provided care for Resident #53 that date. Upon inquiry, the nurse aide related the resident had been out of bed since about 10:45 a.m. Continued observation revealed the resident did not receive care until 3:45 p.m., when NA #99 entered the room with clean linens. NA #99 continued to look outside the door of Resident #53's door and after about 30 minutes requested the assistance of Licensed Practical Nurse (LPN) #128. The NA explained the transfer required the assistance of two (2) persons. The nurse assisted with the transfer back to bed, then asked NA #99 if she could complete incontinence care by herself. The NA informed her no and the nurse asked her to find someone else to assist her. The NA returned to the room about five (5) minutes later and the two (2) NA's performed incontinence care. The director of nursing (DON) reviewed the medical record on 07/20/16 at 3:15 p.m., and acknowledged the nurse aide entries in the medical record did not correlate with the resident's care. The DON reviewed entries related to incontinence care, products utilized and resident transfers each shift. The director of nursing verified the entries indicated the resident had not been transferred back to bed for care on 07/12/16 and 07/20/16. The director also verified the nurse aides had not entered care at the time of delivery, and could not determine when care had been provided. The administrator and director of nursing (DON) was notified at 5:00 p.m. of the concern Resident #53 had been out of bed from 11:15 a.m. until 4:30 p.m. without care on 07/20/16. The administrator was notified NA #11 had acknowledged the resident had not been laid down and/or provided care since her transfer from bed that morning. The administrator acknowledged the facility had not identified the delay in care on 07/12/16 as an allegation of neglect.",2019-07-01
4873,NELLA'S NURSING HOME,5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2016-03-16,224,D,0,1,6KMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of accident/incident reports, facility policy and procedure review, review of immediate and five (5) day reporting information, and staff interview, the facility failed to identify a resident (#77) who was at risk for abusing other residents, develop interventions to prevent occurrences, monitor for triggers of abusive behavior, and reassess the interventions. In addition, the facility failed to implement its written policies and procedures for the prohibition of physical abuse. Residents #6 and #17 were physically abused by Resident #77. This was true for two (2) of four (4) residents reviewed for abuse during Stage 2 of the survey. Resident identifier: #77. Facility census: 75. Findings include: a) Resident #77 On 03/09/16 at 9:16 a.m., review of the medical record for Resident #77 found this resident, admitted on [DATE], had [DIAGNOSES REDACTED]. The admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 09/16/15, had no Brief Interview of Mental Status (BIMS) score because of the resident's inability to understand the questions. The quarterly MDS with an ARD of 12/04/15 indicated no change in the BIMS score. Both MDSs indicated this resident wandered daily. A concurrent review of the care plan dated 09/25/15, found a problem statement of Multiple life style changes, (loss of independence, limitations on lifestyle, chronic disease). Cognitive severely (sic), rarely/never makes decisions. Rarely/never understood, rarely/never understands, wears glasses. Easily distracted, loses train of thought, gets sidetracked. Rambling/irrelevant conversation, unclear/illogical flow of ideas. Short/long term memory problems. Elopement risk. Interventions included Assess coping methods, use of defense mechanisms, feelings about lifestyle changes, any losses associated with illness and ability to ask for help. Assist to identify positive defense mechanisms and promote their use. Provide environment that allows free expression of concerns and fears. Assist to set short and long term goals; provide positive feedback regarding process and focus on abilities rather than disabilities. Reality orientation PRN (as needed). Wonder guard watch. Observe whereabouts (Q) every 30 minutes and PRN. Keep in area well supervised. Attempt (redirecting) abnormal behaviors with food/drink/pain assessment/toileting/activity/etc. An additional care plan, dated 12/09/15, revealed the same problem statement and interventions. In addition a review of the acute care plan at this time revealed the addition of new problems with approaches (interventions) as follows: - On 09/16/15, Resident #77 pulled the fire alarm. Approaches (interventions) included redirection and education given to the resident related to fire alarm. - On 09/30/15, sexually inappropriate behavior toward staff. Approaches included reminding/educating about inappropriate behaviors and assisted to room per resident request. - On 10/11/15, observed tossing trash cans through the air in the dining room. Approaches included patient teaching - reminders of inappropriate behaviors and redirected to room. - On 10/24/15, cursing, yelling at staff while redirecting him out of other resident rooms and was combative by swinging at staff. Approaches included one-on-one required. The physician was notified and ordered [MEDICATION NAME] 2 milligrams (mg) orally every 4 hours prn (as needed) for agression and agitation. [MEDICATION NAME] 2 mg was administered orally. - On 11/01/15, he was arguing with another resident in the dining room and became combative when directed away from other residents. One-on-one staff needed. Resident brought to nurses station and assessed for pain, hunger, thirst and need to toilet. Approaches included [MEDICATION NAME] 2 mg intramuscularly (IM) administered as no improvement with behaviors. Diversional activity, reassurance, remove from area and return to room when behavior inappropriate. - On 12/12/15 Resident #6 was struck by Resident #77 causing a nose bleed. Approaches included provided toileting, snacks, and fluids to redirect. Assess for pain/discomfort. Close observation provided to both residents. Physician notified and ordered psychological evaluation/treatment as indicated. Hospice notified and [MEDICATION NAME] was discontinued related to behaviors with physician approval. Continue to monitor behaviors. - On 12/20/15, Resident #77 hit Resident #17 on the cheek causing a bruise. On 03/09/16 at 10:03 a.m., an interview with the MDS Coordinator revealed she had developed the care plans for Resident #77. When asked if Resident #77 could remember and/or set short and long term goals, she stated No. When asked what was reality orientation, she responded the residents are informed of the current date. When ask if Resident #77 would be able to remember this, she stated No. In addition, she stated he was better than when he was admitted to the facility, but was slowly declining. When an inquiry was made regarding Resident #77 being monitored every thirty (30) minutes and PRN (as needed), the MDS Coordinator stated to her knowledge there was no evidence in the medical record to confirm this intervention was completed. When asked if any other interventions (approaches) were utilized from the acute care plan such as using one-on-one, and administration of [MEDICATION NAME] and/or protecting other residents from being abused, she stated door barriers had been installed upon resident request. In an interview with the nursing home administrator on 03/09/16 at 2:46 p.m., she stated she was aware of the incidents involving Residents #77, #6 and #17. She was not aware that there was no evidence to confirm Resident #77 had been monitored every 30 minutes. The NHA stated there was a consulting psychiatrist who saw residents at the facility, but she was not aware the physician had canceled that apointment. In addition, she stated door barriers had been purchased to prevent Resident #77 from wandering into other residents' rooms. When asked if she felt the facility was meeting the needs of Resident #77 and protecting other residents from this resident, she stated they were doing the best they could. The NHA stated when there is an acute episode with Resident #77, the episode is recorded on the acute care plan as well as the interventions (approaches). She stated she was not aware if these interventions were included in the care plan. A review of the facility's abuse policy and procedure was conducted on 03/15/16 at 2:17 p.m The policy stated The facility will conduct a thorough investigation of each allegation . Two (2) bullet section stated Identify all witnesses and Interview all individuals who may have information concerning the incident, including the resident (even a confused resident may be able to provide valid information), all individuals who were working at the time of the incident, anyone the resident may have shared information with . On 03/16/16 at 9:24 a.m., an interview was conducted with the Social Worker (SW). The SW agreed and confirmed no witnesses were interviewed or statements taken as per facility policy. This information would be needed in order for the facility to attempt to identify what triggered Resident #77's behaviors and develop effective care plan interventions for preventing further abusive behaviors.",2019-07-01
5513,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-12-11,224,G,1,0,V8DE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review, staff interview and policy review, the facility failed to ensure each resident was free of neglect. The facility failed to fully operationalize procedures to ensure residents received adequate supervision and/or monitoring to prevent a fall with harm. The facility failed to monitor Resident #92 after the resident had received two (2) doses of a newly prescribed emergent injectable anti-anxiety medication [MEDICATION NAME] ([MEDICATION NAME]). After receiving the second dose of [MEDICATION NAME], Resident #92 had an unwitnessed fall with injury requiring medical intervention at an acute care hospital where he expired in less than 24 hours of transfer. There was no evidence the resident was monitored and/or supervised after receiving either dose of the medication [MEDICATION NAME]. Resident #88 did not receive adequate supervision/monitoring during a shower and had a fall from a shower gurney causing harm with a severe injury requiring medical intervention and continued use of an immobilizing cervical collar. This practice was found for two (2) of six (6) sample residents who were reviewed for falls. This practice had the potential to affect all residents in the facility. Resident identifiers: #92 and #88. Facility census: 91. Findings include: a) Resident #92 On [DATE] at 2:30 p.m., a review of the accident/incident log revealed Resident #92 had a total of two (2) unwitnessed falls without injury, one (1) on [DATE] at 0245 (2:45 a.m.) and two falls on [DATE] at 6:00 p.m. and 7:00 p.m. Copies of the accident/incident reports were provided on [DATE] at 3:30 p.m. and found not to match the accident/incident log. The accident/incident reports identified an unwitnessed fall without injury on [DATE] at 0245 (2:45 a.m.) and one (1) report for [DATE] for unwitnessed falls without injury at 6:00 p.m. and 7:00 p.m. (This was found to be inaccurate; the resident only had one fall at 7:00 p.m.). On [DATE] at 9:30 a.m., a record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Transfer/Discharge Report, by an unknown author dated ,[DATE] 5:30 p.m. stated, . Resident fell several times today. unable to calm, possible head injury . A review of the nursing progress notes on [DATE] at 09:45 a.m., revealed the following documentation: ---[DATE] at 17:15 (6:15) of Resident had been having increased agitation . Notified MD. received order for [MEDICATION NAME] 1 mg IM (intramuscular) x 1 dose now repeat in 1 hr. if needed . ---[DATE] at 17:59 (7:59 p.m.) IM [MEDICATION NAME] given as ordered at 1800 (6:00 p.m.) to (L) arm . ---[DATE] at 01:58 (1:58 a.m.) Resident is alert and verbal with increased confusion. Resident received IM [MEDICATION NAME] 1 mg at 6p, resident continued to have behaviors and was found on floor beside bed IM [MEDICATION NAME] 1 mg administered at 7P per MD orders . Resident continued to flail around and was unconsolable and was found on floor after second dose of [MEDICATION NAME]. Resident found with head against bottom bed bar, no visible injuries noted . Redness noted to back of head . Respirations even and labored . PA ordered to send resident to Mon Gen for eval . Resident left facility via Star city EMS (Emergency Medical Service) at appox 8 P . (Note was made after Resident was transported to the hospital on [DATE].) There is no evidence in the record of the incident being reported to the appropriate state agencies or of an investigation by the facility of the unwitnessed fall which required medical intervention, nor of the resident being monitored and/or supervised following the administration of either doses of the injectable medication [MEDICATION NAME]. During an interview with Licensed Practical Nurse (LPN) #11 on [DATE] at 11:40 a.m. she commented that she was the nurse going off shift on [DATE]. Resident #92 was aggressive on [DATE] and was trying to destroy the furnace in his room. LPN #11 had notified the Physician and received an order for [REDACTED].#92) daughter. I walked past as I was leaving about 6:30 p.m. and peeked in the room, he was in bed and no one was in his room with him. The Director of Nursing (DON) was interviewed on [DATE] at 12:20 p.m. and asked to explain the procedure for a resident following an aggressive episode that would require medical intervention. She stated, Call the doctor, call the family, keep a close eye on for the next few hours and someone should stay in the room for the first (1st) hour after giving [MEDICATION NAME] or any emergent medication. On [DATE] at 3:45 p.m., in the company of the Director of Nursing (DON), the Administrator and the ADON, a speaker phone interview was conducted with LPN #95 (who was the oncoming nurse on [DATE]). The DON asked LPN #95 if the resident had fallen twice during her shift as was recorded on the accident/incident report. LPN #95 stated, no just the once at 7:00 p.m . no it is incorrect (the accident/incident report documentation), he only had one fall. I did give the IM [MEDICATION NAME] but did not sign it out, it was very busy and I was worried about caring for the resident. After further discussion LPN #95 stated, I stayed with him for about 15 minutes after I gave the second (2nd) dose of [MEDICATION NAME] and then went out because I was in the middle of medication pass. It is not documented but now I know to document that in the notes. A review of the company [MEDICATION NAME] manufacture's package insert for the injectable medication [MEDICATION NAME] ([MEDICATION NAME]), (obtained at the acute care hospital pharmacy) on [DATE] at 8:45 a.m. revealed, Elderly patients .do not operate machinery or motor vehicle during the first 24 hours .monitor for possible respiratory distress's in elderly patients .monitor for falls related to sedation On [DATE] at 9:00 a.m., a review of the community hospital records revealed Resident #92 was admitted to the hospital on [DATE] with the chief complaint of agitation and combativeness, multiple falls and [MEDICAL CONDITION]. Resident #92 expired on [DATE] at 2:15 p.m. The cause of death on the Death Certificate was listed as: a. Acute hypercapnic [MEDICAL CONDITION]. b. Benzodiazepines overdose. A review of the facility reference, Nursing (YEAR) Drug Handbook revealed the following information regarding the medication [MEDICATION NAME] ([MEDICATION NAME]): CONTRAINDICATIONS & CAUTIONS .use cautiously in elderly, acutely ill or debilitated patients. PATIENT TEACHING .Warn patient to avoid hazardous activities that require alertness or good coordination until effects of drug are known. Due to the resident being newly admitted to the facility, having un-witnessed falls with the latest fall needing medical intervention, the resident expiring in less than 24 hours of being transferred to the community hospital and due to the listed causes of death, it should have been reported to the appropriate state agencies and thoroughly investigated by the facility. Also the resident should have been monitored and/or supervised following the administering of the emergent newly prescribed injectable anti-anxiety medication [MEDICATION NAME]. . b) Resident #88 A review of the clinical record for Resident #88 at 3:00 p.m. on [DATE] revealed he was an [AGE] year old male admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. His assessments by his physician included hallucinations, paranoia, delusions, and physical and verbal aggression. He had been determined by a physician to lack the capacity to form medical decisions. Resident #88 was totally dependent on staff for all activities of daily living for over a year. He required use of a mechanical lift for transfers. Due to his poor cognition, he was unable to communicate his needs in an understandable manner. The resident exhibited almost daily behaviors which included being easily agitated during personal care and hitting, shouting, and cursing during personal care. Because of restlessness, and no self-safety awareness due to his cognitive impairment he had been assessed to be High Fall Risk and several safety interventions were included in his Care Plan including: --[DATE] - Bed in low position --[DATE] - Landing mats beside bed --[DATE] - Bed alarm when resident is in bed to alert staff for when resident needs assistance --[DATE] - Mechanical Lift for transfers --[DATE] - Padding to side rails --[DATE] - When resident is out of bed and in his wheelchair a seatbelt will be utilized to assist with body positioning complicated by decreased safety awareness and inability to comprehend verbal safety prompts when given by staff and others. During independent interviews with RN #82 at 8:40 a.m. on [DATE], and RN #11 at 12:30 p.m. on [DATE], both nurses verified that the resident frequently struck out at caregivers and flailed out when touched. They said the interventions identified in the care plan were needed and followed daily. Nurse Aide (NA) #5, when interviewed at 1:15 p.m. on [DATE], said the aides tried to work in pairs for transfers and personal care of Resident #88. At 10:00 a.m. on [DATE], Resident #88 fell from a shower gurney in the shower room approximately three (3) feet onto a tile floor sustaining a laceration to his forehead and a head injury later diagnosed as an acute displaced type II odontoid fracture and fractures through the posterior archy of C1. The fall was observed and the resident received immediate emergency care, 911 was called, and he was transferred to an acute care hospital. The facility immediately reported the incident to the appropriate state offices, suspended the aide involved, and began an investigation. The Immediate Fax Report to the Nurse Aide Registry stated the following: Allegation: CNA was showering this resident, she put the rail down on the shower gurney and turned to get the hoyer pad and the resident rolled off the gurney hitting the floor sustaining a [MEDICAL CONDITION]. All staff working at the time of the incident were interviewed during the investigation and the Five Day Follow-up Report sent to the Nurse Aide Registry on [DATE], stated, Resident did sustain a neck fracture after his fall. After investigation this facility determined this was an accident, however this CNA did fail to follow safety rules and was terminated for such. She was also in her probationary period. In a signed statement from the aide present in the shower room and assigned to care for Resident #88 at the time of the incident she stated: On this day [DATE] I was assigned to shower (Resident #88). While showering (Resident) he was being combative @ times. (CNA #5) another CNA was also in the shower room with me showering another male resident also Licensed Practical Nurse (LPN #11) the treatment nurse came in to change his bandage. I had finished (Resident #88's) shower had him dressed and a lift under him for he was being showered on a shower bed. (CNA #5) had left to transport her resident and was coming back to assist and I had turned my back for a minute to reach for (Resident's) Chair which was in arms length reach and he had rolled himself off of the shower bed. A signed written statement from NA #5 validated the behavior of the resident during his shower and that she left the room with her resident intending to return to assist with Resident #88. Seven (7) staff members completed written statements (LPN#11, NA#5, Registered Nurse (RN) #34, RN#82, NA#69, NA#89, and NA#115. All confirmed the resident was aggressive and not cooperative with care. After review of the investigation completed by the facility and interviews with LPN#11 at 12:30 p.m. on [DATE] and NA #5 at 10:30 a.m. on [DATE], who were both present shortly prior and immediately after the incident, it was apparent NA #115 was negligent in her care of Resident #88. During an interview with the director of nurses (DON) and assistant director of nurses (ADON) at 11:30 a.m. on [DATE], the DON acknowledged she had made the decision that NA #115 had neglected her supervision responsibility to Resident #88 when she lowered the side rail and turned her back allowing him to fall and because of this neglect she was terminated. The ADON agreed with her. A review of the personnel file for NA #115 revealed she had been trained and licensed in another state in 1991 and her license in that state was in good standing when transferred to West Virginia. Her background checks were done on [DATE] and were returned as satisfactory. She had been hired on [DATE], and completed her required orientation which included training on transfers and Alzheimer's training. The Alzheimer's training reviewed the safety and care of cognitively impaired residents.",2018-12-01
5692,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2015-01-29,224,D,0,1,WCKU11,"**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 two (2) of three (3) residents reviewed for nutrition were free from neglect. Goods and services for the prevention of weight loss were not provided as ordered. Resident identifiers: #16 and #74. Facility census: #108. Findings include: a) Resident #16 Review of the weights and vital sign summary found the resident's most recent weight was 117.8 pounds on 01/20/15. The previous recorded weight was 131 pounds on 12/23/14. A nutritional assessment was completed on 11/04/14. The registered dietitian noted the resident had a 7.5% weight loss (a significant weight loss) in the past three (3) months. The dietitian ordered a house supplement and other interventions to address the resident's weight loss. During the survey, on 01/21/15, the resident was still receiving a house supplement, four (4) ounces, two (2) times a day at 10:00 a.m. and 2:00 p.m. At 2:50 p.m. on 01/21/15; the resident was sitting in her chair with a bedside table which contained two (2) cartons of the house supplement. Observation found the resident had not consumed any of the supplements. The paper cartons containing the supplements, were opened; however, the resident had no straw and no glass. Review of the Medication Administration Record [REDACTED]. At 2:57 on 01/21/15, the administrator and the director of nursing (DON) were asked to observe the supplement which was still on the resident's bedside table and to review the MAR. The DON confirmed the consumption of the supplement and the documentation on the MAR indicated [REDACTED] b) Resident #74 Review of the weights and vital sign summary found the resident weighed 165 pounds when admitted on [DATE]. Her last recorded weight was 140.9 pounds on 01/20/15. On 01/06/15, the physician ordered a house supplement, four (4) ounces two (2) times a day, at 10:00 a.m. and 2:00 p.m., for weight loss. At 12:53 p.m. on 01/22/15, review of the MAR found the nurse, Employee #15, had already documented the resident refused her 2:00 p.m. house supplement. The DON and the administrator were asked to review the MAR indicated [REDACTED]. The DON confirmed the 2:00 p.m. snack had not yet been served, although the nurse had already documented it was refused by the resident. c) Review of the facility's policy for Abuse Prohibition found, (Name of the company) will prohibit abuse, neglect, involuntary seclusion, and misappropriation of property for all patients .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. Resident #16 and Resident #74 each had an order for [REDACTED].#15, the nurse responsible for the residents, failed to ensure the supplements were provided, consumed, and/or monitored. The nurse documented Resident #74 refused the supplement more than an hour prior to the receipt of the supplement by the resident. In addition, Resident #16 consumed none of the supplement provided. The same nurse documented the resident consumed 100% of the supplement.",2018-08-01
5973,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2014-10-15,224,D,0,1,GZSS11,"Based on resident interview, review of the facility's abuse policy, and staff interview, the facility failed to investigate an allegation of misappropriation of resident property for one (1) of two (2) residents who were reviewed for the care area of abuse during Stage 2 of the survey. The facility did not implement their written policies and procedures that prohibited misappropriation of resident property. Resident identifier: #15. Facility census: 59. Findings include: a) Resident #15 Interview with Resident #15, on 10/07/14 at 2:43 p.m., revealed a nursing assistant (NA), Employee #25, came into her room and the resident caught the NA going through her dresser drawers. Resident #15 said she had a red cup, part of a set that was a gift from her son. The resident said the NA started to take the red cup. The resident said she told the NA not to take the cup. Resident #15 said a few days later the cup showed up missing. She said the next time she saw the NA, she asked her (the NA) if she got the cup. The resident said at first the NA denied getting the cup, but then admitted she had taken it because she did not have anything to drink out of that day. The resident said she was very upset and told the NA to go get the director of nursing (DON). The resident said she got her cup back after that. On 10/13/14 at 4:15 p.m., review of the facility's Abuse Policy, initiation date July 1973 and latest revision September 2008, revealed misappropriation of resident property was to be reported immediately. Their policy stated At no time does staff have a right to a resident's personal property. It also stated, All allegations of abuse involving mistreatment, neglect, or misappropriation of resident property will be reported per facility policy and in accordance to state and federal law. Their policy instructed an initial / immediate investigation to include question resident, staff, and any other witnesses. Initial reporting to the appropriate agencies included in their policy were reporting all allegations to the West Virginia Department of Health and Human Resources Adult Protective Services, Office of Health Facilities Licensure & Certification, and Nursing Aide Registry. The Social worker would head a secondary investigation and a Five Day Follow-Up would be sent to the Nursing Home Program. On 10/14/14 at 1:27 p.m., an interview with Employee #52, Social Worker (SW), revealed if an accusation occurred where a staff member took something belonging to a resident, a reportable incident report would be filled out and filed. The SW said, All abuse and neglect incidents are reported. She explained, . the person's supervisor would be made aware of the incident and possibly that person might be suspended because that is being abusive of property. Interview with the director of nursing (DON), on 10/14/2014 at 2:06 p.m., revealed she did not investigate the situation to rule out a potential misappropriation of property, even though the aide, Employee #25, informed the DON she had borrowed a resident's personal cup. When asked if staff were allowed to borrow items from residents, the DON replied, No, absolutely not. They know better. The DON was asked if she was concerned about the fact the aide borrowed the resident's cup when she should have known better. The DON shook her head in an affirmative motion and stated, If I had known more about it then, I would have investigated it. The DON agreed if it had been investigated, she would have known more about it. The NA was not available to interview because she was off from work due to a death in her family.",2018-05-01
6380,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,224,G,0,1,35BV11,"**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 four (4) residents reviewed for accidents was free from neglect. The resident was assisted with toileting by one (1) nurse aide; however, the resident's care plan indicated he required the assistance of two (2) for toileting. The resident fell while transferring to the toilet, resulting in a head injury and was subsequently sent to the emergency room . Resident Identifier: #59. Facility Census: 77. Findings Include: a) Resident #59 On 06/24/14 at 8:35 a.m., review of the resident's nurses' notes, revealed an entry dated 03/11/14 at 3:11 p.m., stating, Resident pulled call bell out of wall and tipped over nightstand with drawers. Resident came out of room stating he had to piss. Aide called to room to take resident to bathroom. Aide had resident holding onto bar which she moved wheelchair out of way and resident fell in bathroom onto floor hitting back of head and bottom . Resident complained of pain in the back of head . Resident in bed lethargic, resting with eyes closed at times, not wanting to get up to use the bathroom. Resident pulled penis out of brief three times and urinated on self and in bed . Resident noted to have cough and congestion in throat and this nurse questioned the need for chest x-ray . Talked with physician at 11:45 AM and orders given to send resident to ER (emergency room ) . Sent out regarding changes in status, lung sounds and bump on head. (The time of the fall and the time the resident was sent to the emergency room was not indicated in the nurse's note.) Further review of the resident's medical record found the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of 03/03/14, found the Brief Interview for Mental Status (BIMS) was not attempted. The resident was noted to have short term memory problems, disorganized thinking was coded as continuously present and did not fluctuate, and he had trouble concentrating on things. According to the assessment, walking in his room only occurred once or twice in the look back period and walking in the corridor did not occur. For toilet use, he was coded as the extensive assist of one person and for balance, all areas were coded as Not steady, only able to stabilize with staff assistance. The assessment also identified the resident had active [DIAGNOSES REDACTED]. (No additional assessments were conducted. The next record was a Death in Facility record dated 03/13/14.) Upon inquiry, at 10:00 a.m. on 06/24/14, as to the time Resident #59 was transported to the ER for evaluation, Employee #66, medical records personnel, provided the resident's transfer form. The transfer form contained a nurse's note, written by Employee #11, a licensed practical nurse on 03/11/14 at 12:24 p.m. The form included, Resident lost balance due to weakness and fell in bathroom this morning. Hit head and had neck at abnormal angle upon observation of scene . Resident lethargic and unresponsive to voice stimuli . Dr. notified with order to send to emergency room for evaluation and treatment. CT scan of head and chest x-ray if needed. On 06/19/14 at 1:21 p.m., Employee #2, a registered nurse (RN), was asked how many staff members were assisting the resident at the time of his fall. She stated Employee #32, a nurse aide (NA), was the only staff member assisting Resident #59 at the time of the fall. The care plan was reviewed on 06/20/14 at 9:20 a.m. The ADL (Activities of Daily Living) function / Rehabilitation Potential portion of the care plan indicated the resident required the extensive assistance of two (2) with transfers and total assist of two (2) with toileting. This problem was dated 01/20/14, three (3) days after the resident was admitted . It was reviewed by the facility on 02/28/14, and remained the same.",2018-04-01
6422,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,224,H,1,0,S2LQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident observation, resident interview, and staff interview, the facility failed to prohibit the neglect of two (2) of five (5) sampled residents. The facility neglected to ensure optimal management of Resident #59's pain to prevent undue pain and mental anguish. Since July 2014, facility staff had consistently neglected to assess Resident #59's pain for location, nature, and severity before the administration of medication and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. This constituted actual harm for Resident #59. For Resident #7, the facility staff neglected to take appropriate actions to implement the Registered Dietitian's recommendations. The facility staff also neglected to notify the physician promptly of the resident ' s weight loss; therefore, delaying his ability to assess and/or provide interventions to prevent additional weight losses. As the facility failed to implement the dietitian ' s recommendations and failed did not promptly notify the physician to assess and/or provide interventions to prevent further weight loss, the weight loss could not be determined to be unavoidable. This represented actual harm to Resident #7. Additionally, the facility staff failed to adequately monitor Resident #7 ' s skin during weekly skin assessments and while providing treatments. Resident #7 developed an avoidable pressure ulcer, which also constituted actual harm for Resident #7. Resident Identifiers: #59 and #7. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 12:33 p.m. on 03/02/15, found Resident #59 had frequent complaints of abdominal pain, and pain in her left and right sides, since July 2014. She had a computerized tomography (CT), without contrast, of the abdomen and pelvis completed on 07/04/14 at a local hospital. The impression was, A possible tiny non-bstructive distal left [MEDICAL CONDITION] calculus is seen. A probable renal mass raising the possibility of renal cell [MEDICAL CONDITION] is also seen. A ventral Hernia containing a loop of colon is also identified. While out to the hospital on [DATE], she also had an ultrasound of both kidneys. The impression for this was, The examination is limited due to the patients large body habitus. A left renal mass is identified raising the possibility of renal cell [MEDICAL CONDITION]. She had another CT of the abdomen completed on 08/19/14. The impression for this was, A 3.4 CM left renal mass believe to [MEDICAL CONDITION] essentially the same as previous 07/23/14 exam. Ventral hernia with non-obstructed small bowel loop of the lower abdomen. Mild constipation. 3 cm (centimeter) uterine fibroid. On 09/08/14, she also had an X-ray of the abdomen which indicated, No acute Findings or Bowel Obstruction. They compared this to an x-ray of the abdomen taken on 12/30/12, which also indicated no bowel obstruction. Review of the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/10/14, found the resident was on a scheduled pain medication and an as needed (PRN) medication. At that time, the assessment indicated no non-pharmacologic interventions were utilized. The coding for pain indicated the resident had moderate intensity pain rarely. The quarterly MDS, with an ARD of 09/05/14, indicated the resident was not on scheduled pain medication, but did receive PRN [MEDICATION NAME]. The resident's pain interview indicated she had pain frequently that made it hard to sleep at night and limited her activities. Severe was checked for the resident's response for the intensity of her pain. Further review of the resident's medical record found the facility staff failed to ensure Resident #59 consistently received adequate pain management. At times, there was no evidence the resident's complaints of pain were treated. Staff also failed to assess Resident #59's pain for location, nature, and severity before the administration of medication, and/or neglected to reassess her pain for the effectiveness of the pain medication after administration. Staff also failed to implement non-pharmacological interventions in attempts to alleviate Resident #59's pain. No evidence was found to indicate staff monitored the resident for passage of the kidney stone. The failure of facility staff to effectively manage Resident #59's pain on an ongoing basis since July 2014 resulted in Resident #59 periodically suffering from pain for longer than necessary, which constituted physical harm for Resident #59. 1. July 2014 Review of Resident #59's medical record for July 2014 found the resident received ordered as needed (PRN) pain medication and/or complained of pain on the following instances in which Resident #59's pain was not assessed to determine the location, nature, and or severity, and the effectiveness of the pain medication was not determined unless otherwise noted. By not assessing the location, nature, and severity of the pain, information about the resident's pain was not available to communicate to the physician for evaluation. No non-pharmacological interventions were identified as being employed to address the resident's pain. a. 07/03/14 Review of Resident #59's medical record found she began complaining of left side pain on 07/03/14 at 10:00 p.m. Licensed Practical Nurse (LPN) #20 assessed the area and noted no bruising or redness on 07/03/14 at 10:00 p.m. LPN #20 did note administering pain medication at that time. A routine dose of of Tylenol 1000 milligrams (mg) was due at 10:00 p.m. There was no indication LPN #20 assessed whether the dose of Tylenol at 10:00 p.m. was effective in relieving Resident #59's pain. At that time, the resident also had an order for [REDACTED]. There was no indication the attending physician and/or Resident #59's healthcare decision maker were notified of Resident #59's complaints of pain on 07/03/14. b. 07/04/14 Resident #59 again complained of pain in her left side on 07/04/14 at 7:25 p.m. LPN #5 noted she wanted to go to the emergency room (ER) for an evaluation. The resident was sent to the ER, but prior to her leaving the facility, there was no indication her pain was assessed and/or treated. There was no evidence of attempts to obtain additional orders from the attending physician to treat Resident #59's pain prior to sending her to the ER. c. 07/05/14 Resident #59 returned from the ER at 2:44 a.m. on 07/05/14 with new orders for [MEDICATION NAME] 5/325 every 6 (six) hours as needed (PRN) for pain. It was also noted at this time, Resident #59 had a kidney stone and a three (3) centimeter mass. At 1:33 p.m. on 07/05/14, Resident #59's attending physician was notified of her visit to the ER and he gave a new order to discontinue her routine dose of Tylenol 1000 mg twice daily at 10:00 a.m. and 10:00 p.m. Resident #59's MAR indicated [REDACTED]. d. 07/06/14 LPN #20 noted, on 07/06/14 at 1:41 a.m., Resident #59 was medicated with [MEDICATION NAME] one (1) time for complaints of left sided pain with relief noted. Review of 07/06/14 MAR found it did not reflect administration of [MEDICATION NAME] as identified in the nurse's note. e. 07/07/14 LPN #32 noted, at 8:06 a.m. on 07/07/14, Resident #59 was given one (1) dose of [MEDICATION NAME] for complaints of left sided pain. LPN #32 noted the medication was effective. However, there was no indication LPN #32 assessed for the nature and severity of the resident's pain before the administration of medication and/or the effectiveness of the pain medication after administration. f. 07/08/14 - 07/09/14 Resident #59's MAR indicated [REDACTED]. g. 07/12/14 - 07/13/14 Resident #59's MAR indicated [REDACTED]. h. 07/15/14 Resident #59's MAR indicated [REDACTED]. i. 07/21/14 to 07/23/14 Resident #59's MAR indicated [REDACTED]. LPN #5, at 5:41 a.m. on 07/22/14, noted Resident #59 was complaining of stomach pain and headache. LPN #5 indicated she administered PRN Tylenol with relief. There was no indication LPN #5 assessed the severity of Resident #59's pain prior to and after the administration of the PRN Tylenol. Registered Nurse (RN) #58 noted at 10:04 a.m. on 07/22/14, Resident #59's attending physician was in the facility and notified of Resident #59's complaints of pain in her left side. There was no indication the physician assessed Resident #59 and he provided no new orders on that date. At 7:35 a.m., RN #59 telephoned Resident #59's health care decision maker and obtained permission to send Resident #59 out to the ER if the physician requested. RN #59 noted, at 7:45 a.m. on 07/23/14, Resident #59 was moaning and complaining of severe abdominal pain. RN #59 assessed the resident as having severe abdominal pain, rated a 10 (ten) plus on a scale of 0 - 10 with zero (0) being no pain and ten (10) being the worst. RN #59 noted a .large protrusion noted at the umbilicus (navel) area warm/tender to touch. At 9:41 a.m. on 07/23/14, RN #58 noted Resident #59 was sent to the ER for abdominal pain. The resident remained at the facility for nearly two (2) hours, until 9:41 a.m. on 07/23/14, at which time she left the facility via ambulance. During the two (2) hours she remained at the facility, she received no treatment for [REDACTED].#59 at 7:45 a.m. Review of Resident #59's MAR for 07/23/14 found no pain medications were administered to Resident #59. There was no further mention of the resident's ventral hernia found in subsequent nursing entries. j. 07/30/14 Resident #59's MAR indicated [REDACTED]. 2. August 2014 Review of Resident #59's medical record for August 2014 found the resident received ordered as needed pain medication and/or complained of pain on the following instances. Again, unless otherwise noted, there was not assessment of the location, nature, or severity of her pain and no assessment of the effectiveness of the medications. There were no non-pharmacological interventions identified. a. 08/07/14 LPN #20 noted a 5:10 a.m. on 08/07/14 that Resident #59 awoke and requested to go the ER for abdominal pain. At 5:23 a.m. on 08/07/14, LPN #20 noted Resident #59's healthcare decision maker was notified of Resident #59's complaint of abdominal pain and was advised Resident #59 was medicated with her as needed pain medication. LPN #20 noted the healthcare decision maker would prefer to give the medication time to work and if the resident continued with complaints of pain to call him back and he would come and talk with the resident. LPN #20 noted she explained the conversation to Resident #59 who was not happy with her brother's decision. Review of Resident #59's MAR found she was medicated with [MEDICATION NAME] 5/325 mg on 08/07/14. There was no indication LPN #20 assessed the severity/intensity of Resident #59's prior to administration of the as needed pain medication. There was also no evidence to suggest LPN #20 reassessed the resident after the PRN pain medication was administered and had time to be effective, as the resident ' s brother had requested. b. 08/15/14 Resident #59's MAR indicated [REDACTED]. c. 08/19/14 Resident #59's MAR indicated [REDACTED]. d. 08/20/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. It should be noted this administration note was linked to the administration of [MEDICATION NAME] 5/325, but [MEDICATION NAME] 5/325 was not administered on that date. There was no indication the nurse who administered this medication assessed the resident's pain for severity/intensity prior to administering the PRN Tylenol, and there was no indication the nurse reassessed the the resident to determine if the PRN medication was effective. e. 08/21/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. f. 08/24/14 Resident #59's MAR indicated [REDACTED]. g. 08/26/14 Resident #59's MAR indicated [REDACTED]. An administration note on the MAR indicated [REDACTED]. An additional administration note on the MAR indicated [REDACTED]. h. 08/28/14 to 08/30/14 Resident #59's MAR indicated [REDACTED]. i. On 08/20/14, 08/21/14, and 08/26/14 it was noted Resident #59 complained of bilateral lower extremity pain. There was no evidence to suggest the facility made any attempts to determine the cause of the pain in her bilateral lower extremities, nor evidence to suggest the attending physician and/or healthcare decision maker were notified of her bilateral lower extremity pain. 3. September 2014 Review of Resident #59's medical record for 09/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 09/01/14 Review of Resident #59's MAR for 09/01/14 found she was administered her PRN [MEDICATION NAME] 5/325 on 09/01/14. b. 09/03/14 - 09/08/14 On 09/03/14 at 3:43 a.m. LPN #60, noted Resident #59 received her PRN pain medication twice that shift for complaints of abdominal pain. LPN #60 noted Resident #59 had a bowel movement and her bowels sounds were present in all four (4) quadrants. On 09/04/14 at 1:43 a.m. LPN #60 noted Resident #59 had complaints of abdominal pain and was given PRN pain medication. On 09/05/14, Resident #59's MAR indicated [REDACTED]. On 09/06/14 at 5:11 p.m., LPN #5 noted Resident #59 was calling out from her bed stating, My belly is going to bust. LPN #5 noted the resident had received her PRN pain medication. There was no evidence to suggest LPN #5 assessed the severity of Resident #59's pain prior to administering the PRN pain medication, nor did she reassess her pain for severity to determine if the PRN pain medication was effective. On 09/07/14, Resident #59's MAR indicated [REDACTED] On 09/08/14 at 10:38 a.m., RN #61 noted Resident #59's attending physician was in to evaluate why Resident #59 had been complaining of abdominal pain and crying. He ordered to obtain a KUB to check for ileus disease. Further review of the record found this testing was obtained and ileus disease was not diagnosed . Additionally, on 09/08/14 Resident #59's MAR indicated [REDACTED]. Dhe received a second dose of PRN [MEDICATION NAME] at 1:36 p.m. on 09/08/14, for complaints of pain to the right side accompanied by crying On 09/09/14 at 2:24 a.m., Resident #59's MAR indicated [REDACTED]. It should be noted this information was contained in the Administration notes on the MAR; however, the dosage of [MEDICATION NAME] 5/325 was not initialed as given on the MAR. Resident #59 had complaints of pain to the abdomen and/or right side daily from 09/03/14 through 09/08/14, there was no evidence to suggest Resident #59's attending physician was notified of her daily pain until the morning of 09/08/14. There was also no evidence to suggest Resident #59's healthcare decision maker was made aware of her daily complaints of pain. c. 09/19/14 - 09/21/14 Review of Resident #59's MAR indicated [REDACTED]. The source of Resident #59's pain was only identified on one (1) of the three (3) days she received the PRN pain medication. On 09/21/14 the location of Resident #59's pain was identified as being in the abdomen d. On 09/19/14 and 09/20/14 there was no evidence to suggest Resident #59's pain was assessed for location, nature, and severity before the administration of medication and/or the effectiveness of the pain medication after administration. On 09/23/14 at 12:26 a.m. LPN #20 noted Resident #59 had some complaints of leg discomfort and was medicated with her PRN pain medication. She additionally noted that the Resident was screaming and keeping the residents on the hallway awake. LPN #20 noted there was no reasoning with the resident. At 12:46 a.m. LPN #20 noted resident continued to scream and was now complaining of shortness of breath even though her oxygen saturation was in the upper 90's. LPN #20 again noted she was unable to reason with the resident. At 1:00 a.m. LPN #20 noted she heard Resident #59 screaming as she has been since 12:30 a.m Upon entering Resident #59's room LPN #20 observed the resident laying in the floor beside her bed. LPN #20 indicated she had slid off the bed and continued to yell and scream. She again noted she was unable to reason with Resident #59. At 1:45 a.m. LPN #20 noted Resident #59 continued to yell and scream and disturb the other residents. She again indicated she was unable to reason with the resident. She noted the resident was screaming at staff instead of speaking to them in a normal tone. There was no mention by LPN #20 that she reassessed Resident #59 for pain after administering the PRN pain medication at 12:26 a.m., despite the fact Resident #59 continually screamed, yelled, and even slid off her bed. LPN #20 also failed to assess the severity of the Resident #59's pain prior to administering the PRN pain medication. At 8:18 a.m. on 09/23/14, LPN #5 noted she had spoken with Resident #59's healthcare decision maker and notified him about the resident sliding off the bed. She noted the resident's health decision maker indicated he and his wife would be in later today to speak with the resident about her behaviors. Resident #59's MAR indicated [REDACTED]. e. 09/26/14 to 09/28/14 Resident #59's MAR indicated [REDACTED]. Beginning on 09/15/14 the facility implemented a new pain observation tool. Nursing staff were to observe and/or question for pain every four (4) hours and PRN while awake. The documentation on this tool was inconsistent with the documentation contained in the rest of Resident #59's medical record. The documentation on this tool was reviewed and found Resident #59 was positive for pain on 09/16/14, 09/21/14, 09/22/14, 09/23/14, and 09/27/14. It should be noted Resident #59 was not medicated for identified pain on 09/16/14 and 09/22/14. Additionally, it should be noted that on 09/19/14, 09/20/14, 09/24/14, 09/26/14, and 09/28/14 Resident #59 was given PRN pain medication, but the pain observation tool was marked to indicate she was not having pain. Review of Resident #59's medical record for October 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 4) October 2014 a. 10/01/14 - 10/02/14 At 11:00 a.m. on 10/01/14 RN #49 noted that Resident #59 was complaining of abdominal pain at her hernia site. She noted her PRN pain medication had been administered about five (5) minutes prior to Resident #59's complaints. RN #49 noted the resident complained the pain medication was not helping her pain. RN #49 applied a warm compress to the abdomen and attempted to reach the resident's health care decision maker. RN #49 then spoke with the resident about waiting until her attending physician was able to visit to review her pain medication regimen before they sent her to the emergency room . RN #49 noted Resident #59 was in agreement with this plan. Review of Resident #59's MAR found she received a PRN dose of [MEDICATION NAME] on that date At 9:55 a.m. on 10/02/14, RN #41 noted Resident #59's attending physician was in and reviewed her pain medication regimen. The physician wrote a new order for [MEDICATION NAME] 5/325 as needed every four (4) hours instead of every six (6) hours. The physician also added a scheduled dose of [MEDICATION NAME] 5/325 three times a day at 10:00 a.m., 2:00 p.m. and 10:00 p.m. Resident #59 began receiving this routine scheduled dose of [MEDICATION NAME] at 10:00 a.m. on 10/02/14. b. 10/04/14 to 10/07/14 At 10:54 a.m. on 10/6/14, LPN #5 noted Resident #59 had constant complaints of her side hurting. LPN #5 indicated the resident had been medicated by the medication nurse. She noted she had spoken with Resident #59's health care decision maker and he did not want the resident sent out of the facility. LPN #5 noted that the healthcare decision maker stated, every time she is sent out they always send her right back because nothing is ever wrong with her. The health care decision maker stated he would come in and talk to the resident that day. LPN #5 noted Resident #59 was not happy about her brother not wanting her sent out of the facility. There was no mention of assessments to determine the severity of the pain Resident #59 was experiencing, or assessments to determine if scheduled doses of pain medication were effective in order to determine if resident needed to be medicated with the PRN [MEDICATION NAME] for which she had an order. Additionally there was no testing and or evaluations completed by facility staff to determine the cause of Resident #59's pain. At 2:54 p.m. on 10/06/14, LPN #62 noted Resident #59 had shown a decrease in the volume of complaints and she was administered pain medication for continued complaints of stomach pain. At 10:39 p.m. on 10/06/14, LPN #7 noted Resident #59 was guarding her stomach and crying in pain and she had done so for the last two (2) nights. She noted bowel sounds were present, were hypoactive in all four (4) quadrants, abdomen was distended in right lower quadrant and tender to touch. LPN #7 noted Resident #59 screamed in pain when she was turned on her stomach. She noted Resident #59 was medicated with scheduled [MEDICATION NAME] one (1) time that shift. She noted she had requested a physician evaluation for pain. There was no evidence in the medical record of Resident #59 to indicate she was having pain in her abdomen and guarding her stomach on 10/04/14 or 10/05/14 as indicated in the 10/06/14 entry by LPN #7. LPN #7's note on 10/06/14 was the first mention of Resident #59's pain which she had experienced on the previous two (2) nights. There was no evidence to suggest Resident #59's pain was assessed for severity and/or relief of pain upon administration of scheduled pain medication on 10/04/14 and 10/05/14, in order to determine the need for PRN pain medication, which was not administered at all on 10/05/14. There was no indication nursing staff assessed Resident #59 to determine the cause of her continued pain in her abdomen. LPN #7 noted she had requested the physician evaluate the resident for pain, but there was no indication nursing staff had called Resident #59's attending physician to notify him of her continued abdominal pain. The heath care decision maker was not made aware of Resident #59's complaints of pain on 10/04/14, 10/05/14 and 10/06/14 until LPN #5 phoned him at 10:54 a.m. on 10/06/14. Resident #59 received a dose of her PRN pain medication on 10/04/14 and 10/06/14. At 8:34 a.m. on 10/07/14, LPN #5 noted Resident #59 was being combative and yelling out at staff. She noted the medication nurse tried to give the resident her pain medication for her complaint of stomach pain and the resident refused stating, You all are not helping me, I want the police. She noted she explained to the resident they were trying to help her, but she would not let them. Resident #59 proceeded to kick over the bedside table and continued to yell out. LPN #5 noted she called the health care decision maker and he would be at the facility shortly to calm the resident down. At 8:46 a.m. on 10/07/14, LPN #5 noted Resident #59's brother was at the facility to see her. At 8:54 a.m. 10/07/14, LPN #5 noted the resident's brother wanted her sent to the ER for an evaluation. At 9:20 a.m. on 10/07/14, LPN #5 noted the resident was transported to the ER at 9:20 a.m. on 10/07/14. At 5:46 p.m. on 10/07/14 LPN #5 noted Resident #59 returned to the facility from the ER with [DIAGNOSES REDACTED]. Resident #59 had made multiple complaints of abdominal and side pain beginning 10/04/14 through 10/07/14. The facility failed to assess for the cause of the pain, failed to treat the pain effectively, and failed to assess for the severity of the pain prior to and after administration of PRN pain medications on 10/4/14 and 10/06/14. Staff also failed to assess for the effectiveness of her scheduled pain medication to determine if she needed further medicated with the PRN doses [MEDICATION NAME] to control her pain. Additionally, they failed to notify the attending physician of the continual complaints of pain, and failed to notify the healthcare decision maker of her complaints of pain until 10/06/14. This resulted in Resident #59 suffering undue pain as well as mental anguish. On 10/07/14 Resident #59 was noted to be combative with staff and was noted to state, You all aren't helping me, I want the police. Resident #59 had at that point endured pain for three (3) consecutive days and felt as if the facility staff was not helping her. It was not until her brother arrived at the facility and requested she be sent to the ER that Resident #59 was sent out of the facility for treatment for [REDACTED]. The facility was unable to show any evidence of attempts to manage and control her pain at the facility. They made no attempts to determine the cause pain and/or to treat the cause of the pain. b. 10/10/14: Resident #59's MAR indicated [REDACTED]. c. 10/16/14: Resident #59's MAR indicated [REDACTED]. Review of Resident #59's pain observation tool found the resident was identified as having pain on 10/04/14, 10/06/14, 10/08/14, and 10/13/14. Please note this report was again inconsistent with the rest of Resident #59's medical record. She was identified as having continual pain from 10/04/14 through 10/07/14 in the nursing progress notes, she received a PRN dose of [MEDICATION NAME] in addition to her scheduled pain medications on 10/10/14 and 10/16/14 and was identified as not having pain on these dates on the pain observation tool. Additionally, the pain observation tool identified she had pain on 10/08/14 and 10/13/14 with no mention of the pain in the progress notes or administration of any pain medication other than her scheduled [MEDICATION NAME] 5/325 three (3) times a day. This tool was ineffective in identifying when Resident #59 experienced pain. Review of Resident #59's medical record for 11/2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: 5) November 2014 a. 11/12/14: Resident #59's MAR indicated [REDACTED]. b. 11/16/14: Resident #59's MAR indicated [REDACTED]. c. 11/21/14: Resident #59's MAR indicated [REDACTED]. d. 11/28/14: Resident #59's MAR indicated [REDACTED]. h. Review of Resident #59's pain observation tool for the month of November 2014 again found inconsistent documentation between the pain monitoring tool and the MAR. Resident #59 received PRN pain medication on 11/12/14, 11/16/14, 11/21/14, and 11/28/14. The pain observation tool indicated Resident #59 was negative for pain on all of these dates. 6) December 2014 Review of Resident #59's medical record for December 2014 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 12/08/14: Resident #59's MAR indicated [REDACTED]. b. 12/09/14: Resident #59's MAR indicated [REDACTED]. c. 12/22/14: Resident #59's MAR indicated [REDACTED]. d. 12/28/14: At 10:14 a.m. on 12/28/14, LPN #36 noted that Resident #59 had poured water on herself multiple times to get the staff to change her pants. She noted Resident #59 was complaining that her pants were too tight. LPN #36 noted, she told the resident her pants were not too tight and to quit being disruptive. She advised the resident that the nurse aides were busy feeding and bathing other residents and that she could not keep pouring water on herself just to get changed. LPN #36 then noted Resident #59 began to complain of stomach pain and nausea. She indicated she gave Resident #59 a [MEDICATION NAME] shot and the resident was noted to be resting about 30 minutes after the shot. There was no indication in Resident #59's medical record that LPN #36 had assessed the resident for pain upon her complaints that her pants were too tight. There was no mention of pain until after the staff had changed the resident's pants on several occasions and after LPN #36 had advised Resident #59 that she was being disruptive. At that time, Resident #59 mentioned pain when she complained of pain in her stomach. Once the resident complained of pain, LPN #36 failed to assess the severity of the pain and/or the possible causes of the stomach pain. LPN #36 proceeded to treat the complaints of nausea, but failed to assess and/or treat Resident #59's complaints of stomach pain. This note was entered into the medical record at 10:14 a.m., which was 14 minutes after Resident #59 had received her scheduled dose of [MEDICATION NAME]. LPN #36 failed to assess the severity of Resident #59's pain did not assess the effectiveness of the resident ' s scheduled pain medication to determine if a PRN dose [MEDICATION NAME] was needed. Resident #59 was not administered her PRN [MEDICATION NAME] on 12/28/14. e. 12/30/14: Resident #59's MAR indicated [REDACTED]. 7) January 2015 Review of Resident #59's medical record for January 2015 found the resident received ordered PRN pain medication and/or complained of pain on the following instances in which her pain was not effectively assessed and/or monitored: a. 01/18/15: Resident #59's MAR indicated [REDACTED]. b. 01/31/15: Resident #59's MAR indicated [REDACTED]. 8) February 2015 For the month of February 2015, Resident #59 received no doses of her PRN pain medication. Additionally, Resident #59 had not voiced any complaints of pain except on 02/09/15. On 02/09/15, Resident #59 complained of abdomin",2018-03-01
6623,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2014-08-20,224,D,0,1,R6QV11,"Based on observation, staff interview, family/responsible party interview, and record review, the facility failed to ensure two (2) of twenty-two (22) sample residents were free from neglect. The residents were not provided necessary services to avoid physical harm and/or mental anguish. Each resident was left unattended for lengthy periods of time. Both experienced incontinence episodes during the time staff neglected to check on them and/or otherwise provide for their needs. Resident #25 was left in a shower chair for more than two (2) hours. Resident #21 was left in the dining room without repositioning and/or incontinence care for four (4) hours on one (1) occasion and more than five (5) hours on another occasion. Resident identifiers: #25 and #21. Facility census: #34. Findings include: a) Resident #25 A review of reportable allegations on 08/12/14 at 10:00 a.m., noted an allegation reported to state agencies by the facility's previous social worker. The initial complaint was dated 06/06/14 at 3:30-5:45 p.m. It indicated Resident #25 was returned to her room by the shower aide, Employee #29, a nursing assistant (NA), and left in the shower chair for the floor NA to care for her. According to the report, the resident required assistance of two (2) for transfers, Employee #64 (NA) could not find immediate assistance, went to lunch, and forgot about the resident. Resident #25 was found at approximately 5:45 p.m., by the unit clerk, Employee #22 (NA/ward clerk), still in her shower chair, totally exposed, and had urinated and defecated. According to the report, the allegation was reported on 06/09/14. It indicated an extension request was made because the allegation of neglect was not made in a timely fashion by staff. The report indicated the social worker was not notified until three (3) days after the incident occurred, when she arrived to work and discovered the complaint form under the door. An interview with the resident's responsible party, on 08/14/14 at 11:30 a.m., confirmed the resident was totally dependent upon staff for care. b) Resident #21 Observations on 08/12/14 during Stage 1 of the survey revealed the following: -- 8:10 a.m.: Resident #21 was observed seated alone at a table in the dining room, with his breakfast on the table in front of him. He was asleep in his chair. An incontinence pad was noted between the resident and the chair in which he was seated. The meal was observed in its entirety. Resident #21 was observed asleep throughout the majority of the meal, only waking briefly. He did not eat his breakfast. Observation revealed staff had no interaction with the resident, other than speaking when his breakfast was placed on the table in front of him. No attempts to awaken the resident or prompt him to eat were observed. -- 9:35 a.m.: Resident #21 was again observed alone, sleeping at the table while sitting up in his chair. -- 10:30 a.m.: Resident #21 was again observed alone, sleeping at the table while sitting up in his chair. -- 11:30 a.m.: Resident #21 was again observed alone, sleeping at the table in the dining room while sitting up in his chair. -- 12:00 p.m.: Resident #21 was again observed alone at the dining room table. He was awaken by staff when they placed his meal tray on the table in front of him. 2. At 6:15 p.m. on 08/12/14, Resident #21 was observed during the evening meal. He was asleep in his chair at the table. On 08/12/14 at 6:30 p.m., an interview was conducted with the resident's wife. She was seated beside Resident #21, who was sleeping while seated in the chair at the dining room table. She voiced a concern, stating, I think he is too sleepy, and I am afraid that when I am not here, he does not get prompted enough to eat. At 8:40 p.m. on 08/12/14, Resident #21 was observed still asleep at the dining room table. His pants were visibly wet, as was the incontinence pad on which he was seated. Employee #14, a nursing assistant (NA) was in the dining area at the time of this observation. Upon inquiry, Employee #14 verified she was the NA assigned to provide care for Resident #21. She verified the resident had been in the dining room area since she came on shift at 3:00 p.m. She stated prior to dinner, he had been sleeping in a recliner, in the back part of the dining/activity room, with his wife at his side. Upon inquiry, the NA said he had not been toileted, or provided incontinence care, for the duration of her shift. She acknowledged she was aware the resident had been sleeping at the table since the evening meal. Employee #14 said she had been so busy this shift with all the residents on the back hall, she had not gotten to him yet. Employee #14 said Resident #21 required the assistance of two (2) for transfers and toileting. At this time, the NA asked another staff member to help assist her with transferring the resident into a wheelchair. 3. On 08/12/14 at 8:45 p.m., the DON was informed of the observations regarding Resident #21. She was made aware of the resident's visible incontinence and that he was left asleep in a chair at a table in the dining room. The DON was informed that at 8:30 p.m., Employee #14 admitted she had not provided toileting or incontinence care for Resident #21 since she came on shift at 3:00 p.m. that day. The DON responded by saying she had been in her office most of the day, and had not noticed the resident had been in the dining room asleep all day. At 9:00 p.m. on 08/12/14, the DON said Employee #14 had just told her she believed the resident had spilled something, and that it was not urine. At that time, an observation was made with the DON. The resident was still wearing the pants he was wearing during the observation at 8:40 p.m. The pants were observed wet in the crotch area, on both sides around the seat of the pants, as well as both hip areas. Upon observation of the resident's pants, the DON said, Yes, they are wet, I won't argue on it. Upon further inquiry, the DON was asked if the resident should have been toileted, provided incontinence care, and repositioned during the shift, to which she said, Yes, he should have. 4. On 08/13/14 at 2:00 p.m., Resident #21 was observed in a recliner asleep in the back section of the dining room. The resident's wife was sitting beside him. She said she feels like he was ignored. She said he was usually in the dining room anytime she visited at varying times of the day. She said she watched staff take care of the other residents, leaving him for last. She said she did not know why that was, and it worried her. She reported that while she was there visiting, it was rare for staff to ask if he wanted a between meal drink or for them to reposition him. She said after dinner was when she felt it was the worst. She stated she had voiced concern over his being alone. When asked if he had spilled anything the night before while she was there, she said he spilled a little bit of coffee on his left side. She said the clothing protector got most of it, but a little ran on the left side of his pant leg. She said she told a staff member he had spilled a little coffee on the left side of his pant leg before she left the facility for the night a little before 8:00 p.m.",2017-12-01
6734,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2013-11-13,224,E,0,1,IQK011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review, and policy review, the facility failed to ensure each resident was free from mistreatment. The facility failed to develop and implement policies and interventions which addressed a resident whose personal history and current behaviors indicated he was at risk for abusing other residents. This included a failure to implement their own abuse policies and procedures. Residents in the facility expressed they felt fearful for themselves and others in the environment in which they lived. The residents suffered from physical abuse, mental abuse, verbal abuse, and had the potential to suffer from sexual abuse. The failure to protect residents from abuse affected three (3) sample residents and one (1) resident identified through a random opportunity for identification. This practice had the potential to affect more than an isolated number of residents residing in the facility. Resident identifiers: #5, #87, #66, # 83, and #145. Findings include: a) Resident #5 During an interview with the Resident Council President (Resident #5) on 11/06/13 at 10:00 a.m., he immediately stated to the surveyor upon entering his room, I guess you know about the big problems we have here. When told the survey team was not aware of a big problem, he said, Well everyone knows about it. The resident stated there was a resident (he named Resident #145) of whom people were afraid. Resident #5 said, He is beating people up. He said he was not aware of anyone being hurt yet, but Resident #145 had grabbed him and other people. He stated if something was not done about this man, he was afraid one of the helpless residents who can't defend themselves will be hurt. Resident #5 said Resident #145 was admitted after the last council meeting, but everyone had been talking about it and something needs to be done. When asked if he had talked to any of the staff, he stated, Yes, the administrator and the nurses. He stated the resident wandered into everyone's rooms at night and used cuss words that you should not have to listen to. Resident #5 reiterated he was afraid if something was not done, Resident #145 was going to hurt someone. He said the ladies got upset with Resident #145's language and they should not have to be exposed to the things he says to them. Resident #5 said he rings his light when he comes in his room, but worries about the residents who are helpless and not able to yell for help. He stated Resident #145 Was walking and grabbed him from behind while he was in his wheelchair and twisted his arm. b) Resident #87 During an interview on 11/06/13 at 11:05 a.m., Resident #87 stated Resident #145 was inappropriate. When asked if she felt afraid, she stated, Yes, everyone is. Resident #87 referred to Resident #145 as mean. She said he came in her room one night and sat on her bed and it scared her. She said none of the residents want him around because they are afraid of him. Resident #87 said there were three (3) ladies who have a snack together every night whom the resident bothers. She said, Something should be done. When asked if Resident #145 made her feel her environment was not safe, she stated Yes. c) Resident #83 During an interview with Resident #83, on 11/05/13 at 1:00 p.m., he said, A resident on C hall is mean. The girls are afraid of him. He identified girls as staff. The resident said he did not know the individual's name, but knew the resident resided on C hall. He said the resident would Push people up the hall, and when the staff tried to stop him, he threw staff against the wall and twisted their arms. Resident #83 said the resident had put a staff member in the bathroom, locked the door and would not let him out. He added, It isn't right. He is mean and someone could get hurt. During another interview on 11/06/13 at 11:00 a.m., Resident #83 identified the resident he described as Resident #145. d) Resident #66 An interview with Resident #66 on 11/05/13 at 8:30 a.m. revealed Resident #145 had entered her room, grabbed her foot, and asked, Do you want to do it? She said when she responded, Do it?, Resident #145 said, Do you want to f_ _ _? Resident #66 denied abuse, but said she is fearful for other residents who cannot protect themselves. During another interview on 11/06/13 at 11:05 a.m., Resident #66 said she could not remember the date or time of that incident because time runs together here. She reiterated the resident grabbed her foot while she was in bed and it startled her. She added, I don't like that dirty talk. e) Resident # 145 This resident's nursing notes were reviewed. These notes identified the resident was admitted in the evening at 17:45 (5:45 p.m.) on 10/18/13. It was noted his inappropriate behaviors toward others started the day after his admission. His notes were as follows: -- 10/19/13 - 04:40 - Resident pushing another resident in wheelchair into his room. Staff attempted to get resident and wheelchair from room. Resident began to get agitated and yell at staff. Staff members were able to get resident in wheelchair out of room. Neither resident or staff was injured. -- 10/19/13 - 05:41 - Staff members attempted to assist resident with toileting and resident became aggressive. Resident grabbed male CNA (certified nursing assistant) by the arm and wrist while yelling at him. After convincing resident to let the CNA go the resident then came out of the restroom and shut the door trying to hold the bathroom door shut with the CNA inside. Redirected the resident and took him for a walk with this nurse. Staff member denies any injuries. Will continue to observe. -- 10/19/13 - 16:33 - Resident has been wandering within facility. No attempt to exit noted. He has been generally pleasant but becomes agitated easily. Cursing and swearing at times. CNA report that resident went over to roommate in room and showed him his fist, saying 'I'll hit you!' then walked away. Will monitor closely. -- 10/19/13 - 18:45 Dr. In to see resident with new order noted for [MEDICATION NAME] 5 mg po (by mouth) daily for dementia. -- 10/20/13 - 16:12 - Night shift staff reported that resident was up during the night wandering in and out of rooms, pushing other residents in w/c (wheelchairs), yelling at other residents/staff etc. Resident has been resting in bed quietly much of the day. His wife sat with him at lunch. Resident appeared pleasantly confused. Will continue to monitor. -- 10/21/13 - 01:17 - Resident awake at this time. Standing by roommates bed yelling at him stating go to sleep! Assisted resident back to his bed. Will continue to observe. -- 10/21/13 - 18:42 - Resident exhibited wandering for most of the shift. Resident was redirected easily out of others rooms. -- 10/21/13 - 19:44 - Resident being very aggressive this evening. He grabbed a guests arm and attempted to pull her down the hall. RN (registered nurse) intervened and redirected resident. Resident has attempted to close the door when LPN (license practical nurse) was in the room and told her to get into his bed. He also attempted to get another resident into his room. Staff is monitoring frequently. -- 10/22/13 - 01:50 - Resident continues to be awake ambulating in the hallways. He is easily agitated with staff and other residents. Continuing to monitor. -- 10/22/13 - 05:17 - Resident has been awake all night. Physically aggressive behaviors noted. He has pushed staff and yelled down the hallways. He walks into other residents rooms trying to lay in other bed. Resident has been shown his bed and assisted to bed but gets back up in a few minutes yelling at staff. He attempted to pull his roommate out of the bed. Frequent monitoring continues. -- 10/22/13 - 07:16 - Resident very combative and refused medication. -- 10/22/13 13:21 - Resident refused a.m. care until 12:30 p.m. Resident has wandered all shift and he has been easy to redirect. Resident does get agitated around other residents at times. -- 10/22/13 - 14:51 - Attending physician notified via fax regarding behaviors since admission and current meds. Awaiting response -- 10/22/13 - 18:11 - Medication administration Note - Resident refused. I do not need a d_ _ _ shot. -- 10/22/13 - 22:50 - Resident very agitated and aggressive this evening. He continues to attempt to uncover his room mate and stated 'lets tear him apart'. He sneezed in the hallway and CNA (certified nursing assistant) said 'bless you' and resident responded with 'F_ _ _ you'. He has sexually inappropriate behaviors with staff. He has yelled out in the hallways and attempted to enter other rooms becomes very angry when staff is attempting to redirect. -- 10/23/13 - 06:56 Resident was assisted to bed around 2:00 a.m. and has slept well throughout the night. -- 10/23/13 - 12:04 - Resident has exhibited sexually inappropriate behaviors towards staff several times so far this shift. While CNA assisted resident with his a.m. care resident stated to CNA 'you want this. Come on touch it.' Resident was pointing to his penis while talking. The resident was educated about behavior. CNA was walking resident to the dining room for lunch. As resident walked by me at my med cart he grabbed my buttock and stated 'woo hoo'. I educated resident about behavior. Resident has made several comments when female staff entered his room. 'Come get in bed with me good looking. I wished you were in my bed. I can't wait to get you in my bed.' Will continue to observe. -- 10/24/13 - 02:04 - CNA assisted resident in to bed and resident stated 'You better not come in here with your pants off. I will stick it in you then feel you up and you will float like a balloon.' Spoke with resident about behaviors. Will continue to observe. -- 10/25/13 - 04:18 - Resident has made sexually inappropriate comments to the CNA this shift. Resident stated 'come on baby lay down with me.' Resident also has been trying to go into other female resident's rooms. Resident gets very agitated when staff tries to redirect him out of other resident's rooms and combative at times. This nurse tried to offer snack or to sit down this seems to help some with behaviors. -- 10/25/13 -16:17 - Resident has spent much of the day sitting near nurses desk calling out to staff and other residents saying 'Hey come here! You need some help? I got what you need' etc. No combativeness notes so far this shift. Will continue to monitor. -- 10/25/14 - 20:25 - Resident was in a female resident's room. When CNA went to try and get resident out of room resident jumped out of the wheelchair and begin to hit CNA. Wheelchair was in between resident and CNA. CNA denies any injuries. -- 10/26/13 - 05:12 - Resident entered the hall way and voided in the hall way. Staff guided him check him and lead him back to bed. The LPN (licensed practical nurse) mopped the floor. -- 10/26/13 - 12:49 - Resident exhibited verbal and physical aggression with staff during care. Resident refused his shower and all a.m. care. I knocked on residents door because his room mate had his call light on. As I knocked on the door the resident screamed out 'Don't be beating on my d_ _ _ door.' I explained to the resident I was knocking before entering out of courtesy. Resident yelled 'Get the h_ _ _ out of here before I knock your d_ _ _ head off.' When the staff took resident to the shower CNA started to assist resident remove his shirt and resident stated 'Don't take my p_ _ _ _ _ off. CNA tried to explain she was trying to assist him in taking a shower. Resident pushed CNA and stated 'you let me out of here or I will kill myself and you too.' Will continue to monitor. -- 10/27/13 - 05:29 - Resident wandered from room to room disturbing several residents until staff was able to get him in to bed. -- 10/27/13 - 10:59 - Medication administration note - Resident refused. 'Get those d_ _ _ things out of here. I don't take medicine.' -- 10/27/13 18:32 - Resident has exhibited wandering into other residents rooms, verbally and physically aggressive when staff attempt to redirect resident from other resident's rooms, sexually inappropriate by making comments to female staff during care 'You want to f_ _ _ me?' Resident has been educated throughout the shift regarding behaviors. Resident has also voided in roommates clothes hamper, and a plant in the front lobby and in his hallway. -- 10/28/13 - 01:50 - Resident stated 'I' d like to pat that a_ _ for 30 min . Your pretty, I really like to pat your a_ _ .' ' I got something I like you to massage' 'boy let me tell you what I'd like to pat that b_ _ _ Won't you let me pat it?' Staff politely declined. -- 10/28/13 -14:30 - Fax sent to Dr.(name) re: increased behaviors and review of home medications with resident previously on [MEDICATION NAME] 23 mg (milligrams) new order to increase [MEDICATION NAME] to 10 mg po (by mouth) daily. Call placed to MPOA (medical power of attorney). aware and agreeable to changes. -- 10/28/13 - 21:31 - Resident entered another resident's room this evening and family members were in there. Staff observed resident enter room and then observed resident attempt to grab a family member. Resident became very physically aggressive with staff when redirection was attempted. Staff attempted several times to calm resident down without success. Resident was in the hallway and walked past another resident in a chair and placed his hand on her forehead and shoved her had back. Resident was yelling and cursing at staff. Dr. was paged and a new order received for [MEDICATION NAME] 1 mg po (by mouth) times one dose. -- 10/29/13 - 01:24 - One time dose for [MEDICATION NAME] effective. Resident calmed down and was very pleasant after the medication administration. -- 10/29/13 08:42 - Resident exhibiting worsening behaviors at night with wife informing staff that he was [MEDICATION NAME] home due to his inability to sleep. Noted that the resident has increased aggression, inappropriate sexual behaviors, wandering, and exit seeking after he has been awake all day and worsens throughout the evening as he may become increasingly tired. fax sent Dr. (name) requesting trial dose of Ambien. Awaiting response. -- 10/29/13 - 20:55 - Resident had a bowel movement in roommates trash can and voided in the floor at his roommates bedside. -- 10/29/13 - 22:57 - Fax received from Dr. (name) to [MEDICATION NAME] mg by mouth at bedtime as needed. -- 10/29/13 - 22:57 - Resident was wandering throughout the facility this evening entering resident's rooms. He entered a resident's room on D-Hall and voided in his trash can at his bedside. Resident becomes very aggressive and agitated when staff attempted to redirect. Resident was refusing to lay down for the night and continued wandering. New order [MEDICATION NAME] bedtime noted and administered to resident. Resident assisted to bed shortly after and is currently resting in bed quietly with eyes closed. Call light within reach. Routine toileting and safety checks continue. -- 10/30/13 - 17:46 - multiple episodes of inappropriate sexual behavior this shift i.e., following staff into rooms making sexual comments. No physically aggressive or combative behaviors noted. -- 10/30/13 - 20:05 - Resident grabbed another resident's wheelchair from behind. When the resident turned to see who had hold of his chair resident cursed him, grabbed his wrist and attempted to hit resident without success. -- 10/30/13 e 23:09 - Received order per Dr. (name) for [MEDICATION NAME] 0.5 mg po (by mouth) for behaviors. Pharmacy noticed. POA (power of attorney) to be notified in the a.m. -- 10/31/13 e 15:15 - Care Plan Meeting Note - Initial Review: Current weight is 187. Is on LCS (low concentrated sweets) Is in use of wander guard for resident's safety. Has had noted physical and verbally aggressive behaviors. At times difficult to redirect. Wife visits often. Has notified staff that he has had increased trouble sleeping over the past few years. At this time resident is expected to have long term placement in facility. -- 10/31/13 - 18:06 - yelling at roommate. Wandering in rooms. -- 11/01/13 - 11:05 - Social Service Note - Resident is in-capacitated. No plans for discharge and resident remains appropriate for placement. His family is supportive and visits on a regular basis. Resident's wife was appointed Health Care Surrogate. Care plan developed regarding resident impaired cognition, wandering and disruptive behaviors. Continue to follow up as needed. -- 11/01/13 - 14:16 - Refused a.m. care, verbally aggressive with care, wandering. -- 11/01/13 - 10:04 - Resident exhibited refusing a.m. care, wandering into other residents rooms, verbally aggressive with staff when staff attempts to divert resident from other residents rooms. -- 11/02/13 - 5:47 a.m. - Resident aggressive with staff members, attempted numerous times to hit staff. Resident went into female residents rooms and became aggressive when staff attempted to redirect. -- 11/02/13 - 17:07 - yelling at staff and other residents. Resident attempted to wheel a female resident into his room. This nurse was able to remove female. Will continue to observe. -- 11/03/13 - 00:03 - Resident went in to every resident and staff trying to sell a box of tissues. When they wouldn't buy them he would cuss and move on some times becoming difficult. After he gave up on the tissues he patted the lpn (Licensed Practical Nurse) on the back side and stated I would pat that for an hour. Do you like that? The staff told him no and removed his hand from their bottom. -- 11/03/13 - 19:49 -[MEDICATION NAME] mg by mouth administered per order. 1/2 Tablet. -- 11/03/13 - 20:12 - Family member of residents in another room (named room number) came to this nurse and said this resident was in room (named room) trying to get into the bathroom to use the toilet. Upon entering room, found resident sitting on the trash can in the room (not in the bathroom) having a bowel movement. Attempted to assist the resident by offering my hand to help him stand. Told the resident we needed to go to his room to get cleaned up et (and) resident started swinging his fist yelling saying 'I am trying to s_ _ _ '. Explained to the resident that he needed to go to his room and use his toilet and not the trash can and the resident stated 'I don't give a d_ _ _ what you say. I have to s_ _ _ and I am S _ _ _ _ _ _ _ right here.' This nurse went to side 2 (two) to get the CNAs who work with this resident to see if they could assist him back to his room. CNAs X's (times) 2 (two) came to the room and ask resident if they could help him get cleaned up. Resident was compliant with CNAs letting them assist him back to his room. Room (number named) was cleaned up at this time. -- 11/03/13 - 23:05 - Resident attempting to get into female resident's room. When CNA attempted to redirect resident, resident told CNA 'I am going to knock you on you a _ _ .' -- 11/04/13 - 08:40 - [MEDICAL CONDITION] med (medication) assessment [MEDICATION NAME] 0.5 mg BID (twice a day). Comments: Resident was started on the medication r/t (related to) inappropriate behaviors. See behavior notes in behavior folder. Will observe for adverse effects and effectiveness of medication. -- 11/04/13 - 14:03 - Verbal aggressive with care. -- 11/04/13 - 22:40 - Resident being sexually inappropriate towards staff and other residents. Threatening to hit staff and other residents. Cussing -- 11/05/13 - 13:35 Verbally aggressive with staff during care, wandering into other residents rooms. -- 11/05/13 - 18:46 - Resident exhibited verbal aggression towards staff during care. 'If you don't get out of here I will kill you. I will kill myself too with an axe and a knife' .CNA (certified nursing assistant) waited aprox. 30 min for resident to calm down then performed a.m. care. -- 11/06/13 - 00:34 - Resident was wandering within the facility this evening. He was entering other residents rooms and became aggravated when staff attempted to redirect. Resident is physically aggressive with staff. f) Employee #34 (nursing assistant) was interviewed at 11:00 a.m. on 11/06/13. It was verified she was the regular caregiver for Resident #145. She also verified most of his behaviors happened in the evenings after she was gone but the resident was combative with them sometimes. She was asked if she had ever heard other residents on that hall verbalize concerns of being afraid of Resident #145. Employee #34 said she heard some of the ladies talk about being concerned with Resident #145. When asked for the names of female residents on that hall who voiced concerns, she identified Residents #87 and #66. g) During an interview with the director of nursing (DON) at 11:30 a.m. 11/06/13, she was asked for the facility's incident and accident reports. The DON provided three (3) months of reports, and verified these were all of the reports. She was asked if there were any incident reports for the incidents identified in the notes (as listed above) of Resident #145. She verified there was only one (1) report for him, and it was dated 10/28/13. Review of the incident report revealed it was related to a fall on 10/28/13. There were no other incident reports Resident #145. The DON verified there were some incidents that required an incident report, but were not completed. When asked about Psychiatric Services for this resident, the DON verified Resident #145 had not had a Psychiatric evaluation since his admission. h) The facility's policy and procedure titled, Abuse Prevention Policy and Procedure, dated 2012, was provided by the DON on 11/06/13 at 2:30 p.m. Review of the policy revealed the following: 1. Policy Statement This facility shall not condone any acts of resident mistreatment, neglect, verbal, sexual, physical and/or mental abuse, corporal punishment, involuntary seclusion or misappropriation of resident property by any facility staff member, other residents, consultants, volunteers, staff of other agencies service the residents, family members, legal guardians, friends or other individuals. Though it cannot guarantee that such occurrences will not occur at this facility, preventative steps will be taken to reduce the potential for such occurrences. The facility did not take preventative steps for the occurrences of verbal, sexual, mental, and potential physical abuse of residents by Resident There was no evidence the facility identified the abusive behaviors Resident #145 inflicted on others, or established a plan to protect others from the abuse. Even though this resident was confused and did not have capacity, the other residents in the facility suffered from his abusive behaviors. The facility failed to identify the negative impact this had on the residents and their environment. i) The facility's policy also stated in Section 5: Resident to Resident abuse Policy: 5.1. If a resident -to- resident incident occurs, staff should intervene immediately. Separate the resident and take them to areas away from each other until the situation has diffused. 5.9. If the residents are roommates and cannot get along, notify family /guardian etc. of the need for a room change. Temporarily separating the residents until this process can be completed may be necessary to avoid further altercations. There were four (4) documented occurrences with this resident and his roommate, who was also confused. There was no evidence the roommate initiated or participated in the incidents in which Resident #145 was abusive to him. --On 10/19/13 16:33 Resident #145 went over to his roommate in his room and showed him his fist saying, I'll hit you. Resident #145 then walked away. The nursing note said will continue to observe. There was no evidence this was monitored or the resident was removed from the room. --Another occasion was on 10/21/13 at 01:17. Resident #145 was standing by his roommate's bed yelling at him. According to the nursing notes, the resident was assisted back to his own bed in the same room. The note stated Will continue to observe. --On 10/22/13 at 05:17, Resident #145 had physically aggressive behaviors of pushing staff. He was shown his bed, but continued to get back up in a few minutes. He attempted to pull his roommate out of the bed. According to the note, frequent monitoring continued; however, there was no evidence a monitoring system was in place. In addition, there was no evidence the residents were separated to areas away from each other. --Another occasion was on 10/22/13 at 22:50. The nurse's note indicated Resident #145 continued to uncover his roommate and stated Let's tear him apart. There was no evidence the facility followed their policy to separate the residents or provide interventions to prevent Resident #145 from harming his roommate or other residents. Resident #145 was ambulatory and his roommate was not ambulatory. There was more of a potential for harm, as the roommate was less capable of protecting himself when the residents were left alone and in the room together. j) Section 5.6 of the abuse policy stated, Complete all necessary documentation for reporting the incident. During a review of the incident reports from the time of this resident's admission on 10/18/13 to 11/06/13, there were no incident reports found regarding the abuse related incidents described in the nurses' notes during the same time period. The only incident report found was for a fall which occurred on 10/28/13 at 08:45. There were multiple incidents in which this resident was involved, yet no incident reports were completed. k) Section 5.8 of the abuse policy stated, All incidents are to be documented in the resident's medical record with intense monitoring to continue for at least 72 hours. The resident's care plan is to be updated to reflect interventions to reduce the risk of reoccurrence of this behavior. There was no evidence an intense monitoring plan was developed. In addition, there was no evidence the resident's care plan was updated to reflect interventions in an attempt to reduce the risk of reoccurrence of this resident's behaviors. l) Section 6, titled Reporting /Investigation/Response Policy stated Any complaint, allegation, observation, or suspicion of resident abuse, mistreatment or neglect, whether physical, verbal, mental, or sexual, involuntary or voluntary, is to be reported, thoroughly investigated and documented in a uniform manner as detailed below: Reporting- All employees are required to immediately notify the administrative or nursing supervisory staff that is on duty of any complain, allegation, observation, or suspicion of resident abuse, mistreatment or neglect so the resident's needs can be attended to immediately and investigation can be undertaken. Nursing notes, dated 10/28/13 at 21:31, stated Resident #145 entered another resident's room and the family members were in there. Staff observed the resident attempt to grab a family member. The resident then became very physically aggressive with staff when they attempted re-direction. Staff attempted several times, without success, to calm down the resident. The resident was in the hallway and walked past another resident in a chair. He placed his hand on her forehead and shoved her head back. Resident #145 was yelling and curing at staff. The physician was paged and made aware of the situation. A new medication order was received for [MEDICATION NAME] 1 mg x (times) one (1). Although the resident pushed another resident's head back and there was physician intervention, this incident was not identified as abuse or reported to the state agencies. During an interview with the DON, on 11/12/13 at 2:00 p.m., it was verified the facility did not do incident reports unless there was a fall or an injury. She was asked about the process for monitoring situations to identify if a resident has abusive behaviors that are impacting other residents's living environment. The DON stated the 24 hour report was pulled up daily and behaviors could be reviewed daily by the social worker. The Social Worker (Employee #71) was interviewed on 11/12/13 at 3:00 p.m. She confirmed there had not been any incidents related to behaviors reported for Resident #145. She reviewed the reporting policy, and stated the only time there was a requirement to report to state agencies was if there was physician intervention. She stated she was not aware of any incident requiring physician intervention involving this resident.",2017-11-01
6778,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-06,224,D,1,0,1Q9011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, and review of the facility's abuse policy, the facility failed to ensure two (2) of five (5)residents reviewed were free from neglect. Resident #146 was not provided services related to a wound on the scalp. Resident #13 was not provide prompt services for skin breakdown around her gastrostomy tube. Resident identifiers: #146 and #13. Facility census: 145. Findings include: a) Resident #146 Review of a nurse's progress note dated 08/11/14 at 8:50 a.m., on 11/05/14, revealed Appt (appointment) with Dr. (name) on 8-27-14 @ (at) 10:00 A.M. POA (power of attorney) (POA's name) aware. Interview with the director of nursing (DON) revealed Resident #146 was referred to the physician, a dermatologist, for issues related to her scalp. Results of the consultation were requested at that time. On 11/05/14 at 12:20 p.m., the resident's records from the hospital were obtained. Review of the hospital admission information, dated 10/24/14, found the documentation indicated a wound was located on top of the resident's head with moderate thick purulent drainage. No measurements were recorded. Several photos, taken upon admission were included in the documentation. They showed the wound covered almost the entire top portion of the resident's head. Observation of the photos of the scalp revealed crusted, thickened scab layers covering the top of the resident's head, with matted knotted hair growing through it. Hospital wound care documentation, dated 10/25/14, the day after admission, revealed the wound on top of resident's head had a large amount of thick purulent drainage with noted improvement. The photo revealed many of the previous crusted scab layers were no longer present. On 11/06/14 at 10:25 a.m., an interview was conducted with Employee #117, registered nurse (RN) treatment nurse, concerning Resident #146's scalp and the missed dermatologist appointments. The treatment nurse stated the first time Resident #146's dermatologist appointment was missed was because the resident was admitted to the hospital. The treatment nurse stated, The second appointment was missed because I failed to write the order when I rescheduled it, and I forgot to enter it in the appointment log book, so it was missed. The treatment nurse confirmed it was her error that Resident #146 was not seen by the specialist for the condition of her scalp. At 10:45 a.m. on 11/06/14, an interview was conducted with the director of nursing (DON). The DON said, At one point we were treating her (Resident #146) for psoriasis. In August, when the new company took over, I did the body audit and saw it was a dry area that appeared to be attached. I did not know if it was a tumor or mass and instructed my staff not to scrape at it. I discussed it with the facility physician here and the resident was referred to a dermatologist. Our physician here does not usually refer them, so there was a concern. The first appointment was 08/27/14, but the resident ended up in the hospital. The second appointment was 09/24/14 and the order was not written, so it was missed. When asked if the DON thought there had been a delay in care, the DON replied, I agree there was a delay in care, partly because she was in and out of the hospital due to dysfunctional G tube (gastrostomy tube) issues. b) Resident #13 On 11/04/14 at 2:15 p.m., accompanied by the DON, an observation was made of Resident #13's feeding tube insertion site. The DON removed the split gauze dressing used to cover the site. The site was excoriated and had two (2) small open areas, one (1) at 7:00 o'clock and one (1) at 1:00 o'clock. There was wet bloody drainage noted on the gauze dressing. The DON disposed of the soiled dressing and stated she would get the resident's nurse to apply a clean dressing. When asked about the excoriation and open areas, the DON said she would have to check on the treatment for [REDACTED]. Review of the resident's medical records, on 11/05/14 at 5:10 p.m., revealed no entry about replacing the split gauge dressing around the G tube on 11/04/14. There was also no documentation regarding the excoriation and small open areas around the feeding tube insertion site. No evidence was found that the physician was notified of these areas. The record contained only a late entry referencing the initial dressing change the nurse did at 9:00 a.m. on 11/04/14. On 11/05/14 at 5:33 p.m., the DON was asked what had been done about the resident's excoriation and open areas. The DON said she thought the floor nurse had taken care of it. The DON was informed that the medical record contained only a late entry about the initial dressing which was applied at 9:00 a.m. on 11/04/14. The DON said she would get the treatment nurse to get an order to address it. Review of the medical record, on 11/06/14 at 2:12 p.m. revealed a nursing progress note, dated 11/05/14 at 19:07 p.m. (7:07 p.m.), by the treatment nurse. It said, On assessment noted G site very red with some pinpoint excoriation surrounding entire G site extending outward 2 cm. Old dark green drainage noted on old split sponge. No blood noted. No foul odor detected Phone Dr. (name) and received new orders for G-site treatment .Order faxed to pharmacy. Staff aware of new orders. The resident's excoriation and open areas were observed by the DON at 11/04/14 at 2:15 p.m. The facility neglected to notify the physician regarding the resident's skin condition until 11/05/14 at 7:07 p.m. This was more than 24 hours after the areas were observed by the DON. c) Review of facility's abuse policy, the section entitled Policy Interpretation and Implementation number 4.f. indicated Neglect is defined as failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness.",2017-11-01
6938,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2013-12-11,224,D,0,1,KCD511,"Based on complaint/concern review, resident interview, staff interviews, and policy review, the facility failed to implement its written policies and procedures regarding neglect and misappropriation of property. Resident #33 had clothing purchased with his funds by the facility that he did not authorize. An allegation of neglect regarding Resident #59 was made by a family and was not investigated. This practice had the potential to affect more than an isolated number of residents. Facility census: 115. Resident identifiers: #33 and #59. Findings include: a) Resident #33 On 12/03/13 at 9:45 a.m., Resident #22 stated the facility had purchased clothes for him that he did not want. Employee #5, a licensed social worker, stated the resident's clothes were too small and his butt would hang out of the back of his pants. She said she had spoken to the resident and told him that his funds were getting too high and he would lose his Medicaid benefits when it got to $2000.00. She stated the resident did agree he needed some slippers. Employee #5 confirmed clothes were purchased for the resident and had delivered them to the resident's room. She said the nursing assistants had put the clothing away and completed the inventory sheet. Employee #5 stated that it was two (2) days before she knew the resident had an issue with the clothing and that the resident refused to talk to her. When asked if anyone else attempted to speak to the resident, she stated Employee #13, a licensed social worker had also tried to speak to the resident. A review on the facility's complaint log, on 12/04/13 at 08:32 a.m., revealed there was no complaint regarding the purchase of clothing for Resident #33. The facility's concern log was reviewed on 12/04/13 at 8:50 a.m. A concern, dated 10/29/13, regarding Resident #33, stated he needed larger clothes and that he did not need shoes, but needed slippers. The resolution was that clothes were ordered. Another concern, dated 11/14/13, stated Resident #33 was mad over his new clothes and stated he did not want them. The outcome stated it was discussed with the resident. The follow up to this concern stated the resident would not discuss the situation with the recorder and the concern was marked as resolved on 11/14/13. The facility's reportable incidents were reviewed on 12/04/13 at 9:30 a.m. This incident was not documented as being reported. Resident #33 was interviewed again on 12/04/13 at 9:57 a.m. regarding his new clothes. He stated he did not want the clothes and that they had gotten rid of his old clothes. Resident was asked if he had picked out any of the new clothes. He stated he did not ask for and did not want the new clothes - that they were too big. The resident was asked if the facility staff had told him he was going to lose his Medicaid benefits. He stated he still had four hundred dollars ($400.00) to go before he was going to lose his Medicaid benefits and he said it would have never gotten that high. Employee #5 was interviewed on 12/04/13 at 4:17 p.m. When asked what had happened to the resident's old clothing, she stated she did not know as she only put the clothing in the resident's room. On 12/09/13 at 2:44 p.m. the reporting of incidents to the State regarding abuse and neglect for Resident #33 was discussed with the director of nursing (DON). She stated she was not in the facility the day the incident occurred. She stated the facility had purchased some new sweat pants for the resident in a size he had requested, and they had sent his clothing to the dry cleaner to be hemmed. In an interview, on 12/09/13 at 3:09 p.m., with Employee #13, a social worker, she stated she did not report the concern immediately as she passed the concern on to the assistant director of nursing. However, she stated she did complete a concern report on 11/15/13, after the issue was reported to her by the State ombudsman. A review of the facility's policy regarding the Procedure to prevention and reporting resident mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of resident property stated centers were required to report these alleged violations to the Administrator and DON/designee immediately. Immediately meant as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement. b) Resident #59 A review of the facility's concern reports, on 12/04/13 at 8:32 a.m., revealed a concern was made by the family of Resident #59 on 09/26/13 regarding their family member being dehydrated. This allegation was not located in the facility's reportable incidents. The facility investigated and signed off on the concern in-house. A review of the reportable incidents, on 12/04/13 at 9:30 a.m., did not find any reported incidents regarding Resident #59. In an interview, on 12/09/13 at 2:44 p.m., with the DON, she stated this should have been reported to the State.",2017-10-01
7206,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2014-07-17,224,D,1,0,VOMG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, abuse/neglect policy review, and staff interviews, the facility failed to ensure one (1) of six (6) sampled residents and one (1) resident identified during the grievance report review were free from neglect. Resident #106 had her call light on, when a staff member entered her room and proceeded past the resident, and toward the switch that turned the call light off, before addressing the resident. When the resident voiced her health concern, the staff member said she would tell the resident's nurse. The staff member did not report the resident's health concern to the nurse. Resident #136 had ask her nurse aide to look at her bottom and the nurse aide refused. The nurse aide told the resident she could do that herself. Resident Identifiers: #106 and #136. Facility Census: 135. Findings Include: a) Resident #106 On 07/16/14 at 2:40 p.m., Resident #106 was observed lying in bed calling out for someone to help her. When asked if she could reach her call light, she said, It doesn't do any good to push that, they just come in and turn it off. The resident pushed the call light and within 30 seconds, a nurse aide (NA), Employee #86 entered the resident's room, she walked past the foot of the resident's bed to turn off the call light before speaking to the resident. The NA asked what the resident needed. Resident #106 said, My heart hurts, it is my heart. The NA then said to the resident, We had this talk yesterday, if you would quit worrying all the time, your chest wouldn't hurt. After a pause, the NA said, I will tell the nurse. The NA was then walked out in the hall, spoke with other staff members, and ask if any residents needed vitals taken. At 2:50 p.m. on 07/16/14, licensed practical nurse (LPN), Employee #35, said she was not aware Resident #106 had asked for a nurse regarding her heart hurting. She verified the Employee #86 had not reported the concern to her. The LPN said she would check on the resident. She immediately went to the resident's room to check on her. On 07/16/14 at 3:00 p.m., it was reported to the director of nursing (DON) that a NA had failed to follow through and report a resident's health complaint to the nurse caring for the resident. The DON was also made aware the NA was in the process of turning off the call light before even addressing the resident. She said the nurse on the unit had already reported this information to her. During an interview on 07/16/14 at 3:25 p.m., Resident #106 said she was just so anxious all the time. She said she often felt like she could not breathe and could pass out at any moment. She was getting continuous oxygen via her nasal cannula. Her oxygen was set at 2 liters a minute. She also reported there were several nurse aides that just enter her room and turn off her call light without asking what she needs. Resident #106 said some of the nurse aides just ignore her. At 3:30 p.m. on 07/16/14, the DON said that Employee #86 had been written up. She said the NA admitted that she was going to turn off the light, and had not asked the resident what she needed upon entering the room. She also verified that she did not report the resident's health concern regarding her heart hurting to the nurse, as she told the resident she would. The DON said she was going to educate the staff in regards to answering call lights and reporting resident complaints/problems to the nurses. At 1:00 p.m. on 07/17/14, the DON provided copies of the resident's care plan, the facility's abuse/neglect policy, the disciplinary write-up for Employee #86, and the behavior monitoring sheets for the Resident #106. When asked what the policy was in regards to employees and alleged neglect, the DON said, the employee would be suspended pending investigation. She also said alleged occurrences should be reported. When asked about the occurrence on 07/16/14, the DON said she had not considered that neglect because the resident was assessed by the nurse. When asked if the nurse would have assessed the resident had the surveyor not reported it to the nurse, she agreed the assessment would not have occurred. She then agreed, had it not been for surveyor intervention, the nurse would never have known to assess the resident, and that was neglect on the part of the NA. A review of Resident #106 care plan, on 0717/14 at 9:30 a.m., revealed the following areas of concern: 1) Risk for [MEDICAL CONDITION] related to Chronic Obstructive [MEDICAL CONDITION] Disorder ([MEDICAL CONDITION]), and frequent complaints of shortness of breath. Intervention: Monitor oxygen saturation. Observe for signs and symptoms (s/s) of acute respiratory insufficiency: anxiety, confusion, restlessness, shortness of breath (SOB) at rest, cyanosis, and somnolence. Observe/document/report to physician as needed (PRN), any s/s of respiratory infection: fever, chills, increased sputum, chest pain, dyspnea, increased coughing or wheezing. Oxygen as ordered. 2) Identifies complaints of generalized pain. Identifies resident is at risk for potential injury from falls due to a history of falls, weakness, and [MEDICAL CONDITION] drug use. Intervention: Call light is to be available and answered promptly. b) Resident #136 On 07/16/14 at 10:03 a.m. a review of the facility's grievance reports revealed the a grievance report was initiated for this resident on 04/24/14 by Employee #17, a registered nurse (RN). The report noted Resident #136 asked an aide to look at her butt and the aide had told the resident she could do it herself. The resident had asked the aide what her name was and the aide responded Why do you want to know? The resident stated in the grievance that she just felt ignored.",2017-07-01
7247,GOLDEN LIVING CENTER - MORGANTOWN,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2014-06-17,224,J,1,0,I24N11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, physician interview, and observation, the facility failed to ensure resident to resident mistreatment and abuse by failing to identify residents whose personal histories rendered them at risk for abusing other residents. The facility failed to develop and implement intervention strategies to prevent occurrences, failed to monitor for changes that would trigger abusive behavior, and failed to reassess interventions on a regular basis. The facility also failed to protect residents from potential abuse and/or neglect by failing to conduct an investigation of an injury of unknown source that constituted harm. The absence of investigation prevented the facility from considering any corrective action to prevent similar injuries to residents. Resident #13 had a tender swollen area on her thigh which was not reported to the physician in a timely manner. When she continued to complain of pain, an x-ray was ordered, followed up by a computerized tomography (CT) scan. The CT scan identified the resident had bilateral [MEDICAL CONDITION] with impaction. Between the initial identification of the tender swollen area, therapy provided passive range of motion (PROM) to the lower extremities. Furthermore, the facility failed to attempt to identify the cause of the fractures for this nonambulatory resident. The failure to communicate the resident's tender, swollen, painful thigh to the physician in a timely manner in conjunction with the failure to communicate this finding to the therapists, and the failure to attempt to identify the cause of the injury resulted in a determination of immediate jeopardy. The Administrator was notified of the immediate jeopardy situation at 2:45 p.m. on 06/11/14. A written notice of the findings was provided to the administrator. At 5:12 p.m., the administrator provided a written plan for the immediate removal of the immediate jeopardy situation. The interventions outlined in the facility's plan were observed to be in place during a brief tour. The abatement plan of correction was prepared and sent to the State Survey Agency at 5:20 p.m. The plan of correction was accepted by the State agency at 5:40 p.m. and the administrator was informed that the Immediate Jeopardy was lifted. Resident #71 was known to hit other residents with her power wheelchair. The facility failed to ensure implementation of effective measures to ensure the resident did not pose a risk to other residents. These concerns were found for two (2) of sixteen (16) sampled residents, but had the potential to affect all residents living in the facility. Resident identifiers: #71 and #13. Facility census: 97. Findings include: a) Resident #13 On 06/04/14 at 3:45 p.m., record review found this [AGE] year-old woman was admitted to the facility on [DATE]. She had a chronic deformity with her hips in a flexed position. 1. The facility notified applicable state agencies of an unusual occurrence involving Resident #13 on 04/04/14. The notice was signed by the assistant director of nursing, #51. This notice stated (typed as written): I am reporting an unusual occurrence that initially happened Monday, March 31, 2014 involving one resident Ms. (#13), her DOB is 9/15/1937. She currently has a [DIAGNOSES REDACTED]. (Resident #13) was noted by staff to be having increased amounts of pain in areas of her left hip, resident was made comfortable in bed with positioning and administration of pain medication prior to her being assessed by Nurse Supervisor who noted no [MEDICAL CONDITION] or deformity of left hip with assessment. The resident was continuously monitored for pain and interventions were continued to assist with diminishing resident's pain level. (Resident #13) did receive an x-ray of her left hip which reflected left femoral head/neck fracture. Nurse Supervisor was then given a verbal order for a CT scan of left hip. This resident was ordered an orthopedic consultation and was continued on non weight bearing status until given the verbal ok via consult and facility doctor. After results of CT scan were received which reflected bilateral [MEDICAL CONDITION] resident was directly admitted to hospital for further evaluation and treatment. 2. Review of progress notes found Resident #13 was sent to the local acute care hospital on [DATE] where she was admitted with a [DIAGNOSES REDACTED]. Upon her return to the facility on [DATE], it was noted, (typed as written) . resident arrived to facility @1500 from (local hospital) via EMS (emergency medical services) to room (room number). Pleasant and cooperative. Alert to self only, speech clr (clear) hearing and vision intact, makes some needs known to staff, Lng (lung) sounds clr non labored no cough . skin warm pink intact, Sara lift for transfers, Diet mech soft, no c/o (complaints of) pain, (physician's assistant) aware of arrival confirmed all meds (medications) as per d/c (discharge) summary cont (continue) [MEDICATION NAME] 500 mg (milligrams) BID (two times a day) x (times) 5 days for Resp inf. (respiratory infection). -- A progress note dated 03/29/14 at 5:30 stated (typed as written), Situation: Resident has guarding, crying and c/o pain in left leg Assessment: Resident has tender, swolen (swollen) area to her left thigh. Resident afebrile, VS (vital signs) WNL (within normal limits). cries out when area is touched. No evidence of bruising or injury. Response: Currently monitor, will notifiy MD for further instructions. -- Continued complaint of pain was documented on 03/30/14 at 12:50 (typed as written): Resident was in her bed crying, saying her back hurt. -- Continued complaint of pain was documented on 03/31/14 at 12:50 (typed as written): Situation: Recent left hip xray d/t c/o pain Assessment: resident moaning, @x's (at times), went asked to locate pain, resident changing answer with each question, c/o (complained of) R (right) hip, abd (abdomen), r (right) leg, and l (left) hip, no [MEDICAL CONDITION] or instability noted. @x's moving BLE (bilateral or both lower extremities) without discomfort. Response: Notified MD (physician) of results, orders to obtain CT (computerized tomography) scan of left hip outpatient, Hoyer lift and bedrest until further notice. -- A progress note of 04/01/14 at 13:43 stated (typed as written): Resident placed on complete bedrest following possible left hip Fx. (fracture) C/O pain to hip, unable to verbalize pain level, but continued to moan, facial grimacing and guarding during care. X-ray results showed an examination completed 03/31/14 at 14:48:59 suggested left [MEDICAL CONDITION] with impaction. A CT evaluation was recommended. The results of the CT scan, completed on 04/02/14 at 14:39:12, showed a subcapital fracture right femoral neck, and impacted subcapital left femoral neck fracture. 3. On 06/09/14 at 3:30 p.m. an interview was conducted with physical therapist, contracted Employee #108, and head of the therapy department. She provided therapy progress notes. Resident #13 received physical therapy on 03/27/14, 03/28/14, and 03/29/14. She was discharged from therapy on 04/02/14. Her therapy also included training staff with use of Sara lift, chair positioning and bed positioning. The notes documented Resident #13 sat with her legs flexed most of the time due to her bilateral contractures. The treatment provided on 03/29/14 took place from 5:07 to 5:33 p.m., for a total of 26 minutes. The note stated (typed as written): PROM (passive range of motion) with end range (the furthest a joint moves) stretch to bilateral LE's (lower extremities) for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch. Res (resident) with occasional complaints of discomfort that were alleviated with release from stretch position. Upon conclusion of treatment, res resting in approximately 45 degrees of hip and knee flexion bilaterally. 4. On 06/11/14 at 11:40 a.m. an interview was conducted with the registered nurse (RN) supervisor, RN #50. She commented she was the supervisor on duty. She said she was not made aware of the left hip being swollen on 03/29/14. She said the day shift nurse should have followed up on the swollen tender left hip. She said she contacted the doctor and got an order because of the pain on 03/30/14 for the x-ray to be done on 03/31/14 because it was not considered an emergency. She said the director of nursing told her to do a pain evaluation on the 31st and she did evaluate her then. She agreed this was a delay in care and notification of the physician. She said she was not aware therapy treated her on 03/29/14, they should not have because of the documented change in her condition. 5. During an interview on 06/11/14 at 11:04 a.m., the Director of Nursing #24 said she was not aware of the therapy treatment because she could not see what therapy charted because the two (2) electronic medical record (EMR) systems were different. She said the contracted therapy department did not have access to the facility's EMR, and the facility did not have access to the contracted therapy department's EMR. She acknowledged that the treatment was contraindicated for Resident #13, and could have caused injury or exacerbated any existing injury. 6. During an interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said he was unaware of the therapy treatments after Resident #13 returned from the hospital. He said based upon the documentation of onset of pain and swelling, and crying out when the area was touched, the therapy treatment of [REDACTED]. 7. A confidential interview was conducted with a nursing assistant (NA) on 06/10/14 at 10:30 a.m. She said communication between the nurses and the aides was not good. She was concerned when Resident #13 came back from the hospital on [DATE] because they were still being told to use the sit to stand (Sara) lift on her, even with her contractures and her confusion. She said therapy did training on how to use the lift, but said the Sara lift was unsafe for Resident #13. According to the NA, they had a lot of trouble due to her contractures. The resident would yell and cry out when they used it. The aides told the nurses. Then, after the x-rays showed fractures, they changed her to a Hoyer lift for all transfers. 8. An interview was conducted with NA #68 on 06/10/14 at 11:20 a.m. She said staff had difficulty using the Sara lift with Resident #13 due to her contracted position. 9. During the interview on 06/12/14 at 1:20 p.m., the attending physician for Resident #13 said use of the Sara lift for Resident #13 was contraindicated due to her contractures. He said he was unsure of how the fractures happened, but due to the impaction, it would have been from impact and pressure from an up and down movement. 10. Review of physician orders [REDACTED]. Medical Records Coordinator #22, confirmed this during an interview on 06/10/14 at 12:10 p.m. 11. The review found therapy had treated the resident immediately after her readmission of 03/26/14. They treated her on 03/27/14 and, 03/28/14, and even after the onset of guarding, crying and c/o pain in left leg has tender, swollen area to her left thigh .cries out when area is touched as documented by nursing on 03/29/14 at 5:30 a.m., the therapy department treated her with endrange stretch to bilateral LE's for improved positioning. Deep tendon pressure and light soft tissue massage provided to increase resident's tolerance during stretch. The director of nursing, nurse supervisor, and the attending physician stated this treatment was contraindicated, and could have caused injury or exacerbated existing injury. The aides continued to follow their instructions to use a Sara lift for all transfers until her bilateral [MEDICAL CONDITION] with impaction were identified, even though they had difficulty doing so and the resident was in apparent pain during these attempted transfers. The attending physician said use of a Sara lift was contraindicated for Resident #13 due to her bilateral hip contractures. It was not possible to categorically state when and how Resident #13 sustained her injuries, but the facility's documentation was that she had no complaints of pain upon her readmission on 03/26/14 and she was to use the Sara lift for transfers. The facility conducted no investigation of these injuries in an attempt to determine the cause. This resulted in a determination of an immediate jeopardy to the well-being of residents. The Administrator was notified of the immediate jeopardy situation at 2:45 p.m. on 06/11/14. A written notice of the immediate jeopardy was provided and a plan of correction requested for the amelioration of the immediate jeopardy. At 5:12 p.m., the administrator provided a written plan of correction for the immediate removal of the immediate jeopardy. The interventions were observed to be in place during a tour. The abatement plan of correction was prepared and sent to the State Survey Agency at 5:20 p.m. The plan of correction was accepted by the State agency at 5:40 p.m. and the administrator was informed the immediate jeopardy was lifted. b) Resident #71 Record review on 06/03/14 at 2:42 a.m. found Resident #20 was injured 05/26/14 at 2:30 p.m., when Resident #71 propelled her power wheelchair into him, knocking him out of his wheelchair. He fell to the floor striking his head. Additional review of Resident #71's medical record found this [AGE] year-old woman was admitted to the facility on [DATE], and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was determined by a physician to lack the capacity to make informed medical decisions. Her Brief Interview for Mental Status (BIMS) score as assessed on 05/12/14 was 08, indicating moderate cognitive impairment. The review of the record began on 06/03/14 at 2:42 p.m. A review of the resident's medical record found documentation indicating the resident had been identified by the facility as being at risk for dangerous, impulsive behavior since 2009. There were three (3) documented episodes of Resident #71 deliberately striking other residents with her power wheelchair. There was no evidence of any systematic effort to address this ongoing concern until the most recent accident resulted in Resident #20's injury. Progress notes following the incidents were noted as follows (typed as written): 1. On 02/15/13 at 13:52, a general note text included: Resident was given blank paper as she had asked for and had laying on desk at nurses station. When pt moved away from desk briefly, another female resident came to the desk and lifted papers to look at them, then laid them back down on the desk and moved away. Pt had noted this and ran her electric w/c into back of other female residents w/c. Back up and bumped into her again. Spoke w/ (with) resident and was warned of consequences of being removed from her w/c for rest period if it occurred again. Pt (patient) calm at this time. Attempted to explain but pt was not listening. 2. On 08/18/13 at 14:02, a general note text included: Alert, able to make needs known at times. Medicated per orders. Resident attempted to jam her electric w/c (wheelchair) into another resident's w/c this shift b/c (because) she was angry with him, easily redirected. Distance provided between two and no further occurrences noted. 3. On 01/16/14 at 21:17 (9:17 p.m.), a Behavior Charting included: Resident was arguing with (initials of another resident), who was in her room going through her things. Resident used her motorized wheelchair to hit into (initials of other resident) which prompted (initials of other resident) to bite her foot. Prior to the incident, the resident was sitting at the desk and saw the other resident going into her room. After the residents were separated, the other resident was taken to activities. Resident #71 remained at the desk with staff. Resident had visible bite mark c/o pain at bite site and was given Tylenol. 4. On 02/20/14 at 13:49, it was noted the resident was doing things to agitate her roommate like sitting in front of television, or blocking the bathroom so the roommate could not get in or out. 5. 04/28/14 at 22:21, a behavior charting entry noted the resident was upset because (name of other resident) wandered over and ate some of Resident #71's fruit. Resident #71 ran her wheelchair into the other resident's wheelchair three (3) times. Neither resident was injured during this event. 6. On 05/26/14 at 16:38, another behavior entry noted the resident was angry that another resident had bumped into her wheelchair. She rammed her wheelchair into his wheelchair knocking him over causing him to hit his head on the ground. According to the note, there was no time for interventions because Resident #71 had rammed the other resident's wheelchair too quickly. An interview was conducted with the Administrator, Employee #38, on 06/03/14 at 4:40 p.m. He said there was no incident report completed for the resident to resident incident documented in nurses' notes on 04/28/14, but agreed there were three (3) deliberate power chair ramming incidents documented for 01/16/14, 04/28/14, and 05/26/14. He was asked for evidence of assessments, consultations, discussions with the family, or policy and procedure for screening for safe operation of power wheelchairs. On 06/05/14 at 1:10 p.m., the Administrator advised the facility had no policy and procedure for assessing whether residents were safe to physically control and operate, or psychologically appropriate to operate, power wheelchairs prior to permitting their use in the facility. He said they had written a policy following the incident of 05/26/14, but had to give thirty (30) days notice to residents prior to implementing it. He said there were psychological consultations for Resident #71, but these had been for self-injurious behavior and not to address aggression with her power chair. Earlier evidence of behavior issues were found when requests were made for screening for safe use of power chairs. The evaluating physical therapist concluded on 10/12/09 that Resident #71 was deemed safe to control the functionality of the power chair based upon apparent observations by therapy staff for 5 times for one hour. There was an additional note that stated (typed as written): No episodes of impulsive, dangerous behavior. There was no explanation as to why this was so documented. The administrator confirmed, during an interview on 06/09/14 at 9:00 a.m., there must have been some prior concern related to impulsive dangerous behavior, although there were no references found in the record. He also agreed that Physical Therapy would not be the appropriate professional to evaluate the risk for impulsive dangerous behavior. A care plan focus item for behaviors was found, which stated (typed as written): I sometimes have behaviors which include Bumping into other people with the power and door/walls wheelchair. Date Initiated: 5/22/2012. The goal associated with this item was: My behavior will stop with staff intervention to decrease my episodes to less than monthly thru the next review. Interventions implemented were (date initiated: 6/2/2014) : 1. Attempt interventions before my behaviors begin such as reminding me that I could hurt someone or talk to me about things that interest me such as my family. 2. Do not seat me around others who disturb me. 3. Give me my medications as my doctor has ordered. 4. Help me to avoid situations or people that are upsetting to me. 5. Keep resident from middle of hallways and middle of lobbies to ensure other patient safety . 6. Encourage resident to utilize bell on her WC to alert staff that she needs assistance. Whan a potential confrontation may occur to staff to redirect her behavior and staff will intervene to ensure residents are kept safe. 7. Keep my family involved with my care and any behaviors that I am displaying with my motorized WC so they can help ensure my safety and safety of others around me. (Date Initiated: 5/30/2014) 8. Turn down speed of w/c to medium. On 06/04/14 at 9:30 a.m., both Resident #20 and Resident #71 were observed in the lobby adjacent to the South nurses' station. Resident #71, who was in her power chair drove by Resident #20, then turned and drove in front of him, turned and passed by him a third time. She backed her chair against a wall about three (3) feet from Resident #20 and watched him as he moved slowly around the area, sometimes bumping into other residents who occasionally pushed him away or verbally rebuffed him. He moved toward Resident #71, but never got close enough to touch her. There was no confrontation between the two (2) residents, but Resident #71 watched him intently the entire time. Virtually the same scenario was repeated on the morning of 06/05/14. Again, there was no actual confrontation between the two (2) residents, but they were in very close proximity for a period of at least 20 minutes. Staff made no effort to redirect or relocate any of the residents assembled in the area. During the interview of 06/05/14 at 1:10 p.m., the Administrator confirmed there was long-term evidence of ongoing concern regarding safety issues related to aggressive behavior towards other residents by Resident #71. He agreed the record showed staff were aware of these concerns, but no systematic assessment, consultation, or dialogue with outside professionals or the family was attempted in order to ensure other residents' safety until the injury to Resident #20 on 05/26/14. He agreed many of the care plan interventions were simply impractical or inconsequential. He acknowledged that the power wheelchair was Resident #71's only means of independent ambulation, and that efforts toward ensuring her continued safe use of this equipment should have begun as early as 2009. He confirmed the facility had no means of assessing safe use of power wheelchairs in place for the four (4) residents currently using them.",2017-06-01
7519,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-04-24,224,G,1,0,HZEQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and family interview, the facility failed to implement procedures to ensure residents were free of neglect. The facility failed to provide care and services to ensure residents received the correct diet to prevent choking. The facility did not ensure restrictions regarding swallowing were implemented for Resident #142. The resident did not receive a mechanical soft diet as ordered by the physician, but was served a whole hot dog (not ground) on a bun. As a result of being served the incorrect diet, the resident experienced actual harm when she choked and was sent to the hospital. Subsequently, the facility's investigation of the occurrence failed to identify the resident did not receive a mechanical soft diet as ordered. As a result the facility did not implement measures to prevent this from reoccurring for this resident or other residents. Staff gave inconsistent responses regarding what swallowing restrictions were in place upon her return from the hospital. This was true for one (1) of nine (9) sampled residents and had the potential to affect more than an isolated number of residents who received a mechanically altered diet. Fifty-two (52) residents were receiving mechanically altered diets at the time of the survey. Resident identifier: #142. Facility Census: 141. Findings include: a) Resident #142 Review of the resident's medical record found a nursing entry, dated 03/26/14 at 19:21 (7:21 p.m.), noting the resident's son and a nursing assistant called for a nurse. The note included, Resident was noted to be choking. [MEDICATION NAME] maneuver performed, resident was transferred from the wheelchair to the bed, abdominal thrusts performed. Resident then began to make eye contact and started to mumble. O2 (oxygen) @ (at) 10L (ten liters) with non-rebreather applied, 20g (20 gauge) IV (intravenous) inserted to left inner arm infusing NS (normal saline). Resident's family stated that resident had choked on her hot dog stating 'she put the whole thing in her mouth' . She was transferred to the hospital by ambulance at 7:20 p.m. A review of the physician's orders [REDACTED].#142 was to receive a mechanical soft diet with no bread, and her food was to be cut into small pieces. Further review of the resident's medical record found that on 03/02/14, the resident experienced vomiting and had a decreased level of consciousness. She was transferred to the hospital, where, according to the hospital records, she was admitted due to aspiration (entry of foreign material into the airway). During her hospitalization , she received total [MEDICATION NAME] nutrition (TPN - which is nutrition provided intravenously (IV)). She returned to the facility on [DATE] with physician's orders [REDACTED]. Her readmission orders [REDACTED] which were interventions put in place prior to her hospitalization on [DATE]. These restrictions were, however, included on the resident's dietary card that was on the tray with her meals. She was also to receive a speech therapy evaluation. Review of the resident's plan of care in effect prior to the resident's hospitalization on [DATE], and the care plan revised when she returned on 03/24/14, found the plans did not identify any issues with swallowing problems or any special precautions to be taken for this resident. There were no instructions provided for the amount of supervision needed. Prior to her discharge to the hospital on [DATE], the resident had a recommendation from the Speech Therapist for No Bread and for her food to be cut into bite sizes pieces in addition to the mechanical soft diet. It was unclear if this restriction was to be continued when she returned from the hospital because theses interventions were not included in the resident's care plan in effect prior to her admission to the hospital with aspiration. The care plan was not individualized to identify this resident's specific problem, but stated provide diet as ordered. In an interview with the Speech Pathologist (Employee #171), on 04/22/14 at 10:00 a.m., she stated this resident should not have had bread and her food (fruits and vegetables) should have been cut into bite size pieces. She also said the resident should have had ground meats and not a whole hot dog. According to the Speech Pathologist, the resident was on the Red Napkin program because she had decreased intake. The Red Napkin also meant the resident required supervision. Employee #171 said she had seen the resident in the past and recommended no bread and for the resident's food to be cut in small pieces. She commented this was included on the resident's physician's orders [REDACTED]. This was not because the resident did not like bread, but she should not have it due to her swallowing problems. The Speech Pathologist stated this precaution should have been continued when the resident came back from the hospital. Employee #171 said she was treating the resident for swallowing problems, but did not realize the precautions previously put in place were not continued. This information was still written on her tray card that came with her meal each day. She confirmed anytime a resident went to the hospital and had restrictions put in place by the Speech Therapist, the restrictions should continue when the resident returned. During an interview with the dietitian (Employee #229), on 04/22/14 at 10:15 a.m., she indicated speech therapy had made recommendations for Resident #142 to have no bread. She said this recommendation was made due to the resident's unsafe swallowing. No bread was written on the resident's dietary card and listed as a dislike, but was not really a dislike. It was just written as a dislike to remind the kitchen not to give bread to the resident. She said all of the residents in the facility who had a bread restriction due to unsafe swallowing, had bread written in the dislikes so they would not receive it. She said none of these were truly dislikes, it was for swallowing issues. She stated the kitchen knew if the ticket said the resident disliked bread, the resident should not receive it. During an interview with the dietary manager (Employee #228), on 04/22/14 at 10:20 a.m., she said Resident #142 should not have had a hot dog or a bun. She said the diet recorded in the kitchen stated the resident was to have a mechanical soft diet with no bread. She said the no bread restriction was carried over from before she went to the hospital because they carried these restrictions forward, unless they were changed or discontinued. Her diet was still mechanical soft and the meats should be ground mechanically. In an interview with a registered nurse, Employee #22 (Assistant Director of Nursing), 04/22/14 at 9:45 a.m., an inquiry was made about the procedure for the facility after a resident returned from the hospital. She was asked how the facility ensured the restrictions and precautions previously in place were continued upon the resident's return. She said after so many days, the computer discontinued all of these interventions and the resident was addressed as a new admission. She said the nurses had to look at the prior record for things like restrictions, that were previously part of the resident's care, to see whether the restrictions should be continued. She was specifically questioned about Resident #142's swallowing issues regarding the order for no bread and to cut the food into small pieces. She stated those restrictions should have been included when the nurse wrote the orders upon the resident's return from the hospital, or at least discussed with the physician. She verified there was no evidence this was reviewed when the resident returned from the hospital. In a telephone interview with Resident #142's son, on 04/22/14 at 2:00 p.m., he said he and his wife were in the room visiting with his mother when her dinner tray was brought to her on 03/26/14. He stated he was standing at the door and the girl handed him his mother's tray. He verified the nursing assistant did not look at what was on the tray, she just gave it to him with the lid still covering the plate. He stated when they saw the food on the tray, he said to his mother Are you sure you are allowed to have that? He said he was concerned about her having an entire hot dog because the facility had called him the night before and told him Speech Therapy was going to analyze her because she was having swallowing problems. He said he was also concerned because his mother had just been in the hospital with aspiration and had not been eating anything in the hospital. In the hospital, they were feeding her through her veins with an IV. He said his mother picked up the hot dog and the bun and put the whole thing in her mouth. He said her cheeks were pushed way out on both sides. He told her she had way too much in her mouth and tried to get her to spit it out and then she choked and he yelled for help. A telephone interview was conducted with a nursing assistant (Employee #161) 04/22/14 at 7:30 p.m. She confirmed she had been the nursing assistant responsible for Resident #142 on the evening of 03/26/14. She stated she took the tray off the cart and gave it to the resident's son. She verified she did not remove the lid and look at the resident's tray. She could not confirm whether it was the correct diet because she did not see it, she just gave it to the family. On 04/23/14 at 2:00 p.m., in an interview, the Director of Nursing (Employee #73) stated she was present the night of the choking incident involving Resident #142. She said she was still in the facility that evening and heard the page over the loud speaker for a nurse to come immediately to the resident's room. She stated when she arrived, staff were performing the [MEDICATION NAME] maneuver on Resident #142. She said she immediately went to the resident's tray and noted there was one third (1/3) of an entire hot dog on the tray. She stated the resident's tray card was lying on her tray and indicated she was to get a mechanical soft diet with no bread. She immediately identified the resident had been served the incorrect diet of an entire hot dog that was not ground on a bun. She said prior to her leaving that day, she made sure there were no other residents who had received the wrong diet. The director of nursing stated the nursing assistants were supposed to look at the trays when they served them to make sure the residents received the correct diet. The staff were to check the tray with the diet card that was placed on their tray as a way to double check. When Employee #73 was asked whether an issue was identified or any plan of action was implemented to ensure this did not reoccur, she stated she had not implemented a plan to evaluate how this happened and to prevent reoccurrence. The person identified to investigate incidents in the facility to determine if abuse or neglect occurred was a Registered Nurse (Employee #199). She was interviewed on 04/23/14 at 2:30 p.m. regarding this incident. She was asked if the incident was identified as neglect. She stated no it was not. Employee #199 said she did not identify the resident got anything she was not supposed to get that would result in her to choking. When asked if this would have been determined as neglect if she had identified the resident received the incorrect diet, she said yes because that would have been failure to provide a service.",2017-04-01
7646,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-03-25,224,D,1,0,OP4H11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, of the facility's reported allegations of abuse/neglect, observation, review of staff assignments, and staff interviews, the facility failed to ensure measures were implemented to prevent neglect for one (1) of nine (9) residents reviewed for the provision of care and services. The resident went without care for an entire shift. He was not turned, changed, and was found with his tube feeding formula all over him and his bed. Nursing staff assignments were not promptly posted at the beginning of each shift to ensure each resident was assigned a caregiver and would receive care. The facility did not always implement a process which ensured nursing staff were made aware of any condition changes and/or assignments. Staff members who were new to the facility were not properly supervised and did not receive assistance as needed to provide care in a timely manner and to ensure residents were not neglected. Resident identifier: #1. Facility Census: 125. Findings Include: a) Resident #1 The medical record for Resident #1 indicated the resident was a quadriplegic. He was totally dependent on staff for all of his activities of daily living (ADLs). Resident #1 received daily treatments for multiple pressure ulcers, had a gastrostomy tube (G/T), an indwelling catheter, a [MEDICAL CONDITION], and multiple contractures. A review of the facility's reported abuse and neglect allegation files revealed an incident which occurred on 11/17/13 involving Resident #1. The resident voiced he had not been turned all day. The facility's investigation included a statement from the nurse who checked the resident and cleaned him up at 3:30 p.m., after the situation was brought to her attention. Her statement was: When assisting CNA (certified nursing assistant) on 11/17/13 at 3:30 p.m. in turning the resident, this nurse observed pillow on left side to have caked tube feeding covering the entirety of the underside. When resident was turned to his right side to remove pillow this nurse observed that the flat sheet had adhered to the air mattress and the resident's back d/t (due to) puddle of dried tube feeding that resident was positioned in. No skin breakdown noted once sheet was removed from skin with warm water. Sheet had to be saturated with water to be removed from air mattress. Resident's wound treatments were completed at this time. Resident was given partial BB (bed bath) and was then repositioned comfortably. No complaints of pain/discomfort. The administrator investigated the incident. She called the nursing assistant (Employee #150) after she determined Employee #150 was assigned to Resident #1 during the day shift on 11/17/13. According to the facility's investigation, the nursing assistant (NA) was made aware the resident said he had not been turned all day. The NA said she provided the resident coffee in his room. The NA also said .she did not normally have him and didn't realize . According to the report, the administrator asked the NA how she could not realize a quadriplegic resident would need assistance with turning? The nursing assistant stated, Well to be honest, I didn't even realize that he was on my assignment until toward the end of my shift. The administrator asked her why she documented in the ADL book that she had provided assistance if she had not. The NA was suspended then terminated. There was no evidence the facility did an investigation to identify each staff member who had interaction with Resident #1 that day, and/or to identify who should have provided necessary care at various times throughout the shift. There were staff members who were responsible for giving his medications, monitoring his catheter and [MEDICAL CONDITION], administering his G/T feeding and flushing, and monitoring his pressure ulcer treatments. There was no evidence any staff member was questioned about this resident's neglect other than Employee #150, the NA. The administrator was questioned about the neglect investigation on 03/21/14 at 2:00 p.m. She verified she had not investigated or considered there was neglect from any staff member other than the NA. She verified the investigation did not include other staff members who should have been caring for the resident or supervising Employee #150. In addition, the administrator said she did not look into the process of staff to resident assignments, even though the NA said she was not aware the resident was on her assignment. b) Staff Assignments and Communication On 03/19/14, a tour of the facility was conducted and the staff assignments were reviewed at 8:30 a.m. This verified the shift for the nursing assistants working at that time started at 7:00 a.m. There was no nurse at the nurses' station and Employee #64 (Social Worker) was asked if she knew where the assignment sheets were for the day. She obtained a sheet and it was noted these assignments were for the prior day, 03/18/14. She looked around the nurses' station and said she did not see another one. Employee #35 (Nursing assistant) was observed at 8:35 a.m. on the South hall picking up breakfast trays. She was asked if she could verify where the assignment sheet for day shift was located. She went to the nurses' station and obtained the same sheet provided by the Social Worker which was the prior day's assignments. She said they must not yet have completed the sheet for today. The nursing assistant verified she had been in the facility since 7:00 a.m. that day. She said sometimes the assignment sheet did not get completed until later. At 8:40 a.m. on 03/19/14, Employee #116 was observed completing the assignment sheet for the South side of the building. She was writing the the names of the staff for each assigned room on the assignment sheet. When interviewed at that time, she verified the assignment sheet was not yet completed. She was asked how everyone knew what to do when they came in, and to which residents they were assigned, so all residents would receive care. She stated, Most of them already know who they are going to have and if they do not know they usually come and ask. This observation was an hour and forty minutes after the nursing assistants came on duty. The assignment sheet on the North Unit was observed at 9:15 a.m. It was completed at that time. It was then verified at 9:50 a.m., this assignment sheet was changed and there was a new assignment sheet completed. Random confidential staff interviews confirmed the assignments were not always posted until later in the shift and not when you first arrived. Staff members said it was often 8:45 a.m. to 9:00 a.m. before it was posted even though their shift began at 7:00 a.m. According to the nursing assistants, sometimes they had the same people and other times it changed because of peoples' preferences or call offs. One staff member stated you had to look at the assignment sheet closely when they posted it because it was not always the same. You may not have who you think you have. They hold assignments for people and people who got there first often got their desired assignment. The person making the assignments had a lot to do with who you got. During one interview, the nursing assistant (NA) was asked to review the assignment sheet and stated, See, now it's already changed, you have to go back and check or you may not know you have someone. It was confirmed the original assignment sheet she had looked at was different, and she had different rooms than earlier. The assignment sheet was observed and verified the rooms were mixed up and the rooms assigned were not always even close together. The nursing assistant verified sometimes you may have one room on one hall and the rest on the other hall and it would be easy to miss someone. One staff member explained the process of assignments and verified it would be easy for a resident to be missed, especially if you did not look at the assignment sheet and recheck it. Random interviews with nursing assistants verified day shift nursing assistants did not even always see the night shift nursing assistants. Sometimes they got report and made rounds with the oncoming shift, sometimes they did not. When asked if they got report from the nurses, they verified they rarely got any type of report. The director of nursing (Employee #2) confirmed, on 03/20/14 at 4:20 p.m., it was the facility's process for report to be given from the nursing assistant leaving to the nursing assistant coming on at each shift change. She said a verbal report should also be given from the nurse to the nursing assistant. She was questioned about the posting of assignments and stated those change so much it was hard to do, but they needed to post them as early as they could. c) Supervision and Assistance The facility was entered at 6:30 a.m. on 03/21/14. The assignments were verified and the nursing assistant (Employee #93) assigned to Resident #1 was interviewed. The nursing assistant stated she was not State-tested (had not taken the required competency test to become registered) yet and would go take her test this week. She said this was her third day on the floor by herself. She verified she had twenty-three (23) residents on her assignment and had not done final rounds on all of her resident's yet. She was observed working by herself until 7:00 a.m. It was verified the nurse supervising the nursing assistant (Employee #93) was Employee #115. She was observed in the hall picking up paper out of the floor and moving carts around at 6:55 a.m. She was never observed checking on Employee #93 from 6:30 a.m. until she left at 7:15 a.m. The nurse was observed going down the hall at 7:20 and stated, I am going home. She did not check to make sure the nursing assistant completed her assignments, or see if further assistance was needed to ensure the residents' care was provided. The Director of Nursing confirmed, on 03/20/14 at 3:00 p.m., Employee #115 would have been the supervisor for Employee #93 that morning. At 7:00 a.m., the day shift nursing assistants were observed arriving. One of the day shift nursing assistants (Employee #107) was observed going into resident rooms with NA Employee #93. She did not assist with completing care, but held two (2) residents on their sides while Employee #93 changed them, provided peri-care, a dry brief, and clean sheets. Employee #93 went to get supplies, then was observed performing peri-care to Resident #51 and Resident #119. It was 7:50 a.m. when she was observed performing incontinence care to Resident #119. The nursing assistant was observed until 8:30 a.m. There were no observations of anyone assisting her to complete care for her twenty-three (23) residents, or supervision to make sure her assignment was completed. She stated she had an extremely busy night and one (1) of her assigned residents passed away that morning, requiring a lot of extra time. The Director of Nursing (Employee # 2) was made aware of the observations that were made the morning of 03/21/14 between the hours of 6:30 a.m. and 8:30 a.m. She verified the nurse supervising Employee #93 should have been Employee #115. She verified the nurse should have made sure the rounds were completed and gotten Employee #93 assistance if she needed it to ensure timely rounds were completed. She verified on the time cards Employee #93 clocked out of the facility at 9:00 a.m., and her supervising nurse, Employee #115, clocked out at 7:23 a.m.",2017-03-01
7671,GREENBRIER MANOR,515185,"ROUTE 2, BOX 159A",LEWISBURG,WV,24901,2013-01-17,224,D,0,1,C1G011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interviews, and resident interview, the facility failed to ensure one (1) of twenty-five (25) Stage 2 residents was free from neglect. The facility failed to assess, monitor, and provide medical interventions in a timely manner for a resident with diabetes and recurrent urinary tract infections. There was no evidence of physician's orders [REDACTED]. There was also no evidence of interventions to prevent the urinary tract infections this same resident was experiencing. This lack of monitoring and interventions for both the glucose level and urinary tract infections had the potential to adversely affect the physical comfort, mental, and psychosocial well-being for one (1) of four (4) residents reviewed for diabetic care, who was also one (1) of five (5) residents reviewed for urinary tract infections. Resident identifier: #15. Facility census: 88. Findings include: a) Resident #88 This resident had a [DIAGNOSES REDACTED]. Upon review of physician's orders [REDACTED]. Review of the medical record revealed evidence of concern related to diabetes which included a [DIAGNOSES REDACTED]. A nursing note, dated 07/15/12 at 2:36 p.m., revealed the resident had a blood glucose level of 294. There was no order for this test, and no documentation regarding why this test was obtained. Additionally, there was no evidence the results of this test were provided to anyone, including the physician or any nursing administrative personnel. According to the American Diabetes Association, the blood glucose target range for diabetics is 70-130 before meals and less than 180 after meals. Employee #3, a registered nurse, was requested to provide the most recent glucose values for Resident #15. Employee #3 presented a medication administration sheet, dated 10/01/06 to 10/31/06, in which blood glucose values were completed twice per day. Employee #3 also presented a physician's orders [REDACTED]. No other evidence was presented by Employee #3 that blood glucose levels or Hemoglobin A1C values were obtained between 11/02/06 and the date of the investigation, 01/10/13. On 01/10/13 at 4:00 p.m., the director of nursing (DON) stated she would look for additional information pertaining to glucose levels for Resident #15. On 01/14/13 at 9:00 a.m., the DON stated she was unable to find further information. At On 01/16/13 at 8:45 a.m. Resident #15 stated her leg was removed after she went to a doctor to get her toenails trimmed. Resident #15 stated the toe became infected, her toes turned black and eventually her leg was removed. Resident #15 stated this occurred because she was a diabetic. 2) Review of Resident #15 ' s lab results revealed the resident had urinary tract infections seven (7) times between 06/08/12 and 01/01/13. Six (6) of these lab results were positive for Escherichia-coli. Antibiotics were ordered. There was no evidence of interventions to assess causal factors and/or prevent UTIs. Nursing notes were reviewed. The notes revealed the resident was catheterized to obtain a urine sample nine (9) times between 08/01/12 and 01/16/13. These same notes contained numerous references to the resident being confused with acting out behaviors. On 01/14/13, during Stage II of the survey, the facility was informed about the findings of multiple UTIs for Resident #15. The infection control nurse, Employee #7, was asked to provide information regarding care planning/interventions concerning this matter. On 01/15/13 at 4:00 p.m., Employee #7 provided a training/in-service for prevention of urinary tract infections/personal hygiene care dated 01/15/13. This document was signed by fifteen (15) employees dated 01/15/13 and 01/16/13. This in-service was provided after the situation was brought to the attention of the facility during the survey. No other evidence was provided to confirm the facility had addressed the recurrent UTIs the resident was experiencing. Employee #59, medical records, presented a copy of Resident #15 ' s most recent urologist consult on 01/16/13. The consultation was dated 03/24/10. The consultation noted the resident had a history of [REDACTED]. At the time of the consultation, Resident #15 was prescribed [MEDICATION NAME] daily. The recommendation on the consult was to continue [MEDICATION NAME] every day. A follow-up appointment was set for 03/31/11; however, the resident did not go to the appointment. On 01/16/13 at 4:00 p.m., Employee #59 stated Resident #15 was hospitalized around that time, her leg was amputated, and the facility did not reschedule an urologist follow-up appointment. No other urologist consultation was presented by the facility.",2017-03-01
8068,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2013-10-18,224,G,1,0,52PL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed for accidents was free from neglect. A test eligible nursing assistant (TENA) failed to put up the side safety rail on a shower bed. The resident fell off the shower bed to the floor, sustaining C1 and C2 (first and second cervical vertebrae) vertebral fractures and a nasal fracture. Prior to the incident, the TENA was trained to put up the safety rail and to provide safety measures during resident care. The TENA neglected to implement these safety measures resulting in harm to the resident. Resident identifier: #93. Facility census: 92. Findings include: a) Resident #93 Review of incident reports revealed on 10/07/13 at 6:35 p.m., this resident was transferred from a wheelchair to a shower bed using a mechanical lift by Employee #79, a test eligible nursing assistant (TENA). According to the report, the TENA failed to put up the side safety rail on the shower bed. The TENA turned away to move the mechanical lift out of the way. When the TENA turned back around, Resident #93 was falling from the shower bed and hit the floor. The written statement from Employee #79 stated (typed as written): I, (Employee #79), was going to give (Resident #93) a shower. Me and the aide (Employee #20) brought her to the shower room and used the mechanical lift to put her on the shower bed. We got her on and (Employee #20) brought the chair out of the shower room. I was bringing the lift out. As I was pushing the lift out, I turned around to look at (Resident #93) and saw her grabbing the air. We didn't put the rail up before we moved the chair and lift, I saw her grab and roll over, so I ran to her, but it was just a second too late and she fell out and landed on her side, then hit her head. I immediately ran to get the nurse and went back to hold her head up. The written statement from Employee #20 stated (typed as written): I assisted CNA (certified nursing assistant) with transferring (Resident #93) onto shower bed with hoyer lift. I asked CNA if she needed help undressing resident and she replied no. I told CNA that I would take residents chair back to her room and change residents linens. CNA said OK and I got half way down Far East hallway and CNA yelled at me to come back that resident had fallen off shower bed. I immediately got her nurse and charge nurse. A late entry nurse's note, dated 10/07/13 at 18:35 (6:35 p.m.), described the nurse observed the resident lying on the floor of the shower room at 6:35 p.m. on 10/07/13. The note indicated a moderate amount of blood was on the floor and the resident's head. A laceration was noted to the midline of the resident's forehead from her hairline to her eyebrow line. A small laceration was also noted to the bridge of the resident's nose. The resident was assessed for any further injures while a staff member stabilized the resident from movement of head, neck and shoulders. The resident was noted to be spitting out blood from her mouth and a small amount of blood was seeping from her bilateral nares (nostrils). The emergency medical technicians (EMTs) arrived and transported the resident to the local emergency room (ER). The medical record entry, dated 10/08/13 at 00:09 (12:09 a.m.), indicated a call to the local ER revealed the resident was being admitted to the hospital with [REDACTED]. Review of the resident's current care plan indicated the resident had a history of [REDACTED]. The KARDEX, the specific individualized instructions for the resident's care used by nursing assistants, stated (typed as written): Resident requires total assist with transfers to w/c with use of mechanical lift (450/Medium/purple pad). Another section stated (typed as written): Resident requires total assistance with bathing, grooming, dressing, and bathing. There was documentation of education provided to Employees #20 and #79 on 10/08/13, after the resident fell , stating (typed as written): Resident must be in eyesight when on shower bed & siderails & wheels locked @ all times. Safety is always first. An interview was conducted with the Corporate Nurse Aide Instructor, registered nurse (RN), (Employee #140) on 10/17/13 at 10:25 a.m. She was asked if the State approved nurse aide training program used by the corporation included instruction regarding the use of shower equipment, and supervision of dependent residents in bathing. She said it did, and provided items used in the training entitled, Safety measures for tub baths and showers. These instructions included the statement, Do not leave weak or unsteady persons unattended. This was also included on a post test. The Mosby's Textbook for Nursing Assistants, the primary resource utilized in nurse aide training classes at the facility, included instructions for safety. On page 342 there were instructions to: Protect the person from falls, chilling and burns. Instructions on page included: . lower the sides to transfer the person from the bed to the trolley. Raise the side rails after the transfer. The curriculum for the nursing assistant training program included both written post tests for each section as well as required return demonstrations of tasks, including transfers and bathing. Review of records found test eligible Nursing Assistant #79 received her training at the facility using this curriculum just prior to her hire date of 08/19/13.",2016-10-01
8084,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2013-10-24,224,E,1,0,3OEW11,"Based on record review, staff interview, and review of facility complaints and concerns, the facility failed to develop and implement policies and procedures which ensured four (4) of sixteen (16) residents reviewed were free from neglect by nursing personnel. Agency personnel were not provided orientation or supervision to ensure residents were not neglected due to lack of knowledge regarding the care and services which were necessary to meet the needs of each resident. This affected Residents #68, #99, and #18. In addition, the care for Resident #3 was not monitored to ensure he/she was not neglected. The assigned nursing assistant (NA) left the premises and no one was reassigned to care for the resident. Resident identifiers: #68, #99, #18, and #3. Facility census: 100 Findings include: a) Resident #68 Review of the concern forms, on 10/01/13 at 9:57 a.m., revealed a concern from this resident dated 08/30/13. The resident asked for the bed pan and a nursing assistant (NA) told her to just go in her brief, and she would change her. The NA wrote a statement confirming this had occurred. Review of the corrective action for the incident revealed documentation which stated inadequate training. It also contained a note which read, Great need to give oversight to agency staff to ensure the plan of care was carried out appropriately. b) Resident #99 Review of the concern forms, on 10/01/13 at 8:55 a.m., revealed an allegation the resident did not receive a shower for four (4) days. The concern, dated 08/14/13, indicated staff told the resident they would give her a shower, and did not return. The incident was investigated and substantiated. According to the report, the agency NA documented she provided care, but did not. c) Resident #18 Resident #18 alleged, on 08/29/13, Employee #38 (NA) and Employee #131 (agency NA) had not changed his brief since the previous morning. Employee #38 (NA) was educated on 08/30/13 to check the Kardex daily. She had worked the 3-11 shift. The agency NA, was responsible for the provision of services between 11:00 p.m. and 7:00 a.m. In her statement, she said she had not received training, and was not aware the resident required check and change every 2 hours. d) An interview with the director of nursing (DON), on 10/24/13 at 8:00 a.m., revealed no written information was provided to agency NAs prior to provision of care. She said they made rounds with the nursing assistants, and that was the orientation. The DON said the facility did not have a policy regarding the utilization of agency services and/or training needs. She further added, no form or checklist was utilized to ensure the agency nursing assistants and/or nurses received the information required to care for the residents. e) An interview was conducted with Employee #147 (agency NA) and Employee #154 (agency NA), on 10/24/13 at 4:30 p.m. Employee #154 said she didn't really get any training when she started working at the facility. She said she .would get a run down on the residents. The NA described a run down indicated transfer and toileting status, turn every two (2)hours and other activity of daily living information. Employee #147 said, I got no training. They said here is your assignment, go. f) On 10/23/13, at 8:30 a.m., Employee #127 (administrator) provided concern forms, which she said had generated from a meeting (called resident council) with the ombudsman on 09/23/13. They included resident concerns with staff turnover and agency staff attitudes. g) Resident # 3 Review of a mandatory reporting form, on 10 /24/13 at 1:00 p.m., revealed Resident #3 who resided on the Nutter Fort Hall, was left soaking wet (incontinent of urine) from 7:00 p.m. to 9:00 p.m. on 09/24/13. The daily assignment sheet, reviewed on 10/24/13 at 1:10 p.m., revealed Employee #64 was assigned to Resident #3 from 3:00 p.m. to 11:00 p.m. on 09/24/13. Review of the time detail, on 10/24/13 at 3:30 p.m., revealed Employee #64 left the facility at 7:00 p.m. on 09/24/13. An interview was conducted on 10/24/13 at 4:45 p.m., with Employee #136, a nurse supervisor licensed practical nurse (LPN). When asked who provided care for Resident #3 after Employee #64 left the facility, she stated no one was responsible for caring for this resident from 7:00 p.m. until around 8:30 p.m. She stated an NA from Jackson Hall was asked to come to Nutter Fort hall to help around 8:30 p.m. that night. On 10/24/13 at 3:35 p.m., review of a progress note for 09/24/13 revealed Employee #46, an LPN, changed Resident #3 at 9:00 p.m. The noted stated Resident #3 had been left soaking wet. During an interview on 10/24/13 at 4:10 p.m., with Employee # 55 , DON, when asked who provided assistance to Resident #3 on 09/24/13 from 7:00 p.m. to 8:30 p.m., she confirmed no one provided care for the resident during this time period.",2016-10-01
8158,CRESTVIEW MANOR NURSING & REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2013-09-05,224,D,1,0,F9PM11,"Based on observation, record review, staff interview, and policy review, the facility failed to ensure one (1) of four (4) residents reviewed was free from neglect. the resident was not provided the necessary care and services to avoid potential physical harm. Resident #4 was unsupervised while outside on the patio, which resulted in injuries to bilateral lower forearms that required treatment. Resident identifier: #4. Facility census: 66. Findings include: a) Resident #4 Observation, on 09/04/13 at 4:45 p.m., revealed Resident #4 was receiving treatment to both lower forearms by Employee #18, the director of nursing (DON), in the activities room . During an interview on 09/04/13 at 4:46 p.m., with Employee #18, she revealed the resident had an accident while out on the patio deck. Employee #18 stated she was not sure at this point how Resident #4 injured himself. She stated by reviewing the video recording, she would know how the resident received his injuries. Observation of the video recording, on 09/04/13 at 5:50 p.m., with Employee #18, revealed the resident was outside on the patio being supervised by Employee #46, an activity assistant (AA). The resident was wheeling himself down the sidewalk beside the building. The video only showed the resident wheeling himself down the sidewalk, but not how he injured himself. The DON confirmed after watching the video that Employee #46 was not supervising this resident. An interview was conducted with Employee #46 and Employee #18 on 09/04/13 at 5:55 p.m. Employee #46 revealed she was responsible for supervising the residents out on the deck. She stated she did not see the resident going down the sidewalk because the pillars were in the way. Employee #18 asked her when the resident was out of her site, should she have gotten up and to see where the resident was? Employee #45 confirmed she should have gotten up and gone to see where the resident was, but did not. Review of the care plan, on 09/04/13 at 6:30 p.m., revealed an intervention dated 10/26/12, stating to allow the resident to sit on the back patio with supervision, if weather permitted. A statement written by Employee #72, activities, on 09/05/13 at 11:00 a.m., stated she went on the back patio to get people in for dinner. Employee #40 yelled for help with Resident #4 because he had himself braced on his forearms on the railing at the end of the sidewalk. Review of a Consecutive Employee Warning Report, on 09/05/13 at 11:05 a.m., revealed Employee #40 had reviewed a disciplinary report with Employee #46 on 09/04/13. The report described the violation of a failure to supervise the resident on the back patio as care planned, which resulted in Resident #4 requiring treatment to his arms. Employee #46 stated she knew he was to be supervised. He was on the patio, but she failed to keep eye contact with the resident. She stated she was talking with two other alert/oriented residents about their dogs. Review of the adult protective service mandatory reporting form, on 09/05/13 at 11:07 a.m., revealed Employee #40, activity supervisor(AS), documented evidence under describe incident/injuries: Neglected to supervise resident while outside per plan of care. Resident wandered away in a wheelchair, down the sidewalk and ran into the sidewalk rail. Did not fall, but ran his arms in the rail, causing him to have skin tears. Review of the facility's policy, on 09/05/13 at 11:10 a.m., revealed the facility had a policy under neglect, which identified neglect as a failure to take precautionary measures as ordered to protect the health and safety of the resident, and failure to provide services that resulted in harm.",2016-09-01
8189,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2012-05-18,224,G,0,1,6XWO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to implement written policies and procedures to prohibit neglect for one resident (resident #28) of 3 residents sampled from 8 residents identified by the facility to have had a fall and/or fracture in the last 30 days. Findings Include: Resident #28 was admitted on [DATE] with [DIAGNOSES REDACTED]. Review of the most recent quarterly Minimum Data Set (MDS) dated [DATE], revealed the resident was totally dependent on two or more staff for physical assistance with transfers. Review of the care plan for Transfers dated August 3, 2011 revealed the resident has a potential for injury and impaired ability to self-transfer. The resident requires use of full body mechanical lift and 2 person assistance with transfers to/from bed and chair. The care plan goal was for the resident to be transferred with identified transfer devices/assistance through next review on July 10, 2012. Review of the Resident Care Cardex which outlines relevant resident care needs revealed the resident requires use of a LBGC (Lean Back Geri-Chair). A change of condition form was completed on April 29, 2012 due to increased pain and decreased range of motion. A physician's orders [REDACTED]. Nurse's Notes on April 29, 2012 also document the change of condition. The radiological report, dated April 29, 2012, could not exclude a fracture/dislocation. Recommended were repeat images or a CT (computed tomography). Documented on the report was notification to the physician and his instructions to continue to monitor. A change of condition form was completed on May 2, 2012 due to redness and warmth of the right leg. Physician orders [REDACTED]. [MEDICAL CONDITION] was ruled out. Physician orders [REDACTED]. Nurse's notes on May 3, 2012 documented increased pain to right hip and decreased range of motion. A physician's orders [REDACTED]. The CT report, dated May 4, 2012, revealed the presence of a spiral type fracture involving the distal tibial diaphysis with mild medial angulation distally and an additional oblique fracture involving the distal fibular diaphysis also demonstrating mild medial angulation distally. Following the confirmation of an injury of unknown origin, the facility initiated an investigation. The preliminary investigation revealed on April 27, 2012, a Certified Nursing Assistant (CNA) employee #110 had inappropriately transferred the resident during a shower. Furthermore, it was discovered the employee had failed to assess for correct placement of the right foot and the resident's foot was caught under the footrest of the geri-chair. At the time of the incident, the employee reported to the nurse the resident complained of pain to the foot, yet, but did not report the incident of the foot getting caught in the chair. Observations of the resident on May 14 and 17, 2012 were conducted. The resident was observed in bed with a geri-chair next to the bed. An interview with Certified Nursing Assistant (CNA) employee #110 was conducted on May 17, 2012. Employee #110 stated on April 27, 2012 he gave resident #28 a shower. At the time of the shower, he failed to transfer the resident per her plan of care. Specifically, he failed to use a mechanical lift during transfers. Employee stated he had not verified resident #28's care requirements on her care plan nor on the resident care cardex prior to the transfer. Also, employee #110 stated when he changed the position of the Lean Back Geri-Chair, the resident got her foot caught under the footrest of the geri-chair. Employee #110 stated the resident complained of pain to her boot (understood to mean foot). He reported to the Licensed Practical Nurse (LPN), employee #170, the resident had complained of pain, however, he failed to report the resident had caught her foot under the footrest of the geri-chair. Furthermore, during same interview, employee #110 shared his perception that he failed to provide the necessary care and services the resident required for proper transferring and failed to report to the nurse an accident/incident involving the resident's foot. An interview with LPN employee #170 was conducted on May 17, 2012. She stated on April 27, 2012, employee #110 reported to her resident #28 complained of pain during the shower. She stated she then assessed the resident's foot and it appeared within normal limits. She then medicated the resident with her routine scheduled pain medication. Interviews were conducted with the Director of Nurses (DON) and the Assistant Director of Nurses (ADON) on May 17, 2012. The DON and the ADON summarized the results of the investigation into the injury (fracture) of unknown origin and concluded on April 27, 2012, employee #110 did not use a mechanical lift for transfers as indicated and had not verified placement of the foot prior to changing the position of the Lean Back Geri-Chair. The resident caught her foot in the gap of the footrest which likely resulted in the fracture identified days later. Staff also concluded employee #110 had failed to report the incident to the nurse at the time. Review of the facility's Abuse & Neglect Prohibition policy states each resident has the right to be free from mistreatment, neglect, abuse, involuntary seclusion and misappropriation of property. Neglect means failure to provide goods and services neccessary to avoid physicial harm, mental anguish, or mental illness.",2016-07-01
8920,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2011-12-08,224,D,0,1,NP7N11,"Based on observation, staff interview, and review of job descriptions, the facility failed to ensure four (4) of four (4) residents seated in the dining room on the 2B unit of the facility received the necessary care and services to avoid potential physical harm and/or mental anguish. The facility failed to assure these residents were monitored on this behavioral unit. Residents #21, #35, #22, and #41 were left unsupervised while the staff member, who was assigned to monitor the residents, was found soundly sleeping and drooling while seated in the dining room. Resident identifiers: #21, #35, #22, and #41. Facility census: 90. Findings include: a) Residents #21, #35, #22, and #41 A random observation of the 2B dining room, on 11/28/11 at 11:05 a.m., noted four (4) residents were seated throughout the dining room. Further observation noted a facility staff member was seated in a chair against the left wall of the dining room. The staff member had her head propped up with her right hand and was soundly asleep. She was drooling from the right side of her mouth. The staff member was awakened. She jerked upright, wiped the drool from her chin and stated, I wasn't asleep. When asked her name, she identified herself as Employee #83 and stated she was employed as a monitor. This observation was immediately reported to the charge nurse, licensed practical nurse (LPN) Employee #160, and the unit manager, registered nurse (RN) Employee #59. ------------ The assistant administrator, Employee #12, provided a job description for the position of monitor. The position description identified the official title of hospitality aide. Under the heading of Nature of Work, was found the following, The Hospitality Aide is a member of the nursing service team. This individual performs in the clinical environment under the supervision of an RN or LPN, contributes to his/her assigned resident's plan of care by observing specific needs and reporting to charge nurse and/or the shift supervisor. The Hospitality Aide provides no hands-on care to the residents. ------------ Employee #83 was interviewed at 11:45 a.m. on 11/28/11. She identified herself as a facility monitor and was noted to be seated outside a resident room. She was asked what her job duties consisted of. She stated that she was supposed to monitor the environment to see if residents needed assistance, got into altercations, or otherwise needed help. She stated that she reports to the nursing staff when she sees residents who need assistance.",2016-03-01
9002,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-02-07,224,G,1,0,G0P011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, family interview, and hospital record review, the facility failed to ensure residents were free of neglect by failing to assess, monitor, and provide medical intervention timely for a resident who had worsening decubitus ulcers, and for two (2) dependent residents who were incontinent. Three (3) of fourteen (14) sampled residents were found to have evidence of neglect. Resident identifiers: #89, #71, and #78. Facility census: 118. Findings include: a) Resident #89 Review of a 01/02/13 nursing progress note revealed this resident was noted to have reddened areas to bony prominences to bilateral lateral hips. The physician was made aware. Review of a 01/02/13 physician's orders [REDACTED]. Review of Section M of the Minimum Data Set (MDS), with an assessment reference date (ARD) of 01/16/13, revealed this resident had two (2) Stage I pressure ulcers. Review of the medical record found no evidence of any further assessment and monitoring of the reddened ischial tuberosities from 01/02/13, at their discovery, until after the resident was seen in the emergency roiagnom on [DATE]. Review of a nurse's progress note, dated 01/24/13 at 6:04 a.m., revealed a nursing assistant had found blackened areas on foot during the resident's bath. The nurse assessed has 3 areas on right foot lateral side 1st is 1 inch below 5th toe that measures overall 4 cms (centimeters) with 2.3 x 1 cm blackened area. 2nd is 1/2 inch above that is 2 cm in length with 1/2 cm x 1 cm area that is blackened and 3rd is directly over talus lateral ankle that is red. Anterior surface of foot is slightly [MEDICAL CONDITION] . Prevalon boots applied. MD notified. Will have day nurse call POA (power of attorney). Review of a nurse's progress note, dated 01/24/13 at 11:57 a.m., found an order from the attending physician to send the resident to the emergency room for evaluation and treatment of [REDACTED]. Review of the hospital's emergency room record and attending physician's assessment, dated 01/24/13, revealed this resident was assessed as having Stage 2 decubitus ulcer ischial tuberosity on left. Larger stage 2 decubitus ulcer over the right ischial tuberosity and in the center that has black eschar. The physician also assessed areas along the lateral border of the right foot, primarily over the base of the 5th metatarsal and along (the) metatarsal head both of which have central areas of skin necrosis. The physician recommended that this resident be referred to the wound care center for follow-up, and scheduled an appointment for 01/30/13 at 8:30 a.m. Review of a Concern Form, dated 01/25/13, revealed the family of Resident #89 had met with administrative staff. The form included, . (Resident ' s name) was unable to D/C (discharge) home with family on 1/25/12 due to a decline in his health and a pressure area to his R (right) hip that has gotten worse. The facility follow-up included placing Resident #89 on a flap care bed to encourage more aggressive potential for wound healing, and for the resident to be evaluated by the wound team. Review of a nurse's progress note, dated 01/25/13, revealed this resident had five (5) pressure ulcers, with three (3) of the five (5) located on the right foot. The nurse noted a Pressure ulcer to proximal metatarsals with necrosis 2.4 x (symbol for by) 1.1 cm. R (symbol for right) lateral foot noted with necrosis .5 x (symbol for by) .5 cm. and R (symbol for right) tallus noted with increased non-blanchable reddened area .2 x .(symbol for by) .5 cms. R (symbol for right) hip noted with necrotic area 3 x (symbol for by) 6 cm, dry L (symbol for left) hip noted with eschar and scab that measured 2.4 x (symbol for by) 6 cm. dry skin. Review of a social service note, dated 01/25/13, by a former social service intern, revealed that the resident's family member stated she is angry about the circumstances that have come about regarding finding necrotic areas on this resident's skin. Review of a significant change MDS, with an ARD of 01/31/13, found the resident was assessed with [REDACTED]. The largest area had measurements of 3.0 by 6.0 centimeters. During an interview with a nurse, Employee #23, and the administrator, on 02/06/13 at 6:00 p.m., they were asked if they had any further information about when the reddened area on the ischial tuberosities had declined, or when they were staged or measured prior to the emergency room visit, or when those areas became necrotic or had scabs or eschar. They had no answers to these question. No evidence was produced prior to exit to indicate that ongoing monitoring and assessment had been done. During an interview with the former treatment nurse, Employee #138, on 02/07/13 at 2:20 p.m., she said in her assessment on 01/25/13 of the ischial tuberosities, the right hip had necrotic tissue and was black in color, but not open. It was 3.0 cms x 6.0 cms. During an interview with another nurse, Employee #110, at that time, she said this area was still blackened and about the same. In an interview with the Administrator, on 02/07/13 at 12:30 p.m., she said they had held another Ad Hoc meeting on 01/18/13 where they identified during an audit that pressure ulcers were a problem area. During a second Ad Hoc meeting on 02/01/13, she said they identified problem areas related to skin. She said a skin sweep was completed on all the residents on 01/29/13 (which was verified by surveyor), and PUSH tools were completed for every skin area by 01/31/13. They had another skin sweep scheduled for 02/05/13 and 02/06/13. Also, they were transitioning to a wound team comprised of four (4) registered nurses, rather than their former method of one licensed nurse and the Director of Nursing. They were interviewing for a new wound nurse. She said they were in the process of completing staff education for the nurses and nursing assistants. Also, they had various types of mattresses, and changed out two surfaces for upgrades. b) On 02/05/13 at 8:15 a.m., a list of concerns/grievances was requested for the months of January and February, including any and all that had yet to be resolved. The administrator provided a log of concerns/grievances completed, which was dated through 02/02/13. She indicated no other concerns/grievances had been completed and no others were outstanding. 1) Resident #71 Review of Resident #71's medical record, on 02/05/13 at 2:30 p.m., revealed she had a concern with incontinence care on 02/03/13 at 09:14 a.m. A skilled progress note related the resident's husband had approached the nurse in the hallway at 8:14 a.m., stating his wife had not been cleaned from a bowel movement that had occurred prior to 6:00 a.m. It noted staff were in Resident #71's room and had advised the resident, while trays are being passed we can not change people, however, as soon as trays are finished she will be the first one changed. The nurse indicated the resident was satisfied at that point. The nurse further added, At 0700 (7:00 a.m.) housekeeping had approached her and advised the patient wanted cleaned up. She noted at 0806 (8:06 a.m.) patient was washed up by CNA (nursing assistant) on the floor. Educated pt on call bells and use of how to get help. Patient stated she told night shift nurse she needed cleaned and night shift did not come back into room. Patient's husband asked who he needed to talk to about getting resident to another facility. Advised social services will be in tomorrow a.m. and I will let them know as well they wanted to speak to social services. Pt husband asked why there were not barrels in each room like the hospital. Explained infection control and how the facility operates. Another note, dated, 02/03/13 at 10:11, related staff, Checked with patient . Advised this nurse made a note on the incident that occurred and note placed on social services door for Monday morning. Patient advised, ask for nurse personally if there are any issues today. During an interview with Resident #71, on 02/05/13 at 5:15 p.m., she related, I asked the girl to clean me up and she said she wasn't allowed. A lady, a little bit before six came in and changed me. I had a bowel movement a little bit after that. Sometimes I can tell and sometimes I can't tell If I have to have a bowel movement. It's the same way with the urine. I rang the bell at 6:15 a.m. Later, the lady brought in her breakfast (pointed to roommate). I asked her, when you get finished can you come back and change me. She didn't answer yes, or no, maybe, or anything. I kept laying and laying and laying. No one ever came. She had finished her breakfast and I still hadn't got breakfast and was still laying in a mess, so I called my husband and he came down here and raised hell. They said they would write her up. I know she has friends she works with and they might do something to me. I haven't seen her since. No one came in before my husband got here. He asked me, have you been changed yet, and I told him no. When asked if she knew the name of the staff member, she stated, I think I would know her if I saw her. She further added, to my knowledge, nobody came to see me. This is the first I heard about it again, since the incident. The resident's spouse was interviewed on 02/05/13 at 6:00 p.m. He stated, I was home and I got a call at 8:00 in the morning. She said I need you to come out here. I've been here for 2 hours waiting on someone to change my diaper. I spoke with (Employee #128's name), my wife has been here for 2 hours waiting to get her diaper changed. She told me that they don't do those services. She said breakfast started at 7:00 a.m. We have to deal with cross contamination. She said I would have to talk with (Employee #110's name). The patient advocate, she has blonde hair, (identified as Employee #79) was sitting at the nurses' station. I asked (Employee #79's name) about the concern and she said she would investigate it. She said she was going to have to instruct the staff. Resident #71's spouse added, another incident is the bedpan. I went into the bathroom and it had fecal matter all over the bedpan. I spoke with (Employee #79's name) about this also. He further added, when (name of Resident #71) was admitted to the facility, the hospital had just removed the catheter. He further added, She had it for 28 days, from December 26, 2012 to January 24, 2013. The facility should know she would require bladder retraining. Upon inquiry, Resident #71's husband said he was not aware of any toileting plan, and she would wet, two or three times, before being changed. The intervention/task form, completed by nursing assistants, was reviewed on 02/06/13. It noted the resident had received care at 3:49 a.m. No further entries were completed until 2:29 p.m. The 2:30 - 10:30 shift data, on 02/03/13, provided no evidence care had been provided on that shift. During an interview with the Employee #124, on 02/06/13, she reviewed the concern form and said she had never heard anything about that. She added, Waiting three hours, that is on the lines of neglect, I would think. This is the first I heard about it. I've had no concerns at all with this family. The social work intern reported she was not aware, either. 2) Resident #78 The facility concern log was reviewed on 02/06/13 at 8:00 a.m. It noted Resident #78's daughter had reported a concern on 01/07/13. It indicated, on Friday 01/04/13, the resident was soiled and patient stated he had been sitting in it all day. Evening aide cleaned him up and stated it was dried on. Family states it was running down his leg into his shoe. Review of the medical record, on 02/06/13 at 8:05 a.m., reveal an order dated 12/31/12. It read, cleanse excoriation to scrotum et coccyx after each incontinence episode and apply z guard. The care plan was also reviewed. It noted At risk of urinary incontinence related to history of incontinence, cognitive deficit, communication deficit, impaired mobility, physical limitations and diabetes. At risk for complications: goal maintain in as clean and dry dignified state as possible. Interventions included, Urinal with in reach, assistance with toileting, incontinent care as needed, remind and assist as needed upon rising before and after meals activities therapy and bedtime. Additionally, a general progress note, dated 01/06/13 at 5:38 a.m., indicated the resident is incontinent of bowel and bladder. Perineal area and scrotum macerated due to constant wetness . During an interview with Employee #40 (nursing assistant), on 02/06/13 at 9:50 a.m., she stated, he requires assist of one and she had to help him when she assisted with toileting. Resident #78 was interviewed on 02/06/13 at 10:00 a.m. He said he remembered the incident and stated, I was having a lot of problems back then. He said he still requires assistance, sometimes. Observation of the room revealed he did not have a urinal within reach. Upon inquiry with Employee #83 (licensed practical nurse), she said they are kept in the bathroom and the residents asks for them, because they tend to make a mess. The care plan was reviewed with the LPN. She confirmed it noted the urinal was to be within the resident's reach. The resident's room was then observed by the nurse and she verified the urinal was not within the resident's reach. She checked the bathroom and stated, it isn't in here either. Employee #124 (social worker), reviewed the concern form regarding incontinence management. Upon inquiry, she stated, yes, I would report it. When asked whether it had been reported, she said, no. She further added, I know it wasn't reported.",2016-02-01
9035,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2013-03-14,224,F,0,1,RKHC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of policy and procedures, review of incident reports, and staff interview, the facility failed to implement their written policies and procedures regarding neglect. Resident #222 was not administered insulin as ordered by the physician, resulting in harm. When the facility became aware of the situation, their written policies and procedures for abuse/neglect were not implemented. The facility did not recognize the incident as neglect, did not report the incident, and did not investigate the incident. The facility's policy contained directives regarding each of these tasks. This practice affected Resident #222, but had the potential to affect all facility residents. Resident identifier: #222. Facility census: 113. Findings include: a) Resident #222 An incident report regarding this resident, dated 12/14/12 at 1:25 p.m., was reviewed. It described a medication error-omission. The documentation included, CNA reported resident to be vomiting large amount of brown emesis. Upon checking blood sugar it was 838 with a new order for insulin per order and recheck in 2 (two) hours. Upon reassessment of blood sugar it was resulted in a high reading. Resident was then sent out for assessment to (the hospital). Upon further investigation it was discovered that the resident had no orders for SSI (sliding scale insulin) and had not up until this point had orders printed off for his insulin. Resident had been without his insulin from 12/11/12 until this point. During an interview with Employee #87, a registered nurse, on 03/12/13, she stated she completed the incident report when this issue was discovered. She stated facility staff thought the resident got his insulin because his insulin vial was open in the medication cart. Employee #87 said facility staff thought it was given, and had just not recorded it on the resident's medication record. She was unable to provide evidence an investigation was completed to further explore this incident. Medical record review revealed the resident was admitted to the facility on [DATE]. His discharge instructions from the hospital, dated 12/11/12, included instructions for the resident to receive Insulin [MEDICATION NAME] ([MEDICATION NAME]) 100 unit/ml solution 45 units subcutaneous daily every evening. This was verified and ordered by the physician at the nursing home. In addition, the physician at the nursing gave instructions to Notify the MD (medical doctor) if blood sugar less than 60 or greater than 400. The Medication Administration Record [REDACTED]. Also, the MAR indicated [REDACTED]. On 12/14/12 at 19:38 (7:38 p.m.) the resident's blood glucose was at a critical level. It was 838 mg/ml (normal glucose level 70-108 mg/ml). A nursing entry, dated 12/14/12 at 8:00 p.m., noted the physician was aware of the blood glucose level of 838. New orders were received for, 20 units of [MEDICATION NAME] R (regular) x (times) 1 (one) Now and recheck in two (2) hours if over 400 give 10 units if under 400 use s/s coverage. New order was also received for accu-checks TID (three times a day) with meals use sliding scale coverage per orders. At 11:45 p.m. on 12/14/12, another nursing note indicated, Resident given regular insulin at 8:00 p.m. finger stick still registered HI at 10:00 p.m. Physician made aware order to send resident to the hospital for [MEDICAL CONDITION]. The resident was admitted to the hospital with [REDACTED]. Review of the facility's policies regarding neglect revealed the facility's definition of neglect was accurately defined: Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. At the time of the survey, the facility was aware of the situation with Resident #222, but had not identified the situation as neglect. As a result of the facility's failure to identify neglect, the facility also failed to implement the following procedures contained in their abuse prohibition policy: 1. The administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect . 6. Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will: 6.1 Report as follows . 6.1.1 OHFLAC Long Term Care Department of Health and Human Resources (DHHR) electronically via OHFLAC Facility and Nurse Aide Reporting Portal. 6.1.2 DHHR Adult Protective Services (APS) . 6.1.3 Ombudsman Program . 6.2 Conduct an immediate and thorough investigation that focuses on: 6.2.1 whether abuse or neglect occurred and to what extent; and 6.2.3 causative factors; and 6.2.4 interventions to prevent further injury. 6.3 The investigation will be thoroughly documented and recorded on the Center log. Ensure that documentation of witnessed interviews is included (refer to #8.1 - #8.3 below). 8. The Administrator or designee will report findings of all completed investigations within five days to: 8.1 The local OHFLAC Long term Care Program, electronically via OHFLAC Facility and Nurse Aide Reporting Protocol. At the time of the survey, the facility had not implemented any of the components of their Abuse policy regarding the incident with Resident #222.",2016-02-01
9112,SHENANDOAH CENTER,515167,50 MULBERRY TREE STREET,CHARLES TOWN,WV,25414,2013-02-12,224,G,1,0,8F5011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of incident reports, staff interview, resident interview, and family interview, the facility failed to ensure each resident was free from neglect. Two (2) of seven (7) residents reviewed for falls were not provided care and services necessary to prevent physical harm. A paraplegic [MEDICAL CONDITION] fell out of bed while care was being provided, and sustained a significant injury. Appropriate interventions were not initiated until after the resident had a fall resulting in a serious injury which required surgery. Another resident fell when left unattended in the bathroom. The resident's minimum data set (MDS) assessment prior to the fall noted the resident required extensive assist of one for transfers and required staff assistance when moving (including on and off the toilet) due to unsteadiness. The MDS indicated the resident required extensive assist (weight bearing) of one with toileting. Resident identifiers: #71 and #20. Facility census: 73. Findings include: a) Resident #71 [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 11/14/12, revealed she was coded for bed mobility as totally dependent. She required a two+ person physical assist to complete this task. She scored a 15 (fifteen) on the Brief Mental Assessment (BIM), the highest score possible to attain, which signified that she was cognitively intact. An incident report, dated 01/19/13 at 2:25 p.m., was reviewed. It revealed Resident #71 slid out of bed onto the floor while one (1) aide, Employee #97, was providing incontinence care for her. She was transferred to an acute care facility at 2:40 p.m. From there, she was transferred and admitted to another acute care hospital, where she underwent surgery to repair a fractured right femur that was sustained from the fall. Review of a nurse progress note, dated 01/20/13 at 8:38 a.m., as a late entry for 01/19/13 at 2:25 p.m., revealed the resident was found on the floor next to her bed, with her head at the foot end of the bed, and lying on her back. The nurse assessed the resident was alert at the time of the incident. The resident's November 2012 care plan revealed no specific guidelines related to the number of persons required to assist with transfers and turning, but did say nursing assistants (NAs) were to provide care for her in pairs. During an interview with the administrator, on 02/11/13 at 11:45 a.m., she said this resident had been a one-person assist for activities of daily living (ADL) and hygiene prior to her fall on 01/19/13. She said aides were to care for this resident in pairs due to safety needs of the aides, as this resident had been known to make untrue allegations in the past, and had exhibited attention seeking behaviors toward staff. An interview was conducted with the resident on 02/11/13 at 12:30 p.m. At that time, she alleged Employee #97 assisted her to bed on 01/19/13 with the Hoyer lift, with no other staff assistance. She said the aide did not place her up high enough in the bed during the Hoyer lift transfer, and she had little of the left upper side rail to hold on to. She alleged the aide refused assistance from other staff twice, and proceeded to clean and help the resident turn, with no other staff assistance. The resident alleged the aide had accidentally flipped her out onto the floor after she told the resident to turn onto her left side, and then pulled quickly on the pad beneath her. The resident said since her return to the facility, after having surgery to repair the fractured right femur sustained from the fall, there were always two (2) staff present when turning her because she had to be log rolled. Also, she said since the accident, staff now always raised the lower left rail when they were turning her until she was repositioned. Confidential staff interviews, with twelve (12) nursing assistants on two (2) shifts, on 02/11/13, found that seven (7) of those interviewed acknowledged this resident was able to assist with turning during care, and only one (1) staff member was required for this task prior to her fall on 01/19/13. Five (5) of those interviewed reported that prior to the fall, they always used two (2) people to help with the turning and repositioning of this resident. They unanimously agreed that since the fall on 01/19/13, they now always used two (2) staff members for turning, repositioning and cleaning this resident. In addition, they now raised the left lower rail when turning her onto her left side. The upper rails were always left raised. Review of the current care plan revealed a revision, dated 01/23/13, to raise the left lower side rail when giving care or turning the resident, otherwise it was to be down. On 02/11/13 at 3:00 p.m., the administrator produced an in-service education agenda, dated 01/24/13 and signed by the Director of Nursing, noting that a third side rail had been added to the left side of Resident #71's bed at the bottom. When rendering care to her, both rails at the top of the bed, in addition to the bottom left side of the bed, were to be raised. After care had been completed and the resident positioned in bed, the bottom rail might be lowered. This will assist in keeping her leg from coming off the bed when turning her to the left side during care. The sign-in sheet contained signatures of 35 NAs. A second in-service education agenda was signed and dated by the Director of Nursing on 01/29/13. In it, she directed that two (2) people were to turn and reposition Resident #71. The use of the third side rail on the left side of her bed was to be up when turning and repositioning, then lowered after the repositioning was complete. Also, pillows were to be placed between the legs when turning her (log rolling), and utilizing the draw sheet to turn her as a unit. The sign-in sheet was signed by thirteen (13) registered nurses, eight (8) licensed practical nurses, and thirty-one (31) nursing assistants. Review of the current care plan revealed a revision, dated 01/30/13, for a pillow to be placed beneath the resident's right leg when turning to stabilize the leg, and to turn her utilizing the log roll method to keep the leg in position. b) Resident #20 The roster/sample matrix, printed 02/11/13, was reviewed on 02/11/13 at 11:00 a.m. Resident #20 was noted to have fallen. Review of the incident reports revealed a fall occurred on 11/26/12. Further review of the incident report, dated 11/26/12, revealed the resident had been left unattended in the bathroom. The nursing assistant related she had left the resident unattended while obtaining supplies. The medical record, change in condition progress note, dated 11/26/12, noted the resident had fallen in the bathroom. It also noted a loss of balance, with lower extremity weakness. Further review of the change in condition progress notes revealed a history of falls. The physical therapy evaluation, completed on 11/28/12, was reviewed with Employee #98 (Physical Therapist.) She said the evaluation indicated Resident #20 required assistance with transfers. During a resident observation, on 02/11/13 at 10:15 a.m., Resident #20 was propelling herself in her wheelchair. She was going from room to room, searching for her daughters. Resident #23 said, she's confused. The resident was again observed on 02/11/13 at 11:20 a.m. She was visiting with a family member. She was not oriented to place or time. Another observation, on 02/12/13 at 8:00 a.m., revealed the resident lying in bed. She was alert and talkative. She was unable to relate place and time concepts. She could not state the season, month, or year. She did not know who was president of the United States. Review of the care plan, on 02/12/12 at 11:30 a.m., revealed the resident was easily distracted and had trouble staying focused. It also noted she had poor safety awareness and needed frequent reminding. The social services evaluation, completed on 11/05/12, noted the resident's BIMS score was 3 (severely cognitively impaired). A family member was interviewed on 02/11/12 at 11:19 a.m. She stated she was aware the resident had fallen. She said, it usually happens right around the 4:00 hour, when (Resident #20) gets agitated and nervous. She said the resident required assistance when toileting. She related the resident had fallen twice, recently. She said one incident occurred when she was on the potty. She said the resident told her, I fell in my sh__. She further added the resident probably didn't want to sit there any longer. Nursing assistant, Employee #17, was interviewed on 02/11/12 at 2:30 p.m. She said Resident #20 required assist of one (1) for transfers with limited assistance. She also stated the resident was at risk for falls, but had no fall precautions. Review of the medical record, on 02/11/13 at 5:00 p.m., revealed on 09/27/12, prior to the fall on 11/26/12, a lift-transfer-repositioning evaluation was completed. It noted the resident required the use of a gait belt for transfers. The evaluation noted the resident could not ambulate or transfer safely, independently, or without supervision. The MDS nursing assessment, completed on 11/05/12, indicated Resident #20 had fallen since the prior assessment. It also noted she had severe alteration in judgement. The MDS, with an ARD of 11/06/12, noted the resident required extensive assist of one for transfers. It also noted she was not steady, and only able to stabilize with staff assistance when moving from a seated to standing position; walking; turning around; moving on and off the toilet and surface to surface transfers. The MDS indicated the resident required extensive assist (weight bearing) of one with toileting. The physician's orders [REDACTED]. These included [MEDICATION NAME] (antidepressant), [MEDICATION NAME] (narcotic [MEDICATION NAME]), [MEDICATION NAME] (antipsychotic), [MEDICATION NAME] (diuretic), and [MEDICATION NAME] (narcotic [MEDICATION NAME]). Employee #46, a licensed practical nurse, (LPN) was interviewed on 02/12/13 at 7:54 a.m. She stated falls interventions depended on the care plan and the resident's cognition. She was unaware of a protocol for fall prevention when toileting a resident at risk for falls. On 02/12/13 at 7:58 a.m., Employee #16, a nursing assistant, was interviewed. When questioned about Resident #20's toileting protocol, she stated, We stay with her, because she is a fall risk. She gets up and down. We have to stay with them, because they get down and up, Resident #20, I'll have to look. She may need help, stated Employee #64, an LPN, on 02/12/13 at 8:05 a.m. She then reviewed the resident's activities of daily living (ADL) flow sheet, and stated, Yes, she is dependent on staff, they should have stayed with her.",2016-02-01
9163,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2013-01-23,224,G,1,0,71W211,"**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 neglect by failing to assess, monitor, and provide medical intervention timely, for an [AGE] year old resident with diabetes and an existing pressure ulcer when she developed a blackened area on her right great toe. There was no evidence of assessments or interventions until six (6) days after the initial identification. This delay had the potential to adversely affect the progression of the wound and comfort of the resident. Resident identifier: #119. Facility census: 118. Findings include: a) Resident #119 This [AGE] year old resident had [DIAGNOSES REDACTED]. She also had a had been receiving treatment for [REDACTED]. A progress note, dated 12/13/12, by Employee #126, a licensed nurse, identified the family's concern with the resident's great toe on the right foot. The nurse assessed the area, and noted a dark purple hematoma on toe. No evidence of any additional assessment or monitoring of the changes to the right great toe were found until six (6) days later on 12/19/12 at 5:47 a.m. On 12/19/12 at 5:47 a.m., a registered nurse (Employee #1), documented Resident has blackened area on right great toe and 4th great toe, her foot is [MEDICAL CONDITION] and cool. Skin of foot is red with striation . No dorsal or post tibia pulse appreciated with Doppler. Left foot has sore on 2nd toe . Will report to MD (doctor). In an interview with Employee #126, on 01/23/13 at 8:50 a.m., she said she had faxed the physician about the right great toe on 01/13/12, and verbally passed the information to the oncoming shift. She said the right great toe looked purple, it seemed to have been a sudden change, and had given the appearance of perhaps having been bumped. Employee #82 (registered nurse) was interviewed on 01/23/13 at 9:05 a.m. She said they kept copies of faxes sent to the physician in the physicians' mailboxes until they received a response. They would re-fax the physician if there was no response. All resolved faxes were filed in a book at the desk. This book was thinned on occasion when it was getting larger, and the older ones were shredded. Review of the resolved fax book, on 01/23/13 at 9:10 a.m., found the faxes in the book only went back to 12/20/12. An interview with the director of nursing (DON), on 01/23/13 at 1:45 p.m., revealed the first time the condition of the resident's right great toe had been placed on the 24-hour report was on 12/19/12. This was after Employee #1 had written the entry about the condition of the resident's toe and noted to call the doctor. The DON said an appointment was then made with the podiatrist, who saw the resident on 12/19/12 at 4:45 p.m. She could find no evidence to support a physician had been notified, or had evaluated the toe, between 12/13/12 and 12/19/12. The podiatrist's progress note, dated 12/19/12, noted Resident #119 had dry gangrene of the right hallux (big toe). He recommended the resident be seen by an orthopedic physician as soon as possible. According to the resident's record, her medical power of attorney had made an appointment for 12/27/12 with an orthopedic surgeon. However, due to an increase in the resident's level of pain, she was sent to a local hospital on [DATE], at which time she was admitted . According to a 12/25/12 nursing progress note, the resident was transferred for pain evaluation due to uncontrolled pain in the right lower leg. Review of the admitting hospital's medical records, revealed that upon admission the resident was found to have avascular (having few or no blood vessels) right great toe with a lot of pain and color changes, and gangrene due to secondary diabetes mellitus. An orthopedic consultation dated 12/16/12 revealed an impression of dry gangrene, right foot, and a recommendation for a BKA ([MEDICAL CONDITION]) right lower extremity. She underwent a right [MEDICAL CONDITION] on 12/27/12. Resident #119 had been admitted to the facility in November 2012 with a Stage II pressure ulcer to the right heel. This was the same foot on which the great toe had a blackened area. Record review found the absence of a weekly body audit on 12/11/12, with the most recent body audit having occurred on 12/04/12, and the next on 12/17/12. Neither noted the condition of the right great toe. Record review also found the absence of a weekly measurement and assessment of the pressure ulcer to the right heel on 12/20/12, with the most recent one having occurred on 12/13/12, and no other prior to her transfer to the hospital on [DATE]. Interview with licensed nurse Employee #81, on 01/22/13 at 9:30 a.m., found that every resident was to have a skin audit done weekly. Although they were usually done by the treatment nurse, the floor nurses were to do them in the absence of the treatment nurse. During an interview with the Director of Nursing (DON), on 01/22/13 at 2:45 p.m., she produced weekly body audit sheets dated 12/04/12 and 12/17/12 for Resident #119. She was unable to locate a body audit sheet for 12/11/12 at that time, or prior to exit. She said that body audits were to be done weekly.",2016-01-01
9197,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-06-08,224,G,0,1,MZQB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was madedo not resuscitate by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use (created on [DATE]) G -minimize skin breakdown risks (created on [DATE]) I - . Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. (created on [DATE]) - P -Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising (created on [DATE]) G -Will have no adverse effects (created on [DATE]) andWill maintain lab values within therapeutic range (created on [DATE]) I -Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care. (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P -At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION] created on [DATE]) G - Minimize risk for falls (created on [DATE]) I -Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE]). None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titledClinical Services FYI - Post Fall Evaluation (FYI File - [DATE] - Number 34): Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: . Medication a) Anticoagulant therapy . Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process. According to the directions on the neurological evaluation flow sheet:Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the residentmissed his chair and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed):resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning. The LPN also noted the type of incident as a(f)all without injury (or minor injury) . Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, andresident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest. Contrary to the information outlined above in the document titledClinical Services FYI - Post Fall Evaluation , Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. Tx (treatment) initiated to (L) elbow. Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot. An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written):Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue. At 6:00 p.m. on [DATE], another nurse wrote:Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results. At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded); at,[DATE] (no specific time recorded); and at,[DATE] (no specific time recorded) - On [DATE] at,[DATE] (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded(arrow pointing down) ROM to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded(arrow pointing down) R as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at,[DATE] on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at,[DATE] and [DATE] at,[DATE] . No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated:Resident brought back to facility . Resident also has large bruising area on buttocks D/T (due to) fall. After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases likeresting in bed with eyes closed;Resident resting quietly;resting quietly no acute distress; andresting in bed. There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. -I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes. - On [DATE] at 11:22 a.m. -Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware. (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. -New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow. - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement:Significantly different from previous result (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written):Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%. The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated:Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]. The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated:(Name of transport service) here to p/u (pick up) for ortho appt. There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm. The report read:The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding. He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma wasold and she did not relate it to the fall (even though the CT report indicated the subdural hematoma wasprobably old and that alarge amount of acute bleeding was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the residentwent bad in the ambulance and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma wasold, and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team'sright to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: Resting in bed with eyes closed. Easily aroused. Afebrile. Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain. There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility. The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed): . This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated . Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. Under t",2016-01-01
9398,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-11-15,224,E,1,0,TJP411,"Based on medical record review, staff interview, and a review of the reportable allegations of abuse and neglect, the facility failed to ensure female residents were free from inappropriate sexual behavior by a male resident. Resident #89 had displayed inappropriate sexual behaviors toward four (4) female residents. Resident identifiers: #4, #24, #84, #74, and #89. Facility census: 89. Findings include: a) On 11/14/12 at approximately 10:00 a.m., a review of Resident #89's medical record revealed this resident had engaged in sexually inappropriate behavior toward four (4) female residents. A review of the general progress notes revealed a note from a registered nurse dated 10/05/12 at 2:20 p.m. The note stated, RN was notified by laundry staff at 7:07 pm that elder was observed by her touching a female resident in a sexual and inappropriate way in activities DR (dining room). RN (registered nurse) redirected elder to his room. Female elder was unable to verbalize situation or defend herself from it, however, she did not show any apparent signs of distress from it. While RN was escorting elder back to his room, elder would try to approach other female residents and attempt to show them his (genitals). Elder was left in his room, lying down at that time while RN went to get direction from policy/protocols for situation. By 7:45 pm both aides working that side of East Hall (Employee #9 and Employee #80 CNA), reported to RN that elder had been observed in 2 separate female resident's rooms undressing them. One of the lady's gown was pulled completely off and lying on her abd (abdomen) while he was attempting to get her bra off her. Elder was attempting to pull of the other lady's gown when aide walked in the room and noted situation. Both aides informed me that there was another female resident that is A&O (alert and oriented) to psn (person) & is very aware of her environment. Per aides, this lady verbalized and displayed fear towards elder, and stated elder tried to get in bed with her and was acting 'inappropriately' with her. RN notified (named physician) by 8pm and received orders to send elder to (name of psychiatric unit). After the incident at 7:07 p.m., Employee #99 (RN) assisted the resident back to his room and left him unattended. The facility had no evidence to show Employee #99 had informed other nursing staff of Resident #89's behavior on 10/04/12. The facility had not made an effort to ensure the immediate safety of other female residents after a male resident had displayed inappropriate sexual behaviors. Consequently, the resident wandered out of his room and into the rooms of three (3) other females where he displayed inappropriate sexual behaviors toward them. Employee #96 (director of nursing) indicated the facility did not have documentation showing they had ensured the safety of the female residents during this time. Nursing documentation, on 10/05/12 at 5:03 p.m., showed the facility transferred the resident to a local inpatient psychiatric unit on 10/05/12. Employee #96 (director of nursing) stated the facility did transfer the resident to the local emergency roiagnom on the night of 10/04/12. However, the exact time of this transfer was not documented. Employee #96 verified the resident returned to the facility after this transfer. The hospital told the facility they would inform them when a bed on the hospital's psychiatric unit became available. It remained unclear as to what time the resident returned to the facility on the night of 10/04/12. The facility did not have evidence they monitored the resident's behavior after he returned on 10/04/12. However, there was no indication any further female residents were subjected to inappropriate sexual behaviors after the incidents on 10/04/12 between 7:00 p.m. and 7:45 p.m. Employee #96 and Employee #98 (corporate registered nurse consultant) confirmed Employee #99 no longer worked at the facility. They provided a copy of the substantiated allegations of sexual abuse completed by the facility. The facility confirmed the four (4) female residents were victims of sexual abuse by Resident #89.",2015-11-01
9551,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2009-11-20,224,E,0,1,5V2011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure residents received treatments as prescribed by their physicians. This was true for three (3) of twenty-one (21) sampled residents and six (6) random residents. There was no evidence these nine (9) residents received their scheduled treatments on 11/14/09 (7:00 a.m. - 7:00 p.m. shift) as prescribed by the physician. Resident identifiers: #16, #15, #24, #33, #42, #76, #78, #111, and #112. Facility census: 157. Findings include: a) Resident #16 Resident #16 was observed on 11/17/09 at 9:35 a.m. in his room. The treatment nurse (a registered nurse - Employee #122) was observed changing the dressing on his left lower leg. The existing dressing was observed to be dated 11/11/09. The treatment nurse confirmed the date on the dressing to be 11/11/09 and then removed the dressing which had been covering a skin tear. The area was observed to be scabbed over and free from any redness or drainage. The treatment nurse reviewed the November 2009 treatment sheet and reported the dressing was scheduled to be changed on 11/14/09. The treatment nurse reported the treatment was not initialed on 11/14/09, which would have indicated the treatment was completed as ordered by the physician. Resident #16's medical record, when reviewed on 11/17/09 at 10:30 a.m., confirmed the physician had ordered the following treatments: Cleanse area to (L) Shin with NSS, pat dry, apply OpSite Q3days (every three days) and PRN (as needed), Moisture Barrier to coccyx BID (twice daily), Moisture Barrier to ABD fold BID, and Check O2 SAT QS (every shift) if below 90% notify MD. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator (Employee #78), when interviewed on 11/18/09 at 4:35 p.m., stated the treatment nurse (Employee #122) reported the omission of the treatments to her, an allegation of neglect was reported to the State agencies, and the facility's investigation into this was ongoing. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #16 had been reported to the State agencies. The director of nurses (DON - Employee #165), when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. b) Resident #15 Resident #15's medical record, when reviewed on 11/17/09 at 2:10 p.m., revealed the physician had ordered the following treatments: Check SPO2 every shift and PRN notify MD if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #15's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #15 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. c) Resident #24 Resident #24's medical record, when reviewed on 11/17/09 at 2:20 p.m., revealed the physician had ordered the following treatments: Barrier cream to peri area and buttocks BID. Skin prep to bilateral heels QS D/T (due to) redness / soft. Abdominal binder at all times as tolerated, remove for care, and float heels while in bed, may remove for care. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #24's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #24 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. d) Resident #33 Resident #33's medical record, when reviewed on 11/17/09 at 240 p.m., revealed the physician had ordered the following treatments: Check O2 SAT QS and PRN, below 90% notify MD, Greers Goo to buttocks BID, [MEDICATION NAME] cream to thigh and ABD fold BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #33's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #33 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. e) Resident #42 Resident #42's medical record, when reviewed on 11/17/09 at 2:45 p.m., revealed the physician had ordered the following treatments: Moisture barrier cream to peri area and buttocks QS and PRN, Check placement of tab alert Q shift, Sensor pad to bed, check placement Q shift, and [MEDICATION NAME] cream 1% apply to entire back BID and PRN. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #42's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #42 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. f) Resident #76 Resident #76's medical record, when reviewed on 11/17/09 at 2:50 p.m., revealed the physician had ordered the following treatments: Aspercreme to (L) hip and neck BID, Mupirocin 2% - apply around suprapubic cathter TID (three times daily) until healed [MEDICAL CONDITION] ([MEDICAL CONDITION]-resistant Staphylococcus aureus). Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #76's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #76 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. g) Resident # 78 Resident #78's medical record, when reviewed on 11/17/09 at 3:00 p.m., revealed the physician had ordered the following treatments: Apply [MEDICATION NAME] lotion to feet QD (every day) and as needed, [MEDICATION NAME] 2.5% with [MEDICATION NAME] lotion apply to face BID. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #78's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #78 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. h) Resident #111 Resident #111's medical record, when reviewed on 11/17/09 at 2:15 p.m., revealed the physician had ordered the following treatment: Corn pad to right 2nd digit once daily and PRN until resolved. Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #111's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #111 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done. i) Resident #112 Resident #112's medical record, when reviewed on 11/17/09 at 3:20 p.m., revealed the physician had ordered the following treatments: O2 SATS QS- if Review of the November 2009 treatment sheet revealed these treatments were not initialed as having been completed on the 7:00 a.m. - 7:00 p.m. shift of 11/14/09. The administrator, when interviewed on 11/18/09 at 4:35 p.m., reviewed Resident #112's November 2009 treatment sheet, acknowledged the treatments were not initialed for the 7:00 a.m. - 7:00 p.m. shift on 11/14/09, and stated she would conduct an investigation to determine if the treatments were completed. The administrator, when interviewed on 11/18/09 at 5:15 p.m., confirmed the treatments were not completed as ordered by the physician and provided evidence that neglect involving Resident #112 had been reported to the State agencies. The DON, when interviewed on 11/19/09 at 2:00 p.m., reported she had interviewed the staff nurses who were assigned to the unit on 11/14/09, and there was a communication error among the staff, and the treatments were not done.",2015-10-01
9892,EASTBROOK CENTER LLC,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2011-08-25,224,G,0,1,MZQB12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of hospital records, review of facility policies and clinical services notices, and staff interview, the facility failed to provide care and services necessary to avoid physical harm for two (2) of fourteen (14) sampled residents. - Resident #141, who was receiving an anticoagulant on a routine basis, had a witnessed fall at 10:45 a.m. on [DATE], during which he struck the left side of his head and left shoulder with force sufficient to cause a fracture to his upper arm. The licensed practical nurse (LPN) recorded the fall on the incident report and in the nursing notes, initially noting as the only injury a skin tear to the left elbow. Shortly after, the resident complained of left shoulder pain; a nurse notified the physician of the shoulder pain, and the physician ordered an in-house x-ray of the left arm. There was no evidence to reflect nursing staff, at the time of the fall or at any time thereafter, notified the physician that the resident had hit his head. After the fall occurred, staff did not follow facility policy, by not moving the resident until he was examined by emergency personnel or a head injury was ruled out. Although a neurological evaluation form was initiated for this fall, the assessments recorded were not complete / accurate (e.g., several entries identified limitations in motor movement to the wrong limb), and times were not always recorded; as a result, it could not be verified that these neuro checks were being completed at progressive intervals as specified in the directions on the form. After the fall on [DATE], the resident was noted to have a significant decline in the self-performance of activities of daily living, which was attributed to possible pneumonia with no consideration that a head injury may have caused or contributed to these declines. On [DATE], prior to the resident leaving the facility for an outpatient appointment with an orthopedist, the nurse was notified that the resident's international normalized ratio (INR - a system established by the World Health Organization for reporting the results of blood coagulation (clotting) tests) was critically high. The nurse noted an order to administer Vitamin K to promote blood clotting but did not administer it before allowing the resident to leave the facility, nor did the nurse communicate to the family or the orthopedist's office that the resident had a critically high INR which placed him at risk for uncontrolled bleeding. Upon leaving the orthopedist's office later that same day, the resident became unresponsive and was transported to the hospital at his son's request, where he was diagnosed with [REDACTED]. The resident, who was deemed not to be a candidate for surgery, was made""do not resuscitate"" by his son (who was also his designated medical power of attorney representative - MPOA), and the resident expired on [DATE]. - The care plan of Resident #33, who had a history of [REDACTED]. On the evening of [DATE], a nurse recorded in his medical record an entry describing his urine as being dark, cloudy, and foul-smelling; there was no evidence this information was communicated to the resident's attending physician or a registered nurse (RN), and no further nursing assessment was completed. On the morning [DATE], a nurse recorded in his medical record an entry regarding the resident's complaint of pain associated with his catheter, as well as an episode of vomiting; again, there was no evidence this information was communicated to the resident's attending physician or a RN, and no further nursing assessment was completed. On the early morning of [DATE], the resident was found by staff to be unresponsive; he was subsequently transferred to the hospital where his catheter, when removed, was found to have purulent drainage, and he was admitted with [DIAGNOSES REDACTED]. Facility census: 140. Findings include: a) Resident #141 1. A review of Resident #141's closed medical record revealed this [AGE] year old male was admitted to the facility for rehabilitation on [DATE], with [DIAGNOSES REDACTED]. The resident had been determined by his attending physician to lack the capacity to understand and make informed medical decisions. Review of his most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of [DATE], found he had the ability to express ideas and wants, was able to be understood by staff, and was able to understand when staff spoke to him. The resident was also independent with eating; independent with staff supervision with: bed mobility, transfer, and ambulation; required limited assistance with dressing; and required extensive assistance with toilet use and bathing. He was also known by staff to pace / walk the halls most of his waking hours, and he was a former jogger. Resident #141 was on [MEDICATION NAME] therapy due to the presence of an implanted cardiac pacemaker to treat [MEDICAL CONDITION] and was being monitored and maintained with a [MEDICATION NAME] time (PT) of 23 (normal range 11.9 - 15.4) and an INR of 2.0 (normal range with pacemaker 2.5 - 3.5). The record revealed frequent monitoring of his lab values with adjustments made to his [MEDICATION NAME] dosage as needed. The resident had been receiving 7.0 mg of [MEDICATION NAME] daily since [DATE], but his [MEDICATION NAME] was held on [DATE] and [DATE] due to an elevated PT of 26.3 and an elevated INR of 2.4. He was then restarted on 6.0 mg [MEDICATION NAME] daily. - 2. The care plan in effect for Resident #141 prior to [DATE] included the following problems (P), goals (G), and interventions (I) related to anticoagulant therapy (quoted as typed): P - At risk for alteration in skin integrity / pressure ulcers / bleeding and bruising related to: episodes of bowel and bladder incontinence, fragile skin, progressive dementia and anticoagulant use"" (created on [DATE]) G -""minimize skin breakdown risks"" (created on [DATE]) I -""... Observe skin condition with ADL (activities of daily living) care daily; report abnormalities. ..."" (created on [DATE]) - P -""Anticoagulant therapy to treat A fib ([MEDICAL CONDITION]): At risk for adverse effects - bleeding and bruising"" (created on [DATE]) G -""Will have no adverse effects"" (created on [DATE]) and""Will maintain lab values within therapeutic range (created on [DATE]) I -""Administer per physician orders. Have Vitamin K or [MEDICATION NAME] available and administer per physician orders. Observe for and report adverse effects such as blood in urine / stool, gums / nose bleeding, bruising. Review lab reports and report results to physician. Use soft toothbrush for oral care."" (All interventions were created on [DATE].) - 3. Resident #141 sustained four (4) falls in [DATE] - on [DATE], [DATE], [DATE], and [DATE]. A care plan had been developed to address the resident's risk for falls on [DATE], with additional interventions added on [DATE] and [DATE] (after the second fall). The problem (P), goal (G), and interventions (I) addressing falls are as follows (quoted as typed): P -""At risk for falls due to unsteady gait-wandering-dementia, [MEDICAL CONDITION] medications, Hx. (history) of [MEDICAL CONDITION]"" created on [DATE]) G - Minimize risk for falls"" (created on [DATE]) I -""Administer medication per physician's orders [REDACTED]. Encourage to transfer and change positions slowly (created on [DATE]). Provide assist to transfer and ambulate as needed (created on [DATE]). Reinforce need to call for assistance (created on [DATE]). Encourage and assist as needed to wear proper non-slip footwear (created on [DATE]). Have commonly used articles within easy reach (created on [DATE]). Evaluate effectiveness and side effects of [MEDICAL CONDITION] drugs with physician for possible decrease in dosage / elimination of medication (created on [DATE]). Observe for and report changes in gait / balance (created on [DATE]). Review medication regimen created on [DATE])."" None of the above interventions related to the resident's risk for falls identified the anticoagulant therapy as a factor affecting the extent of injuries that could be sustained as a result of falling. - 4. According to a document titled""Clinical Services FYI - Post Fall Evaluation"" (FYI File - [DATE] - Number 34): "" Falls are a common source of patient injury. Identifying fall risk factors is an important nursing evaluation process that occurs during a patient's stay. In the event that a patient does fall, a comprehensive clinical evaluation by the nursing supervisor is important to determine the extent of injury and the need for additional intervention. Do not move the patient prior to completing the evaluation. Clinical system areas of focus for a post-fall evaluation may include: "" ... Medication a) Anticoagulant therapy ... Anticoagulant therapy combined with a head injury increases the risk for intracranial bleeding. ..."" "" Neurological evaluation (neuro check) is completed whenever there is a witnessed fall when a patient hits their head; following an un-witnessed fall when a head injury may be suspected and following non-fall patient events which result in known or suspected head injury such as a suspected hemorrhagic stroke. In the event of a fall with suspected head, neck or spinal injury, staff should keep the patient warm but NOT MOVE (both words in bold - not caps - in the original document) the patient until emergency personnel arrive or head, neck or spinal injury has been ruled out. "" The licensed nurse's evaluation of a patient's condition after a fall, identification of changes in condition and recognition of emergent situations is critical to achieving positive patient outcomes. The licensed nurse is responsible for completing this evaluation and reporting changes in condition to the attending physician whenever any symptoms, sign or apparent discomfort is sudden in onset, a marked change in relation to usual symptoms or unrelieved by initial interventions. Documentation of changes in condition is completed using the SBAR (situation - background - assessment - recommendation) process."" According to the directions on the neurological evaluation flow sheet:""Complete neurological evaluation with vital signs initially, then every 30 minutes x 4, then every hour x 4, then every 8 hours x 9 (72 hours). More frequent evaluations may be necessary. ..."" Based on these directions, a resident should receive no less than seventeen (17) neuro checks completed at progressive intervals. - 5. A review of the incident reports revealed the falls on [DATE] and [DATE] were unwitnessed, and the nurse assessing him found no injuries. The fall on [DATE] was witnessed, and the report stated the resident""missed his chair"" and fell in a sitting position with no injury. Documentation on the incident reports corresponding with these falls indicated the physician and the family member were notified. After the fall on [DATE], neuro checks were started at 5:05 p.m. These checks, which were to include assessments of the resident's level of consciousness, orientation, pupils, motor movement, communication, and vital signs, were not always complete and were not completed at the progressive intervals required by the directions on the neurological evaluation flow sheet as stated above: - On [DATE] at 5:05 p.m.; at 5:35 p.m.; at 6:05 p.m. (vital signs only); at 6:35 p.m. (vital signs only); at 7:35 p.m. (vital signs only); at 8:35 p.m. (vital signs only); at 9:35 p.m. (vital signs only); and at 10:35 p.m. (vital signs only). - On [DATE] at 6:30 a.m. and at 2:00 p.m. - On [DATE] at 2:00 a.m.; at 6:00 a.m.; and at 8:00 p.m. - On [DATE] at 4:30 p.m. and at 8:00 p.m. - On [DATE] at 8:00 a.m. None of the neuro checks recorded at these times contained abnormal findings. 6. On [DATE] at 10:45 a.m., Resident #141 sustained another fall. An LPN (Employee #128) recorded the following description of the fall in an incident report (quoted as typed):""resident leaning toward right, fell against doorway of room [ROOM NUMBER] hitting head and landing on left side sustaining skin tear to left elbow, had removed tennis shoes earlier because of sore on bottom of left foot was wearing nonskid socks. Had been pacing all morning."" The LPN also noted the type of incident as a""(f)all without injury (or minor injury)"" . Elsewhere on the incident report, Employee #128 recorded that the physician was notified at 11:00 a.m. on [DATE], a message was left to notify the family of the fall at 11:00 a.m. on [DATE], the resident was not seen by the physician at the facility, the resident was not taken to the hospital, and""resident assessed, neuro checks continue, tx. (treatment) initiated to left elbow, tennis shoes applied encouraged to rest."" Contrary to the information outlined above in the document titled""Clinical Services FYI - Post Fall Evaluation"" , Resident #141 - whom staff witnessed hitting his head during the fall - was not evaluated by emergency personnel and there was no evidence that a head injury was ruled out. There was also no evidence that the nurse informed the physician or the family that Resident #141 had hit his head during this fall. - The nursing note entry describing the fall, made by Employee #128 and dated 10:45 a.m. on [DATE], stated (quoted as written):""Resident up ad-lib. noted leaning toward right. fell against doorway of room [ROOM NUMBER] hitting head and landing on (L) (left) side, sustaining s.t. (skin tear) to (L) elbow. ... Tx (treatment) initiated to (L) elbow. ... Call placed to (physician's name), told of fall, N/O (new/order) obtain STAT x-ray (of left arm and hand) ordered. Also notif. (notified) of blister to foot."" An entry in the nursing notes by Employee #128, at 11:45 a.m. on [DATE], stated (quoted as written):""Resident up ad-lib. Stumble at nurses station stabilized by staff. Neuro (checkmark) continue."" At 6:00 p.m. on [DATE], another nurse wrote:""Ice applied to (L) elbow. No V/C (voiced complaints) from resident. Resident able to move extremity. Awaiting x-ray results."" At 9:00 p.m. on [DATE], the x-ray results revealing a [MEDICAL CONDITION] humerus were reported to the physician, and he immediately ordered the resident transferred to the hospital for treatment. The resident was returned to the facility with a shoulder immobilizer in place and a new order for pain medication ([MEDICATION NAME]). - 7. After the fall on [DATE], neuro checks were started at 10:45 a.m. In spite of the fact that a nurse witnessed the resident hitting his head during this fall, these neuro checks were not always accurate or complete (with temperature readings being recorded in the spaces intended for pulse oximeter readings, and pulse oximeter readings being omitted on several occasions) and the times these checks were completed were not always recorded, making it impossible to determine whether they were completed at the progressive intervals required by the directions on the neurological evaluation flow sheet: - On [DATE] at 10:45 a.m.; at 11:15 a.m.; at 11:45 a.m.; at 12:15 p.m.; at 2:15 p.m.; and at 6:15 p.m. (A nursing note, at 9:00 p.m. on [DATE], stated Resident #141 was sent to the ER, and he did not return to the facility until the early morning of [DATE].) - On [DATE] (no time recorded); and at"",[DATE]"" (no specific time recorded) - On [DATE] at"",[DATE]"" (no specific time recorded); at"",[DATE]"" (no specific time recorded); and at"",[DATE]"" (no specific time recorded) - On [DATE] at"",[DATE]"" (no specific time recorded) Beginning with the first entry on the sheet for this fall at 10:45 a.m. on [DATE], the nurse recorded""(arrow pointing down) ROM"" to indicate an abnormal finding (decrease in range of motion) with respect to the motor movement of the right upper limb. This same notation was made with respect to an assessment of the motor movement of the right upper limb at 11:15 a.m., 11:45 a.m., and 2:15 p.m. on [DATE]; at 6:15 p.m. on [DATE], the nurse recorded""(arrow pointing down) R"" as an abnormal finding for motor movement of the right upper limb. (Note: The injured arm was his left upper limb, not his right upper limb.) Beginning with the first entry on the flow sheet for [DATE] (with no time recorded) and continuing through the entry at"",[DATE]"" on [DATE], the nurse completing the form noted a problem with motor movement of the left upper limb. No problems with motor movement of either upper or lower limbs were noted when the last two (2) entries were recorded on the form for [DATE] at"",[DATE]"" and [DATE] at"",[DATE]"" . No other abnormal findings were noted. - 8. An entry in the nursing notes, in the early morning of [DATE], stated:""Resident brought back to facility ... Resident also has large bruising area on buttocks D/T (due to) fall. ..."" After entries identified the presence of a skin tear to the left arm on [DATE] and the presence of a large area of bruising on the buttocks on [DATE], no additional entries made in the record during the remainder of his stay in the facility contained either a nursing assessment (or a physical description) of his appearance after the fall. There was no further mention of the large bruise on his buttocks and no description of physical findings about his head, which hit the door frame during the fall. There was also evidence in the nursing notes or care plan that were reflective of staff's recognition that the resident's anticoagulant therapy was a potential concern with respect to injuries associated with the fall. - 9. Prior to the fall on [DATE], Resident #141 had been self-ambulating frequently when awake and was able to feed himself independently. After this fall, he required 100% feeding by staff, was frequently refusing to eat or drink. Additionally, nursing entries on [DATE], [DATE], and [DATE] all contained phrases like""resting in bed with eyes closed"";""Resident resting quietly"";""resting quietly no acute distress""; and""resting in bed."" There was no documentation in his record to reflect that staff observed the resident ambulating after [DATE], and the resident now required staff assistance with eating; these reflected a significant change in Resident #141's self-performance of activities of daily living. The resident's PT on [DATE] was 23.0 with an INR of 2.1. This was reported to the physician, and the resident's dosage of [MEDICATION NAME] remained the same with an order for [REDACTED]. Prior to and after the fall on [DATE], there was evidence to reflect the physician acted upon Resident #141's health concerns once they were brought to his attention by nursing (e.g., blister on foot, signs / symptoms of possible pneumonia, complaints of arm pain, lethargy, abnormal lab results, etc.). However, there was nothing in the physician progress notes [REDACTED]. - 10. Review of the physician's progress notes found the following entries, which appear as recorded (out of chronologic order) and are quoted as written: - On [DATE] at 11:50 a.m. -""I saw the pt again today because (1) He fell a couple of nights ago & fractured L humerus (2) He continues to be restless since we have tapered off [MEDICATION NAME] (3) When I went into room - he was flushed and agitated. Temp 99.9 HR 70's irregular. Lungs with bibasilar crackles. Mouth looks a little dry. No LE (lower extremity) [MEDICAL CONDITION]. I spoke with his son - who also noted a 'wild' look in his Dad's eyes recently. We discussed fracture, need to change pain regimen and med strategies for his agitation. He is in agreement with the treatment (illegible) changes."" - On [DATE] at 11:22 a.m. -""Pt is sedated this morning - missed breakfast. O2 sat 94%. Lungs - coarse BS (breath sounds). Abd (abdomen) soft. Labs were basically OK - Will (check) CXR (chest x-ray) - but probably not a good idea to go for ride to ortho. Nursing aware."" (This entry may have been incorrectly dated; it corresponds with a late entry record by nursing for [DATE].) - On [DATE] at 4:50 p.m. -""New developments - (Resident #141) continued to poor PO intake and alertness although he did better at times. Not really SOB (short of breath). He continues not to leave arm immobilizer arm. Na (sodium) was 177 last night - he started IV fluids And it was down to 166. PT / INR was also elevated. So [MEDICATION NAME] on hold. His O2 Sat currently - 92% with HR (heart rate) 84. He gets a little restless at times. Lungs with fine basilar crackles. Mouth dry - but he actually looks better and more comfortable than last visit. Nursing comforting family - they agree with us trying to not linger and are discussing Code Status. Will go ahead and change antibiotic to [MEDICATION NAME] IV since we have IV access. Labs in AM (morning). Since stable at present - Will continue fluids - plan change to ? NS tomorrow."" - A review of laboratory tests, completed on [DATE], revealed the following: Sodium - 167 (normal range 136 - 146) Chloride - 136 (normal range 98 - 110) Blood urea nitrogen (BUN) - 70 (normal range 8 - 21) Calcium - 11.4 (normal range 8.4 - 10.2) All of these values had the highlighted statement:""Significantly different from previous result"" (previous results were dated [DATE]). The labs were repeated on [DATE] and were approximately the same. - 11. The first nursing note after the [DATE] fall that contained a detailed description of the resident's physical status was recorded at 7:15 a.m. on [DATE], by an LPN (Employee #128), which stated (quoted as written):""Resident opens eyes to name, non-verbal, color pale, acyanotic. Peri-orbital [MEDICAL CONDITION] noted, chest rise = (equal) bilat (bilaterally). Lung sounds (down arrow) on (L), = on right. Abdomen soft with hypo-active bowel sounds. (Negative) perepheral [MEDICAL CONDITION], Perephal IV (intravenous) (R) (right) (down arrow) arm 0.45 N/S (normal saline) @ 125 liter / hour, no redness or [MEDICAL CONDITION] noted at site. VS = 97.2 (temperature) - 88 (pulse) - 24 (respirations) - ,[DATE] (blood pressure). O2 saturation 93%."" The next entry, by Employee #128 at 7:45 a.m. on [DATE], stated:""Stat PT/INR called to Dr. (name), PT 95.4 INR 9.53. N/O rec (received) & noted. Vit(amin) K PO (by mouth) 5 mg today, PT/INR on Monday [DATE]."" The next entry, by Employee #128 at 8:15 a.m. on [DATE], stated:""(Name of transport service) here to p/u (pick up) for ortho appt."" There was no evidence that this nurse communicated this critically high INR value to the resident's family or the orthopedist's office, to alert them to the possibility of uncontrolled bleeding. Review of the resident's Medication Administration Record [REDACTED]. The resident was allowed to leave the facility at 8:15 a.m. on [DATE] via non-emergency transport for an appointment with an orthopedist to have his left arm checked, even though the resident had a critically high INR level and without first administering the Vitamin K (to reduce the resident's clotting time). - 12. A review of the ambulance transport records revealed Resident #141 had become non-responsive and his blood pressure was recorded as ,[DATE] when leaving the physician's office shortly after 11:00 a.m. and, at the son's request, the resident was taken to the hospital emergency room (ER) at 11:29 a.m. on [DATE]. - 13. A review of the resident's hospital discharge record revealed that, upon arrival to the ER, the patient was nonresponsive. He was afebrile, with a respiratory rate of 24, heart rate of 89, and blood pressure of ,[DATE]. He had ecchymosis, mostly on the left side of the body, probably due to his recent fall. He opened his eyes once but only had a blank stare. Resident #141""underwent a head CT which showed a right-sided subdural hematoma with mass effect, resulting in right to left midline shift of 1.1cm."" The report read:""The subdural appeared to be very loose and probably old. There was a large amount of acute bleeding."" He was transfused, given 6 units fresh frozen plasma, given Vitamin K intravenously, and admitted the the hospital. When there continued to be no change and he was determined to not be a candidate for surgery, the son (who was the resident's medical power of attorney) opted to make the resident a DNR (do not resuscitate), and his pacemaker was disabled. The resident remained unresponsive throughout his hospitalization and began having frequent periods of apnea shortly after admission. The resident's laboratory values included the following: Lactic acid - 2.2 (normal range 0.5 - 2.0) Sodium - 159 (normal range 98 - 110) INR - 9.53 (normal range 2.5 - 3.5; over 4.9 is critically high) Hemoglobin - 7.9 (normal range 14.0 - 16.0) Hematocrit - 24.8 (normal range 41.0 - 53.0) He was transferred to an in-patient hospice unit on [DATE] and expired on [DATE]. Per the history provided to the ER physician by the resident's son, the resident had had a functional decline and decreasing memory for the previous four (4) months. However, the son had noted a marked decrease in the resident's mental status in the previous week. According to the history, the son reported to the hospital physician that, only days ago, Resident #141 was walking and feeding himself. The son also informed the ER physician of the resident's recent falls and the resulting fracture to the left arm. - 14. During an interview with the director of nurses (DON - Employee #4), the director of care delivery (DCD - Employee #24), and a corporate nurse consultant (Employee #195) at 3:45 p.m. on [DATE], they were asked if they could produce any evidence that the physician had been fully informed of the head injury that occurred during the fall on [DATE]. They were very silent on all issues, but the DON was quick to state that she understood that the resident's subdural hematoma was""old"" and she did not relate it to the fall (even though the CT report indicated the subdural hematoma was""probably"" old and that a""large amount of acute bleeding"" was present). She stated she was sure the physician knew the resident had struck his head and that she would contact him and have him talk with the survey team. She did admit that the physician had been prompt to address all other acute problems that were documented as being presented (e.g., arm pain, blister on foot, lethargy, abnormal lab results, elevated body temperature, etc.). On the previous day ([DATE]), Employee #24 had been asked by this surveyor to explain how the resident got to the hospital. He stated then that he did not know, but he supposed that the resident""went bad in the ambulance"" and they took him there. When asked if he knew the resident's current health status or why he did not return to the facility, Employee #24 denied any such knowledge and stated that it was the policy of the facility that, if a resident did not return, to not make any inquiries. Employee #24 appeared surprised when informed that there had been no comprehensive nursing assessments during this resident's significant decline from [DATE] until his transfer from the orthopedist's office to the hospital on [DATE] (which was arranged by his son). - 15. In a subsequent interview with the administrator and the regional director of operations (Employee #193) at 4:35 p.m. on [DATE], the survey team was again told that the physician would contact the team, and would make it clear that he had been informed the resident struck his head during the fall. The administrator stated the only problem with this incident was a lack of documentation of the physician notification. The administrator stated he also understood the subdural hematoma was""old"", and he expressed surprise when informed that the resident's hospital records indicated the presence of fresh bleeding for which the resident had been transfused. The administrator also questioned the survey team's""right"" to investigate an incident that occurred prior to the facility's Plan of Correction completion date for which the team was conducting a revisit. The survey team explained that a complaint investigation was being conducted concurrently with the revisit and that this resident's record was being reviewed as part of both the revisit and the complaint investigation. - 16. At the time of exit at 2:00 p.m. on [DATE], there had been no further information offered regarding Resident #141, no contact was made by the physician with the survey team, nor had there been further mention of any contact to be made by the physician. -- b) Resident #33 Medical record review for Resident #33 revealed a [AGE] year old male resident who came to the facility on [DATE]. He had the following Diagnoses: [REDACTED]. Resident #33 also had an indwelling Foley urinary catheter. - A nursing note, dated [DATE] at 6:30 p.m., stated: ""Resting in bed with eyes closed. Easily aroused. Afebrile. ... Denies pain at present. While assessing pain score from earlier po (oral) prn (as needed) med. Foley to BSD (bedside) with adequate output noted. Dark cloudy urine with foul smell. 480 mls of H20 given with meds. ..."" There was no evidence to reflect nursing staff notified the physician of the dark, cloudy urine, as required by the resident's care plan. - A nursing note, dated [DATE] at 3:00 p.m., stated: ""Resident c/o (complained of) pain in AM (morning) [MEDICATION NAME] given after leg strap (a device used to secure urinary catheter tubing) applied to remove tension. [MEDICATION NAME] alleviated pain but emesis x 1 clear liquid with no blood reported at 2:45 p (p.m.) alerted oncoming nurse of findings and assessed resident together @ time of assessment no distress noted temp 98.2 and resident denied pain."" There was no evidence to reflect nursing staff notified the physician of the resident's complaint of pain associated with his indwelling catheter or of his episode of vomiting. - A nursing note, dated [DATE] at 5:15 a.m., stated: ""Resident unresponsive. Unable to awake. HR (heart rate) in ,[DATE]'s. Unable to obtain BP (blood pressure). 911 activated. See transfer form. Brother notified of transfer. Dr. (name) notified. EMS (emergency medical services) at facility."" The resident was subsequently admitted to the hospital on [DATE] and did not return to the facility until [DATE]. - The hospital consultation summary with a dictation date of [DATE] stated (quoted as typed):""... This is a [AGE] year-old male patient, who currently resides in a nursing home for his severe MS. The patient has been admitted multiple times in the last couple of months with urosepsis and has been evaluated repeatedly by Urology. He is currently entubated and sedated... Apparently, the patient came into the emergency room yesterday with thick purulent drainage from his Foley and [MEDICAL CONDITION]. He was admitted emergently [MEDICAL CONDITION] protocol was started. ..."" Under the heading ""Assessment and Plan"" was: ""1.[MEDICAL CONDITION]ly of urinary origin. ..."" - The facility's policy titled ""Catheter Care: Indwelling Catheter"" (dated "",[DATE]""), provided by the facility on [DATE], contained the following under the heading ""Suggested Documentation"": ""- Care provided and reaction to procedure, size of catheter and balloon. ""- Unusual observations, color and amount of urine and/or complaints and subsequent interventions including communications with physicians."" - Review of the resident's care plan, with a print date",2015-08-01
9926,HILLCREST HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2012-06-01,224,D,1,0,J5IV11,". Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure the implementation of their policies and procedures that prohibit neglect for one (1) of six (6) sample residents. The resident was overheard repeatedly calling for help. Observation revealed the resident was slumped against the side rail of her bed, unable to reposition herself. Her call bell was lying on the floor under her bed. The resident was crying and said she had been left in that position for ""hours."" Resident identifier: #64. Facility census: 78. Findings include: a) Resident #64 During random observations of the facility, on 05/29/12 at 3:10 p.m., a voice was overheard calling, ""Help, help, someone please help me."" Following the sound of the voice, Resident #64's room was entered. She resided in a private room. The resident was found lying on her bed with the head of the bed raised. She was turned on her right side with the upper portion of her body pressed against her upper side rail. A bedside table was in a perpendicular position on the right side of the bed with her noon meal tray still sitting on it. Resident #64 was asked if she needed assistance. The resident was crying. She stated she had called and called for help and no one came. She stated she had been trying to get someone to help her ""for hours"" and no one came. The resident was asked if she could reach her call bell. She stated she did not know where it was. Observation revealed the call bell was lying on the floor beneath her bed. The resident was asked if she could scoot herself away from the side rails. As she sobbed, she stated she could not move herself. During this observation, a nursing assistant (NA), Employee #32, entered the resident's room. She repositioned the resident away from the side rail. When asked what prompted her to enter the room (as the resident's call bell was beneath the bed) and why the resident was left unattended so long, Employee #32 stated it was not her fault. She stated her responsibility was to feed residents in the activity room from 12:15 p.m. until 1:30 p.m. After that, she was responsible for picking up empty trays on the front hall. Employee #32 stated she then started her rounds and always got to Resident #64 last. She stated the nursing assistant assigned to the hall should have checked on Resident #64. Review of the medical record found the current minimum data set (MDS) with an assessment reference date (ARD) of 03/11/12. Review of section G- functional status, found the resident was totally dependent on staff for bed mobility. The current care plan was reviewed. According to the care plan, staff were to keep the resident's call light within reach. A follow-up interview was conducted with Resident #64 on 05/30/12 at 3:20 p.m. The resident stated she could not get her head away from the side rail ""yesterday."" She stated she felt so helpless and all she could do was cry and yell for help. She stated she could not understand why no one would come and help her. .",2015-08-01
10053,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,224,D,0,1,EVU911,"Based on group interview, resident interview, and staff interview, the facility failed to ensure one (1) resident's personal care item was not removed from her room without her permission or without an explanation of the reason for the removal. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 On 10/14/09 at approximately 3:00 p.m., a group interview was conducted with the residents at the facility. At this interview, Resident #55 related she was missing a can of hairspray. She indicated Employee #57 (a maintenance worker) came into her room and removed a can of hairspray given to her by the beautician as a Mother's Day gift. According to the resident, Employee #57 told her she could not have the hairspray because of the aerosol can and took it from her room. On 10/15/09 at approximately 3:00 p.m., Resident #55 was in the hallway of the facility, talking about the items the facility had replaced for her. She she commented that they still had not replaced her hairspray. She also recounted the story of how the beautician had given her the hairspray as a gift. The resident displayed emotions associated with being upset. On 10/15/09 at approximately 2:00 p.m., the administrator related she had no knowledge of the resident's missing hairspray. She said Employee #55 had not told her anything about the incident. The administrator also said her insurance policy recommended the facility not allow any aerosol cans in the building. She presented a page from the admissions contract that listed aerosol cans among items that could not be brought into the facility. On 10/16/09, the administrator called Employee #57 on the telephone, and he told her he did take the hairspray, because the resident could not have an aerosol can in her room. He also said he kept the hairspray locked up and that the resident could contact him when she needed to use it and he would bring it to her. Employee #57 had failed to tell his supervisor or the administrator that he had confiscated Resident #55's hairspray. He simply removed the item without the resident's permission. There was no indication that Employee #57 gave the resident an opportunity to give the hairspray to her husband or another family member to take home. The hairspray was simply removed from the resident's room without her consent. On 10/16/09, several months after the hairspray was taken from Resident #55 by Employee #57, the facility did replace the hairspray with two (2) bottles with pumps, not an aerosol can. .",2015-07-01
10153,ELDERCARE HEALTH AND REHABILITATION,515065,107 MILLER DRIVE,RIPLEY,WV,25271,2010-05-05,224,L,0,1,MKQ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, medical record review, review of facility policies, procedures, and infection control logs, staff interview, a review of the manufacturer's information for OASIS cleaners, and a review of the information from the Centers for Disease Control and Prevention (CDC), the facility failed to provide care and services to avoid physical harm to residents, by failing to develop and/or implement policies and procedures to prevent the spread of disease by one (1) of thirty (30) Stage II sample residents, who was actively symptomatic with a highly contagious infectious organism. Resident #143 had an active infection with a highly contagious organism - [MEDICAL CONDITION] (C. difficile or [DIAGNOSES REDACTED]) - a spore-forming organism from which environmental contamination frequently occurs. Resident #143 shared a room with his wife, Resident #89. Resident #89 had an open portal of entry for acquiring infections (a gastrostomy tube for feeding), she was incontinent of bowel and bladder, and she was dependent upon staff for all activities of daily living (ADLs). Both Residents #143 and #89 were dependent upon staff for performance of their personal hygiene after toilet use. (Resident #143's dependence was associated with his current bouts of diarrhea resulting in bowel incontinence.) The facility failed to isolate or cohort Resident #143 in accordance with its infection control policy, placing his immunocompromised roommate (#89) at high risk for acquiring an infection, and failed to inform Resident #89's legal representative of the risks to Resident #89 associated with cohorting her with Resident #143 while he was contagious. Resident #143 was also very active, attended out-of-room activities, and ate in the dining room. He received therapy in the common use therapy room, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He independently propelled his own wheelchair throughout the facility, touching handrails and other common use surfaces in the process. The facility failed to assure Resident #143 (who was alert and oriented) used appropriate hand hygiene measures after toilet use while actively symptomatic, to prevent the spread of this highly infectious organism as he moved independently throughout the entire facility, putting all of the other residents at risk. There was no evidence to reflect staff members considered the surfaces outside of his room, the common areas, or nursing equipment used by this resident to be contaminated. Nursing care staff did not adhere to infection control guidelines when rendering care to Resident #143. Housekeeping staff did not sanitize Resident #143's room with a cleaning product containing sodium hypochlorite (bleach), as recommended by CDC. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010; they did not indicate the presence the infectious organism for Resident #143. There was no evidence the facility had investigated, monitored, and/or assured that measures are being taken to assure there is no spread of this infection to the other residents in the facility. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and director of nursing (DON) were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. The resident with the infection (Resident #143) agreed to stay in his room until his symptoms resolved. The DON developed an infection tracking form for trending patterns, and the infections for March, April, and May 2010 were researched to assure there were no other risks for transmission to a possible compromised roommate. After observing the facility's actions, assuring Resident #89 was safely moved into another room, and assuring the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. Resident identifiers: #89 and #143. Facility census: 101. Findings include: a) Resident #89 Observation of this resident's room, on 05/03/10, revealed a contact isolation sign posted on the door of this resident's room. Resident #89, a female resident who shared the room with her husband (Resident #143), was observed to be receiving a feeding by her gastrostomy tube ([DEVICE]). The surveyor noted Resident #89 was totally dependent upon staff for all ADLs and that her [DEVICE] offered an open port of entry for infectious organisms. This placed Resident #89 at high risk for contracting a contagious disease. Review of Resident #89's medical record revealed no evidence she had an active infection. Documentation revealed these residents had only moved in the room together in the last few days at the request of the husband (Resident #143). Review of Resident #143's record found he was in contact isolation for [DIAGNOSES REDACTED]. There was no documentation in Resident #89's medical record that her health care decision maker (who was not her husband) was informed of the risks associated with having these two (2) residents share the same room. --- b) Resident #143 1. Review of Resident #143's medical record revealed he was admitted to the facility on [DATE], and that he possessed the capacity to understand and make his own informed health care decisions. He was sent to the hospital on [DATE] and returned on 04/21/10. At that time, he had diarrhea and he tested positive for [DIAGNOSES REDACTED]. He was placed in contact isolation and was treated with [MEDICATION NAME] 500 mg twice a day for seven (7) days. After he finished this course of antibiotics, an order was given on 05/01/10 to obtain a stool specimen to test for the continued presence of [DIAGNOSES REDACTED]. This test came back positive on 05/03/10, and he started another course of [MEDICATION NAME] for seven (7) more days. The resident experienced diarrhea seven (7) times on 05/03/10. He remained in contact isolation at this time. -- 2. Observation found Resident #143 in the dining room area at 11:45 a.m. on 05/03/10. When interviewed, he stated he did not feel well and did not want to eat. He left the dining room independently and was then seen lying in his bed at 12:30 p.m. When interviewed again at that time, he said he just did not ""feel good today"". When questioned about his abilities to perform his own ADLs, he said, most of the time, he did things himself. He reported having had diarrhea and needing assistance cleaning up, but most of the time he did this himself. He said the diarrhea sometimes made him be incontinent of bowel before he could reach the bathroom. The resident was observed in the front lobby at 11:30 a.m. on 05/04/10. A staff member was looking for him, and when she found him, she stated, ""He runs around all the time."" Observations throughout the survey event found this resident was very active, attended out-of-room activities, and ate in the dining room. He received therapy, utilized the same blood pressure equipment as the other residents, used the public shower room, and sat in social settings with others. He also independently propelled his own wheelchair throughout the facility, touching handrails and other common surfaces in his travels. -- 3. In spite of the presence of a contact isolation sign on the door of this resident's room, the nursing assistants and the alert and oriented resident (#143) in that room did not follow contact precautions to prevent spread of the infection. - On 05/04/10 at 9:00 a.m., a very strong, foul odor was detected coming from Resident #143's room. Observation found Resident #143 coming out of the bathroom. This surveyor looked inside the bathroom and saw a raised commode seat with loose stool all over the seat. The resident, when questioned at that time about toileting, said, ""Sometimes, I can just go myself."" The bathroom, when observed again at 10:00 a.m., had been cleaned. This resident was again observed coming out of his bathroom independently at 11:00 a.m. on 05/04/10. There was no staff in the area at that time. - An interview was conducted with a nursing assistant (Employee #55) at 4:35 p.m. on 05/04/10, regarding Resident #143's toileting habits. Employee #55 stated Resident #143 was mostly continent, but he had diarrhea and was sometimes incontinent. He was also noncompliant and needed assistance, although he took himself to bathroom sometimes. He had a broken leg / knee and needed assistance with transferring. Employee #55 stated, ""After you put him on the toilet, he often cleans himself before you come back to help him."" At 4:45 p.m., Employee #55 was asked if she would have resident to wash his hands before he went to the dining room, in order for the surveyor to observe the resident's handwashing technique. Employee #55 agreed and entered this resident's room. She leaned over the foot of his bed, placing her bare hands on the resident's bed linens and leaning on the mattress of his bed where he was lying. Employee #55 was not wearing any gloves when her bare hands came into contact with his bed linens, which were likely to be contaminated with [DIAGNOSES REDACTED]. (See also citation at F441.) After asking the resident if he was ready to go wash his hands for dinner, Employee #55 donned a pairs of gloves - prior to assisting Resident #143 to his wheelchair and after touching the resident's bed linens with her bare hands. She assisted the resident in transferring to his wheelchair. He told her, ""I can wash my own hands."" Employee #55 placed Resident #143 in front of the sink. He turned the water on full blast, and the water splashed all over him and around the sink. He then stuck his hands under the stream of water and rinsed them for seven (7) seconds. He reached up with his wet hands, turned off the water, and obtained a paper towel. He never applied soap to his hands, nor did he use friction when washing his hands. Resident #143 did not effectively wash his hands to prevent the transmission of the [DIAGNOSES REDACTED] throughout the facility. - Observation, on 05/04/10 at 5:30 p.m., found Resident #143 sitting in his bathroom on the toilet by himself. A nursing assistant (Employee #3), who was assigned to care for him, was asked how much assistance she provided to him for personal hygiene after toileting. She stated first he cleans himself up, and then she finishes cleaning him, because he is not totally clean. She said the occupational therapist (OT) was working with him to get him to be able to clean himself. When asked about his handwashing after having a bowel movement, she stated she gives him a disposable wipe to use on his hands after he cleans himself. (There was no mention of the use of soap and water for handwashing.) Observation found Employee #3 did not wear a gown when assisting Resident #143 with personal hygiene after toileting. This employee verified she assisted the resident with cleaning himself after he had a bowel movement. When asked why she did not wear a gown, she stated she only wears a gown if she anticipates coming in contact with stool, and she did not anticipate coming in contact with stool when caring for Resident #143. Facility policy states staff is to wear a gown if it is anticipated that he or she will come in contact with the contaminated body fluids. Given an earlier observation described that found loose stool on Resident #143's toilet seat after he used the bathroom independently, the possibility of a staff member coming into contact with stool, when assisting Resident #143 with personal hygiene after using the toilet, was great. (See also citation at F441.) - Record review found no care plan had been developed to address Resident #143's non-compliance with the contact isolation precautions, including his inadequate handwashing practices. There were no instructions provided (except ""assist him to wash his hands"") to assure this resident did not spread this infectious organism to his immunocompromised roommate and throughout the entire facility, even though the facility was aware that he often provided his own handwashing and his hand hygiene practices were inadequate to prevent the spread of infection. (See also citation at F279.) -- 4. On 05/04/10 at 2:30 p.m., a housekeeper (Employee #114) was observed coming out of Resident #143's room. When questioned about the process for cleaning a room occupied by a resident in contact isolation, Employee #114 reported the cleaning chemical she used in the bathroom was a heavy duty bathroom cleaner by ECOLAB; she also reported using OASIS 531 to clean the floor and wipe off surfaces, such as the bedside table and the side rails. She was aware this was a contact isolation room and stated she used a different rag and mop and changed her mop water after cleaning such a room, so as to not contaminate other rooms. She said she used OASIS 299 to clean the bathroom and fixtures in the bathroom. When asked if she used anything else to clean this room, she verified these were the only two (2) products she used. She was then asked to get the material safety data sheet (MSDS) for each of these products. Review of the MSDS information found neither of these products contained sodium hypochlorite. - Review of information found on the CDC's website with respect to [DIAGNOSES REDACTED] revealed: ""C. difficile is a spore-forming, gram-positive anaerobic bacillus that produces two exotoxins: toxin A and toxin B. It is a common cause of antibiotic-associated diarrhea (AAD). ... The risk for disease increases in patients with: antibiotic exposure, gastrointestinal surgery /manipulation, long length of stay in healthcare settings, a serious underlying illness, immunocompromising conditions, and advanced age. ... [DIAGNOSES REDACTED]icile is shed in feces. Any surface, device, or material (e.g., commodes, bathing tubs, and electronic rectal thermometers) that becomes contaminated with feces may serve as a reservoir for the [DIAGNOSES REDACTED]icile spores. [DIAGNOSES REDACTED]icile spores are mainly transmitted by healthcare personnel who have touched a contaminated surface or item."" Under the heading ""What can I use to clean and disinfect surfaces and devices to help control [DIAGNOSES REDACTED]icile?"" was found: ""Surfaces should be kept clean, and body substance spills should be managed promptly as outlined in CDC's 'Guidelines for Environmental Infection Control in Health-Care Facilities.' Hospital cleaning products can be used for routine cleaning. Hypochlorite-based disinfectants have been used with some success for environmental surface disinfection in those patient-care areas where surveillance and epidemiology indicate ongoing transmission of [DIAGNOSES REDACTED]icile. ... Note: EPA-registered hospital disinfectants are recommended for general use whenever possible in patient-care areas. At present there are no EPA-registered products with specific claims for inactivating [DIAGNOSES REDACTED]icile spores, but there are a number of EPA-registered products that contain hypochlorite. If an EPA-registered proprietary hypochlorite product is used, consult the label instructions for proper and safe use conditions."" (Source: http://www.cdc.gov /ncidod/dhqp/id_CdiffFAQ_HCP.html) - According to the fact sheet provided by the facility as part of its infection control program, the CDC recommended the use of a sodium hypochlorite-based product for the disinfection of environmental surfaces exposed to [DIAGNOSES REDACTED], having identified as a special consideration that [DIAGNOSES REDACTED] is a spore-forming organism and environmental contamination frequently occurs. This fact sheet also stated the facility recommended the use of a pre-mixed EPA-registered, hospital-grade sodium hypochlorite-based disinfectant, rather than using a solution of bleach and water mixed daily. - The DON provided literature supporting the use of 10% sodium hypochlorite solution mixed fresh daily (one (1) part house hold chlorine bleach mixed with nine (9) parts tap water). She verified this was what they should have been using to clean Resident #143's room. - During an interview with the maintenance / environmental service director (Employee #44), he could not provide evidence that staff instructed on any specific method of cleaning a room of a resident with [DIAGNOSES REDACTED]. He also could not produce a specific policy and procedure for the cleaning of a room occupied by a resident in contact isolation. At 3:15 p.m., Employee #44 stated he called ECOLAB and was advised they should wipe down Resident #143's room with bleach, then mist the surfaces with the OASIS product, leave it for ten (10) minutes, then wipe it off. There was no evidence this procedure was written anywhere or that these instructions had been provided to the housekeeping staff. -- 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. 5. Review of the facility's infection control logs found they were not complete for March 2010 or April 2010. They did not indicate Resident #143 had [DIAGNOSES REDACTED] in his stool. There was no evidence the facility had investigated, monitored, and/or implemented measures to ensure there was no spread of this highly contagious infectious organism to the other residents in the facility. - The facility's infection control compliance monitoring procedure (last revised July 2008), and the only mechanisms identified for monitor the compliance of the employees with the facility's infection control policies and procedures were self-evaluation by existing employees and observation of each new employee as follows: - Staff Self Evaluation - Each employee may be given a self evaluation form to complete every six (6) months, which will be reviewed by the infection control nurse. This self evaluation, when reviewed, contained basic questions asking staff if they performed the infection control tasks properly. (Examples: Do you decontaminate your hands before resident contact? Do you use gloves, masks, etc?) - Observation - Each new employee will be observed during orientation. The infection control nurse will then prepare a report and present it monthly or at least quarterly to the infection control committee. These methods of compliance monitoring were ineffective for ensuring the employees were following the policies regarding isolation. There was no evidence the facility monitored current employees through direct observation, to ensure they were following the infection control policies and procedures. (See also citation at F441.) -- 6. The above actions placed all residents of this facility in immediate jeopardy for acquiring an infection by this highly contagious organism. On 05/04/10 at approximately 5:45 p.m., the facility's administrator and the DON were notified of the immediate jeopardy situation. The administrator provided a corrective action plan for removing the immediate jeopardy, including relocating the immunocompromised resident (#89) to another room; providing teaching to Resident #143 and his family member about the infectious organism and the need for appropriate hand hygiene; inservicing staff on appropriate infection control measures to be implemented, including the use of personal protective equipment; disinfecting all resident rooms and common areas with a bleached-based product; and inservicing all housekeeping staff on the proper procedure (and chemicals to be used) for disinfecting the rooms of residents with this infectious organism. Resident #143 agreed to stay in his room until his symptoms resolved. After observing the facility's actions and assuring that Resident #89 was safely moved into another room, and the cleaning tasks were completed, the survey team verified all planned actions were implemented to remove the immediate jeopardy at 8:45 p.m. on 05/04/10, and there was no further deficient practice in this requirement. .",2015-06-01
10510,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-08-09,224,D,1,0,UBFP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, observation, and resident interview, the facility failed to provide goods and services to one (1) of forty-five (45) Stage II sample residents to avoid physical harm and mental anguish. Resident #214 was experiencing pain in her left leg and did not receive treatment for [REDACTED]. She exhibited behaviors (e.g., combativeness), for which the facility obtained orders for and administered antianxiety and antipsychotic medications, but there was no evidence that pain was ruled out as a possible underlying cause the behaviors. The resident also sustained two (2) falls after the antianxiety medication and experienced lethargy after the antipsychotics were started. This resident also had an order to receive follow-up care for her [MEDICAL CONDITION] at the wound clinic. The facility did not make the appointment for this resident, and the wound was not evaluated by the wound clinic until after the surveyor intervened. The facility's failure to identify signs and symptoms of pain and to obtain follow-up care with the wound clinic as ordered resulted in the wound not being assessed and the resident experiencing untreated pain. Resident identifier: #214. Facility census: 105. Findings include: a) Resident #214 Record review revealed Resident #214 was admitted at 9:30 p.m. on 07/19/11. According to the nursing notes, the resident was verbally abusive and combative with staff at that time. There was no specific documentation to describe what she was saying or doing or if she was experiencing pain at that time, nor did documentation reflect any interventions staff had offered in an effort to calm and reassure this resident. A review of her admission physician's orders [REDACTED]. Her [DIAGNOSES REDACTED]. Review of her admission nursing assessment found she had multiple skin issues present on admission and had a [DEVICE]-assisted closure (vac) device applied to a wound on her leg. She had at nine (9) Stage 2 pressure ulcers present on admission, according to a skin assessment completed on 07/19/11. In Section 13.1a (integumentary / feet) of the admission nursing assessment, the assessor failed to mark a response to the following question: ""Is there pain associated with the wound/skin condition?"" - This section of the assessment was left blank. In Section 14.0 of the nursing admission assessment, the assessor responded as follows: - ""At anytime during the last five (5) days has the resident: Been on a scheduled pain medication regimen?"" = No - ""Been on a PRN (as needed) pain medication?"" = No - ""Had pain or hurting?"" = Yes (There was no follow-up documentation on the assessment to describe the pain or hurting the resident was experiencing.) - On 07/20/11 at 4:00 a.m., a nursing note recorded the nurse went in to assess the resident. After the dressing was removed from the left foot, the resident became combative (kicking at staff) and refused to let staff take off the wound vac to measure and apply a new dressing. The wound vac dressing was left on and the device was hooked up at that time. There was no evidence in the medical record that this dressing change had been attempted prior to 4:00 a.m. and no explanation was to why the dressing change took place at 4:00 a.m. (during hours of sleep). - Review of the resident's care plan, date 07/20/11, found the following (quoted as typed): - Problem - ""Pain / Potential for pain related to: [MEDICAL CONDITION]."" - Goals - ""Will report pain less than daily. Pain will decrease within 1 hour of intervention. Will be free from signs and symptoms of pain such as facial grimacing, moaning, or crying."" - Interventions - ""Monitor pain on scale of 1-10. Encourage resident to communicate presence of pain. Document/ report complaints & non-verbal signs of pain. Assist to reposition for comfort. Implement relaxation and/or distraction techniques to assist with pain control. Initialize Palliative Care referral. Encourage Resident to do mild exercise."" There was no recognition by staff that the resident was exhibiting signs and symptoms of pain with dressing changes. There was no plan to provide for routine pain medication and no plan to pre-medicate the resident for pain prior to completing dressing changes - such as when changing the dressing for the wound vac. - On 07/20/11 at 5:00 p.m., a nursing note recorded the resident did not display any combativeness or other behaviors. On 07/21/11, the nursing notes stated that she did not display any behaviors on that day either. According to a nursing note on 07/22/11 at 8:00 a.m., the resident exhibited signs of increased confusion. She was on [MEDICATION NAME] (an antibiotic) for a yeast infection. On that same day at 2:45 p.m., a new order was written for [MEDICATION NAME] 1 mg every twelve (12) hours for seventy-two (72) hours due to anxiety. There was no evidence recorded in the medical record to describe the signs / symptoms she was exhibiting of increased anxiety, and there was no evidence to reflect she had been assessed for pain. On 07/23/11 at 5:20 p.m., staff recorded the resident had been found on the floor beside her bed. Her bed was placed in a low position, and a bed alarm was initiated. (Review of the resident's Medication Administration Record [REDACTED].) On 07/24/11, nursing notes stated: ""S/P (status [REDACTED]. Her bed in low position, mats at bedside bed alarm in place."" There was no documentation to reflect the resident had been exhibiting any behaviors at that time. A nursing note, on 07/25/11, recorded receipt of new orders for [MEDICATION NAME] 25 mg and [MEDICATION NAME] 25 mg BID (twice daily) for [MEDICAL CONDITION]. There was no documentation to reflect the resident was exhibiting signs or symptoms of [MEDICAL CONDITION], nor was there evidence to reflect staff had assessed the resident for pain. - Observation, on the afternoon of 07/26/11, found Resident #214 in her room on the floor beside her bed. A licensed practical nurse (LPN - Employee #13), who was standing beside her, stated the resident had fallen and she had called for someone to help her. She told this surveyor that staff was summoned to assist in getting the resident up. On 07/27/11, the resident's medical record was reviewed to review the factors surrounding this resident's falls. There was no evidence that this fall had been recorded in the nursing notes, no evidence to reflect staff conducted a physical assessment of the resident after the fall, and no evidence that staff had conducted an investigation in an effort to identify [MEDICATION NAME] and/or extrinsic factors that contributed to this fall. The incident / accident reports were reviewed for this time frame, and no report was found for the fall that occurred on 07/26/11. - On 07/28/11, a weekly nursing note stated: ""... she rips off wound vac, combative, curses staff, she is currently receiving [MEDICATION NAME] 25 mg BID. ..."" There was no evidence in the weekly interdisciplinary team (IDT) meeting note that pain was considered or ruled out as a reason for this resident's behaviors and pulling out her wound vac. - Review of the resident's physician orders [REDACTED]. - During observations of this resident on 08/03/11 from 10:00 a.m. to 11:30 a.m., she was noted to be sleeping the entire time. Her lunch tray was provided to her, and at 1:15 p.m., this surveyor approached the resident. She was very lethargic, dozing off while she was eating. When interviewed by the surveyor about her meal, she reported she just wasn't very hungry. (Even though the [MEDICATION NAME] and [MEDICATION NAME] were ordered on [DATE], the first doses of these medications were not available from the pharmacy for administration until the morning of 07/28/11.) Observation found the resident wrinkling her forehead and nose and grimacing. When asked if she was having pain, she stated ""yes"". When asked to describe her pain, she stated, ""A deep pain that is real deep and sharp shooting down my leg and into my foot."" When asked what treatment she received for pain, and she stated, ""It is all right. I do not need any more pills. I take too many now."" - At 1:30 p.m. on 08/03/11, two registered nurses (RNs - Employees #9 and #28A) were asked by this surveyor to assess this resident for pain. Employee #28A asked the resident if she was hurting anywhere, and the resident stated, ""Yes. My leg hurts from here to here."" (As she spoke, the resident pointed to the area surrounding the wound vac on her left lower leg.) The RN asked her if she wanted some pain medication, and she said, ""No. I don't think I need it."" - On 08/03/11, the nurse practitioner (Employee #29A) wrote a note to follow-up with the wound center as soon as possible if not already seen, and to obtain a report from the wound center if she has already been seen. Employee #29A also wrote an order for [REDACTED]."" - On 08/09/11 at 9:30 a.m., Employee #43 (a licensed practical nurse - LPN) was observed performing a treatment to Resident #214's leg. Throughout the procedure, the resident winced and gritted her teeth. At times, she covered her mouth with her sheet, and at other times, she covered her face with both hands, whimpering all the while. She repeated ""golly, golly"" time and time again. At one point, she asked the nurse to quit for a while and let her relax. It was apparent that this resident was in extreme pain, and this was confirmed by Employees #43 and #29A, who was also present at that time. Employee #29A said she would order something stronger for the resident. The treatment was stopped, and they said they were going to let the medication work before they finished the treatment. At 10:05 a.m., they administered [MEDICATION NAME] to the resident. - It was evident this resident was experiencing pain, and this untreated pain could have been the cause of her behaviors. There was no evidence that pain was considered as a causal or contributing factor prior to medicating the resident with antianxiety and antipsychotic medications for behaviors. There was inadequate monitoring of the resident's behaviors for the months of July and August 2011. No behavior monitoring sheet was found for July 2011. The behavior monitoring sheet for August 2011 indicated staff was to monitor her for the behavior of ""fighting"", and documentation on this sheet month-to date indicated she had no episodes of fighting. Additionally, no non-pharmacologic interventions were initiated in an attempt to reduce these behaviors prior to administering antianxiety and/or antipsychotic medications. During an interview with Employee #28A, she was made aware that there was no behavior sheet for July 2011 (when the antipsychotic and antianxiety medications were ordered and administered) and that no documentation was found to justify the use of either the antianxiety medication (e.g., evidence of increased anxiety) or the antipsychotic medications. There was also no evidence that the risks and benefits had been considered before using these medications. There was also no evidence that the facility had considered pain as a possible cause of the resident's combativeness (as she had exhibited combativeness when her wound care was done), nor was there any evidence that the facility considered the time of day that wound care had been done (at 4:00 a.m. - during hours of sleep) as a factor in the behaviors. The resident also suffered two (2) falls after these medications were initiated. The antianxiety and antipsychotic medications were administered without adequate indications for their use, without adequate monitoring, and in the presence of adverse effects (falls and lethargy), and the resident's pain (which was not identified as a possible underlying cause of her behaviors) was left untreated. Follow-up interviews with two (2) nurses (Employees #80 and on 08/08/11 at 12:00 p.m., revealed the facility failed to assure that the appointment was made for this resident to be seen by the wound clinic as ordered. Employee #53 stated during this interview that the nurse who took the order did not call on Monday to make the appointment. She stated the appointment was not made until brought to the attention of the facility by the nurse surveyor. .",2015-02-01
10512,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-10-27,224,D,1,0,2JCC11,". Based on observation, resident interview, and staff interview, the facility failed to provide goods and services to avoid physical harm and mental anguish for one (1) of thirteen (13) sampled residents. Resident #99 was left in his room clad in only an incontinence brief and a hospital gown (without a cover sheet or blanket) and with the air conditioning / heating unit next to this bed set to the fan mode. Resident #99 was also found to have dried bowel movement on his scrotum, buttock, and leg. Resident identifier: #99. Facility census: 102. Findings include: a) Resident #99 During random observations of the facility on 10/26/11 at 9:40 a.m., a male voice could be heard yelling, ""Nurse, nurse. Get me a blanket, nurse. I'm freezing, nurse."" A licensed practical nurse (LPN - Employee #28) was noted to be in the hallway with a medication cart. Observation of this male resident (#99), made from the doorway to his room, found him in his bed with only a hospital gown (which was pulled up to his chest) and a loosely applied incontinence brief. Resident #99 was rolling from side to side in his bed and opening his legs, and his pubic hair and scrotum were visible from the hallway. - After obtaining his permission, the resident's room was entered by this nurse surveyor. The resident immediately started yelling again to bring him a blanket, that he was freezing. Observation found there was no sheet or blanket on the resident's bed or on the floor next to the bed. Closer observation found the resident had a dried brown substance on the front of his leg, and the resident's fingernails were long, jagged, and packed with a brownish-colored substance. The resident stated that a ""nurse"" had come into his room, took his blanket, and turned the heat off. He repeatedly stated that he was freezing and asked this nurse surveyor to get him a blanket and turn his heat on. Observation of the air conditioning / heating unit by the resident's bed found it was set on fan mode and was blowing cool air. This nurse surveyor turned the heat on and informed the resident that staff would be notified of his request for a blanket. - Upon exiting the room, this nurse surveyor notified Employee #28 that Resident #99 did not have a sheet or blanket and was complaining of freezing. Employee #28 stated, as she entered his room, that the resident throws his covers in the floor. She looked around the resident's bed and did not find a sheet or blanket. She stated she would get him a blanket. - At 9:50 a.m. on 10/26/11, a nursing assistant (Employee #15) entered the resident's room with linens. The dried brown substance on the resident's leg was pointed out to Employee #15, who stated the resident had ""dried poop"" on him from last night and he wasn't like that when she left last night. She stated that she came in at 6:00 a.m. this morning (10/26/11) and Employee #63 (the nursing assistant who had cared for the resident on the previous shift) asked her to do a ""walk through"". Employee #15 reported that she had a resident who was going home that day and she wanted to give him a shower so he would be nice and clean, so she signed that she had done the ""walk through"" even though she did not actually do one with Employee #63. Employee #15 said she knew she shouldn't have done that, and that she realized this failure to perform the ""walk through"" with Employee #63 made the ""dried poop"" on Resident #99 her responsibility, even though he wasn't like that when she left last night. When asked if she had checked any of her residents for incontinence care needs this morning, she stated she had not. - Observations were conducted while Employee #15 provided incontinence care to Resident #15. The nursing assistant utilized three (3) washcloths to remove the copious amount of dried bowel movement from the resident's scrotum, left buttock, and left leg. - Employee #28 was informed that the resident was found with dried bowel movement on his body. The director of nursing (DON - Employee #12) was also notified of these findings at 10:15 a.m. on 10/26/11. .",2015-02-01
10741,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,224,G,1,0,H2M211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on closed medical record review, hospital record review, and staff interview, the facility failed, for one (1) of thirteen (13) residents reviewed, to provide care and services, as determined necessary by a comprehensive assessment and plan of care and/or in accordance with accepted standards of practice, to avoid physical harm. Resident #105 did not receive adequate care related to her diabetes as outlined in her plan of care, and abnormal lab values were not appropriately communicated to her attending physician. This lack of care resulted in a critically high abnormal blood sugar level, rendering the resident unconscious and requiring hospitalization . Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 revealed this 89-year ol female had been admitted to the facility' neighboring acute care hospital on [DATE], when she fell at home, where she lived alone, and fractured her left wrist. According to the hospital ""history and physical examination [REDACTED]. This document also stated that the resident had additional medical [DIAGNOSES REDACTED]. The resident was admitted to the hospital and underwent a ""closed reduction and casting of the left wrist"" the following day. A ""Progress Notes"" document from the acute care hospital, signed by a hospital physician and dated 03/25/11, stated: ""Afebrile, doing well, OK for transfer."" The resident was admitted to BJHCCC on 03/25/11 at 15:30 (3:30 p.m.). Her [DIAGNOSES REDACTED]. The resident was ordered no diabetic medication or monitoring when admitted to the nursing home. -- Documentation on the admission nursing assessment noted, on Page 4 of 5 in the area that describes level of consciousness, that the resident had clear speech, made her self understood, was able to express ideas and wants, and was able to understand verbal content. Nurses notes at the nursing home immediately began describing the resident as ""alert with confusion"" or ""oriented to person only."" - On 03/26/11 at 0400 (4:00 a.m.), a note stated: ""Alert /c (with) confusion. ..."" - On 03/26/11 at 0900 (9:00 a.m.), a note stated: ""Alert & oriented to name only. Confused, easily agitated. ..."" - On 03/28/11 at 15:40 (3:40 p.m.), a note stated: ""Pt (patient) has been very confused today. She knows her name but isn't sure of much else. ..."" - 04/02/11 at 0235 (2:35 a.m.), a note stated: ""Alert to name. Reoriented x 2. ..."" - On 04/08/11 at 1000 (10:00 a.m.), a note stated: ""Pt sitting (arrow pointing up) in cardiac chair in day room. Anxious, wants 'to go home.' Continues to yell 'help me.' Redirecting and 1:1 (one-on-one) attempted /c little success. ..."" - On 04/11/11 at 2200 (10:00 p.m.) a note stated: ""Pt Alert /c confusion. Was trying to climb out of bed & becoming slightly agitated so [MEDICATION NAME] was given on schedule @ 2100 (9:00 p.m.). ..."" - On 04/12/11 at 1530 (3:30 p.m.) a note stated: ""Lethargic this AM (morning). Speech difficult to understand. ... Charge nurse aware of pt condition. Dr. (name of attending physician) notified - see new orders."" Review of the physician's orders [REDACTED]. (The results of this urinalysis, reported on 04/12/11, revealed no abnormalities, including no finding of glucose in the urine.) - On 04/13/11 at 1600 (4:00 p.m.) a note stated: ""... Rash all over back & chest. ..."" - On 04/13/11 at 2100 (9:00 p.m.) a note stated: ""Rash to trunk and extremities. ... Pt received [MEDICATION NAME] /c [MEDICATION NAME] this PM (evening)."" physician's orders [REDACTED]. There was no indication that staff had attempted to determine the cause of the rash. -- On 04/15/11, the resident's physician ordered a complete blood count (CBC), basic metabolic panel (BMP), and urinalysis (U/A) with reflex to be completed on 04/18/11. The results of BMP obtained on 04/18/11 included a blood glucose level of 301 (normal reference range is 74 to 106). There was no evidence in the resident's medical record to reflect staff notified the physician of this significantly elevated blood glucose level. -- A U/A submitted for testing on 04/21/11 revealed glucose in the resident's urine. The level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL; this result was identified with ""C"" indicating this was a critically high level. Review of this lab report, with a print date / time of 04/21/11 at 23:55 (11:55 p.m.), found a handwritten notation that was not signed or dated, stating: ""Dr. (name) aware. On call for Dr. (name of attending physician)."" A nurse's note, dated 04/22/11 at 1700 (5:00 p.m.), stated: ""Dr. (name) aware of critical high glucose in urine - on call for Dr. (name of attending physician). - No new orders."" When interviewed on 08/09/11 at 2:00 p.m., the facility's director of nursing (Employee #7) confirmed there was no evidence of any further discussion of the abnormal lab results by facility staff or the resident's attending physician. The resident's attending physician, when interviewed via phone on 08/09/11 at 4:10 p.m., stated these elevated findings could have been the beginning of the resident's decline into the unresponsive state, and that the on-call physician could have ordered coverage for the resident with a small dose of insulin. He also stated the facility staff could have made him aware on the following day of the abnormal findings, for possible further treatment. -- Nursing notes continued to document the resident as being alert with confusion. On 04/30/11 a nurse's note stated: ""Alert /c confusion. St (straight) cathed (catheterized) for U/A /c reflex. Sent to lab at 1815 (6:15 p.m.). ..."" Review of the resident's medical record found no report containing the results of this U/A. When interviewed on 08/10/11 at 8:30 a.m., the DON stated she was not aware that lab results were not on the record. Employee #9 obtained the result from the lab and provided evidence that the test had been completed as ordered. The urinalysis disclosed that the resident again had 1000 MG/DL of glucose in her urine (normal value is 0 MG/DL), and the report stated ""C - Critical Result"". Employee #9 could not provide evidence that the resident's attending physician had been made aware of the findings of the test, which contained critical level abnormalities. -- On 05/01/11 at 1700 (5:00 p.m.), a nursing note stated: ""Alert to name. Difficult to arouse. ... Will continue to monitor."" On 05/02/11 at 1130 (11:30 a.m.), a note stated: ""Nurse aide taking resident to restroom - states 'residents eyes rolling back of her head and she shook a little.' Only lasted a few seconds - placed back to room. ... Charge nurse notified."" On 05/03/11 at 1030 (10:30 a.m.), a note stated: ""Dr. (attending physician) office notified of pts (patient's) lethargy. ... blood sugar registered critical high on (illegible). Awaiting call back."" On 05/03/11 at 2000 (8:00 p.m.) - nine and one-half (9.5) hours later - a note stated: ""Pt unresponsive in AM. Unable to arouse to take meds. ... BS (blood sugar) critical high. Dr. notified & labwork ordered. One time dose of 10 units [MEDICATION NAME] given @ 1200. BS remains critical (arrow pointing up). Dr notified & IV fluids & ATB ordered ..."" At 2130 (9:30 p.m.) on 05/03/11, the resident was transferred to the hospital for a direct admission. Results of the lab studies that were ordered that morning were available on the facility record and revealed a blood glucose level of 1051. All other levels on the basic metabolic panel were abnormal as well, with the exception of the potassium and calcium levels (which were within normal limits). -- Review of the resident's plan of care, on 08/10/11, revealed the resident had been identified (on 03/28/11) by the interdisciplinary team to have: ""Potential for hyper/[DIAGNOSES REDACTED], other complications related to Diabetes Mellitus."" Goals related to this potential problem were: - ""Will remain free of s/sx (signs / symptoms) of complications related to diabetes through review date"" - ""Will maintain blood sugars, other lab values within acceptable range per MD through review date."" Approaches determined necessary to achieve these goals included: - ""Assess / report to MD prn (as needed): [DIAGNOSES REDACTED] s/sx: Tremors, Shaking, Confusion, Headache, Irritability, Hunger, Nausea / vomiting, Cool, clammy, pale skin, Diaphoresis."" - ""Obtain and monitor lab / diagnostic work as ordered. Report results to MD and follow-up as indicated."" -- The resident was transferred to the hospital prior to the care plan's review date and was admitted with a critically high blood sugar level. There was no evidence that two (2) abnormal lab results related to blood sugar levels and glucose in the urine had been reported to the attending physician. The ""history and physical examination [REDACTED]. ... Neurological: Cannot be fully assessed as patient is unresponsive. ..."" .",2014-12-01
10788,MEADOWVIEW MANOR HEALTH CARE,515141,41 CRESTVIEW TERRACE,BRIDGEPORT,WV,26330,2011-08-05,224,G,1,0,PBEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide goods and services to avoid physical harm, by failing to assess / monitor and obtain timely medical intervention for one (1) of seven (7) sampled residents, resulting in a delay in identification and treatment of [REDACTED]. Resident #14 developed a blister on his left great toe, which was identified in a podiatry consult dated 05/12/11, to which the podiatrist applied a topical antibiotic ([MEDICATION NAME]) and recommended follow-up with the attending physician. The facility did not obtain an order to continue the application of this topical antibiotic to the toe until 05/14/11, and there was no evidence the family was informed of the blister or the topical antibiotic ordered to treat this area. There was no evidence to reflect the nursing staff routinely assessed / monitored the status of this blister after the daily application of a topical antibiotic and a dressing were ordered on [DATE], as evidence by a lack of any nursing progress notes from 04/22/11 until 05/19/11. On 05/19/11, the resident's family member brought to a nurse's attention that his left great toe was red and painful to touch, the left foot was warm to touch, and red streaking was present up to the resident's ankle; however, receipt of the order for a topical antibiotic received on 05/14/11 and an acknowledgement of the family's concerns about the resident's left foot were not recorded in any nursing progress notes until a late entry was made on 07/08/11. On the evening of 05/19/11, the physician ordered a 10-day course of oral antibiotics (Keflex) to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose of Keflex was not administered until 6:00 a.m. on 05/20/11, and the 6:00 p.m. dose on 05/26/11 was skipped due ""awaiting delivery from pharmacy"". After the Keflex was started, there remained a lack of evidence to reflect that nursing staff was routinely assessing / monitoring the status of this area as well as the resident's response to the treatment, as evidenced by no description of resident's left great toe in any nursing notes until a late entry was recorded by a nurse on 05/22/11 (with only periodic descriptions recorded thereafter) and the absence of any wound assessment and progress review records describing the affected area. When the presence of yellow drainage was identified in a nursing note signed by the author on 05/22/11, there was no evidence to reflect the nursing staff notified the physician or the family of this new finding. The tip of the toe was noted to be ""blackish / brownish"" in color on 05/26/11, after which the physician discontinued the topical antibiotic to the toe (and ordered the application of skin prep) and discontinued the Keflex for the infection to the toe (and ordered [MEDICATION NAME] for a new upper respiratory infection). There was no evidence to reflect nursing staff notified the resident's family of the change in the status of the resident ' s great toe or of the discontinuation of both the oral and the topical antibiotics to treat the infection. After this discoloration to the tip of the toe was noted, there again remained a lack of evidence to reflect the nursing staff was routinely assessing / monitoring the status of this area, as the documentation began to focus on the resident's respiratory status. On 06/02/11, the physician diagnosed the resident as having gangrene to the left great toe. A subsequent arterial ultrasound revealed impaired circulation to the left lower extremity, and the family elected to place the resident on comfort measures only. On the afternoon of 06/13/11, a 7-day course of Keflex was ordered at the family's request to treat gangrene to the left great toe, which was to be administered four-times-daily (at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m.). The first dose was not administered until 12:00 p.m. on 06/14/11, with the first three (3) doses having been skipped due to ""awaiting delivery from pharmacy"". The last dose was administered at 12:00 p.m. on 06/20/11, with no evidence to reflect the resident received all twenty-eight (28) doses of the 7-day course ordered by the physician, and no evidence to reflect the family or the physician was notified of these missed doses. Resident identifier: #14. Facility census: 59. Findings include: a) Resident #14 1. Medical record review revealed this [AGE] year old male was most recently re-admitted to the facility on [DATE]. According to his comprehensive annual minimum data set assessment (MDS) with an assessment reference date (ARD) of 12/16/10, he was alert, but his score of ""3"" on the Brief Interview for Mental Status indicated his cognitive skills were severely impaired. In Section G, the assessor noted he was totally dependent on staff for the performance of all activities of daily living (ADLs). In Section I, his active [DIAGNOSES REDACTED]. Other health conditions included pain almost constantly and shortness of breath when lying down. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 03/10/11, he remained dependent on staff for the performance of all ADLs. In Section I, the assessor did not indicate the presence of any new [DIAGNOSES REDACTED]. In Section M, the assessor noted he did not have any pressure sores during the assessment reference period, nor did he have any pressure sores during the prior assessment period, by he was at risk for developing pressure sores; the assessor also noted he had no venous or arterial ulcers present during that assessment reference period and no foot problems (including no infections of the foot). According to his abbreviated quarterly MDS with an ARD of 06/02/11, he remained dependent on staff for the performance of all ADLs. In Section I, his active [DIAGNOSES REDACTED]. In Section M, he was noted to have one (1) Stage 2 pressure ulcer (with the oldest Stage 2 ulcer having been identified on 05/20/11) and one (1) Stage 3 pressure ulcer (measuring 3.0 cm x 0.8 cm). The assessor also noted the presence of an infection of the foot (e.g., [MEDICAL CONDITION]). Subsequently, the facility completed and electronically submitted a comprehensive MDS for a significant change in status with an ARD of 07/06/11, in which the assessor noted he remained dependent on staff for the performance of all ADLs, his active [DIAGNOSES REDACTED]. -- 2. According to an article about gangrene found on Medline Plus, a service of the U.S. National Library of Medicine, National Institutes of Health: ""Gangrene is the death of tissue in part of the body. ""Gangrene happens when a body part loses its blood supply. This may happen from injury, an infection, or other causes. You have a higher risk for gangrene if you have: - A serious injury - Blood vessel disease (such as [MEDICAL CONDITION], also called hardening of the arteries, in your arms or legs) - Diabetes - Suppressed immune system (for example, [MEDICAL CONDITIONS]) - Surgery ""Symptoms ""The symptoms depend on the location and cause of the gangrene. If the skin is involved, or the gangrene is close to the skin, the symptoms may include: - Discoloration (blue or black if skin is affected; red or bronze if the affected area is beneath the skin) - Foul-smelling discharge - Loss of feeling in the area (which may happen after severe pain in the area) ""Treatment ""Gangrene requires urgent evaluation and treatment. In general, dead tissue should be removed to allow healing of the surrounding living tissue and prevent further infection. Depending on the area that has the gangrene, the person's overall condition, and the cause of the gangrene, treatment may include: - Amputating the body part that has gangrene - An emergency operation to find and remove dead tissue - An operation to improve blood supply to the area - Antibiotics - Repeated operations to remove dead tissue (debridement) - Treatment in the intensive care unit (for severely ill patients) ""When to Contact a Medical Professional ""Call your doctor immediately if: - A wound does not heal or there are frequent sores in an area - An area of your skin turns blue or black - There is foul-smelling discharge from any wound on your body - You have persistent, unexplained pain in an area - You have persistent, unexplained fever ""Prevention ""Gangrene may be prevented if it is treated before the tissue damage is irreversible. Wounds should be treated properly and watched carefully for signs of infection (such as spreading redness, swelling, or drainage) or failure to heal."" (URL for this article is ) -- 3. Record review revealed a podiatry services progress note date 05/12/11, which noted the presence of a blister on the left great toe, to which the podiatrist applied [MEDICATION NAME]; the podiatrist also recorded the need for follow-up by the facility's physician. ([MEDICATION NAME] is a topical antibiotic.) A box located at the bottom of the form contained a checkmark next to the following statement (quoted as typed): ""Based on review of history medical records and exam; this pt (patient) is at medical risk of significant complications and medical care is indicated."" -- 4. A review of the resident's physician orders, treatment administration records (TARs), and medication administration records (MARs) found the following: - Order Date: 05/14/11 at 10:00 a.m. (quoted as typed) - ""Cleanse lt (left) great toe with dial soap and rinse with NSS (normal sterile saline). Apply [MEDICATION NAME] ointment to toe and cover with a dry dressing."" The order was discontinued at 1:50 p.m. on 05/27/11. Nurses' initials on the TAR indicated this treatment was completed daily from 05/14/11 through 05/26/11. Documentation on the physician order [REDACTED]. Reeval (re-evaluate). Area is unstageable."" - - Order Date: 05/20/11 at 6:00 a.m. - Keflex Oral Suspension 250 mg / 5 ml (""Instructions: Great toe on left foot""); give 500 mg by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. The order was discontinued at 1:47 a.m. on 05/27/11. Nurses' initials on the MAR indicated [REDACTED]. Documentation indicated a dose was missed at 6:00 p.m. on 05/26/11 due to ""awaiting delivery from pharmacy"". According to the physician order [REDACTED]. - - Order Date: 05/27/11 at 3:00 a.m. - [MEDICATION NAME] Oral Tablet 400 mg, give 1 tab once daily at 8:00 a.m. for ""UTI"" (urinary tract infection). (Note: Elsewhere in the resident's record, documentation indicated this antibiotic was for a ""URI"" (upper respiratory infection).) The order was discontinued at 1:00 a.m. on 06/03/11. Nurses' initials on the MAR indicated [REDACTED]. - Order Date: 06/02/11 at 5:00 p.m. - ""TO (telephone order) Arterial ultrasound to Left lower foot Stat, Call office in AM (morning) to get paper faxed."" - Order Date: 06/04/11 - ""... D/C Skin prep to tip of (lt) gt (great) toe. ..."" - - Order Date: 06/13/11 at 4:00 p.m. - Keflex 250 mg / 5 ml (""Instructions: gangrene grt (great) lt (left) toe); give 10 cc (500 mg) by mouth four (4) times daily at 6:00 a.m., 12:00 p.m., 6:00 p.m., and 12:00 a.m. Nurses' initials on the MAR indicated [REDACTED]. Documentation on the MAR indicated [REDACTED]""awaiting delivery from pharmacy""), but no reason was documented for the skipped dose due at 12:00 a.m. on 06/14/11. The order was discontinued at 4:00 p.m. on 06/20/11, although the resident did not receive all scheduled doses for this course of antibiotics. (Note: There was no evidence in the nursing progress notes for this time period to reflect that nursing staff notified the physician and/or the family that the resident did not receive all twenty-eight (28) doses of this 7-day course of antibiotics.) -- 5. Nursing Progress Notes Review of the nursing notes found no entries from 04/22/11 through 05/19/11, and no entries made on 05/19/11 addressed the status of the resident's left great toe. (Note: There was no contemporaneous entry to correspond with the receipt of an order for [REDACTED]. of this new medication order or the reason for its use.) - An entry, with no date or time recorded but signed by a registered nurse (RN - Employee #11) on 05/20/11, stated (quoted as typed): ""Wound assessment: ... He's also on abt (antibiotic therapy) d/t (due to) [MEDICAL CONDITION] to lt (left) grt (great) toe, no odor or drainage noted. Res (resident) did c/o (complain of) pain when area was tx'd (treated), but he's on scheduled [MEDICATION NAME]. ..."" - An entry, with no date or time recorded but signed by a licensed practical nurse (LPN - Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 (Name of attending physician) to see resident this shift, no new orders. Progress note written."" - An entry, with no date or time recorded but signed by Employee #56) on 05/21/11, stated (quoted as typed): ""5/20/11 Resident alert and verbal w/ (with) intermittent confusion observed, able to make some needs known to staff. Resident started Keflex Oral Suspension 250 MG/ML 500MG PO (by mouth) TID (three-times-daily) related to great toe on left foot. No s/s (signs / symptoms) of adverse reaction to medication observed at this time. ..."" (Note: There was no description of the affected area, and the frequency at which the antibiotic Keflex was to be given was four (4) times daily, not three (3) times daily as stated in this note.) - An entry, with no time recorded but signed by Employee #40 (an LPN) on 05/22/11, stated (quoted as typed): ""05/21/11 Late entry Vital signs ... Resident remains on Keflex elixer 250mg/5cc 10cc po (by mouth) administered per md orders qid (four-times-daily). No s/s of adverse reaction noted. Keflex administered for left great toe infection. Resident left great toe red and warm with slight [MEDICAL CONDITION] noted. No c/o pain offered. Dsg (dressing) changed per md orders. Call bell within reach."" (Note: This was the first description of the resident's left great toe to have been documented in the record since the podiatry consult dated 05/12/11.) - An entry, signed by Employee #40 on 05/22/11, stated (quoted as typed): ""05/22/11 1642 (4:42 p.m.) Vital signs ... Resident continues on Keflex elixer 500mg po qid r/t (related to) left great toe infection. No s/s of adverse reaction noted. Left great toe is discolored red with yellow drainage observed. Toe is warm to touch. No c/o pain or discomfort noted. ..."" (Note: There was no evidence that nursing staff notified the resident's family or physician of the yellow drainage from the left great toe, which was a new finding.) - Subsequent entries stated the following: - 05/22/11 at 2317 (11:17 p.m.) by Employee #61 (an RN) - ""... continues to receive Keflex ..."" (No description of the affected toe was provided.) - 05/23/11 at 0318 (3:18 a.m.) by Employee #61 - ""... Resident continues to receive Keflex ..."" (No description of the affected toe was provided.) - 05/23/11 at 1024 (10:24 a.m.) by Employee #40 - ""... Resident continues on Keflex ... Left great toe is discolored red with small amount of yellow drainage noted ..."" - 05/24/11 (no time recorded) by Employee #51 (an LPN) - ""... He is currently on Keflex related to infected toe ..."" (No description of the affected toe was provided.) - An entry, with no date or time recorded but signed by Employee #62 (an RN) on 05/24/11 - ""... Resident taking Keflex for [MEDICAL CONDITION] in L foot and L great toe. ..."" (No description of the affected foot or toe was provided.) - Further entries reiterated that Resident #14 was receiving Keflex for an infected left great toe, with no descriptions of the affected area provided. - The next entry that provided a description of the affected area, which had no date or time recorded but was signed by Employee #11 on 05/26/11, stated (quoted as typed): ""... Res (resident) is on keflex d/t infection to lt grt toe, the tip of toe is blackish / brownish. It's measuring 2.5cmx2.5cm, no odor or drainage, periwound is a pinkish color. Res does yell out in pain when toe is dressed but was already med. (medicated) with a prn (as needed) [MEDICATION NAME]. Once tx (treatment) is finished, res no longer yells out. ..."" (Note: There was no evidence the nursing staff notified the resident's family of this change in the color of the affected area.) - On 05/26/11, the physician discontinued the Keflex for the infected left great toe and ordered [MEDICATION NAME] to treat an upper respiratory infection. On 05/27/11, the topical antibiotic treatment to the toe was also discontinued, and the twice daily application of skin prep for fourteen (14) days was ordered. (Note: There were no entries in the nursing progress notes to reflect the resident's family was notified of the change in the status of the resident's great toe or that both the topical antibiotic ([MEDICATION NAME]) and the oral antibiotic (Keflex), which had been ordered to treat the infection toe, had been discontinued.) - After the [MEDICATION NAME] was started, nursing documentation began to focus on the resident's respiratory status, and documentation of the status of the resident's left great toe diminished in frequency with the following entries noted (all quoted as typed): - 05/28/11 at 11:52 a.m. by Employee #62 - ""... Wound to left great toe, skin prep every day applied. ..."" - 05/29/11 at 3:17 p.m. by Employee #11 - ""... Res has [MEDICAL CONDITIONS], and the area to lt grt toe could be d/t (due to) that disorder. The area is measuring 0.8cmx2cm and is a dark purplish/brownish area. No odor or drainage noted. The tx of skin prep continues as ordered. ..."" - 06/03/11 at 2:30 a.m. by Employee #30 (an LPN) - ""... resident has new order for arterial ultrasound of left lower leg stat. ..."" - 06/03/11 at 6:21 p.m. by Employee #11 - ""Res is on abt d/t infection to lt grt toe, the area is black, no odor or drainage. The outer part of the wound is slightly reddened and a little warm to touch. The area is measuring 2.5cmx2.5cm. He c/ pain when area is touched. He went for ultrasound and per MD and mpoa (medical power of attorney representative) is aware res will be cmo (comfort measures only). ..."" (Note: The resident was receiving [MEDICATION NAME] to treat an upper respiratory infection; contrary to what was stated in this note, the resident was not on any antibiotics at this time to treat the infection of his left great toe.) - 06/04/11 at 12:02 a.m. by Employee #51 - ""... He, Finished his [MEDICATION NAME] for the URI. His right Great toe is black in color and no drainage at this time. ..."" (Note: This entry identified his right (not his left) great toe as the site of the infection.) - 06/04/11 at 6:35 p.m. by Employee #11 - ""Res is on [MEDICATION NAME] d/t an infiltrate ... The wound to his lt grt toe remains black and is warm to touch, no odor or drainage noted. It is slightly reddened around the outside of the nail bed. ..."" (Note: This entry identified that he was still receiving [MEDICATION NAME] when the previous entry stated he had taken his last dose of this antibiotic.) - 06/05/11 at 8:23 a.m. by Employee #11 - ""Weekly summary: late charting ... Per (name of attending physician) he has gangrene to the lt grt toe, and the family has decided that surgery is not an option for him d/t his overall condition. ..."" - After the resident was placed on comfort measures only, the family requested another course of antibiotics to treat the infection to the left great toe. On 06/13/11 at 4:53 p.m., Employee #11 recorded the following entry (quoted as typed): ""... Res is also to start keflex 250mg/ml 10cc po qid x 7 days per Dr. (name) at mpoa's request. This is d/t gangrene to lt grt toe at this time area remains black but is dry. No odor noted, area is warm to touch. ... "" As noted above, documentation on the MAR for June 2011 indicated the first three (3) scheduled doses of Keflex were missed; ""awaiting delivery from pharmacy"" was noted as the reason for two (2) of these skipped doses. There were no entries in the nursing progress notes to reflect that staff notified either the family member (who had requested this course of antibiotics) or the physician that the resident did not receive all twenty-eight (28) scheduled of the Keflex. - Further review of the nursing notes found an entry, dated 07/08/11 at 5:11 p.m., stating (quoted as typed): ""Late entry: On 05/14/11 evaluation of the left great toe revealed red area on tip of the toe, that was warm to touch. Also some dried blood was on the left great toe around the toenail. After reading the consult form from (name of podiatry service), Dr. (name of attending physician) was notified of the findings. [MEDICATION NAME] external topical ointment was ordered for 14 days. On 05/19/11 residents daughter approached the nurses station and asked for a nurse to evaluate the residents left foot. On assessment, the left great toe was very red, and painful to touch. Also, the left foot was warm and red streaked covering foot up to the ankle. At this time, the resident stated the foot was painful to touch, even with the blankets. Dr. (name) was notified of the reassessment on the residents foot. Keflex liquid 500mg 4 times a day for 10 days was ordered. First dose was given on 5/20/11."" -- 6. physician progress notes [REDACTED]. Review of the physician's progress notes revealed an entry dated 04/14/11 which contained no mention of any problems with the resident's feet. The next consecutive entry, dated 05/20/11, also made no mention of any problems with the resident's feet. The next consecutive entry, dated 05/26/11, noted the resident was on Keflex for [MEDICAL CONDITION] of the left great toe and identified a plan to change the Keflex to [MEDICATION NAME] to treat an upper respiratory infection. The next consecutive entry, dated 06/02/11, noted the physician had been asked to re-evaluate the resident's left great toe. The tip of the toe was black. The physician noted, ""... Gangrene (L) great toe - failed antibiotics. ..."" -- 7. Review of the wound assessment and progress review forms on Resident #14's medical record found no such records were initiated to track the status of the blister, which was intact when identified by the podiatrist on the resident's left great toe on 05/12/11. -- 8. Care Plans Review of the resident's care plans found an episodic care plan, dated 05/20/11, stating (quoted as written): Problem: ""Infection great left toe. Goal: ""Will resolve during the next 14 days."" Approaches: ""(1) Antibiotic as ordered. (2) Treatment as ordered. (3) Monitor for improvement or decline of area. Notify MD as needed."" This care plan has a ""D/C (Discontinuation) Date"" of 05/27/11. - There was no evidence that an episodic care plan was developed to address the resident's left great toe on 05/12/11, when the podiatrist identified and treated the blister, or on 05/14/11, when the attending physician ordered the daily application of a topical antibiotic and a dry dressing to the resident's left great toe. The facility also failed to review / revise the resident's care plan to address the need for on-going monitoring of the resident's left great toe and left foot between the date the 05/20/11 episodic care plan was discontinued on 05/27/11 and when the comprehensive care plan was updated on 06/14/11, to note the presence of gangrene and the initiation of comfort measures only. -- 9. In interviews with the administrator, the director of nursing, and the owner on the morning of 08/05/11, they were asked for any additional information to demonstrate the facility's nursing staff had been routinely assessing / monitoring the resident's left great toe from 05/12/11 until gangrene was diagnosed on [DATE], as well as any additional information to reflect the nursing staff had contemporaneously notified the resident's family of changes in the condition of his left foot and when changes were made with medication and treatment orders. The administrator provided evidence of an internal investigation that confirmed a lack of documentation to reflect changes in his left great toe / foot were being routinely assessed / monitored and that staff had failed to notify the family as changes occurred in his left great toe / foot, as well as when changes were made to medication and treatment orders related to the infection. No additional information to the contrary was provided prior to this surveyor's exit on the early afternoon of 08/05/11. .",2014-12-01
10926,"MCDOWELL NURSING AND REHABILITATION CENTER, LLC",515162,PO BOX 220,GARY,WV,24836,2011-07-08,224,G,1,0,34ZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, policy review, and staff interview, the facility failed to provide necessary care and services to avoid physical harm for one (1) of five (5) sampled residents. The facility failed to appropriately monitor Resident #200's glucose levels, failed to assess and monitor a reddened area on the resident's penis, and failed to assess and monitor this resident's intake and output. Resident #200 was admitted to the hospital on [DATE], totally unresponsive, with [DIAGNOSES REDACTED]. Resident identifier: #200. Facility census: 106. Findings include: a) Resident #200 1. Record review revealed Resident #200 was an [AGE] year old white male admitted to this facility on 11/09/10 with [DIAGNOSES REDACTED]. Review of the history and physical, completed by his treating physician on 11/15/10 documented, the resident as being alert and oriented x 4. Review of the admission orders [REDACTED]. Further review found no orders for assessment of the resident's blood glucose levels. - Review of facility policy entitled ""Nursing Care of the Adult Diabetes Mellitus Resident"" (revised 05/01/06) found, under the section entitled ""Purpose"", the following language: ""... 2. Prevent recurrence of [MEDICAL CONDITION]/[DIAGNOSES REDACTED]. 3. Recognize, assist and document the treatment of [REDACTED]. The section entitled ""General Guidelines"" contained the following language: ""If you observe a diabetic resident or is a diabetic resident complains of any of the following symptoms, report it to the Unit Chare Nurse immediately. [MEDICAL CONDITION] d. malaise (appears tired)... b. lethargy (drowsiness)..."" The policy did not provide instructions to the charge nurse for what interventions to provide should the above symptoms be observed or reported. - Review of a complete blood count (CBC) laboratory test from 11/12/10 that the resident's glucose was 265 mg/dl. The physician ordered an Hgb A1c test. The medical record found no evidence this ordered test was provided. A nursing note, written on 11/13/10, documented the following: ""Hgb A1c No lab pick up on Saturdays."" There was no subsequent documentation in the record to indicate the ordered test was obtained. (See F502 for further details.) - Review of the facility's documentation of the resident's meal intake found the resident consumed no food from the noon meal on 12/04/10 through the noon meal on 12/06/10. The medical record contained no evidence the resident's glucose level was checked at any time during this time period. - Review of the nursing notes found an entry 11/30/10 recorded at 1:18 p.m. which documented that therapy staff reported that ""resident is sleeping more than usual"". The medical record contained no evidence the physician was notified of this sign / symptom of [MEDICAL CONDITION], nor that the resident's blood glucose was assessed. Further review found a nursing note, written on 12/06/10 at 11:46 a.m. which documented the following (quoted verbatim): ""patient is lethargic today. not following instructions... not participating well in therapy today"". The medical record contained no evidence that the physician was immediately notified of these signs / symptoms of [MEDICAL CONDITION], nor did the record contain evidence that the resident's glucose was assessed. There was no evidence that nursing staff monitored the resident's condition until he was found, at approximately 5:14 p.m. on 12/06/10, with a decreased level of consciousness and an inability to respond to staff when spoken to. The resident was transported to an acute care facility at approximately 5:30 p.m. on 12/06/10. - Review of the medical records from the acute care facility found the resident was nonresponsive upon arrival at the emergency room . Subsequent laboratory testing found the resident's blood glucose level was of 886 gm/dl (normal range 74 gm/dl to 106 gm/dl), a blood urea nitrogen (BUN) of 115 mg/dl (normal range 7 mg/dl to 18 mg/dl). He was diagnosed with [REDACTED]. Review of the admission and history by the acute care physician found the following statement: ""The nursing home could not find a record of his blood sugars."" -- 2. Review of the medical record found a nursing note, written at 12:03 p.m. on 11/24/10, documenting: ""Patient states his 'penis area' is red."" The nurse informed the nurse practitioner, who ordered [MEDICATION NAME] 200 mg every day for seven (7) days. Review of the Medication Administration Record [REDACTED]. Further review of the record found no evidence to reflect that nursing staff assessed or monitored the site following the initial resident complaint on 11/24/10. Review of nursing notes from the acute care facility, to which the resident was transferred on 12/06/10, found the following: ""Patient has purulent drainage noted from penis."" -- 3. Review of the medical record found Resident #200 had an indwelling urinary catheter present upon admission to the facility on [DATE]. Review of the admission MDS, with an assessment reference date of 11/16/10, found Section H was marked as ""none of the above"" and did not identify that Resident #200 had an indwelling catheter. Review of the care plan found no mention of the resident's catheter, nor any instructions for the care, assessment, and monitoring of the patency of the catheter or assessment of the color, consistency, and amount or urine excreted by the resident on a daily basis. An interview with a corporate nurse (Employee #118), on the afternoon of 07/08/11, revealed that, due to the failure of the assessor to accurately complete the MDS, the resident's indwelling catheter was not addressed in the resident's comprehensive care plan. (See also citations at F278 and F279.) Review of the intake / output records found the section for catheter output had been left blank by facility staff. Further review of the medical record found the resident was found nonresponsive on 12/06/10. He was transported to an acute care facility where he was diagnosed with [REDACTED]. In addition to being indicative of impaired renal function, an elevated BUN is indicative of poor hydration status. Monitoring of fluid intake and output would have afforded the opportunity for early identification of a state of fluid imbalance. .",2014-11-01
10976,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2011-06-30,224,G,1,0,K8MG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, staff interview, family interview, review of the facility's internal investigations into allegations of abuse / neglect, and confidential staff interviews, the facility failed to provide services to one (1) of fourteen (14) sampled residents to protect the resident from physical harm. Resident #119, who exhibited physically and verbally abusive behaviors towards others, was admitted for inpatient psychiatric care on 05/11/11. Prior to this hospitalization , she had shared a room with Resident #95 and had directed some of her abusive behaviors towards this roommate. Prior to her return, nursing staff expressed concern to administrative personnel that Resident #95 was not able to defend herself against Resident #119, and that Resident #119 should not be returned to the same room. When Resident #119 returned from a psychiatric unit to the facility on [DATE], she was placed in the same room as Resident #95. On 05/31/11, Resident #95's daughter voiced a concern to nursing staff, reporting that Resident #95 had told her she awoke that morning with Resident #119 standing over Resident #95's bed with her hands around her throat and making verbal threats to her. This concern was also reported to the facility's social worker that same day. Later in the day on 05/31/11, Resident #119 threw a cup at Resident #95. On 06/02/11, Resident #119 threw an object at Resident #95 resulting in a laceration to Resident #95's forehead, which required emergency room (ER) treatment. Administrative personnel were aware of Resident #119's physically and verbally abusive behaviors toward others (including her roommate) and failed to implement measures to protect Resident #95 from harm. Resident identifiers: #95 and #119. Facility census: 116. Findings include: a) Resident #95 1. Medical record review for Resident #95 revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. According to her Medicare 30-day minimum data set assessment (MDS) with an assessment reference date (ARD) of 05/03/11, her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. She was totally dependent on staff for bed mobility, locomotion, dressing, toilet use, personal hygiene, and bathing, and she required extensive assistive from staff with transferring, walking, and eating. -- 2. Further review of Resident #95's medical record revealed the following nursing notes (quoted as written): - On 05/31/11 at 2:00 p.m. - ""Pt's (patient's) family member came to desk and stated 'my mom told me that her roommate woke her up with her hands around his throat yelling - 'If you don't quit sleeping /c (with) my husband, I will kill you'. Daughter stated 'Mom is very afraid of her roommate and asked for a room change. Asked for a grievance form and assisted to the social services office. Explained the situation to the social service director and commented about the dangers of the two residents in the same room. Will continue to monitor."" - On 05/31/11 at 3:15 p.m. - ""Roommates continue to argue. Assisted resident to nurses desk to ensure safety."" - On 05/31/11 at 5:20 p.m. - ""Resident was sitting in recliner and 'dodged' a empty coffee cup that the roommate had thrown. Continue to have conflict and social services notified of continuing conflict."" - On 06/02/11 at 7:00 a.m. - ""Called to residents room by CNA (certified nursing assistant). Resident found in bed bleeding from laceration on (R) (right) side of forehead. Resident stated someone hit her /c (with) a glass. Cleaned forehead & notified MPOA the sent to (hospital) ER for eval."" On a change in condition documentation form dated 06/02/11 was written (quoted as written): ""6/2 7 AM called to residents resident had laceration to (R) side of forehead. Resident stated someone threw a cup @ (at) her. Sent to (hospital) ER for sutures."" - On 06/02/11 at 12:00 p.m. - ""Back to facility from ER. Laceration was glued using surgical glue with instructions not to get wet & cover /c bandaid, monitor for pain, vomiting headaches."" --- b) Resident #119 1. Medical record review for Resident #119 revealed this [AGE] year old female was originally admitted to the facility on [DATE], and was most recently readmitted to the facility from an inpatient psychiatric stay on 05/24/11. According to her Medicare 5-day MDS with an ARD of 05/31/11, her active [DIAGNOSES REDACTED]. Her cognitive status was severely impaired, her speech was clear, she was usually able to make herself understood to others, and she usually understood what was communicated to her. According to Section E (Behavior), she exhibited the following behaviors one (1) to three (3) days during the seven-day reference period ending on 05/31/11: physical behavioral symptoms directed towards others (e.g., hitting, kicking, pushing, scratching, grabbing, abusing others sexually); verbal behavioral symptoms directed toward others (e.g., threatening others, screaming at others, cursing at others); and other behavioral symptoms not directed toward others (e.g., physical symptoms such as hitting or scratching self, pacing, rummaging, public sexual acts, disrobing in public, throwing or smearing food or bodily wastes, or verbal / vocal symptoms like screaming, disruptive sounds). Review of her most recent comprehensive MDS, an annual assessment with an ARD of 11/23/10, revealed in Section E that, during the assessment reference period ending on 11/23/10, the resident did not exhibit any behavioral symptoms. Review of an abbreviated quarterly MDS with an ARD of 02/23/11 found in Section E that, during that assessment reference period ending on 02/23/11, the resident again did not exhibit any behavioral symptoms. -- 2. Further review Resident #119's medical record found the following nursing notes from 04/13/11 through 05/11/11 (quoted as written): - On 04/13/11 at 6:30 p.m. - ""Resident sitting in lobby and will not come to her room. States someone is coming to meet her."" On a change in condition documentation form dated 04/13/11 at 8:00 p.m. was written: ""8pm Resident continues to remain in lobby & make attempts to go outside. CNA has been assigned to do one-on-one supervision. Call to Dr. (name) @ this x (time). 8:20pm Dr. (name) made aware of resident exit seeking & staying in lobby. Order for [MEDICATION NAME] 0.5 mg PO (by mouth) q6(symbol for 'hours') (every six hours) for exit seeking , yelling, resisting care. MPOA (name) made aware of status & new order. 10:15pm Resident back in room @ this time. Will monitor for further behaviors. ..."" - On 04/19/11 at 11:00 a.m., 04/25/11 at 6:00 p.m., 04/26/11 at 10:00 a.m., and 04/27/11 at 9:50 a.m., nurses documented that the resident refused all medications and that the attending physician was aware. - On 04/27/11 at 2:00 p.m. - ""Dr. (name) in facility @ this time. New order [MEDICATION NAME] 4.6 mg q24hrs (every twenty-four hours). (Name of MPOA) notified."" - On 04/27/11 at 10:45 p.m. - ""Resident combative /c (with) nurse when [MEDICATION NAME] applied, /c hitting & yelling."" - On 04/30/11 at 10:00 a.m. - ""Refused all AM (morning) meds MD aware."" - On 05/03/11 at 10:30 a.m. - ""Resident has (arrow up) agitation, yelling, going thru roommates belongings, going thru belongings of resident in room (#). Staff attempting to redirect still continues behavior. [MEDICATION NAME] given at this time."" - 05/04/11 at 03:00 p.m. - ""Gave PRN (as needed) [MEDICATION NAME] earlier this shift d/t (due to) anxiety AEB (as evidence by) hitting, yelling & refusing care. Effective at this time. ..."" - 05/07/11 at 05:00 a.m. - ""N/O (new order) written for appt (appointment) to be scheduled /c (hospital) for psych eval per Dr. (name) on 5/4/11 at 8pm."" - 05/07/11 at 6:35 a.m. - ""Res (arrow up) in w/c (wheelchair) in Activities at door pushing on bar. This nurse attempted to move res w/c from door et (and) res grabbed this nurses arm et bit (L) (left) forearm. Res then grabbed the flowers on decorative tree, pulling them. Res reached over to table et pulled tablecloth off et threw it in the floor. Then began propelling her w/c to several more table, pulling off table clothes et throwing them into floor. Res then exits Activities room into hallway et goes into her room et gets into bed."" - 05/07/11 at 09:30 a.m. - ""... Gave PRN [MEDICATION NAME] this AM d/t anxiety AEB hitting staff, throwing waste on staff and unable to redirect. Did take PO medication this AM /s (without) difficulty, but them threw water on 100 hall nurse. [MEDICATION NAME] effective at this time. ..."" - 05/08/11 at 9:30 a.m. - ""Resting in bed. Anxiety noted this AM AEB hitting, throwing cups /c water. Attempted redirection /s success, gave PRN [MEDICATION NAME] this AM. Effective at this time. ..."" - 05/08/11 at 8:00 p.m. - ""Walked into residents room to give meds. Resident sat up in bed and knocked cup of pills out of LPN's hand. ..."" - 05/09/11 at 8:00 a.m. - ""Resident has (arrow up) anxiety this AM. Removing clothes, throwing objects in room. [MEDICATION NAME] given this AM."" - 05/09/11 at 10:00 a.m. - ""[MEDICATION NAME] effective. Spoke /c Dr. (name). N/O CBC (complete blood count) / BMP (basic metabolic panel) / UA (urinalysis) C&S (culture and sensitivity) in AM. MPOA aware."" - 05/09/11 at 4:00 p.m. - ""Refused all meds @ this time attempt x 3."" - 05/10/11 at 02:30 a.m. - ""Resident combative hitting, slapping staff. Refusing straight cath. quote, 'You all are not nurses, get out, get out, I'm not letting you look at me your trash.' Unable to obtain cath for UA C &S."" Addendum: ""Resident began screaming, help help."" - 05/10/11 at 4:00 a.m. - ""Labs drawn for CBC, BMP (R) (right) AC (antecubital) By lab tech. Resident again refusing straight cath for UA C&S asked resident if go to restroom and void resident refused. ..."" - 05/10/11 at 9:00 a.m. - ""Resident refused all meds this AM ... Resident refuses to dress, wearing only robe. Attempt x 3 to cath for urine she continues to refuse."" - 05/10/11 at 11:00 a.m. - ""Staff attempting to straight cath resident /s success. She is hitting staff in face / slapping staff / kicking staff. ..."" - 05/10/11 at 5:00 p.m. - ""Refused all meds attempt x 3."" - 05/11/11 at 3:30 a.m. - ""UA obtained via straight cath method D/T (due to) behaviors."" - 05/11/11 at 8:40 p.m. - ""Resident out to (hospital) ER for direct admit to psyche unit D/T behaviors. ..."" - Review of Resident #119's care plan dated 02/24/11 found the following handwritten entries dated 05/09/11 (quoted as written): Focus: ""Behaviors of hitting, biting throwing items."" Goals: ""(Arrow down) Episodes of behaviors. Will not hurt self or others."" Interventions: ""1) MD to look at meds. 2) Offer activities appropriate for resident. 3) Labs per orders. 4) Psyche consult."" - A confidential interview with staff, in the presence of two (2) nurse surveyors on 06/28/11, revealed that, prior to her hospitalization on [DATE], Resident #119 had lived at the facility for years and had never acted like this before. No comprehensive assessment was conducted to address this significant change in Resident #119's behavior. -- 3. Review of the nursing notes for Resident #119 from 05/24/11 through 06/02/11 found (quoted as written): - On 05/24/11 at 4:15 p.m. - ""admitted to skilled services of Dr. (name) for care ..."" - On 05/25/11 at 6:50 a.m. - ""Unable to give TB test. Resident very combative and refused to even let nurse touch her. ... ADD: Resident was spitting in aid's faces. She was throwing items around the room. She was hitting and kicking aids during care. Resident was also throwing items toward her roommate. Aids have expressed to this nurse how they feel unsafe while trying to give care to this resident. Resident also scratched one of the aids leaving a scratch mark on her (L) forearm. It took 3 aids to provide care for this resident."" - On 05/25/11 at 1:50 p.m. - ""Throwing Objects @ Roommate, (arrow up) agitation. [MEDICATION NAME] x i (times one) given, med taken well. Re-directed @ sink basin Washing up."" - 05/26/11 at 10:00 a.m. - ""Resident refused all am (morning) meds smacking meds & water out of this nurses hand across hallway. Will monitor."" - 05/26/10 at 9:50 p.m. - ""... Resident refused all 9P meds slapping out of nurses hand grabing nurses clothing tuging yelling get out."" - 05/26/11 at 11:50 p.m. - ""Resident screaming, (arrow up) in w/c insists not going back to bed in her room insists there is invisible person in there that was trying to choke her. Currently (arrow up) at nurses station sitting in w/c. Will continue to monitor."" - 05/27/11 at 8:00 a.m. - ""... Has been combative /c staff since re-admit from psyche. ..."" - 05/27/11 at 10:15 a.m. - ""Resident refused all meds, spitting them out & throwing water & pitcher across the room. Will contact physician."" - 05/28/11 at 10:00 a.m. - ""Resident took AM medicine but then started hitting @ me and cursing. Administered PRN [MEDICATION NAME] without success, resident still combative. Will continue to monitor."" - 05/30/11 at 9:00 a.m. - ""Resident yelling in hallway @ staff & other residents. Attempted to redirect without success Resident refuses to put clothes on, exposing self to staff and other residents. [MEDICATION NAME] given this AM."" - 05/30/11 at 1:00 p.m. - ""Continues to scream @ staff and other residents. Threw coffee @ housekeeping staff. Picks up tissues and throws them into hallway."" - 05/30/11 at 1:15 p.m. - ""Walking up the hallway /c back of gown open and refusing to allow us to cover her. Smacks the nurse and an aide while attempting to assist her."" - 05/30/11 at 1:30 p.m. - ""Administered PRN IM (intramuscular injection) [MEDICATION NAME] medication in (L) arm. Resident spit & smacked @ staff members."" - 05/30/11 at 4:10 p.m. - ""Resident began screaming and kicking wall when staff was checking on her. Gave PRN [MEDICATION NAME] po (by mouth) to calm resident."" - 05/30/11 at 8:20 p.m. - Res (arrow up) in w/c in hallway, yelling at staff et other residents. Res agitated, resisting care et hitting at staff from w/c when trying to move w/c so res can pass at move from doorway."" - 05/30/11 at 10:00 p.m. - ""Res continues to be agitated, yelling et hitting at staff. PRN [MEDICATION NAME] given. Res took ? meds et refused to finish meds. Will monitor."" - 05/30/11 at 11:30 p.m. - ""Res noted to have throw several objects at room mate, water pitchers et Kleenex, pictures. Res roommate fearful of resident. Res sitting (arrow up) on BS. Res given PRN IM [MEDICATION NAME] to (R) deltoid. Res (arrow up) in w/c at present in hallway. Continues to throw things, pulled 100 MAR (medication administration record) from med cart et threw it in the floor."" - 06/02/11 at 12:30 p.m. - ""N/O noted to send (hospital) ER for medical clearance for psych family aware."" - 06/02/11 at 1:00 p.m. - ""OOF (out of facility) to (hospital) ER via (transport service) for medical clearance to admit to psych."" -- 4. Review of the May 2011 MAR for PRN medications found the following entries: - On 05/25/11 at 1:50 p.m. - [MEDICATION NAME] was administered for ""Throwing Objects @ Roomt (roommate)"" - On 05/29/11 at 1:00 p.m. - [MEDICATION NAME] was administered for ""Throwing objects@ people, yelling, walking down hall naked"" - On 05/30/11 at 11:20 p.m. - [MEDICATION NAME] was administered for ""throwing objects at roommate, hitting staff, yelling in hallway"" -- 5. Review of Resident #119's care plan dated 05/25/11 revealed the following entries: Focus: ""Hx of Resisting treatment / care AEB refusing showers, refusing ADL's (activities of daily living), related to: Cognitive Impairment / dementia, unspecified [MEDICAL CONDITION]."" An undated handwritten addendum to this focus was ""AEB, Hitting staff throwing items."" Goals: ""Resident will comply with care routine, showers and ADLs."" Interventions: ""Administer medication for cognition as ordered. Document care being resisted on behavior monitoring flow sheet. If resident refused care, leave resident and return in 5-10 minutes. Praise / reward resident for demonstrating consistent desired / acceptable behavior."" All of these interventions were dated as having been created on 06/29/10. An undated handwritten addendum to this list of interventions was ""[MEDICATION NAME] as ordered."" Review of the aforementioned nursing notes from 04/13/11 through 05/11/11 revealed the interventions that had been in place since 06/29/10 were not effective in addressing the resident's behaviors, and no new interventions (e.g., increased staff supervision) were added - beyond the administration of [MEDICATION NAME] ""as ordered"" - to address this resident's physically / verbally abusive behaviors toward staff and other residents (including her roommate). --- c) An interview on 06/28/11 at 10:00 a.m. the administrator reviewed the nursing notes for Resident #95 for 05/31/11 and denied any prior knowledge of the grievance made on behalf of Resident #95 or the incidents reflected in the nursing notes for that day. He provided a statement, on 06/28/11 at 4:40 p.m., to include this same information. -- d) In an interview with Resident #95's daughter on 06/28/11 at 4:15 p.m., she confirmed having filled out a report on 05/31/11 regarding her mother's roommate (Resident #119) standing over her, ""pulling her hair"", and saying, ""You stole my husband."" She and the nurse (Employee #41) and took the report to the social worker (Employee #39). According to the daughter, Employee #39 told her they were full to capacity and there was no where to put her. She said the administrator called her at 7:30 a.m. on 06/28/11 and wanted to discuss this with her, and she came into the facility and spoke with him. -- e) Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statement obtained by the facility from the social worker on 06/28/11 (quoted as written): ""I was not aware of an incident where resident's roommate had her hands around her neck and was yelling at resident. I was also not aware of an incident on the same day that an empty coffee cup was thrown at resident. Resident's daughter had talked about a room change based on cognitive functioning of the resident's roommate prior to the incident on 6-2-11. ..."" Review of the facility's records of abuse / neglect allegations, which were provided by the facility's administrator, found the following witness statements obtained by the facility on 06/28/11, all of whom attested to hearing Resident #95 ' s daughter expressing concerns about Resident #95 alleging to the daughter that her roommate (Resident #119) had tried to choke her (all quoted as written): - Employee #106 (medical records) - ""I was at the fax machine at Maple. (Resident #95's) daughter come to the desk & told (Employee #41) the nurse 'I don't know if this is true or not but mother said roommate tried to choke her last night.' (Employee #41) said would you like to file a grievance. (Employee #41) asked me for one. I couldn't find 1 so (Employee #108) reached into file cabinet & handed the grievance to the daughter. The daughter sat in the chair & (Employee #108) told her how to fill it out. She filled it out and asked what to do /c (with) it. (Employee #41) said to give to social worker. Daughter asked where that is & (Employee #41) said I will show you. (Employee #41) brought the daughter around the hallway towards social service office. Later on that day I asked her if she documented on it & told her she needed to. I asked her what the outcome was & she said the daughter said (Employee #39) said there were no empty beds."" - Employee #108 (licensed practical nurse - LPN) - ""Standing at nurses station on May 31, 2011. Dau (daughter) comes up to NS (nurses' station) & said that her mother had told that her room mate had choked her. I 'do not know if it really happened or not.' but mother is terrorized of her room mate. Gave her a grievance form to fill out. Hall nurse brought dau up to talk with (Employee #39). Came back to floor and said (Employee #39) had told her them we were full and could not do a room change."" -- f) Confidential interviews with staff, conducted in the presence of two (2) nurse surveyors on 06/28/11, revealed that, when Resident #119 was ready to return from the hospital for inpatient psychiatric care on 05/24/11, staff expressed concern to the admission coordinator that Resident #119 should not be returned to the room occupied by Resident #95, due to concerns for Resident #95's safety. Confidential interviews with staff also revealed that the daughter's report, on 05/31/11, of her concerns about Resident #119's behavior toward Resident #95 were discussed in one (1) or more morning stand-up meetings prior to 06/02/11, when Resident #95 sustained injuries after being hit in the forehead by an object thrown by Resident #119. The facility was aware of Resident #119's abusive behaviors toward others (including Resident #95) and failed to implement measures to protect Resident #95 from harm. .",2014-10-01
11011,GOOD SHEPHERD NURSING HOME,515038,159 EDGINGTON LANE,WHEELING,WV,26003,2009-10-15,224,D,0,1,2I6B11,"Based on record review and staff interview, the facility failed to immediately report to the State survey and certification agency an allegation of misappropriation of resident property for one (1) of twenty-six (26) residents reviewed. Resident identifier: #10. Facility census: 187. Findings include: a) Resident #10 The medical record of Resident #10, when reviewed on 10/14/09, disclosed (in a nurse's note dated 09/02/09) a family member of this resident reported some missing jewelry from the resident's room to include a pair of earrings, two (2) gold rings, and a silver watch. The note further stated the facility's director of nurses and a social worker were made aware of this allegation shortly thereafter. Review of facility's documentation of allegations of abuse, neglect, and misappropriation of resident property that had been reported to the State agency within the past year disclosed no mention of this allegation. The social worker involved in this incident (Employee #58), when interviewed on 10/15/09 at 9:00 a.m., stated she was working with the family in an attempt to reimburse them for the loss, but she confirmed the allegation had not been reported as mandated by this regulation. .",2014-09-01
11092,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2011-04-12,224,D,1,0,GFJO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide mouth care to one (1) of thirteen (13) sampled residents who required extensive physical assistance from staff to meet his personal hygiene needs. Review of the facility's internal grievance / complaint records revealed an allegation of neglect that had been reported to the social worker on 02/14/11, related to Resident #2 not receiving care, including mouth care. The facility's internal investigation included obtaining statements from two (2) nursing assistants, both of whom admitted to not providing Resident #2 mouth care, believing this was not to be done because the resident was ""NPO"" (to receive nothing by mouth). Subsequent interviews with the director of nursing (DON) and the administrator revealed they were not aware of these statements, and there was no evidence the facility had provided training to staff on the need to provide mouth care for residents who were NPO. Resident identifier: #2. Facility census: 112. Findings include: a) Resident #2 1. Review of the facility's ""Customer first concern / grievance reports"" revealed a grievance reported by the social worker (Employee #123), dated 02/14/11, documenting: ""Family states that when they came to visit resident had not received care yet, (symbol for 'no') mouth care."" The facility's resolution to this concern was documented as: ""... CNA's state mouth care was not given because he is NPO (nothing by mouth)..."" Employee #123 investigated the allegation and obtained written statements from two (2) nursing assistants, during which they admitted they did not provide mouth care, believing it was not to be done because the resident was NPO. Employee #55's statement said, ""I have not brushed resident's teeth, he's NPO."" Employee #39's statement said, ""I have not brushed resident's teeth, NPO."" After this investigation was completed, there was no evidence the facility had inserviced staff on the provision of mouth care to residents who are NPO. -- 2. Review of Resident #2 ' s assessment instrument revealed this 78-year year old male had been admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. -- 3. The director of nursing (DON), when interviewed on 04/11/11 at 4:40 p.m., stated he had no knowledge of the grievance, saying, ""Just because a resident is NPO this does not mean they would not get mouth care."" The DON stated he would ""inservice the staff immediately and report the allegation."" -- 4. The administrator confirmed on 04/12/11 at 11:30 a.m. that he also was not aware of the statements made by the nursing assistants. .",2014-08-01
11300,NICHOLAS COUNTY NURSING AND REHABILITATION CENTER,515190,18 FOURTH STREET,RICHWOOD,WV,26261,2010-03-25,224,D,1,0,4NN911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on the medical record review, observation, and staff interview, the facility failed to assure a nursing assistant (NA) promptly notified the licensed nurse when the NA discovered the wound dressing to a pressure sore was missing for one (1) of five (5) sampled residents, so a new dressing could be applied in a timely manner. Resident identifier: #59. Facility census: 87. Findings include: a) Resident #59 Review of the medical record, on 03/25/10, found a physician's orders [REDACTED]. Review of the March 2010 treatment administration record (TAR), on 03/25/10, found no documentation of a dressing having been applied on 03/24/10. Employees #5 (a licensed practical nurse - LPN), #74 (a NA), and #98 (a NA) assisted with an observation of the resident's coccyx at 1:25 p.m. on 03/25/10. This observation found no dressing present to the open wound on the resident's coccyx. Employee #5 stated the dressing must have fallen off and she would immediately apply another one. In an interview on 03/25/10 at 2:00 p.m., the NA assigned to care for the resident (Employee #74) stated she had toileted the resident before lunch and no dressing had been present at that time. When asked if she had reported to her nurse that the dressing was not present on the resident's coccyx, she stated she should have reported it but did not do so. An interview with the director of nursing (DON - Employee #19), on 03/25/10 at 2:45 p.m., confirmed Employee #74 should have immediately reported the missing dressing to her nurse. This failure to immediately notify the nurse of the missing dressing resulted in a delay in treatment to the resident's wound. .",2014-07-01
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
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
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
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
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
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
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
166,ST. BARBARA'S MEMORIAL NURSING HOME,515012,PO BOX 9066,FAIRMONT,WV,26555,2017-06-20,225,D,1,0,HCKF11,"> Based on review of reported allegations, staff interview, family interview, and policy review, the facility failed to report timely and/or investigate an allegation of abuse for one (1) of five (5) allegations reviewed. Resident identifier: Resident #1. Facility census: 55. Findings include: a) Resident #1 On 06/20/17 at 11:10 a.m., Assistant Administrator (AA) #11 was questioned as to whether the facility had any reportable allegations in the previous three (3) to six (6) months. The AA referred the question to Registered Nurse (RN) #71. Upon inquiry, the RN provided an allegation which she verbalized was being investigated. The immediate reporting form indicated Nurse Aide (NA) #79 had reported the allegation to the DON on 06//19/17, alleging NA #22 had used foul language/cursed at Resident #1 when the resident requested to be put back to bed after being toileted on the three o'clock to eleven o'clock (3:00 - 11:00) afternoon shift. Licensed Practical Nurse (LPN) #66, interviewed on 06/20/17 at about 10:30 a.m., said the LPN's role was to tell the director of nursing (DON), and the DON would do the rest. With further questioning, the LPN said the Charge Nurse would be notified on evenings and weekends, and that person would notify the appropriate entities. NA#79, interviewed via telephone on 06/20/17 at 12:10 p.m. verbalized she usually worked dayshift, but had worked over that day. The nurse aide said the resident was toileted on the bedside commode and when done was put in the wheelchair (w/c). The NA said the resident asked what time dinner was served and was told about 5:30 p.m. NA#79 stated Resident #1 asked to be put back to bed because it was only 4:00 p.m. The nurse aide alleged NA#22 told the resident they were not playing these f-----g games and don't (do not) care what your daughter says. You are not being babied. NA#79 verbalized she notified LPN #63, who was passing medications. The LPN then ensured the resident was placed back in bed. NA #79 verbalized during the interview, that she went back into the room and apologized for what had happened. The nurse aide said Resident #1 did not exhibit behaviors, was a very sweet person. The NA said the resident's routine was to toilet and lay down. The resident would get up fifteen (15) minutes before meals. The NA voiced she thought the family member had talked to the facility about it. Resident #1, interviewed on 06/20/17 at about 12:30 p.m. ,was in bed, lying on left side, awake and alert. The resident verbalized that staff sometimes puts her down too hard when putting her back in bed. Resident #1 said when she had a concern she told her daughter and the daughter talked to the facility. Family Member (FM) #1, interviewed at 12:48 p.m., verbalized she had not made a formal complaint because her mother was confused as to dates and times. FM #1 said the resident informed her that someone said, Well, that was totally unnecessary to another staff person when they were providing care. The family member said she informed RN #73 last week about Resident #1's concerns, but did not file a formal complaint with the facility, because she did not know if it was true. The minimum data set (MDS) with an assessment reference date (ARD) of 04/28/17 indicated Resident #1 had a brief interview for mental status (BIMS) score of 08 which indicated moderate cognitive impairment. During an interview with the assistant administrator, at 1:10 p.m., she voiced the LPN should have started the investigative process, filled out forms, notified the charge nurse, and called the social worker so there was no lag time. The administrator verbalized that she, the director of nursing, and the social worker were out of the building last week. When asked who was in charge, she said Administrator #10, whatever charge nurse, and RN #71. RN #71, interviewed at 1:17 p.m., voiced FM #1 had spoken to her on Monday (06/19/17) about an incident that happened concerning one of the aides, but did not know whether or not it was truthful. The nurse said the FM did not say what happened. The RN voiced everything was brought to the attention of the DON on Monday morning, around 11:00 a.m., but she already knew about it. The DON, entered the office shared with RN #71 at 1:18 p.m. she said NA #79 told her yesterday morning (06/19/17) , and reported the NA thought she had told the med (medication) cart nurse. The DON said the LPN did not identify it as an allegation of abuse, and it was still being investigated. The abuse, neglect and exploitation policy, with an implementation date of 11/15/16, was reviewed on 06/20/17 at 11:47 a.m. The policy defined verbal abuse as follows: the use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to residents or their families, or within their hearing distance regardless of their age, ability to comprehend, or disability. The definition of abuse was noted as the willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish. This also includes the depravation by an individual, including a caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. Number seven (7) of the abuse policy required when suspicion or reports of abuse, neglect or exploitation or reports of abuse occur, an investigation is immediately warranted. Once the resident is cared for and the initial reporting has occurred, an investigation should be conducted. Components of an investigation may include: Interview the involved resident, if possible, and if the resident is cognitively impaired interview several times to compare responses. Other interviews may include family members, roommates, residents in adjoining rooms, staff members in the area, and visitors in the area. During a discussion with the administrator, on 06/20/17 at 1:45 p.m., she verbalized acknowledgement that anyone could have reported the allegation of abuse, including the nurse aide.",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
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
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
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
1564,WHITE SULPHUR SPRINGS CENTER,515100,345 POCAHONTAS TRAIL,WHITE SULPHUR SPRING,WV,24986,2016-12-15,225,E,0,1,32NE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, grievance/complaint review, resident interview, policy review and staff interview the facility failed to ensure they identified, reported and investigated allegations of neglect, and sexual abuse/rape. Resident #54 was observed lying in urine soaked bed with a dried yellowish/brown urine stain. Resident #129 alleged she had not been put on or taken off the bed pan in a timely manner. Resident #36's family alleged he had been incontinent of urine and was not cleaned up. Resident #128 made an allegation of rape/possible sexual abuse by a parent. The parent served as the resident's emergency contact and Health Insurance Portability and Accountablity Act (HIPPA) contact. This practice had the potential to affect all residents in the facility. Resident identifiers: #54, #129, #36, and #128. Facility census: 63. Findings include: a) Resident #54 On 12/05/16 at 11:42 a.m. during the initial tour of the facility, Resident #54 stated to the surveyor, You can poke all you want. I am soaked. Resident #54 said she had not been changed all morning. She said, Feel this, my bed is soaked. After making this observation, the surveyor stepped into the hallway and asked Nurse Aide (NA) #48 if she knew who was assigned to provide care for Resident #54. The nurse aide said she did not know. NA #48 then offered Resident #54 a shower. Resident #54 refused and said she was cold. Resident #54 said she just wanted to get cleaned up. The resident told the nurse aide she was wet clear up her back. She said the bed was soaked and was starting to dry and then became wet again. The nurse aide felt the bed and the resident's clothing to confirm the wetness. At 11:47 a.m. on 12/05/16 Registered Nurse (RN) #5 looked at Resident #54's bed and confirmed it was wet. Resident #54 told RN #5 she was wet. RN #5 said she was not the coordinator for the unit where Resident #54 resided. RN #6 was identified as the coordinator for Resident #54's unit. RN #6 looked at Resident #54's bed a confirmed it was wet and also confirmed it a dark yellow ring on the sheet. RN #6 agreed the resident should have been checked and changed despite her refusal of a shower. On 12/14/16 at 9:00 a.m. an interview with the administrator, Social Worker #72, director of nursing and RN #5 revealed the facility had not reported or investigated the allegation involving Resident #54 on 12/05/16. RN #5 confirmed she was the RN who talked with the surveyor on 12/05/16. She said she remembered seeing a dried ring of urine under the resident's hip. The administrator, RN #5 and the director of nursing all said they did not see how the occurrence on 12/05/16 constituted an allegation of neglect. They stated, how is this willful? Lastly, SW #72 stated, So we are supposed to report the allegation and not wait until we get an outcome? b) Resident #129 A review of the grievances/complaint reports revealed Resident #129 reported on 02/05/16 that she was not placed on or taken off the bed pan in a timely manner. On 12/13/16 at 5:00 p.m. Social Worker #72 said this was not identified, reported or investigated as an allegation of neglect. c) Resident #36 A review of the grievance/complaint reports revealed on 05/12/16 Resident#36's daughter stated she came to visit her father on the evening of 05/10/16, and he smelled of urine and was wet. On 12/13/16 at 5:05 p.m. Social Worker #72 said the director of nursing would have more information on this issue. On 12/14/16 at 8:15 a.m., the director of nursing said this was reported or investigated as an allegation of neglect. She provided evidence to show the facility did report the allegation on 12/13/16. The results of the investigation by the facility revealed the facility substantiated that Nurse Aide #44 did not change the resident in a timely manner. d) Resident #128 During a stage one interview, on 12/06/16 at 10:55 a.m., Resident #128 voiced she was scared of her father and that he was mean. The medical record, reviewed on 12/06/16, indicated the father was Resident #128's emergency contact and authorized Health Insurance Portability and Accountability Act (HIPAA) contact. A discussion with the administrator, on 12/06/16 at about 7:00 p.m., indicated he had no awareness Resident #128 was fearful of her father or any other concerns, and called the social worker (SW) to the office. SW #72 said she had been notified by Unit Manager (UM) #5 of an issue of alleged sexual abuse by the father, about two (2) hours earlier. The social worker stated she had not completed a resident assessment, and that she had not discussed it with the administrator. During a follow-up interview on 12/07/16/16 at about 9:30 a.m., SW #72 again stated she had not completed a social service assessment for Resident #128. Unit Manager (UM) #5, interviewed on 12/07/16 at 9:45 a.m., stated the facility had been informed on the morning of 12/05/16 by the director of the previous nursing home placement (prior to hospitalization ), that as long as her father doesn't find her you'll be okay. The UM verbalized the facility had notified the father on 12/05/16. Upon inquiry, UM #5 stated she was notified on the morning of 12/05/16 by the director of nursing, and was not aware of any action plan in place to protect the resident. A hospital behavioral health note, dated as faxed on 12/01/16, recorded Resident #128 verbalized an allegation of being raped him. A physician's history and physical, dated 12/05/16 noted the chief complaint as a history of [MEDICAL CONDITION] and was sexually abused by father as a child? The physician's plan of care (P[NAME]) included no male attendants and indicated the P[NAME] was discussed with staff and the resident. Additionally, a physician's orders [REDACTED]. A progress note dated 12/05/16 also noted male NA's were not to provide care. The physician's statement of capacity noted Resident #128 lacked capacity due to [MEDICAL CONDITION], cognitive loss, disoriented to person, place and time, inappropriate answers to questions, long-term care indicated. The form noted the resident was notified the father would be making health care decisions during the period of incapacity. Further review of the record on 12/07/16 revealed Resident #128 signed a consent for treatment and release of information, dated 12/03/16. The form contained names allowing permission for the facility to discuss information with family members or friends about her condition and was co-signed by Licensed Practical Nurse (LPN) #14. The Quick PAR (Patient Assessment Review) form, dated 12/01/16 and signed by the CAD, noted, the social worker had stated, Patient did get upset after her father called her. The care plan was silent related to the resident's history of alleged sexual abuse or relationship with her father. During a discussion with the administrator and Clinical Nurse Executive (CNE) on 12/07/16 between 8:10 p.m. and 8:43 p.m., the CNE and administrator confirmed no investigation had been completed related to the allegations of sexual abuse or the resident's relationship with her father. State agencies were not contacted until prompted by the surveyor. The WV Abuse Prohibition policy, with a revision date of 11/28/16 was reviewed on 12/07/16. It noted the facility would identify possible incidents or allegations which needed investigated, and protect the resident(s) during the investigative process. 7.1 noted the facility would Provide the patient with a safe environment by identifying persons with whom he/she feels safe and conditions that would feel safe. The policy noted anyone who witnessed or suspected abuse should report the incident immediately to the supervisor and the executive director (administrator) or designee and other officials in accordance with State law. The policy required the facility conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent, clinical examination, causative factors and interventions to prevent further injury. Further review of the facility's policy titled OPS327 - WV Abuse Prohibition - State of West Virginia, revealed the following: Neglect is 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, Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, or misappropriation of patient property is to tell the abuser to stop immediately and report to his/her supervisor immediately. In addition the policy stated Upon receiving information concerning a report of suspected or alleged abuse, neglect, involuntary seclusion misappropriation of patient property, or an injury of unknown origin, the CED (Center Executive Director) or designee will enter the allegation into the Risk Management System (RMS), Report as follows; OHFLAC (office of health facility licensure and certification) Long Term Care Department of Health and Human Resources (DHHR) The policy went on to state these allegations would also be reported to Adult Protective Services and the Ombudsman Program. The administrator and director of nursing voiced they did not understand the facility's responsibility related to Resident #128's past history of alleged sexual abuse and her stay at the facility. They denied that adult protective services or other Stage agencies had been contacted related to the physician's findings, to the history of allegation of rape voiced by the resident at the hospital, or the previous nursing facility's report that they would be fine as long as the father did not find her. They also said the physician's orders [REDACTED]. The Reporting of Suspected Crimes under the Elder Justice Act (EJA) dated 08/08/11 noted, All covered individuals will be notified by the Corporate Law/Compliance of their reporting obligations under the EJA to report a suspicion of a crime to the state survey agency and local law enforcement for the political subdivision in which the Center is located. A covered individual was defined as anyone who was an owner, operator, employee, manager, agent, or contractor of the Long Term Care (LTC) Center. Serious bodily injury was noted as an injury involving extreme physical pain; involving substantial risk of death; involving protracted loss or impairment of the function of a bodily member, organ or mental faculty; or requiring medical intervention such as surgery, hospitalization , or physical rehabilitation. Criminal sexual abuse was defined as serious bodily injury/harm and be considered to have occurred if the conduct causing the injury was related to aggravated sexual abuse or relating to sexual abuse. During the interview with the administrator, on 12/07/16 at 8:10 p.m., he acknowledged both the physician and the CAD were required to report any allegation and/or suspicion of abuse and protect the resident from potential harm. Social Worker #72 confirmed all alleged violations involving abuse should be reported immediately and no later than two (2) hours after the allegation was made, if the allegation involved abuse or resulted in serious bodily injury, to the administrator of the facility and to the appropriate State agencies in accordance with State law. She confirmed the allegations had not been reported and/or thoroughly investigated to prevent further potential abuse. The social worker confirmed the allegation was not reported or investigated within two (2) hours nor twenty-four (24) hours of the facility's awareness.",2020-09-01
1667,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2017-10-10,225,E,1,1,UKRP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure allegations of abuse were reported and investigated for 3 residents identified during the complaint survey. This included an allegation of physical and verbal abuse for Resident #22 and allegations of verbal abuse regarding Resident #86. These practices affected Residents #22 and #86 but had the potential to affect more than a limited number of residents. Facility census 48. Findings are: a.) Resident #22 Clinical record review revealed a 07/27/17 care plan for behaviors. Interventions include: explain all care, including procedures (one step at a time), and the reason for performing the care before initiating, observe for non-verbal signs of aggression, e.g. rigid body position, clenched fists etc, approach the resident in a calm, unhurried manner, reassure as needed, if resident becomes combative or resistive, postpone care/activity and allow time for her to regain composure. A 07/29/1711:48 AM nurses note (written by RN (registered nurse) #10) stated resident refused to swallow these pill, she was hitting and scratching. behaviors are very bad this morning. MD (medical doctor) is aware of resident's behaviors. Review of facility documents revealed Resident #1 reported to SW (social worker) #39 on 08/01/17 that RN #10 had threatened her roommate. The 08/01/17 12:45 PM typed statement signed by administrator and DON (director of nursing) on 08/01/17 stated that on Saturday around 12 noon She indicated that Nurse (RN #10) entered the room with (Resident #22's) medications. She stated something about (resident #22) still being in bed at this time of day. (NA #8) was present during the exchange. Resident #1 stated NA #8 asked RN #10 to wait until she got Resident #22 up in the chair, RN #10 did not, she got a cloth and wiped Resident #22 eyes, which Resident #22 made and got her riled up. Resident #22 was then hitting RN #10. RN #10 was holding her hands and trying to get Resident #22 to take her medications. Resident #22 keep resisting. RN #10 then said 'you have to take these behavior meds or they will take you out of here to (name of psychiatric hospital). The statement written by NA (nurse aide) #8 stated she asked RN #10 to wait to give Resident #22 her meds until she got her out of bed. RN #10 got a washcloth and washed Resident #22's face and made her mad and then she tried to give her meds she spit her meds out and she yelled at Resident #22 telling her to take her meds. She only got some of her meds in her she was a little harder to get up. The initial 24 hour report on 08/01/17 to the state entities was for verbal threatening comments. The report did not include any allegation of physical abuse. The final 08/03/17 report substantiated conversation but not in a threatening manner. RN #10 was reeducated and returned to duty. The investigation included a statement from RN #10 (alleged perpetrator), NA #8 and LPN (Licensed Practical Nurse) #83. The investigation did not include any evidence of investigation of physical abuse, no physical examination of Resident #22. No other interviewable residents were interviewed. During an interview with DON #35, ADON (assistant DON) #2, Administrator #38 and SW #39, at 09/27/17 at 6:30 PM, SW #39 stated she completed the initial and final reports to OHFLAC (Office of Health Facility Licensure and Certification), APS (adult protective services, and Ombudsman. SW #39 stated she did not interview other interviewable residents. SW #39 only interviewed Resident #1 the roommate. The Administrator stated the file contained no evidence of any physical examination of Resident #22. DON #35 stated he did not examine resident #22. The ADON #2 made no comment. The Administrator after reviewing Resident #1's statement of RN #10 holding Resident #22's hands down, the facility should have reported an allegation of physical abuse and conducted an examination of the resident at the time of the allegation. The Administrator stated the facilities expectation is for staff to attempt other measures than forcing residents to take their medications. Administrator stated I cannot state why the nurse didn't get the resident out of bed before giving the medications. During an interview with Administrator, DON #35, ADON #2 and Clinical Quality Specialist (CQS) #94, on 09/28/17 at 3:50 PM, the Administrator stated we have not further investigated the aspects of physical abuse, involving Resident #22, because we would not be able to see evidence of physical abuse. c.) Resident #86 Clinical record review revealed Resident #86 was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The 09/19/17 physician determined the resident had capacity to make health care decisions. The 09/18/17 nursing admission assessment revealed he was alert and oriented. During an interview, on 09/28/17 at 1:45 PM, NA #23 had told her on 09/26/17, during the evening shift, that NA #26 had told him you should just use your fingers then we wouldn't have to feed you. NA #23 considered this comment to be abusive since the resident couldn't use his arms and had to be fed by staff. NA #23 stated she reported the incident to RN #80 during that same shift. During a phone interview, on 09/28/17 at 2:10 PM, RN #80 stated Resident #86 is totally dependent for eating due to problems with both his arms. RN #80 stated the resident is in the facility for therapy. RN #80 denied being informed of any incident of verbal abuse or Resident being told to use his fingers to eat. During an interview, on 09/28/17 at 3:42 PM, Resident #86 stated he was at the facility for rehab. He stated he had [MEDICAL CONDITION] arthritis and was unable to use his arms. Resident #86 stated that 2 days ago NA #26 had an attitude problem. She told me If I would use my fingers, they wouldn't have to feed me. It upset me at the time He stated I don't want anyone to loose their job. Resident #86 stated he reported the statements to NA #23 when he was upset. During an interview with Administrator, DON #35, ADON #2 and CQS #94, at 09/28/17 at 3:50 PM, the Administrator stated she would consider the comments made to Resident #86 to be verbal abuse. The Administrator stated she had not been informed about the incident. d.) Review of facility's policy and procedure entitled Abuse Prohibition revised 04/07/17 was conducted on 09/28/17 at 6:00 PM. The policy stated .Anyone who witnesses an incident of suspected abuse, neglect, involuntary seclusion, injuries of unknown origin or misappropriation of property .report the incident to his/her supervisor immediately. The policy also states initiate an investigation within 24 hours of an allegation of abuse that focuses on: whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated . The policy also states the investigation will be thoroughly documented The policy also stated report findings of all completed investigations within five (5) working days to the Department of Health using the state on-line reporting system or state approved forms.",2020-09-01
1923,MEADOW GARDEN,515121,276 PENNSYLVANIA AVENUE,RAINELLE,WV,25962,2017-08-03,225,D,0,1,7YX611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reportable allegations of abuse / neglect / and misappropriation of resident property to the proper State officials, policy review and staff interview, the facility failed to timely report an allegation of neglect to the proper State authorities as required by State law. This was true for one (1) of one (1) resident reviewed for the care area of abuse during Stage 2 of the Quality Indicator Survey (QIS). This deficient practice was determined to constitute past noncompliance as it occurred after the last standard survey (completed on 09/08/16 ) and before the start of this on-site survey on 07/31/17. Resident identifier: #34. Facility census: 50. Findings include: a) Resident #34 During stage 1 of the QIS at 10:20 a.m. on 08/01/17, Resident #46 reported his wife and roommate, (Resident #34) did not get the assistance she needed during meal times. He said his wife takes a long time to eat her meals. He said some staff just come in and say, open your mouth, and when she doesn't they give up and go away. He said his wife is unable to feed herself. Record review at 8/3/17 at 2:41 p.m. found the facility had reported an allegation from Resident #34's spouse alleging, .staff leaves tray in room and don't come back for a long time. This happens at dinner time. The initial reporting form to the Office of Health Facilities Licensure and Certification (OHFLA 225) was dated 07/07/17. b) Facility Investigation The facility reported the allegation as required and obtained numerous statements from staff working at the facility to determine if any staff had knowledge of the situation. Review of the staff statements, revealed two (2) nursing assistants provided statements indicating they were aware of the allegations reported by Resident #46. These 2 employees provided signed statements these allegations had previously been reported by themselves to licensed nursing staff. Statement of nursing assistant (NA) #58, signed by the employee on 07/21/17: --I don't assist (name of resident) with her meals. (name of husband) has complained that they haven't taken time to feed her. He said it was evening shift. I reported it to the nurse. I don't remember who. Telephone statement of Employee #19, signed by the director of nursing (DON) and assistant DON on 07/11/17: --I have provided care for (name of resident). I have not assisted with her meals. (name of husband) has told me that they bring her try set it down then come back and try to feed her they try a couple of times then they'll take take it away if she won't eat. I notified the nurse of his complaint. I've talked to just about all the nurses on B-wing about it at some point and I've talked to (name of a nurse) about it. I've never seen any food left at her bedside I don't know of any issues with laying her down or getting her up. At 1:42 p.m. on 08/02/17, the social worker (SW) #64, said she reported the situation to the proper State officials when she became aware of the issue. She said she did not take the statements from the above staff. She said the facility realized they had a problem with staff reporting allegations timely during this time. A plan of correction was put into place regarding mandatory reporters. She said the B-wing nurse now feeds the resident her supper, not the nursing assistants. c) Policy Review Review of the facility's policy for abuse, Neglect, exploitation and misappropriation of resident property found: Initial Report a. Administrator: All incident and allegations of Abuse, Neglect, Exploitation, Mistreatment of [REDACTED]. d) Facility Action Plan for Correction At 2:00 p.m. on 08/02/17, the DON said the facility realized they had problems with reporting. A performance improvement plan is already in place and the situation has not occurred again since all staff were in serviced on abuse/ neglect and the reporting requirements. At 1:21 p.m. on 08/03/17, the DON provided the following information regarding how the facility corrected the problem with reporting allegations of abuse and neglect. The Performance Improvement Plan for abuse/reporting/grievances was dated 07/17/17. The corrective action is as follows: Education of all staff regarding mandatory reporting and concerns/grievances, goal date 08/10/17. Concerns and reportable's are reviewed in daily stand up, (ongoing.) Each concern/reportable is reviewed by CEO (Chief Executive Officer) and abuse coordinator and DON to ensure compliance, (ongoing.) Risk management is reviewed in daily clinical stand up to ensure any incident or injury of unknown origin is identified for reporting as indicated, (ongoing.) Random resident, staff and family interviews will be completed weekly x 4 weeks, then twice a month to ensure concerns/reportable's are resolved-identified areas of concern will be reported to the monthly Quality Assurance committee for tracking (ongoing.) The DON provided copies of the facility's in-servicing of staff. Staff were inserviced on the definitions of abuse (physical, psychological, emotional, sexual, and/or verbal), involuntary seclusion, neglect or misappropriation of property and neglect. Staff were instructed they are mandated reporters and must report the situation immediately to their supervisor, DON and social worker. Based on the staff interviews, review of the reportable allegations of abuse/neglect to the proper State authorities, and review of facility training / in-servicing documents, it was determined the facility had identified an issue with failure to immediately report allegations of abuse and neglect. Staff were provided with needed training/in-servicing. 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 483.13 - Resident Behavior and Facility Practices.",2020-09-01
1997,PENDLETON MANOR,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2017-08-03,225,D,0,1,TNYB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of facility policy and procedure and staff interview, the facility failed to ensure incidents of resident to resident sexual contact was reported to the state agency and thoroughly investigated and interventions to prevent further occurrences were put in place. This affected two of two residents reviewed for abuse during stage 2. This failed practice had the potential to affect an isolated number of residents. Resident identifier: #49 and #79. Facility census: 87. Findings include: a) Resident #49 The medical record of Resident #49 was reviewed on 08/01/17 at 12:57 p.m. and revealed Resident #49 had [DIAGNOSES REDACTED]. The resident's annual Minimum Data Set (MDS) assessment with an assessment reference dated (ARD) of 05/03/17 indicated he had intact cognition with a Brief Interview of Mental Status (BIMS) score of 15 out of 15, had behavioral symptoms that significantly interfered with his participation in social interactions, he would significantly intrude on the privacy and activity of others and he wandered 1 to 3 days of the assessment period. According to this annual MDS assessment, Resident #49 was independent with bed mobility, transfers, locomotion on and off the unit and he was mobile with the use of a wheelchair. All Mood/Behavior notes were reviewed on 08/01/17 at 12:57 p.m. The Mood/Behavior note dated 08/18/16 at 2:12 p.m. documented the nurse was notified by staff that Resident #49 asked another resident for a kiss and was seen lean in and kiss the other resident. The note documented the residents were separated and educated on inappropriate touching and Resident #49 voiced understanding. There was no evidence the incident was thoroughly investigated and reported as an incident of actual or potential sexual abuse. Review of a Mood/Behavior note dated 10/07/16 at 11:56 p.m. documented Resident #49 was observed at 4:00 PM placing his hands underneath a female resident's blouse and kissing her with open mouth, tongue inserted into female resident's mouth. The note stated the residents were both re-directed and the female resident was moved to another area. A Communication noted dated 11/14/16 at 10:19 a.m. documented the resident was grabbing a female resident's breast in dining room. The note documented staff separated the resident's and there was no further incident. There was no evidence the incidents were thoroughly investigated and reported as incidents of actual or potential sexual abuse. Mood/Behavior note dated 02/27/17 at 12:30 p.m. documented Resident #49 was holding on to a female resident with his hand beside the female resident's breast. The note documented she wasn't objecting. There was no evidence the incident was thoroughly investigated and reported as an incident of actual or potential sexual abuse. Mood/Behavior note dated 03/02/17 at 12:51 p.m. documented Resident #49 was separated from a female resident in the dining room. The note documented the female resident was seated beside Resident #49 as he fondled her breast. There was no evidence the incident was thoroughly investigated and reported as an incident of actual or potential sexual abuse. Continued review of the medical record on 08/01/17 at 12:57 p.m. revealed a Communication note dated 03/10/17 at 8:22 a.m. The note indicated it was a late entry for 03/09/17 and documented social services was updated on a comment made by another resident in the main dining room. The note documented a dietary staff member entered the dining room early before breakfast and observed Resident #49 and female resident seated closely together. The note documented the staff member encouraged separation and the female resident went along to her table. Resident #49 stated he was cold and the staff member went to find his [NAME]et and upon return to dining room observed Resident #49 back over next to female resident touching her hand. The staff member again encouraged separation, assisted Resident #49 to put on his [NAME]et and Resident #49 went to his table and awaited breakfast. The staff member further documented she later entered the dining room again during breakfast and another female resident that was present in dining room earlier mentioned to the staff that after she left the dining room Resident #49 went back to the other female's table again and she was not pleased with what see saw to quote It made me sick. There was no evidence the incident reported by the other female resident was thoroughly investigated. The Mood/Behavior noted dated 04/12/17 at 10:31 a.m. documented a nurse aide made the nurse aware she had to separate Resident #49 and a female resident in the dining room as the female resident had her hand in Resident #49's pants around the private parts. The note documented Resident #49 had his clothes protector covering the female resident's hand. Review on 08/02/17 at approximately 8:30 a.m. of the physician monthly progress notes dated 04/12/17, revealed the resident was seen for his monthly nursing home check. The physician documented the resident continued to have some inappropriate sexual behavior with frequent masturbation. This had been discussed with psychiatry and with his family and the family would prefer not to start treatment as it was not likely to be effective and could cause medication side effects. There was no evidence the incident had been thoroughly investigated and reported as an incident of actual or potential sexual abuse Social Services Quarterly Care Plan assessment dated [DATE] at 11:29 a.m. documented Resident #49 remained oriented to person, place and was able to communicate his basic needs daily. Had also had not met goal for having fewer episodes of making sexual comments and inappropriate touching of female resident. The assessment documented the resident was alert and oriented to person, and usually place and times, scoring 15 out of 15 on BIMS; thereby, indicating Resident #49 was cognitively intact. The assessment further documented he catches female residents in dining touching inappropriately and trying to kiss them, and making sexual comments and staff intervene as this upsets other residents. On 08/01/17 at 2:10 p.m., the Director of Nursing (DON), Administrator, 500 nurse manager Registered Nurse (RN) #10 and Licensed Social Worker (LSW) #133 were interviewed regarding Resident #49's inappropriate sexual behaviors toward female residents. LSW #133 stated the resident's behaviors have decreased but has been ongoing since admission to facility in 2013. LSW #133 stated Resident #49 initially would target same female resident who is no longer resident at this facility. LSW #133 and RN #10 stated staff attempt to have the resident receive his meals on his unit but he will sometimes refuse and want to go to main dining room. They stated the resident is supervised by while in the dining room. RN #10 stated the resident had never been sexually inappropriate with female residents residing on his unit. Stated there is a female resident on his unit with common family members who he use to visit with but she does not wish him to be in her room so a velcro STOP sign was placed across her doorway and Resident #49 does not enter her room. The staff denied any occurrences of inappropriate behavior with this female resident. The staff stated all staff aware of Resident #49's sexual behaviors and the need to supervise him. LSW #133 stated in one incident involving a female resident, she was initiating the contact with Resident #49. Staff stated the resident's family did not want him placed on any medications to decrease his libido. The staff stated the resident's cognition varies and he is delusional at times. They further stated resident was receiving psychiatric services but psychiatrist retired in (MONTH) (YEAR) and facility has not been able to get a new psychiatrist close to facility with the closest psychiatrist available to provide services 4 hours away from the facility. During interview on 08/02/17 at 3:30 p.m., the DON provided a handwritten paper with the name of one female resident (Resident #79) identified to have had sexual resident to resident contact with Resident #49 on 10/07/16, 03/02/17, 03/10/17 and 04/12/17. The DON further indicated no thorough facility investigations had been completed of the resident to resident sexual contact involving Resident #49 and no facility reports had been submitted to the survey and certification agency as allegations of sexual abuse. b) Resident #79 Review of the medical record of Resident #79 on 08/02/17 at 9:07 a.m. revealed the resident had [DIAGNOSES REDACTED]., unspecified. Review of the resident's significant change MDS assessment dated [DATE] revealed she had a BIMS of 6, had behavioral symptoms that significantly interfere with his participation in social interactions and would significantly intrude on the privacy and activity of others. Ongoing review of the medical record and specifically the Mood/Behavior Note dated 08/14/16 at 1:28 p.m. revealed Resident #79 had talked about a certain male resident in the facility that she was fond of and she proclaimed was fond of her. Mood/Behavior Note dated 11/13/16 at 2:08 p.m. documented a NA stated a 500 wing male resident grabbed Resident #79 in her private area. The NA removed Resident #79 from him and brought the resident to her room. There was no evidence provided that the facility had thoroughly investigated the incident and reported the incident as an actual or potential resident to resident sexual abuse. The Mood/Behavior Note dated 04/04/17 at 12:28 p.m. was reviewed on 08/02/17 at 9:07 a.m. and documented Resident #79 was removed from the dining room after being observed resting her hand on a male resident's lap (resident was identified as Resident #49) and giving the male resident stimulation to his genital area. The note documented the resident was assisted back to her room in her wheelchair. Communication note dated 04/14/17 at 11:48 a.m. documented Resident #79 was seeking out male resident on 500 wing and touching sexually and making sexual remarks. There was no evidence provided that the facility had thoroughly investigated the incidents and reported the incidents as an actual or potential resident to resident sexual abuse. On 08/02/17 at approximately 8:30 a.m., information was requested regarding the identity of residents involved in resident to resident sexual contact with Resident #49, any facility investigation information regarding resident to resident sexual contact involving Resident #49 and any facility self-reported incidents involving Resident #49. No documentation was provided by the end of the four-day survey regarding any facility investigation information addressing resident to resident sexual contact involving Resident #49 and any facility self-reported incidents involving Resident #49. There was no information provided as to how the facility provided the ongoing safety and security of residents before and after the aforementioned incidence of resident to resident sexual contact involving Resident #49. Review on 08/02/17 at approximately 8:30 a.m. of the facility Abuse and Neglect policy and procedure dated as last revised 11/16, revealed the policy stated alleged and suspected violations involving any mistreatment, neglect, exploitation or abuse will be reported immediately to the administrator and to other officials in accordance with state law, including the state survey and certification agency. The policy further states the location will have evidence that all alleged or suspected violations are thoroughly investigated and will prevent further potential abuse while the investigation is in progress.",2020-09-01
2129,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2016-08-30,225,E,0,1,6MCU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, medical record review, policy review, review of allegations reported to State agencies, concern and grievance forms, and resident council minutes, the facility failed to identify, thoroughly investigate, and/or report timely, allegations of neglect and/or abuse to the appropriate State agencies. Eight (8) of sixteen (16) residents reviewed were affected. Resident identifiers: Resident #14, #10, #31, #2, #77, #85, #40, and #81. Facility census: 53. Findings include: a) Residents #14 and #10 Allegations reported to State agencies, reviewed on 08/24/16 at 1:15 p.m., revealed a file with two (2) alleged violations reported to the Office of Health Facility Licensure and Certification (OHFLAC), dated 07/21/16 with an unknown occurrence date and time. The residents involved were Resident #14 and Resident #10. The five (5) day follow-up indicated the incident occurred on 07/11/16 or 07/12/16, but was not reported to the administrator until 07/20/16. The State Operations Manual (SOM) 483.13 requires the facility to ensure all alleged violations involving mistreatment, neglect, or abuse be immediately reported to the administrator of the facility and to other officials in accordance with State law. Immediately is defined as, as soon as possible, but ought not to exceed 24 hours after discovery of the incident. b) Resident #40 On 08/24/16 at 1:15 p.m., review of occurrences reported to State Agencies found no evidence an issue reported by Resident #40 regarding Resident #75's behavior(s) was reported to the appropriate State Agencies. During a Stage 1 interview on 08/22/16 at 3:42 p.m., Resident #40 alleged fear of Resident #75. She said she was in the hallway, Resident #75 grabbed her and kissed her. When asked where he kissed her, she said her cheek and placed her hand on her face. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. She added the mean man was dangerous and they (the facility) knew it, and kept him knowing. The resident said the facility should have done something sooner. Resident #40 alleged fear of the resident (identified as Resident #75 by the director of nursing (DON). A progress note, dated 06/12/16 indicated Resident 40 had expressed her concern regarding Resident #75 and was told by the nurse to stay away from him. On 08/24/16 at 1:15 p.m., review of occurrences reported to State agencies found no evidence Resident #40's allegation regarding Resident #75's behavior was reported to the appropriate State agencies. The DON and current administrator, interviewed on 08/24/16 at 2:54 p.m., confirmed no investigation had been completed regarding Resident #40's allegation/concern reported to the nurse regarding Resident #75. During another discussion, at 4:07 p.m., the administrator related the facility had additional information they would like to share. The DON stated that Resident #75 thought Resident #40 was his daughter and would pet down her back and kiss her on the head. The director said she did not know it was actually sexual behavior because the resident had dementia. With further inquiry at about 4:30 p.m. on 08/24/16, the Nurse Practice Educator (NPE) provided a handwritten grievance form (all others had been type written), dated 06/12/16. The investigation and action indicated Administrator interviewed resident, resident (Resident #40) stated resident (initials of Resident #75) Kiss her on the top of the head not lips, Resident voiced no additional concerns. No additional information was provided on the form. During another interview with Resident #40 on 08/30/16 at 10:47 a.m., in the presence of another surveyor, when asked to describe the incident with Resident #75 she again said she was in the hallway when Resident #75 grabbed her and kissed her on the cheek. The resident related she did not know why Resident #75 kissed her, but it scared her and she told the nurse. The resident said the nurse told her to stay away from him. With further inquiry, Resident 40 stated she felt fearful and voiced she would not have been able to get away from Resident #75 if he approached her and stated, He was crazy. The resident stated she had always been afraid of Resident 75. The administrator, interviewed on 08/30/16 at 1:22 p.m., acknowledged the incident should have been reported to the appropriate State agencies as an allegation of abuse, and should have been investigated. He acknowledged no evidence was available to indicate the facility had thoroughly investigated the allegation reported by Resident #40. c) Residents #31, #85, #2, and #77. Concern/grievance forms found five (5) allegations for four (4) resident which indicated they were allegations of abuse and/or neglect. Residents #31, #85, #2, and #77. 1) Resident #31 A grievance/concern form, dated 04/13/16 indicated Resident #31's family member observed a resident throw a glass of water on her mother. The nurse aide (NA) did not offer to change the resident. Additionally, the perpetrator had a fork, attempting to take Resident #31's food. When the family member expressed concern that Resident #31 might be hurt, the NA provided assistance. The resolution indicated the NA was educated on offering assistance to residents with difficulty eating and a choice of dining areas was available to each resident. Another incident, dated 07/15/16) indicated Resident #31 requested to toilet following lunch and was told she had to wait until the residents were back in their rooms. The form indicated an investigation was completed and noted Resident #31 received assistance after the residents were placed in their rooms. 2) Resident #85 A report dated 07/07/16, indicated Resident #85 reported she was left on the bedside commode (BSC), that her hip was hurting, and she was in pain. She was unable to state how long she was on the BSC, or provide the name of the nurse aide (NA). According to the report, the director of nursing (DON) spoke to the NAs, who related they had placed her on the BSC and left to care for another resident. The DON indicated the facility was unable to determine the length of time the resident was left on the BSC. No witness/investigative statements were provided by the facility and no evidence was present to indicate the allegation had been reported to the appropriate State agencies. 3) Resident #77 On 06/21/16, Resident #77 alleged that a nurse aide (NA) was rude to her, purposefully hit her with the mechanical lift lift when she was transferred for toileting, and was given a bath on the toilet and did not want one. The resolution indicated the social worker conversed with Resident #77 at length and the resident did not repeat any of the allegations. No evidence was present to indicate the facility had reported or thoroughly investigated the allegations of abuse. 4) Resident #2 Resident #2 reported on 06/24/16 that the nurse aides (NA) on duty did not put her to bed in a timely manner. When Social Worker (SW) #32 interviewed the resident on 06/24/16, Resident #2 reported that when she puts her light on, the nurse aides will say they will go get help and they do not return. The report indicated the incidents happened on shifts where three (3) specific people worked and provided their names. No evidence was presented to indicate an investigation had been completed or an allegation of neglect had been reported to the appropriate State agencies. During an interview on 08/24/16 at 4:46 p.m. with Resident #2, the resident stated certain nurse aides did not respond to call lights and/or answer them timely. The resident said it was three (3) specific nurse aides, and she had informed the facility. c) Resident council minutes, reviewed on 08/23/16 at 2:48 p.m. for the period of 02/01/6 through 08/23/16, identified concerns voiced on 07/05/16 regarding residents being left on bedpans for extended periods of time, call lights not answered timely, or turning off call lights without assisting residents. A note dated 07/24/16 indicated the facility response was, Staff can't (can not) be in two (2) places at once. During meals staff are assisting others, be patient and they will answer lights as soon as possible. Complaints were also voiced at the meeting on 05/06/16, 04/08/16, 03/04/16, and 02/05/16. There was no evidence these issues were investigated. d) The abuse prohibition policy dated 05/01/16, reviewed on 08/23/16 indicated neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish or mental illness. Abuse was defined as the infliction or threat to inflict physical pain or injury . The policy indicated anyone who witnessed an incident of suspected abuse or neglect was to tell the abuser to stop immediately and report the incident to the supervisor immediately. The facility was to conduct an immediate and thorough investigation which would be thoroughly documented and recorded. e) The administrator, interviewed at 3:30 p.m. on 08/24/16, stated the first thing to do after an allegation was made was to report the allegation and complete an investigation. He confirmed no evidence was present to indicate a thorough investigation had been completed or that the allegations of abuse and/or neglect had been reported to the appropriate State agencies. A follow-up interview with the director of nursing (DON) and administrator, on 08/24/16 at 4:07 p.m., confirmed the allegations had not been reported to the appropriate State agencies and upon exit of the facility on 08/30/16, had not provided additional information to indicate a thorough investigation had been completed for the alleged violations reported for Resident #31, #2, #77, #85, and #40. Upon inquiry, the DON voiced neglect was the failure to provide a good or service to the resident. f) During an interview with the Nurse Practice Educator (NPE), on 08/30/16 at 10:10 a.m., the nurse said she performed all the training for abuse, neglect, and misappropriation of property. The NPE stated that when an allegation was made, the facility investigated, then determined whether or not the allegation would be reported. The NPE said the allegation would not be reported unless substantiated. The regulatory requirement is for allegations to be reported immediately. The immediate reporting requirement is not contingent upon whether the investigation finds the allegation is or is not substantiated. The results of the investigation are reported in the 5-day follow up report. g) Resident #81 On 08/22/16 at 2:47 p.m. a Stage I interview of the Quality Indicator Survey (QIS) was conducted with Resident #81. When asked whether he had any missing personal items, he replied, Yes my wallet with identification, insurance card, food stamp card, bank card, and $100.00 in cash. He said he had told the nurses and the Social worker. During an interview on 08/23/16 at 9:30 a.m., Social Worker (SW) #32 stated, He (Resident #81) said his wallet was missing and this is the first of I heard of it. A medical record review on 08/24/16 at 2:44 p.m. revealed this [AGE] year old male was admitted from an acute care community hospital on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE], discharged to the hospital on [DATE], re-admitted on [DATE], discharged to the hospital on [DATE] for surgery and re-admitted on [DATE]. His [DIAGNOSES REDACTED]. Documentation indicate he ws documented to have capacity to make medical decisions. His Brief Interview for Mental Status (BIMS) score was 15 indicating that he was cognitively intact. The Nursing Home Administrator (NHA) stated in an interview on 08/24/2016 at 3:28 p.m., if it is a missing item such as clothes then it is searched for within 24 hours to see if it is in the laundry or another room, but if it is money then automatically an incident/accident report is completed and reported to the appropriate State agencies. Resident #81 reported in a follow-up interview on 08/25/2016 at 8:58:a.m., They found my keys but not my wallet with the contents. I am not sure if it is at the hospital or somewhere else, but I had it when I left my apartment. This is upsetting because it has my social security card, my insurance card, my food stamp card, and my bank card. In this day and age who knows what someone would do stealing my identify. SW #32 stated, I did not fill out a concern and/or an incident/accident form because I didn't think I needed to for his missing wallet and personal identification. She further agreed a concern and or incident/accident form should have been completed, an investigation should have been conducted, a report to the appropriate State agencies completed due to the possible misappropriation of funds, and credit, bank, and social security cards. h) The administrator agreed changes would need to be implemented and education completed for reporting and completion of documentation for reportable occurrences. He commented he had taken over the facility as administrator on 07/05/16 and was not aware of all of the system failures at present, but was working on getting the matters resolved that had been brought to his attention during the survey. He further stated the facility policy/procedure was not followed in this matter and provided a copy. f) A review of the facility's policy/procedure titled GRIEVANCE/CONCERN on 08/25/16 at 10:45 a.m. stated, .Center leadership will investigate, document, and follow up on all formal concerns and grievances registered by any patient or patient representative On 08/25/16 at 10:55 a.m. a review of the facility's policy/procedure titled Abuse Prohibition--State of West Virginia revealed it included, .6. Upon receiving information concerning a report of .misappropriation of patient property .the CED or designee will: 6.2 Report as follows: 6.2.1 OHFLAC (Office of Health Facility Licensure and Certification) .DHHR (Department of Health and Human Resources) Adult Protective Services and Ombudsman program.",2020-09-01
2352,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2017-02-28,225,D,0,1,MNKY11,"Based on a review of the facility's grievances, concerns, a review of the facility's policy on abuse prohibition, and staff interview the facility failed to ensure they identified and reported two (2) of 38 grievances for allegations of neglect to the appropriate State agencies. Resident #40 and Resident #44 both reported issues related to not receiving their medications. These allegations were not identified as neglect nor were they reported to the appropriate outside State agencies. Resident identifiers: #44 and #140. Facility census: 89. Findings include: a) Resident #44 A review of the grievances/concerns revealed a grievance/concern dated 03/16/16 for Resident #44. The grievance/concern stated, Resident believed she did not get her pain medication. b) Resident #140 A review of the grievances/concerns revealed a grievance/concern dated 03/30/16, which stated, Resident reported she did not get any medication on the evening of 03/29/2016 . I investigated and could not find any evidence of this . MARS (medication administration records) were signed and documented correctly. c) Record review A review of the facility's abuse prohibition policy revealed the facility defined neglect 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. d) Interview On 02/23/17 at 9:30 a.m., an interview with Social Worker #2 revealed she had not identified or reported the allegations of neglect made by Resident #44 and Resident #140. She said she was not sure why the facility had not identified or reported these grievances/concerns and allegations of neglect.",2020-09-01
2538,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2017-08-08,225,H,0,1,0QX311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy and procedure review, accident/incident reports review, resident interviews and staff interviews, the facility failed to ensure incidents of verbal abuse, physical abuse and sexual harassment were identified, thoroughly investigated and reported to the appropriate State agencies. The facility's failure to identify and investigate allegations of verbal abuse, physical abuse, psychological abuse, and sexual harassment also resulted in a failure to ensure alleged victims were protected from further abuse, resulting in actual harm. These finding affected more than a limited number of residents residing in the facility. Resident identifiers: #127, #13, #96, #136, and #45. Alleged perpetrator: #86. Facility census: 88. Findings include: The following information was discovered in a review of Resident #86's nursing progress notes of occurrences of behaviors toward other residents. a) Resident #13 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A Brief Interview for Mental Status (BIMS) performed on 06/05/17 revealed a score of 11 meaning Moderately impaired cognition. Review of the grievances/concern forms on 08/02/17 at 8:00 a.m. found grievance/concern forms dated: -- 06/15/17 (typed as written): (Name of Resident #13) stated that when he is going by room [ROOM NUMBER] (room of Resident #86 and near the dining room), that the man in the cowboy hat yells things at me. He (Resident #86) said, Get the f---- out of the hallway! (Name of Resident #13) said that he shouldn't have to listen to that or worry about it. -- 06/16/17 (typed as written): MSW (Masters of Social Work) and CED (Administrator) met with resident (Resident #86) to discuss another resident's (Resident #13) concern that he (Resident #86) had been cursing and yelling at him (Resident #13) in the hallway. Informed resident (Resident #86) that this behavior is inappropriate and cannot continue. Resident (Resident #86) verbalized understanding but also indicated the behavior would continue should he feel it needed AEB (as evidenced by) him stating And I'll do it again. Resident (Resident #86) verbalized he felt as if he were protecting another resident. SS (social services) will follow as needed. Resident #13 stated during an interview on 08/07/17 at 3:30 p.m., regarding the incident that occurred on 06/15/17, that it, Made me afraid because didn't know what he was going to do. That was abusive to me and my roommate told me that is called verbal abuse and that is exactly what it was. Didn't feel the facility did that much about it. The staff did not tell me anything other than they did speak to him. Well it didn't help because once or twice since then he has yelled and cussed at me when I went out in the hall even with staff. Now I am afraid to come out of my room and to go down the hallway even with staff. His room is close to the dining room so I don't want to go there for meals either because I don't know what he will do to me. This grievance/concern was not recognized or identified as abuse by the facility, lacked a thorough investigation including witness statements, and was not reported to the appropriate State agencies as per facility policy and federal guidelines. Furthermore, the failure to identify these occurrences as abuse and to protect Resident #13 from additional abuse resulted in psychological harm to Resident #13. b) Resident #127 Review of the resident's medical record on 08/02/17 at 10:30 a.m. revealed he was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. A BIMS performed on 07/26/17 revealed a score of 03 meaning severe impaired cognition. He was unable to be interviewed during the survey due to impaired cognition. On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #127: -- 05/11/17 late entry for 05/09/17 (typed as written): Resident (Resident #86) was done eating and was sitting at his table and usually he leaves right after he is done. Brought in resident (Resident #127) to sit at his table for second seating at the empty space he (Resident #86) yelled and stated let me get the hell out of here. He isn't suppose to sit at my table. Informed nursing. -- 05/11/17 (typed as written): Today at lunch resident (Resident #86) was yelling at another resident (Resident #127) for standing up. Resident (Resident #86) goes over to the resident (Resident #127) standing up calling him names and stated if he (Resident #127) didn't sit down he (Resident #86) would knock him down. Went back and got the social worker again. Informed nursing of the incident. -- 06/22/17 (typed as written): During lunch today (first name of Resident #86 was done eating and his tablemate was done eating and had already left. Went to bring in the second seating and sat him (Resident #127) at the table and (first name of Resident #86) started yelling and threw his clothing protector at the other resident (Resident #127). Told (first name of Resident #86) that was inappropriate to throw something at another resident. The other resident's (Resident #127) wife was with him. He (Resident #86) does this at the lunch meal and at times at dinner. Reported to the Administrator. -- 06/23/17 (typed as written): During lunch today (first name of Resident #86) and his table mate was finished with their lunch and his table mate had already left. I asked (first name of Resident #86) if he was finished with his lunch and he stated yes. When I went to clear the table (first name of Resident #86) started yelling that no bastard was sitting at the table and he would flip the f***king table over if I tried to sit someone there. I explained to him that he was finished and other residents needed their lunch, he left the dining room saying if he came back up the hall and the bastard was sitting there he would flip the f***king table over. This incident involved Resident #127 coming to sit at the table and for a cognitively intact person, would result in psychological harm. c) Resident #96 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #96: -- 07/15/17 (typed as written): Resident (Resident #86) in room in wheelchair when another resident (Resident #96) coming down hallway, nurse on right side of other resident (Resident #96) in between other resident (Resident #96) and this resident's (Resident #86) door. (Name of Resident #86) began yelling and making threats directed toward other resident (Resident #96). This nurse proceeded to keep conversation with other resident (Resident #96) as to avoid other resident (Resident #96) calling attention to (name of Resident #86). (Name of Resident #86) continued to verbally threatened other resident (Resident #96) until other resident (Resident #96) was out of hearing distance. All attempts at redirection unsuccessful, resident (Resident #86) continues to yell out doorway cursing fell ow resident at this time Review of the medical record on 08/07/17 at 3:45 p.m. revealed Resident #96 was admitted on [DATE] with a recent re-admission on 02/16/17. His [DIAGNOSES REDACTED]. His most recent BIMS was coded as 13 on 06/29/17 indicating he was cognitively intact. During an interview with Resident #96 on 08/08/17 at 10:11 a.m., he stated, (Name of Resident #86) tried to ram me with his wheelchair, yelling and cursing when I was going down the hallway and has really been terrorizing other residents. The incident made me angry that this would happen because he had a shoe horn which he threatened to hit me with and cut me. He did hit my chair and would have hit my arm if I hadn't moved it off of the arm rest. I went to the nurses about it and all they said was that he wouldn't give it to them so they said there is nothing they can do about it. When inquired if he had reported this to the administrator or social services he stated, There is no need they never do anything about it, just say that is the way he is. Next time I will just call the cops because my brother is a retired cop and now a magistrate in (name of a nearby town) and he said that is verbal abuse and assault. Will just let the cops do something about it since this place won't do anything and doesn't care that we are being abused and terrorized by him. It is very upsetting to have to go down the hall and wonder if he is going to verbally or physically attack you. I am afraid for other residents like those people that are confused and won't go down the hallway just stay in their room. For me just don't like it is right to be in a nursing home and worry about being abused or assaulted. The medical record review for Resident #96 and #86 was found silent for the occurrence referenced as assault in Resident #96's interview. The facility's failure to identify abuse and to protect residents resulted in psychological harm, and fear of physical harm to Resident #96. In addition, Resident #96 expressed fear for cognitively impaired residents residing in the facility. d) Resident #136 On 08/02/17 at 1:35 p.m. a review of the nursing progress notes for Resident #86 revealed the following occurrences involving Resident #136: -- 07/13/17 (typed as written) SW (social worker) and Administrator met with (first name of Resident #86) regarding verbalizations from an alert but confused female resident that she feels uncomfortable around the man in the cowboy hat. Resident (Resident #86) initially did not acknowledge which resident we were talking about but then did recall trying to help get a tangle out of her (Resident #136) hair one day. Resident verbalized understanding of request and said he would not have any contact with her. A review of the incident/accident forms, grievances/concern forms did not reveal any forms related to the previous progress note documentation. The facility failed to recognize this occurrence as sexual harassment although the definition for sexual harassment includes, unwanted physical touching that makes a person uncomfortable. Review of the medical record on 08/07/17 at 3:20 p.m. revealed Resident #136 was admitted on [DATE] with a recent re-admission on 07/25/17. Her [DIAGNOSES REDACTED]. Her most recent BIMS was coded as 03 on 06/28/17, indicating severe cognitive impairment. She was unable to be interviewed during the survey due to impaired cognition. e) Resident #86 Review of the resident's medical record on 08/02/17 at 1:35 p.m. revealed Resident #86 was originally admitted on [DATE] and the most recent re-admission on 04/08/17 following a hospitalization . His [DIAGNOSES REDACTED]. He had been determined by his attending physician to have capacity to make his own medical decisions. Most recently assessed on 07/05/17 to have a BIMS score of 15 showing him to be cognitively intact Employee #K reported during a confidential interview that Resident #86 is rude and mean to other residents especially the residents with dementia like (name of Resident #127). It is certainly considered verbal abuse and he is sometimes physically abusive to other residents, I know that, but it just keeps happening with no consequences. We all report it to the nurses, supervisors, and social service, but no one does anything about it. They just say, 'Oh, that is just the way he is,' but one of these days he is going to really hurt someone. He has targeted (Resident #13) because of his race to the point he (Resident #13) is scared to come out of his room. Those are just a few of the residents afraid of him, but you will never find out who they are because none of the nurses chart anything anymore because they said is a waste of their time when nothing is ever done about it. I hope this new administrator changes things because the residents should not have to put up with abuse all the time. During a confidential interview with Employee #W, she stated, (Name of Resident #86) perceives himself as a southern gentleman and seemed to target (name of Resident #13) due to his race according to (Resident #13). Which could be due to his (Resident #86) upbringing and culture, but should not have been allowed to happen. It should have been documented as an incident and reported to the state as verbal abuse at least. No psychiatric services or treatment have been attempted or made available for this resident since he has been here, I think he was here since 2014. Not really sure he would be receptive to any psychiatric services, but it should have at least been attempted and offered because of how he treats other residents. He yells, screams and curses other residents, rams them with his wheelchair and threatens to hit them or cause bodily harm. I agree that we as a facility have not been protecting residents from abuse as a whole by (Resident #86) or any other resident with behaviors like this. The progress notes you found are probably only a handful of actual incidents that have occurred in the facility for all residents because most of them don't even get documented anywhere by staff. Yes, the dining room incident and also any incident involving where (Resident #86) was yelling, screaming and cursing at a resident is considered verbal abuse and should have been reported because every staff member here is a mandatory reporter, but we dropped the ball on all of the reporting of behaviors by residents. We have just really been lax and have not addressed resident behaviors in this facility because we just say that is just the way they are and let it go. We should not have been as lax or accepting of these behaviors because we did put our other residents at risk and allowed them to be abused. Agree that no psychiatric evaluations or treatment were initiated for the residents with behaviors which caused not only neglect on the facility part for treatment and management but also allowed abuse of other residents in our facility under our watch. I do admit this is sad and shameful on all of the staff and management here to have allowed this to happen because we did not think about it being abuse and could have helped all residents by getting the residents with behaviors help and keep the other residents safe. Some of the residents (Resident #86) has had incidents with were residents who have dementia and not able to help their actions. These other residents are not cognitively able to defend themselves and depend on the facility to keep them safe. On 08/08/17 at 8:55 a.m., Social Worker (SW) #5 explained social services had not been involved in clinical meetings in the past and were unaware of behavioral incidents because these were handled by nursing. Under the new administration, social services would be included not only in morning meetings, but also daily clinical meetings so they would have knowledge of incidents and could report them as they were brought to the attention of Social Services. After review of the progress notes for Resident #86 involving incidents of behaviors directed toward other residents and staff, SW #5 stated, I was not aware of all of these, would have completed incidents reports for these and reported them to the state agencies for verbal abuse. She further stated, The previous administrator attempted to involve the daughter with his behaviors, but it didn't go anywhere. Upon inquiry regarding her role in the treatment of [REDACTED].#86, she stated, My hands were tied by the previous administration. The new facility Administrator (who began this position on 07/31/17) acknowledged residents' behaviors and reported their needs were not being met, during an interview on 08/08/17 at 10:10 a.m. He stated, This is something that will be a priority due to having several residents with behaviors that need to be evaluated and their actions addressed. After review of the previously referenced progress notes he agreed all of these should have been documented, investigated and reported. This will certainly be done under my administration. On 08/08/17 at 10:30 a.m., review of the facility's policy titled OPS300 Abuse Prohibition found it included the following excerpts (typed as written): POLICY (Name of corporation) will prohibit abuse, mistreatment . for all residents . The center will implement an abuse prohibition program through the following: -- Prevention of occurrences; -- Identification possible incidents or allegations which need investigation; -- Investigation of incidents and allegations; -- Reporting of incidents, investigations and Center response to the results of their investigations. Federal Definitions: Abuse is defined as the willful inflicting injury, .or mental anguish . Instances of abuse of all patients, irrespective of any mental or physical condition, cause physical harm, pain or mental anguish . It includes verbal abuse . Willful, as used in this definition of abuse, means the individual must have have acted deliberately . -- Verbal Abuse is any use of oral, written, or gestured language that willfully includes disparaging and derogatory terms to patients or their families . -- Sexual Abuse is a non-consensual sexual contact of any type with a resident. It includes but is not limited to sexual harassment, sexual coercion or sexual assault. -- Mental Abuse includes, but not limited to humiliation, harassment, and threats of punishment or deprivation. Mental abuse may occur either verbal or nonverbal conduct which causes or has the potential to cause the patient to experience humiliation, intimidation, fear, shame, agitation , or degradation . -- Neglect is 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 . Process 5.1 Anyone who witnesses an incident of suspected abuse, neglect . is to tell the abuser to stop immediately and report the incident to his/her supervisor immediately. 5.1.1 The notified supervisor will report the suspected abuse immediately to the Center Executive Director (CED) or designee and other officials in accordance with state law. 6. Upon receiving information concerning a report of suspected or alleged abuse, mistreatment, or neglect, the CED or designee will perform the following . 6.2 Report allegations involving abuse (physical, verbal, sexual, mental) not later than two hours after the allegation is made . Review of the incident/accident forms, grievances/concerns forms, and incidents reported to State agencies, found them silent for the previously referenced nursing progress notes except where identified - indicating the facility did not document on the appropriate forms, did not conduct investigations and/or thorough investigations including witness statements, and did not report allegations of abuse which include allegations of verbal and physical abuse, and an allegation of possible sexual harassment. e) Resident #45 The resident was [AGE] years of age. He was admitted to the facility on [DATE] and subsequently discharged on [DATE]. He went into [MEDICAL CONDITION] during [MEDICAL TREATMENT] and passed away at the hospital. Review of complaints/grievances on 08/07/17 at 11:47 a.m. found a complaint filed by Resident #45 on 05/10/17. He told a Licensed Practical Nurse (LPN) a Nursing Assistant was rude to him and cursed at him when he attempted to get a cup from the drinking cart (nurses' cart) and a couple of cups fell on to the floor. Neither the LPN or the Nursing Assistant were current employees. The investigation included a witness statement by the Nursing Assistant who allegedly cursed at him. She stated he was getting cups off the nurses' cart and she told him he could not get into the nurses' cart. She also said, I didn't curse at resident. The investigator met with the resident and told him the issue was addressed with the employee and explained infection control issues. He was told if he needs a cup to ask staff for it related to infection control. The investigator wrote He voiced understanding and I assured him administration would speak with said CN[NAME] He was ok with this. The complaint was not recognized as an allegation of verbal abuse and therefore was never reported. During an interview on 08/08/17 at 11:21 a.m., Administrator #111 agreed the complaint was an allegation of verbal abuse and should have been reported.",2020-09-01
2704,DAWN VIEW CENTER,515163,PO BOX 686,FORT ASHBY,WV,26719,2017-01-06,225,E,0,1,YTR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of grievance/concerns and reportable incidents, and staff interview, the facility failed to report allegations of abuse/neglect to required State agencies in a timely manner for four (4) of fifteen (15) grievances/concerns. The facility also failed to thoroughly investigate an allegations of abuse/neglect for one (1) of two (2) residents identified during a review of the reportable incidents. Allegations of abuse/neglect involving Residents #19, #21, #73 and #4 were not reported to the required State agency. The allegations of abuse and/or neglect regarding Resident #19 was not thoroughly investigated. Resident Identifiers: #19, #21, #73 and #4. Facility Census: 63.Findings Include: a)Failure to report concerns/grievances to required state agencies Review of grievances/concerns found four (4) of fifteen (15) were allegations of abuse/neglect in which was not reported to the appropriate state agencies as required. 1.) Resident #19 On 11/09/16 Resident #19's daughter expressed the concern her mother was placed in bed the previous night with her daytime clothing on and she had food on her face and clothing. 2.) Resident #21 On 11/25/16 Resident #21 provided a hand written note to the Assistant Director of Nursing (ADON) with the following concerns (typed as written): --On 11/23/16, I (Resident #21) never received my dinner tray that I had ordered and when I did get my tray an hour late (6pm) it was stone cold. --On 11/24/16, Thanksgiving I did not receive my medication on 7-3 shift and the NA did not come in and check on us. I had to ask them to empty my catheter bag, which was full and backing up in the tubing. My [MEDICAL CONDITION] bag was full and had not been changed. --On 11/25/16, 7-3 shift, again the NA did not come to check on me and my catheter bag and [MEDICAL CONDITION] was full and I had to ask them to provide care. 3.) Resident #73 On 11/21/16 at 9:30 a.m., The ADON noted Resident #73 was tearful, and when asked what was wrong Resident #73 stated, I never want to get another shower. They did not wash my butt or front (perineum) and did not give me a wash cloth so I could do it myself. 4.) Resident #4 On 12/13/16 at 6:30 p.m., Resident #4 requested to go to bed and she was told she had to wait until two (2) nurse aides (NA) were available. She stated it was 9:30 p.m. before she received care and was put to bed. Additionally, all three (3) of her roommates were put to bed before her. On 01/05/17 at 8:45 a.m., an interview was conducted with the Nursing Home Administrator (NHA) and the Director of Nursing (DON). During this interview the grievances/concerns for Residents #19, #21, #73 and #4 were reviewed and they both agreed these were allegations of neglect/abuse and should have been reported to the appropriate agencies b) Failure to investigate concerns/grievances Review of the facility's reportable incidents for the previous four (4) months, found on 11/17/16, the resident's daughter voiced concerns about her mother's complaints of pain when her left arm was moved on 11/16/17 and on 11/17/16 when her left arm was moved and hanging down. These concerns were voiced to the DON. The NHA reported the allegations to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman. The 5-Day Follow Up report indicated Resident #19 had a dislocation of the left shoulder requiring sedation to be manipulated into place. The daughter indicated her mother had indicated pain on 11/16/16 and 11/17/16. During an interview, on 01/05/17 at 8:45 a.m., the NHA and the DON confirmed they failed to get interviews /statements from all the nursing staff working during the period of injury (11/16/16 and 11/17/16). They failed to get statements from Employee #5, licensed practical nurse (LPN) whom had assisted a NA to transfer the resident to bed on 11/16/16, Employee #28, a NA whom done range of motion exercises to Resident #19's upper extremities on 11/16/16 and Employee #15, LPN who completed a body assessment on 11/16/16.",2020-09-01
3469,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,225,D,0,1,ITHZ11,"Based on record review, policy review of Grievances and Complaints and reportable incidents, family interview and staff interview, the facility failed to report allegations of neglect to required State agencies in a timely manner for one (1) of six (6) months of grievances/complaints reports reviewed. The facility also failed to thoroughly investigate an allegation of neglect for one (1) resident. Allegations of neglect involving Resident #78 was not reported to the required State agency. The allegation of neglect regarding Resident #78 was not thoroughly investigated. Resident Identifier: #78. Facility Census: 83. Findings Include: a) Resident #78 Review of the facility's reportable incidents for the previous six (6) months, found on 07/27/17, the resident's daughter voiced concerns about her mother still in her pajamas in the afternoon when she came in to visit on 07/23/17. These concerns were voiced to Social Services Supervisor (SSS) # 85 on 07/27/17. The facility obtained witness statements from six (6) employees. Two (2) of the six employees indicated they did not provide care for Resident #78 on 07/23/17. Nurse Aide (NA) #17 stated, I provided no pt (patient) care to Resident #78 besides serving lunch to her. She was up in chair and dressed appropriate. Another unidentified staff member stated, Resident #78 slept well all night, no c/o (complaints). Clean/dr (dry) when shift was over. Nurse Aide #50 stated, I didn't get to do rounds as early as I wanted to. I changed her that morning around 9:00, but she wasn't ready to get out of bed just yet. Then I had another resident that was throwing up and I waited with her until the ambulance came to get her. By the time she left it was lunch time. After lunch, I went to her room and her daughter was already there. I explained to her what happened. A statement from Unit Charge Nurse (UCN) /Licensed Practical Nurse (LPN) #49 stated, This nurse worked 7A-7P 7/23/17. During the morning hours (room #) c/o (complained of) N/V (nausea/vomiting). Multiple emesis with declining condition. This nurse & assigned CNA #50 spent an extended amount of time with resident which resulted in sending to ER (emergency room ) with admission. Due to this incident CNA ran late completing duties with other residents. (Resident #78) daughter did visit during lunch hour and requested washcloths (washcloths) to clean her mother's face & dressed her. Daughter was made aware by CNA of a resident being ill & requiring attention. Again voiced zero complaints on exiting or re-entering the facility to this nurse. Review of the facility's reportable incidents for the previous six (6) months, found on 07/27/17, the resident's daughter voiced concerns about her mother still in her pajamas in the afternoon when she came in to visit on 07/23/17. These concerns were voiced to Social Services Supervisor (SSS) # 85 on 07/27/17. The grievance/complaint report did not indicate if and/or when it was reported to Director of Nursing (DON) #8 and/or Executive Director (ED) #106. The facility failed to report the allegations to to the Office of Health Facility Licensure and Certification (OHFLAC), OHFLAC-Nurse Aide Registry, Adult Protective Services (APS) and the Ombudsman, as outlined in the Facility's Abuse, Neglect and Exploitation Policy, Section 5, and failed to investigate the allegations of neglect. The Grievance/Complaint Report indicated the date assigned was 07/27/17. The date to be resolved by 07/30/17; however, Resident #78's daughter was notified and the Resolution of Grievance/Complaint was completed on 08/02/17 by SSS #85. On 09/20/2017 at 10:08 a.m. Resident #78's daughter was interviewed by phone. The daughter said she was in the building on 07/23/17 at around 1:30 p.m. She said Resident #78 told her no one had been in to care for her that day. She said she took her mother into the bathroom, took her brief off her and the brief was soaked with urine. The urine was yellow in color and had a very foul odor. The daughter felt the brief had been on her mother for a long time possibly from the night before. She said her mother's face also had not been washed. The daughter stated that the staff told her they were busy with a sick resident and apologized to her for not being able to attend to her mother's needs. The daughter said she told the staff if they were that busy they needed a backup plan for other staff to help. On 09/20/17 at 10:48 a.m. the administrator and director of nursing were present for an interview in which the administrator said the facility did not identify or report this issue as an allegation of neglect. He did not feel this issue constituted an allegation of neglect. The administrator said he did not feel the resident had suffered mental anguish and therefore felt the facility had no obligation to report to outside State agencies. The administrator was asked if the facility had obtained a statement from Resident #78. The administrator said they had not. Resident #78 was assessed as having a BIMS (brief interview of mental status) of 12 on the MDS with an assessment reference date of 05/02/17. A BIMS of 8-12 indicated moderate impairment. A BIMS of 13-15 indicated cognitively intact.",2020-09-01
3670,JACKIE WITHROW HOSPITAL,5.1e+110,105 SOUTH EISENHOWER DRIVE,BECKLEY,WV,25801,2017-04-06,225,D,0,1,X3BK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, facility and dental staff interviews and resident interview, the facility failed to ensure Resident #84 received dentures the dentist had made for the resident; made no attempt to try and locate the dentures until surveyor intervention; and failed to identify this occurrence as neglect and/or timely report the occurrence to the appropriate state agencies until after surveyor intervention. This is true for (1) of three (3) residents, reviewed for the care area of abuse during a Quality Indicator Survey (QIS) anD concurrent complaint investigation, #WV 065. This practice had the potential to affect more than a limited number of residents. Resident identifier: #84. Facility census: 90 Findings include: a) Resident #84 On 04/05/17 at 9:49 a.m. review of the current care plan revealed resident at risk for mouth pain has had dental extractions, awaiting dentures to be made. Review of records revealed no notations or revisions concerning resident ever receiving dentures. On 04/05/17 at 10:55 a.m., during interview and review of records with unit manager RN #105, it was discovered that Resident #84 should have had upper and lower dentures of which the unit manager and the Health Service Workers (HSW) on the unit were not even aware and should have been aware. The current care plan revealed resident at risk for pain has had dental extractions, awaiting dentures to be made. The resident moved to the unit on 12/12/16 from another unit in the facility, and lived on the current unit one hundred fourteen (114) days before it was determined, through surveyor intervention, the resident was supposed to have dentures. Continued interview and record review with RN #105 that began at 10:55 a.m. on 04/05/17, revealed Resident #84 received dental services last year in (YEAR). The resident had his teeth extracted at the dentist's office on 01/15/16, and then on 02/02/16 at the dentist's office alveoplasty was performed (A minor oral surgical procedure to ensure proper fit of dentures, by smoothing and reshaping the jaw bone ridge.). A dental consult dated 04/27/16 noted, I have checked and resident has resources for dentures. Can you please start this process? Thank you. Dental consult dated 05/04/16, revealed, 1st (first) impression for upper and lower dentures next appointment 2nd (second) impression and jaw relation. Dental consult dated 05/18/16, revealed, 2nd and jaw relation next appointment try in. The last dental consult on record, dated 06/08/16, revealed, Try in upper and lower dentures will send to lab and they will return on Monday and if patient has any trouble I will see the next time that I am here. RN #105 stated, I have looked through the records and cannot find anything else about dentures. I was not aware the resident had dentures, or even was supposed to have dentures when he transferred to this unit. I don't know where the dentures are. When asked when the resident moved to the unit, RN #105 looked in the records and replied the resident moved to this unit on 12/12/16 from another unit in the facility. RN #105 said, When the resident came to this unit he did not have any dentures. On 04/05/17 at 11:11 a.m., RN #105 went to the resident's room and asked Resident #84 where his dentures were. RN #105 reported to this surveyor the resident told the nurse he never had any dentures, but they had pulled all his teeth. Interview of Resident #84 by this surveyor, on 04/06/17 at 9:25 a.m., revealed resident had his teeth pulled and had dentures made but never did receive dentures. Resident #84 said, They pulled all my teeth, and I never got any dentures like they said I would. When asked if he ever asked anyone about where or what happen to his new dentures, Resident #84 said he didn't think so. RN #105 told this surveyor, on 04/05/17 at 11:23 a.m., that upon just having called the Dental lab, she was told. (Name of person) delivered the dentures to the facility's front desk switch board on 06/09/16. While trying to determine: where the resident's dentures were; what process was used to ensure residents received dentures once the dentist has the dentures made; how dentures are tracked from the dental lab to the resident; who was aware or should have been aware the dentist was having dentures made for the resident; and when should the resident have received the dentures, the assistant administrator was notified. The assistant administrator was notified about the situation and issues, by this surveyor via phone, on 04/05/17 at 11:29 a.m. The assistant administrator was informed Resident #84, had dentures delivered to the facility on [DATE] according to the dental lab and the facility's Resident Accounts. The assistant administrator was told the resident denies ever having received them, and about the staff's inability to locate the dentures at this time. This surveyor requested information on when something is delivered to the facility for a resident how it is processed and/or tracked. The Assistant Administrator said she would get back to the surveyor with the information. As of the exit date the Assistant Administrator did not provide any further communication or information concerning this issue. On 04/05/17 at 11:33 a.m., this surveyor called the Dentist's office to clarify what the process was of providing dentures to a resident in the facility. Interview of the Dentist's secretary, via phone, revealed the process of getting dentures to a resident in the facility is as follows: (dental lab's name) delivers the denture to the facility; (dental lab's name) places the dentures in the box designated for the floor/unit the resident resides on; then the nurse on that floor/unit gives the resident their dentures. The dentist instructs the facility to place the resident on the dentist's schedule if there are any problems or adjustments that need to done to the dentures. Sometimes the nurses places the resident on the schedule and sometimes they don't. Some resident's do not have any problems and there's no need to. When asked if the Dentist ever does any other follow ups to see how well the resident is doing with their new dentures, the secretary replied No. Interview with Resident Accounts Employee #146 and Employee #157, on 04/05/17 at 12:42 p.m., revealed resident had Medicaid resources that agreed to pay for his dentures. This surveyor was given a copy of the invoice dated 06/09/16 for dentures and a copy of the check, dated 07/12/16, that was used to pay for the dentures. Employee #146 explained the owner of the Dental Lab is the only person that delivers the dentures to the facility. Employee #146 said, (name of person) drops off dentures at the front desk switchboard and walks across the hall to my office and hands me the invoice for them. That's how (name of person from dental lab) does it. The name Employee #146 said, was the same name RN #105, on 04/05/17 at 11:23 a.m., and had said delivered the dentures to the facility's front desk switch board on 06/09/16. Based on the dental labs delivery/invoice for dentures dated 06/09/16 and the discovery date of 04/03/17, Resident #84 did not receive or have use of the upper and lower dentures, paid by Medicaid resources, for two hundred ninety nine (299) days. On 04/05/17 at 5:51 p.m., Surveyor # conducted a QIS Abuse Prohibition Review interview with LSW #72, Licensed Social Worker. The interview revealed staff do not have to wait for her (LSW) to do an immediate reporting, staff have been trained on when to report and how to report. LSW #72 said staff do not wait until she (LSW) comes to work to make out an immediate reportable. An interview with DON on 04/06/17 at 11:14 a.m., revealed when asked, What has been done so far concerning Resident #84's missing dentures? The DON said they had looked for the dentures in the resident's room and interviewed the resident last night. The DON stated the resident said he did not get them. The DON also said, We'll start the whole process all over again, starting with another dental consult. We talked to the dentist last night, he said the last thing he knew about the dentures was in his notes. It is just a mystery. We'll get him (Resident #84) taken care of. The DON was asked again, Is there anything else the facility has done concerning Resident #84's missing dentures? The DON replied, No, nothing else I can think of. During the interview with the DON, at no time was it mention the incident would be reported. On 04/06/17 at 11:23 a.m., interview with the Administrator, revealed when asked, What has been done so far concerning Resident #84's missing dentures? The Administrator said, the DON and other staff looked for dentures in the resident's room and on all the floors and out front, but could not find them. The staff talked to the resident last night and he said he did not get them. The Administrator also said, We talked to the dentist, he said if he wrote it he did it, and what was in his notes is what he did. We will have to get them for him (dentures for Resident #84). During the interview with the Administrator, at no time was it mention the incident would be reported. Interview with the administrator, on 04/06/17 at 12:15 p.m. with Surveyor # present, revealed the resident can use their resource once per year, so the facility has plans to start the process all over again and get Resident #84 a set of dentures. The administrator said the facility was going to change the process and procedure of handling deliveries of dentures, so that the dentures and invoice will go to the same facility designated person. This surveyor asked if the facility had done anything else related to the missing dentures since becoming aware of the situation yesterday morning, for example, had they thought about reporting the incident to state agencies. The Administrator replied, No, we did not report it. The administrator said any time we have any doubts, we go ahead and do a reportable, and she could show us how many reportable that have been completed. When asked if she had any doubts about this situation needing to be reported. The Administrator replied, We did not report it, I did not think we needed to. This surveyor asked, When the dentures were purchased, at that time did the dentures not become the property of that resident? If so, would not the facility think about the incident as either misappropriation of property, or even neglect seeing as long as it has been, and would they not do an immediate reportable when they became aware? The administrator replied, We did not report it, I did not think we needed to. But we will report it, if you think we should. The administrator also said that she will consult the Licensed Social Worker and see if she thought it should be reported. Review of the facility's Abuse, Neglect or Violation of Resident Rights policy, on 04/06/17 at 1:05 p.m., revealed in the 'Purpose' section that Allegations of abuse, neglect or violations of a resident's rights may be filed in relation to any aspect of a resident's treatment or care at the facility. Under the policy's 'Procedures' section reveled in Section C: #1 Be aware of what constitutes an allegation of abuse and/or neglect, as well as resident's rights.; and #2 Be familiar with state and Federal law, which requires all facility staff employees to report incidents of actual, suspected or possible abuse and neglect, and/or violations of resident's rights. The administrator, just prior to QIS Exit conference on 04/06/17 at 1:45 p.m., gave this surveyor a copy of a reportable completed for this incident.",2020-09-01
3884,MERCER NURSING AND REHABILITATION CENTER,515052,1275 SOUTHVIEW DRIVE,BLUEFIELD,WV,24701,2016-08-19,225,E,0,1,5Q6I11,"Based on a random opportunity for discovery, staff interview, policy review, review of the abuse/neglect reporting requirements for West Virginia nursing homes and nursing facilities, and review of an employee disciplinary action form, the facility failed to thoroughly investigate and report allegations of neglect/abuse to the appropriate State agencies immediately in accordance with State law. This had the potential to affect more than an isolated number of residents. Resident identifiers: #91 and #77. Facility census: 75. Findings include: a) Employee disciplinary action form 1. On 08/16/16 at 4:00 p.m., an unrequested employee education and counseling form was found lying beside a surveyor's computer in the conference room where surveyors were working. No personnel files were in the room as there were times when no members of the survey team were present. How the document came to be in the conference room could not be determined. The employee education and counseling form included: - The name of Nurse Aide (NA) #74 - Date of the employee education and counseling form: 06/02/16 - The form required documentation for Area of Improvement: Define Situation. Poor Resident care-Resident's are being left up in wheelchairs without being checked on. Resident's are not being put to bed in a timely manner. (Name of Resident #91) reported that you were very hateful and rough putting her feet in the bed this evening. Also, she stated that last week you took her call light from her. (Name of Resident #77) does not want you to do her showers after your attitude last week. This is unacceptable work performance. Told oncoming CNA (certified nurse aide) that Resident didn't want her shirt off when in fact resident was never checked on. - The resolution for action taken: CNA needs to be aware that we are here to take care of the needs of the resident. This is the 2nd employee counseling/education form from this nurse. Next is written warning, followed by suspension and then termination if this problem isn't corrected. CNA needs to have better time management skills and try to do something's by herself. NA #74 responded to the counseling form by documenting: It's hard to do care when you have to ask 4-5 times for help when the person has to have 2 people to sit over onto the bed to get them changed. I am not rough with any pt. (patient) and I do not have an attitude towards any of them. The counseling form was signed by NA #74 and Licensed Practical Nurse (LPN) #62 on 06/02/16. The counseling form did not list the residents' names that were, Being left up in wheelchairs without being checked on. 2. On 08/16/16 at 4:20 p.m., review of the facility's grievance/concern forms and reportable allegations of abuse/neglect for the period 06/02/16 to present, found no evidence facility reported the allegations related to NA #74 to the required State agencies. Additionally, there was no evidence the facility investigated the allegations regarding NA #74. 3. Staff Interviews At 4:48 p.m. on 08/16/16, after being shown the counseling form, Social Worker (SW) #67 said, This is the first time I have ever seen this. It looks like we would have checked into it to see if it was a reportable. At 5:06 p.m. on 08/16/16, the director of nursing (DON) said, I didn't know anything about this, when shown the counseling form. She stated she would typically see the education forms. She said the Clinical Care Supervisor (CCS) might know something about the form and added The nurse is supposed to get permission from the CCS to discipline employees. At 5:14 on 08/16/16 CCS #95 said, I might have seen this, I don't know. At 8:52 on 08/17/16, SW #67 verified the allegations on the employee education form dated 06/02/16, had never been investigated, or reported. At 10:40 a.m. on 08/17/16, when asked if she had any further information to show the facility had investigated and/or reported the allegations concerning NA#74 to the required State agencies before surveyor intervention, she said the nurse who completed the education form was educated. The DON said the issues detailed on the education form were being reported to the State agencies as required. The DON confirmed the allegations were reported after surveyor intervention. 4. Review of the facility's policy and procedure for, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident's, Reporting, and Investigation, at 11:00 a.m. on 08/17/16 found it included: . 6. Upon receiving information regarding an allegation of abuse or neglect the Executive director or designee shall: a. Immediately refer to the Step One: Decision Tree for Determining the Reportability of an Incident or Allegation and Step Two: Internal and External Notification of A Reportable Incident or Allegation (see Tables 1 and 2) to assure notification if the event is reportable and initiate an investigation. b. Report the allegation (s) to the appropriate state agencies within the required time frames. Refer to reference, NH (nursing home) Reporting Requirements 06/2012, for information on reporting requirements. c. Initiate an investigation. The investigation shall be immediate and thorough. All interviews will be documented on a witness statement and will be conducted in the presence of the Executive Director or his/her designee e. The investigation will be completed on the state required forms",2020-04-01
3916,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,225,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, personnel record review, staff interview, and policy review, the facility failed to screen personnel for a background of abuse, neglect or mistreatment and investigate and report allegations of abuse. The facility failed to identify, thoroughly investigate and/or report timely allegations of physical, emotional, mental and/or sexual abuse to the appropriate State agencies. This practice has the potential to affect more than a limited number of residents. The facility also failed to operationalize policies and procedures related to completion of criminal background checks as required, for one (1) of ten (10) employees reviewed and failed to implement policies and procedures related to reporting and/or a thorough investigation of allegations of abuse. This practice affected one (1) of one (1) residents reviewed for abuse, and had the potential to affect more than a limited number of residents. Facility census: 109. Resident identifier: Resident #164. Employee identifier: Nurse Aide (NA) #20. Resident identifiers: #164. Facility census: 109. Findings include: a) Resident #164 During a Stage 1 interview with Resident #164 on 11/01/16 at 11:58 a.m., when asked the question: Has staff, a resident or anyone else here abused you, this includes verbal, physical or sexual abuse? She stated, Yes. She further stated, A gentleman here grabbed me on my arm either Friday or Saturday to put my hand on his privates, can't remember his name, but he was a friend of my husband. I told my speech therapist on Monday and she reported it. Upon further inquiry as to why she did not report it when it occurred, Resident #164 stated, Because it was embarrassing and it upset me because this gentleman used to be a friend of my husband. I was talking with my speech therapist on Monday and it just came out during our conversation. I should have told someone when it happened but it was just shocking and I could not believe it happened and he would do that. Speech Therapist (ST) #31 reported during an interview on 11/02/16 at 8:50 a.m., Resident name (Resident #164) reported the abuse to me on Monday 10/31/16 and I reported it to the social worker, for her (the social worker) to further investigate the reporting of abuse. Resident name (Resident #164) stated, He grabbed me. The resident stated she wasn't sure about reporting it because she had known him through her husband, but I explained that I needed to report this because it is considered abuse. The resident not seem upset about the incident and she had mentioned it during just our general conversation and told me it was Resident name (Resident #79). Review of the facility grievances/concern forms on 11/02/16 at 10:45 a.m. revealed a form dated 10/31/16 concerning Resident #164. Documentation of the incident stated (typed as written): Resident name (Resident #164) stated another resident (Resident initials of Resident #79) was attempting to grab her hand. She said she pulled her hand away. She said that she did not feel uncomfortable with the situation that it was no big deal. She said that (Resident initials of Resident #79) was a friend of her husband. Attached to the form was a statement by ST #31. Also attached was an interview statement of Resident #79 interviewed by the Nursing Home Administrator (NHA). The initial statement of the interview (typed as written) states; I spoke with (Resident #79) related to an alleged advance that he may have made on a female resident. During an interview with Social Services Director (SSD) #54 on 11/03/2016 at 8:22 a.m., she commented, the other resident (Resident #79) had been a friend of her husband and was grabbing for her hand. The SSD #54 said she informed the Director of Nursing (DON) and completed a grievance/concern form. She reported the resident did not seem uncomfortable, nor did she expand about the incident. Upon further inquiry SSD #54 stated, Since she (Resident #164) just said he grabbed my hand, I didn't ask her to expand on the situation. Sometimes when people know each other they will sometimes just grab your hands as a greeting, so I assumed that was all it was. When asked if SSD #54 used the word abuse during the resident interview was the word abuse used, the SSD #54 stated, No I just used the word unsafe because sometimes the word abuse will upset a resident, but I will interview her again. Maybe I didn't ask enough questions and ask her to explain more the first time. Upon further inquiry after reviewing the Grievance/Concern form, she did not reply when asked if it should have been investigated as an allegation of sexual abuse. SSD #54 stated, If she would have felt unsafe or uncomfortable about the incident I would have reported it. She did not reply when asked again if this allegation should have been investigated and reported as an alleged abuse allegation. She did state, The investigation is not complete yet because we just received it on Monday and no interventions have been put into place because it was just a concern nor was it seen as an incident or reported to any state agencies. Resident #164 commented tearfully during a follow-up interview with on 11/03/2016 at 9:06 a.m., that the Social Worker had just been in her room. The Resident stated, I told her the same thing I told you yesterday (11/01/16) and the same thing I had told her on Monday (10/31/16), that Resident name (Resident #79) grabbed my arm to pull my hand down toward his private area. I didn't tell you his name yesterday though because I didn't think you would know who he was, but I had told her (SSD #54) his name. His (Resident #79) room is down here somewhere and every time he goes past my room, he (Resident #79) just stares at me. Resident #164 was tearful and visibly upset during the interview stating, They just don't want to believe things like this happen here and how upsetting it is for this to happen to a person. SSD #54 reported on 11/03/2016 at 9:19 a.m., that she had spoken with Resident #164 and she (Resident #164) had stated, the male resident had grabbed her hands and she motioned toward down. SSD #54 commented she would talk with the NHA and report this issue now as an allegation of sexual abuse. She explained the process that each morning the incidents/accidents and grievances/concerns are reviewed in the department meetings and after reviewing these determine whether to report any allegations. The SSD #54 stated, Maybe I should have asked more questions on Monday (10/31/16) of the resident and completed a better investigation. Review of the medical record on 11/03/2016 at 9:36 a.m. revealed Resident #164 was admitted on [DATE], her [DIAGNOSES REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 10/28/16 showed a brief interview for mental status (BIMS) score of 13, indicating the resident has intact cognitive function. Resident #164 has the capacity to make medical decisions as documented by her attending Physician on admission to the facility. The NHA reported during an interview on 11/03/16 at 10:00 a.m., We are currently in the process of reporting the alleged sexual abuse to the appropriate state agencies. He agreed the facility did not identify the allegation as sexual harassment or abuse, report to the appropriate State agencies and investigate appropriately. Employees are educated annually to recognize and report abuse and neglect. Upon inquiry as to why the allegation was not reported when it was discovered, he stated, We went with the interview information that we had, but I did not realize it was insufficient. He did not reply when inquired as to why the verbiage advances was used in his interview with Resident #79, but not treated as an allegation of sexual harassment and/or abuse. A review of the facility Abuse Prohibition Policy and Procedure for the included the following: --Identification of possible incidents or allegations which need investigation. --Investigation of incidents and allegations. --Protection of patients during investigations. --Sexual Abuse includes, but is not limited to, sexual harassment, sexual coercion, or sexual assault. --Upon receiving information concerning a report of suspected or alleged abuse, neglect report to appropriate State agencies. --Conduct an immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent. b) Criminal background checks During a personnel record review related to criminal background checks, with the Human Resources Regional Director (HRRD) #150, on 11/02/16 at 2:30 p.m., the director provided a copy of a State police background check, dated 12/07/15 for Nurse Aide (NA) #20, who was hired on 11/19/15. Upon inquiry, the director related no information was present to indicate the facility had entered the NA into the West Virginia (WV) Cares system. The administrator, interviewed at 2:40 p.m., said the WV Cares form was completed on paper on 11/11/15 and submitted, and was informed at a later time that he had to submit it electronically. The administrator provided a copy of the bill from Morphotrust, which noted a payment in the amount required for only a State background check. He confirmed a federal background check had not been completed. The SAFRAN MorphoTrust USA guideline, with a revision date of Sept (YEAR) (September (YEAR)) was currently doing the fingerprinting for WV CARES for both a West Virginia (WV) and Federal Bureau of Investigation (FBI) background check. Communications between MorphoTrust and WV Cares, dated 11/02/16, noted WV CARES won't (will not) have the result. WV Cares was not the agency of record, nor was a FBI (Federal Bureau of Investigation) check done. If the applicant needs processed under WV CARES, she will need to be printed again either in one of our livescan locations or we will need to get another set of fingerprint cards with the agency noted as WV CARES. We do not keep cards after 90 days, so our cardscan team does not have anything to research. The time card, reviewed on 11/03/16 indicated Employee #20 had worked at the facility as recently as 11/01/16, and the other number of days for August, (MONTH) and (MONTH) of (YEAR): --October (YEAR) the NA worked twenty-three (23) of thirty-one (31) days; --September (YEAR) the NA worked twenty-one (21) of thirty (30) days; and --August (YEAR) the NA worked twenty-two (22) of thirty-one (31) days. The administrator acknowledged, during an interview on 11/03/16, the facility did not follow-up to ensure Nurse Aide #20 had been entered into the WV-CARES system.",2020-04-01
3948,WILLOW TREE HEALTHCARE CENTER,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2016-05-26,225,D,0,1,ULQ211,"Based on review of allegations of abuse and staff interviews, a staff member failed to report an allegation of abuse immediately to the facility. This affected one (1) resident of three (3) reviewed for abuse allegations. Resident identifier: #10. Facility census: 99. Findings include: a) Resident #10 Review of Resident #10 ' s abuse allegation on 05/25/16 revealed an investigation dated 04/18/16. The investigation indicated the incident occurred on 04/10/16, but was not reported until 04/18/16. Two housekeepers (#27 and #28) reported the abuse allegation to the Environmental Service Director #22. The investigation of the allegation indicated housekeeper #87 was near the resident's room on 04/11/16 and heard Nurse Aide (NA) #38 tell the resident to stop that and then heard a slapping noise. The documentation from employee statements #27, 28, 81 and #87 indicated during a break on 04/17/16 the four employees had a conversation about the incident that occurred on 04/11/16. The statements indicated housekeeper #87 mentioned to the other housekeeper's #27, 28 and 81 what she heard on 04/11/16 involving NA #38 and Resident #10, but had never reported it. During an interview with Housekeeper #87 on 05/25/2016 at 1:44 p.m., she stated she failed to report the alleged abuse that happened on 04/11/16. She stated she did not witness abuse, but did hear a noise that sounded like a slap, but since she didn't see anything she didn't know if it was just a noise or if the NA slapped the resident or if the resident slapped the N[NAME] During an interview with Housekeeper #28 on 05/25/16 at 2:00 p.m. stated the housekeepers were taking a break on Sunday 04/17/16. She stated Housekeeper #87 told them she thought that NA #38 slapped Resident #10 on 04/11/16, but was not sure if it happened or not. The housekeepers told her even if she was not sure she needed to report it. During an interview with Housekeeper #27 on 05/25/16 at 2:05 p.m., she stated during a break on 04/17/16 housekeeper #87 told her and the other housekeepers #28 and #81 that she thought she heard NA #38 spank the resident and told her to be good. Housekeeper #27 said she told housekeeper #87 that they were giving her till the end of the day to report the allegation of abuse and if she did not they would. She stated housekeeper #87 told the other housekeepers she was not sure anything really happened, but she would report it. She stated then on 04/18/16 when they came to work she and Housekeepers #28 and #81 decided to go to their Supervisor make sure that Housekeeper #87 did report the allegation. The abuse investigation and statements from staff reviewed again on 05/25/2016 at 2:47 p.m. after housekeepers #27, 28 and 81 reported the allegation of abuse to the Environmental Services Director who then reported to the Director of Nursing (DON). During an interview with the DON on 05/25/2016 at 2:56 p.m., she stated after the report of the alleged abuse on 04/18/16 NA #38 was suspended pending investigation. She further stated the allegation of abuse could not be verified. The DON stated Housekeeper #87 told other co-workers during a break on 04/17/16 of an allegation of abuse occurred on 04/11/16 that she was going to report it to her supervisor. The DON verified housekeeper #87 failed to report the allegation of abuse that occurred on 04/11/16 and that it was not reported timely. The DON verified the allegation of abuse was not reported until 04/18/16 and should have been reported on 04/11/16 when the incident occurred to a supervisor.",2020-04-01
3997,MAIN STREET CARE,5.1e+155,"189 SUMMERS HOSPITAL ROAD, SUITE 300",HINTON,WV,25951,2016-02-26,225,F,0,1,RR1211,"Based on record 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 Employees #36, #37, #5, #8, #13, #16, #19, and #20 who were hired by the facility after 08/01/15 did not have an eligible fitness determination with a state and federal fingerprint-based background check through the West Virginia Clearance for Access: Registry and Employment Screening (WV CARES). Prior to the effective date of the WV CARES program, Employee #18 had worked outside of the state of West Virginia in the last five years and the facility failed to obtain a federal fingerprint based criminal background check. This requirement is based on the single state Medicaid agency Nursing Home Employment Restrictions Policy 514.4.1. These employees had access to all residents residing in the facility, therefore placing all residents at risk for potential harm. Employee Identifiers: #36, #37, #5, #8, #13, #16, #19, #20, and #18. Facility Census: 30. Findings include: a) Nurse Aide #18 Review of the facility's employee listing of current employees, which included the employee's hire date and job title, at 11:00 a.m. on 02/24/16, found Nurse Aide (NA) #18 was hired by the facility on 07/27/15. A review of NA #18's personnel file at 12:00 p.m. on 02/24/16 found an application for employment dated 07/20/15. This application indicated that from (MONTH) of 2002 to (MONTH) of (YEAR) NA #18 had worked as a nurse aide at a nursing home that was located in a neighboring state. When asked to provide evidence of NA #18's fingerprint based federal background check, the Director of Nursing (DON) was unable to locate the background check and stated she would have to e-mail the company that completed the check to inquire about its status. Later in the afternoon on 02/24/16, the DON stated they had ordered the federal fingerprint background check because NA #18 had in fact worked in another state, but they could not locate the results. She stated the company that completed the check was going to e-mail her the results as soon as they were found. At the time of exit on 02/26/16 at 12:30 p.m., the facility had not provided a federal fingerprint based background check for NA #18. Review of the Nurse Aide schedule for 02/2016 found NA #18 was scheduled to work 20 of the 29 days in the month of 02/2016. b) 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). b) Employee #36, #37, #5, #8, #13, #16, #19, #20 At 11:30 a.m. on 02/24/16, the Nursing Home Administrator (NHA) was asked to provide the letter from WV CARES that showed that Employees #36, #37, #5, #8, #13, #16, #19 and #20 were fit for employment at the facility. The NHA stated that he had not run any of his employees through WV CARES. He stated, From what I understand it is bottlenecked and a mess. He said he thought the program was voluntary and he did not have to participate unless he wanted to. He indicated he had not used WV CARES for any of his employees. An additional review of the Active Employee Roster provided by the facility found the following eight (8) employees had been hired by the facility after 08/01/15 without a federal or state fingerprint-based background check nor a subsequent eligible fitness determination. 1. Licensed Practical Nurse (LPN) #36 was hired on 11/06/15. 2. LPN #37 was hired on 01/04/16. 3. NA #5 was hired on 10/27/15. 4. NA #8 was hired on 09/08/15. 5. Activity Assistant #13 was hired on 02/05/16. 6. NA #16 was hired on 09/25/15. 7. NA #19 was hired on 08/24/15. 8. NA #20 was hired on 11/23/15. Review of the Nursing and Nurse Aide schedule for (MONTH) (YEAR) found both LPNs and all five (5) nurse aides were scheduled to work multiple shifts during that month. Activity Assistant #13 was observed working daily during the course of the survey, which began on 02/23/16 and ended on 02/26/16. An additional interview with the NHA at 2:15 p.m. on 02/24/16, again confirmed he had not utilized WV CARES for any of his employees including those hired after 08/01/15.",2020-04-01
4009,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2017-03-01,225,E,1,0,WA6611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, policy and procedure review, accident/incident reports review, allegations of sexual abuse review, and staff interviews, the facility failed to ensure incidents of sexual abuse were identified, thoroughly investigated and reported to the appropriate State agencies. The failure to identify and investigate allegations of sexual abuse also resulted in a failure to ensure alleged victims were protected from further potential abuse. This was true for seven (7) female residents (#26, #39, #51, #49, #24, #37 and #1) and unidentified female resident(s) who were the recipients of nonconsensual sexual contact by Residents #10, #11, and/or #62. Facility census: 61. Findings include: a) Resident #26 1. Review of the resident's medical record for the past six (6) months found a nurse's note dated 08/16/16 at 16:00 (4:00 p.m.) stating resident wandering in wheelchair in hallway noted being inappropriate by male resident removed from residents. This incident was reported to the Social Worker (SW) on 08/17/16 - no time noted. In a summary of the investigation, the SW noted On (MONTH) 16, (YEAR) (name of Resident #26) was found in the hallway with another male resident. The male resident had his hand down (Resident #26s) pants. (Resident #26) was attempting to get away from the male. Staff moved (Resident #26) away from the male. The SW noted this was reported to the appropriate State agencies as an allegation of resident to resident altercation and concluded abuse or neglect did not occur. A review of the report sent to the State agencies contained the immediate reporting form, the five-day follow up report, and the report to the Ombudsman and Adult Protective Services (APS). In an interview with the Social Worker (SW) on 02/24/17 at 11:38 a.m., when asked for the witness statements for this incident, she responded, I don't have any witness statements. When asked if the Director of Nursing (DON) or the Nursing Home Administrator (NHA) would have any additional information such as witness statements, the SW replied No. She stated, I did witness statements a long time ago, but haven't for a while. In addition, when asked about reporting the event between Resident #26 and Resident #62, the SW was asked how she determined this was a resident to resident altercation and not sexual abuse. The SW stated she did not consider it sexual abuse, but agreed in retrospect it was sexual abuse. 2. On 10/06/17 at 10:06 a.m., a nursing entry noted Resident #62 was found reaching for the crotch of Resident #39. Again at 18:47 (6:47 p.m.), Resident #62 was found reaching for the crotch of Resident #39 and residents were separated. An incident report, dated 10/06/16 at 18:40 (6:40 p.m.) stated Resident #62 was observed to forcefully grab 2B's (Resident #26) L (left) arm as she was ambulating via wheelchair past resident. Resident observed to attempt to reach with other hand toward resident's crotch. The Contributing Factors section of the report stated Resident redirected several times to stay away from 2B. Resident sat and watched her go up long hall and back down before grabbing her. The Prevention section of the report stated Resident is continually monitored for sexual inappropriateness against this resident. Residents are separated and whereabouts monitored as closely as possible by staff. This incident report was signed by a Licensed Practical Nurse (LPN #183) and noted to have two (2) witnesses only identified by first name and job title. The physician notification was originally marked as Yes and then marked through with no date/time of notification. The Director of Nursing, Administrator, and Social Worker signed the report on 10/10/16. The Medical Director who was also the attending physician signed the incident report on 11/01/16. The Social Worker, DON and Administrator confirmed this incident of sexual abuse was not reported to any State agency on 02/27/17 at 3:12 p.m. No evidence was found to support the resident was protected from further nonconcensual sexual contact. b) Resident #39 A review of the resident's medical record from 02/13/17 through 03/01/17 revealed Resident #39 was originally admitted on [DATE] and readmitted on [DATE]. Medical [DIAGNOSES REDACTED]. The resident's annual MDS with an ARD of 06/16/16, identified the resident had problems with hearing, speaking, and/or vision, and was usually able to make herself understood and to ususally understand others. The resident's Brief Interview for Mental Status (BIMS) score was 99, inidcating the interview could not be completed. BIMS scores on her quarterly MDSs, completed on 09/15/16 and 12/15/16, were 01 and 02 respectively. Both BIMS scores indicated severe cognitive impairment. A continuing review of the medical record for Resident #39 found an amended Monthly Nurse's Notes on 02/05/17 at 17:37 (5:37 p.m.) stating sexual behaviors with male resident. An additional amended Nurse's on the same day at 17:40 (5:40 p.m.) stated touching inapportiatlity (sic) other males. On 02/05/17 at 15:32 (3:32 p.m.) in a CNA/Nurse's Note stated Resident (#10) in female resident room, she (Resident #39) was lying on her bed, male resident sitting on side of her bed, with her hand in his attempting to have her touch him, she attempting to pull her hand away when entering room. Resident #10 stated to her Oh, come on. He released her hand and returned to his own room. On 02/01/17 at 6:42 p.m. Nurse's Note stated Resident #10 was found by staff on top of female (Resident #39) with his [MEDICAL CONDITION] bag off and bowel movement all over Resident #39. Resident #10 and #39 were kissing on the lips. Both residents were separated and were showered. The MDS Coordinator stated on 02/03/17 at 9:06 a.m., in a behavior monitoring nurse's note for Resident #10 that the SW, DON and NHA were notified of Resident #10's recent sexual activity toward Resident #39 when his [MEDICAL CONDITION] bag had come off and stool was all over the other resident. On 02/28/17 at 12:55 p.m., the MDS Coordinator confirmed the sexual abuse of Resident #39 by Resident #10. In an interview with the social worker (SW) on 02/28/17 at 11:04 a.m., she stated she had been informed that Resident #10's [MEDICAL CONDITION] bag had come off and Resident #39 had been covered in stool. The SW had been told that when these two (2) residents were in a room together, it was consensual sex. She stated she informed Resident #39's responsible party and was told that sex would not be consensual and there was to be no sexual contact with this resident. Ask if she reported this incident to any of the appropriate State agencies and she stated No. c) Unidentified Female Residents Between (MONTH) (YEAR) and (MONTH) (YEAR), there were twenty (20) incidents where alleged perpetrators Residents #10, #11 and #62 were observed by staff committing non-consensual sexual acts. Through interviews with the Social Worker, Director of Nursing and Administrator, staff interviews, review of accident/incident reports, events reported to the appropriate state agencies and resident medical record review, no evidence was found these events were considered sexual abuse and therefore not reported to the appropriate State agencies. As stated by the Administrator, on 02/28/17 at 3:15 p.m., the system failed. If there were no incident reports completed, the events were not made known to administrative staff to report and investigate and therefore we did not investigate the events and report as per our policy. c) Resident #51 On 02/22/17, review of the significant change minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found this resident had a Brief Interview for Mental Status (BIMS) score of two (02). This score indicated severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. Confidential Interviewees (CI) #3 and CI #4, in separate interviews, said they had witnessed Resident #62 inappropriately touch Resident #51. Both said they reported what they saw to the nurse in charge at the time of those events. CI #3 said she saw Resident #62 touch Resident #51 inappropriately this past fall. She said Resident #62 tried to feel Resident #51's belly, and touched her legs. CI #4 said Resident #51 liked to sit in a recliner. She said she had seen Resident #62 wheel up in his wheelchair beside her recliner, and put his hands in her crotch. She said she separated them, and informed the nurse whenever this occurred. Review of the occurrences reported to State Agencies (SA) for the past year found none related to these staff interviews. According to an incident report dated 12/08/16, Resident #51 sat in a recliner chair by the nurses' station, when male Resident #62 pulled up her shirt and fondled and stared at her breasts. According to the incident report, staff quickly removed the male resident and notified the nurse in charge of the event. This incident report was signed by the director of nursing on 12/12/16, by the licensed social worker on 12/21/16, and the physician and the administrator on 01/11/17. Review of the occurrences reported to the SAs for (YEAR) and (YEAR) found no evidence this event was reported to the required State Agencies. In an interview on 02/28/17 at 1:00 p.m., the director of nursing (DON) said this act was unwanted and should have been deemed sexual abuse. The DON telephoned the licensed social worker (LSW), who confirmed there was no report made to State agencies of the 12/08/16 event. The DON said this incident should have been reported to State agencies and investigated, and it was not. She said staff failed to follow the facility's abuse policy. An interview was completed with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m. She said anything that is deemed abuse, neglect, or misappropriation of property is sometimes reported to her. Sometimes she finds it on her own. She said neglect also included not being taken care of by staff, and sexual things. She said she, the DON, the administrator, the nurse manager, and the secretary met daily Monday through Friday. At that meeting, they discussed incidents, but said they do not always get the incidents the day they occur, for whatever reason. The LSW said she was not made aware on 12/08/16 of the incident between Resident #51 and Resident #62. She said had she been made aware of this incident at that time, she would have completed an investigation, and reported to State agencies. d) Resident #49 On 02/22/17 review of the resident's medical record found the most recent quarterly minimum data set (MDS), with assessment reference date (ARD) of 11/24/16, found her Brief Interview for Mental Status (BIMS) score was three (03), indicating severely impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. In separate confidential interviews with CI#1, CI#2, CI#6, CI#10, and CI#11, all five (5) said they had witnessed inappropriate touching or inappropriate sexual behaviors of male residents toward Resident #49. All five (5) said they reported what they saw to the nurse in charge at the time of those events. CI #1 said she did not witness it, but other staff removed male Resident #11 and male Resident #62 from Resident #49 on 02/20/17. CI #1 said the nurses reported inappropriate touching to the director of nursing and to the social worker. She said nursing staff were aware those two (2) male residents touched female residents inappropriately over their clothing. She said the 02/20/17 incidents were the first time she had ever heard anything about Resident #49 being touched inappropriately. CI #2 said Resident #62 wheeled his wheelchair through the hallway, and goes real slow when he sees a female resident. She said she had heard handicapped Resident #49 holler, and then found Resident #62 with his hands between her legs. She said she was aware that Resident #11 had touched Resident #49 inappropriately over her clothing. She said she reported inappropriate touching to the nurse in charge whenever it occurred. CI #6 said she had seen male Resident #62 in Resident #49's room. She said if you asked Resident #49 if she wanted him in her room, she said, No. CI#10 said she had seen male Resident #11 put his hands on Resident #49's inner thighs and her crotch area many times. She said Resident #49 generally sat at the nurses' station in her wheelchair, but no one paid any attention to her. CI#11 said once in the past few weeks, she came down the hall and saw male Resident #62 in Resident #49's room. Her blankets were off, and she wore no pants or undergarments. She said she heard Resident #49 tell him to get away from her. At that time, she observed Resident #62 putting his hands between her legs. She said she told Resident #62 that he could not be in her room, and could not touch these women. She said she always reported those kinds of behaviors to the nurse in charge. Review of the occurrences reported to State agencies for the past year found none related to the incidents described in staff interviews. e) Resident #24 On 02/22/17 medical record review of the most recent quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/26/17, found her Brief Interview for Mental Status (MDS) score was four (4), indicating severe cognitive impairment. The assessment identified she had fluctuation of inattention and disorganized thinking. Pertinent [DIAGNOSES REDACTED]. CI #1 said that male Resident #62 had inappropriately touched female residents since his admission to the facility. She estimated this to be about one and a half years. She said he used to bother Resident #24 by touching her groin through her clothes, but she was a spitfire and would tell him to get away. She said Resident #24 could speak up for herself and would not tolerate it. CI#11 said that once over a month ago, she saw male Resident #62 sitting in his wheelchair next to Resident #24's bed. She said Resident #24's covers were off of her, and she acted scared to death. She said Resident #24 clenched her hands into fists and held them beneath her chin, with her elbows bent and her arms covering her chest area. She said Resident #24 shook because, He scared the crap out of her. She said she heard Resident #24 tell him to leave. CI #11 said she reported this to the nurse in charge at the time. Review of incidents reported to State agencies in the past year found none related to these staff interviews. f) Resident #37 On 02/22/17, review of the resident's annual minimum data set (MDS), with an assessment reference date (ARD) of 11/03/16, found the resident assessed to have a BIMS score of two (2), indicating severe cognitive impairment. She also had inattention and disorganized thinking present that fluctuates over time assessed. Pertinent [DIAGNOSES REDACTED]. CI #4 said she had seen male Resident #62 inappropriately touch Resident #37. She said she told Resident #62 that he did not need to go into those ladies' rooms, to which he replied, She wanted it. She said she always reported the inappropriate behaviors to the nurse in charge. CI #5 said she had seen Resident #10 snuggle up next to Resident #37 in the solarium, and run his hand up her leg. She said this happened just a short while back. She said she told him no, and he jerked back his hard. Review of the incidents reported to the State agencies for the past year found none related to these staff interviews. g) Resident #1 On 02/22/17, review of the resident's quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/01/16, found her assessed to have a BIMS score of twelve (12). The MDS with an ARD of 12/01/16 assessed her BIMS score as nine (9). Both scores indicated moderately impaired cognitive functioning. Pertinent [DIAGNOSES REDACTED]. CI#11 said she had seen Resident #52 touch Resident #1 inappropriately. She said she had seen him rub on Resident #52's legs and inner thighs. When she saw him do that, she told him he could not do it and made him leave. He replied that he did not do anything. She said she reported this to the nurse in charge at the time. Review of the incidents reported to State agencies for the past year found none related to these staff interviews. On 02/22/17 at 10:00 a.m., Resident #1 was playing bingo by herself unassisted in activities, and able to carry on conversation. When asked if any of the men here at the facility have touched her inappropriately in private parts of her body, she replied in the negative. She said she would not put up with that. h) On 02/28/17 at 1:00 p.m., the information received during the confidential interviews was discussed with the director of nursing (DON). The occurrences reported during these interviews were: - One staff member reported witnessing Resident #62 inappropriately touche Resident #51. - One or more staff members said they witnessed Resident #62 and Resident #11 inappropriately touch Resident #49. - One or more staff members said they witnessed Resident #62 inappropriately touch Resident #24. - One or more staff members said they witnessed Resident #10 inappropriately touch Resident #37. - One or more staff members said they witnessed Resident #52 inappropriately touch Resident #1. The DON said she was not made aware by the staff that those female residents were inappropriately touched by those male residents, except for one day recently. She said that on 02/20/17 staff reported that Resident #49 was touched inappropriately by two (2) male residents the same morning. She said staff completed incident reports and reported to State agencies for those two (2) events. The DON said staff should have filed an incident report any time this type of behavior was observed, and this was not done. She said had that been done, then an investigation would have ensued. The DON said their facility policy explained that unwanted sexual touch was sexual abuse, and that those occurrences should be reported to State agencies. She said the reporting to State agencies was not done because there was no incident report completed on inappropriate sexual touching. She said an investigation was not done because there was no incident report completed for those behaviors. She said the first step was getting the incident report completed, and any staff member could begin an incident report. She said she reviewed the incident reports daily. If there are any incident reports which require reporting to State agencies, then those incidents were assigned to the licensed social worker for follow-up. i) During an interview was with the licensed social worker (LSW) on 02/28/17 at 2:30 p.m., it was discussed that one or more staff members in confidential interviews said they had witnessed inappropriate touching of female residents by male residents. Those female residents inappropriately touched were Residents #51, #49, #24, #37, and #1. The LSW said she was aware Residents #62, #11, and #10 had sexual behaviors. She said staff should have completed incident reports each time not only for the male perpetrator, but also for the female victim. She said apparently nurses do not do so. She said there are some things we need to work on and change to ensure the responsible parties of victims were notified, incident reports were completed, and the safety of female residents was ensured. The LSW said she has never heard of any inappropriate touching by Resident #52. She said Resident #52 and Resident #1 liked each other, but they did not even hold hands and she had never seen any inappropriate behaviors between them. j) In an interview on 02/28/17 at 4:38 p.m., the administrator acknowledged facility staff did not identify all issues of inappropriate touching and/or sexual abuse they were aware, or should have been aware of, as abuse situations. She said the lack of incident reports of abuse situations led to the absence of investigation into those issues, and failure to report all incidents of abuse to appropriate state agencies. She agreed that these practices led to the failure to protect some of its female residents from further abuse.",2020-03-01
4023,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2017-03-29,225,E,1,0,CMPK11,"> Based on staff interviews, review of facility staffing sheets, and review of the facility's investigation, the facility failed to protect residents from further abuse when it allowed a Health Service Worker who was suspended for alleged abuse to return to work prior to completing its investigation. This had a potential to affect more than a limited number of residents. Resident identifier: #57. Facility census: 57. Findings include: a) Resident #57 Review of the facility's investigation of an alleged incident of abuse revealed on 03/02/17 at 5:20 p.m., Health Service Worker (HSW) #30 had abused Resident #58 physically, emotionally, and psychologically. Pending an investigation, the facility suspended HSW #30 on 03/02/17 at 7:02 p.m. After requesting two (2) extensions to complete the investigation, the facility completed and submitted the results of the investigation to the State agency on 03/15/17. The facility substantiated the allegation based on review of video footage of the incident and resident and staff interviews. Review of facility staffing assignments revealed HSW #30 returned to work on 03/06/17 at 6:00 p.m. until 10:30 p.m. on the same hall that Resident #57 resided. HSW #30 again worked on Resident #57's hall on 03/07/17 from 2:00 p.m. until 5:45 p.m. During an interview on 03/21/17 at 3:06 p.m., Assistant Administrator (AA) #102 stated on 03/06/17 he and the administrator made the decision to bring HSW #30 back to work 03/06/17 since the investigation did not show the resident was physically harmed. AA #102 stated HSW #30 worked back on the floor for one and 1/2 shifts and that he had reviewed the video footage prior to making the decision to bring HSW #30 back to work. In an interview on 03/21/17 at 3:45 p.m., Administrator #90 and AA #102 stated that after bringing HSW #30 back to work on 03/06/17, they determined they needed to further investigate the incident on 03/07/17 and sent HSW #30 home again. They then brought her back to work in the dietary department on 03/08/17. On 03/27/17 at 11:51 a.m., the administrator stated HSW #30 had been re-suspended after interview with the surveyor on 03/21/17 and pending investigation by Nurse Aide Registry. During an interview on 03/27/17 at 2:22 p.m., Social Work Supervisor (SWS) stated she became aware of the abuse allegation on 03/02/17 from Recreation Specialist (RS) #52 and Resident #6. The SWS stated her investigation was not complete when HSW #30 was brought back to work on 03/06/17. The SWS stated she had only been able to work on the investigation for one day.",2020-03-01
4137,JOHN MANCHIN SR HEALTH CARE CENTER,515075,401 GUFFEY STREET,FAIRMONT,WV,26554,2016-11-04,225,E,0,1,JLJC11,"**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 an allegation of verbal abuse, voiced by Resident #8, was reported to the appropriate State agencies and thoroughly investigated. Resident identifier: #8. Facility census: 29. Findings include: a) Resident #8 A review of the clinical record for Resident #8 at 2:00 p.m. on 11/02/16 revealed she was a [AGE] year old female. Her brief interview for mental status (BIMS) was 15; which indicates she was cognitively intact. She had been determined by a physician to have the capacity to make medical decisions. Additionally, a review of the nurse's notes found a note written by Employee #77, licensed practical nurse (LPN) on 10/05/16. This note read, At approximately 5 a.m., resident rang her call bell. When answered, she replied, Am I not allowed to take a bowel movement in there anymore and pointed to her bathroom. When asked what she meant, she stated that the HSW had screamed like a maniac because I had a bowel movement didn't you hear it? When this nurse answered, No, I did not hear anyone yelling, she got visibly upset and stated, Of course, you would take her side. The HSW was not heard yelling at her and the resident was upset because she said, And she had to clean my bottom, too. When it was explained that the HSW was only trying to help her, she got even more upset and staff left the room so as not to upset her further. Resident was checked on around 6:00 a.m., and she was sleeping in her bed, with the call bell in place. Interview with Resident #8, on 11/02/16 at 3:30 p.m., found when asked if anyone had abused her mentally, physically, verbally and sexually. She replied, Yes, the aides (HSW) verbally yell at me especially when I have accidents (bladder and/or bowel incontinence). On 11/02/16 at 4:15 p.m., an interview with the Director of Nursing (DON), found that she was not aware of this reported allegation of verbal abuse. She was aware LPN, #77 had told them the resident was upset with a HSW, but had not mentioned she had yelled at her. On 11/03/16 at 1:24 p.m., an interview with Social Worker (SW) #42, Social Worker, found she had spoken with Resident #8 on 10/05/16 at 1:43 p.m. She further stated, I did not report it to the appropriate State agencies due to I was unaware of the HSW yelling at the resident. Review of the abuse and neglect policy found the following: The resident has the right to be from verbal, sexual, physical, and mental abuse, corporal punishment, and involuntary seclusion. Our hospital will ensure that residents are not subjected to abuse by anyone, including, but not limited to, hospital staff, other residents, consultants or volunteers, staff of other agencies serving the resident, family members or legal guardians, friends, or other individuals. The Administrator confirmed on 11/03/16 at 3:00 p.m. the alleged allegation of verbal abuse voiced by Resident #8 was not reported and/or investigated as it should have been. b) Policy Review On 11/04/16 at 10:00 a.m., review of the abuse and neglect policy, revealed the chain of command was to report to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated all employees working during the shift of allegation would be questioned individually. A form indicating the date, time reported, response and description of the abuse is to be related to the Resident Advocate, the SW. The Administrator and the SW are responsible for the investigation of the incident.",2020-02-01
4166,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2016-02-05,225,D,0,1,5SB711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, observation, medical record review, and policy review, the facility failed ensure an injury of unknown origin was reported to the administrator and/or investigated thoroughly when identified. This was found for one (1) of two (2) residents reviewed during the Stage 2 investigation. A bruise of unknown origin had not been reported or investigated for Resident #36. Resident identifier: #36. Facility census: 60. Findings include: a) Resident #36 and Resident #11. During a Stage 1 interview on 02/03/16 at 8:37 a.m., a confidential source related Resident #36 had acquired a bruise on her chin and her breast and said, I know she could not have done it herself. The interviewee related the nurse aide found the areas, and called for the nurse to assess the resident. According to the interviewee, It happened just before the room change on 02/01/16. The quarterly minimum data set (MDS) assessment, with an assessment reference date of 01/05/16, reviewed on 02/03/16 at 11:30 a.m., revealed a brief interview for mental status (BIMS) was not completed due to the resident was rarely/never understood. The care plan noted Resident #36's activities of daily living (ADL) status was complicated by cognitive loss/dementia, late effects of a [MEDICAL CONDITION] [MEDICAL CONDITION], and she was nonambulatory. The resident's care plan did not address actual or potential bruising. An observation on 02/03/16 at 12:11 p.m., noted Resident #36 in the dining room sitting in a geri chair, reclined to 45 degrees. Her right arm was resting across her chest, and her left arm was resting over her chest toward her chin, but not touching her chin. An interview with Registered Nurse #87 (RN), who was present during the observation, related the resident was able to straighten out her arms. Upon inquiry, she related the resident no longer spoke. An attempt at conversation elicited no response from the resident. 02/03/2016 at 1:53 p.m., review of progress notes revealed a skin assessment completed on 02/02/16, which noted no injury/wounds. On 02/01/16, the resident was moved to room [ROOM NUMBER]C. A skin check, dated 01/26/16, indicated no injury/wounds were present. An interview with Nurse Aide (NA) #67 on 02/03/16 at 2:06 p.m., revealed she had observed a yellow bruise on Resident #36's chest when she showered her, but could not remember to whom she reported the area. NA #67 further added, It would have had to be a shower day, otherwise I would not have seen it. The NA related the resident transferred with a mechanical lift and was totally dependent for all activities of daily living included feeding, showering, dressing, and toileting. Upon inquiry, the nurse aide related a form was completed on shower days and staff noted skin impairments such as bruises and skin tears. Licensed Practical Nurse #72 (LPN), on 02/03/16 at 2:19 p.m., revealed she remembered a bruise, but could not remember how long ago it had been. LPN #72 indicated the resident had a history of [REDACTED].#79 review information on the electronic medical record (EMR). LPN #79, the treatment nurse, related he was not aware of a bruise, and indicated none had been noted in the EMR or risk management. Activity of daily living records, reviewed on 02/03/16 at 2:45 p.m., revealed Resident #36 received showers on 01/02/16, 01/09/16, 01/16/15, and 01/30/16. Review of the skin sheets that correlated with the resident's showers found none of the sheets noted a bruise. On 02/03/15 at 4:12 p.m., concerns/grievance/complaint forms and reportable allegation reports, reviewed for a six (6) month period, found no evidence of a complaint or investigation for Resident #36. A follow-up interview with the administrator and director of nursing on 02/04/16 at 9:09 a.m., confirmed Resident #36 did have a bruise under her chin. The administrator related it had been reported to RN #45, but an incident report had not been completed. The nurse related it may have been, How she placed her hand under her chin or her [NAME]dy bear's nose, which was hard. An observation on 02/04/16 at 9:20 a.m., revealed Resident #36 up in her chair. Her head was tilted forward, resting on her chest. The DON related the bruise was in a place not visible to the eye unless the resident's head was tilted back. Further observation revealed a dime size dark bruise beneath the resident's chin, toward the right side of the jaw. During the observation on 02/04/16 at 9:20 a.m., the DON looked at the care bears and indicated one of them may have caused the bruise under the chin. No explanation was provided related to the alleged bruise on Resident #36's chest. The facility's abuse prohibition policy titled, OPS327-WV Abuse Prohibition - State of West Virginia indicated an injury of unknown origin presented as an injury not observed by any person or the source of the injury could not be explained by the person, or the injury was suspicious because of the location of the injury was not generally vulnerable to trauma . The policy indicated anyone who witnessed an incident of unknown origin was to report to the Administrator or designee and other officials in accordance with State law. The facility's policy included the facility would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent; clinical examinations for signs of injuries; causative factors; interventions to prevent further injuries; and would be documented in the risk management system (RMS). Review of the risk management report, on 02/04/16 at 10:15 a.m., found the circumstances of the event were, Reported to nursing staff that resident was noted to have a bruising underneath of chin. Upon assessment, noted a 0.4 cm circular bruise to right underneath side of chin . Reported by staff area had been discovered on 01/31/16 and reported to RN supervisor and 7a-7p (7:00 a.m. to 7:00 p.m.) nurse. During a follow-up interview with the administrator on 02/04/16 at 3:30 p.m., she related the facility had not completed an injury of unknown origin report to the State agencies, and had not completed an investigation to determine whether abuse or neglect had occurred.",2020-02-01
4198,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2017-04-11,225,D,0,1,XDKG11,"Based on record review and staff interview, the facility failed to report immediately (within the first 24 hours) an incident of resident-to-resident abuse requiring physician intervention to the required State agencies. This was true for one (1) of eight (8) reportable incidents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The incident involved Residents #61 and #88. Resident Identifiers: #61 and #88. Facility Census: 113. Findings Include: a) A review of the facility's reportable incidents for the previous 12 months at 6:41 a.m. on 04/06/17 found an immediate fax reporting of an allegation to the Office of Health Facility Licensure and Certification (OHFLAC) Nursing Home Program completed by the Social Services Director on 03/17/17. Handwritten under the section titled, Allegation Information was, (typed as written) Date of incident: 03/12/17. Time of Incident 7:52 p.m. Location of Incident: Facility Hallway. Brief Description of the Incident: Alleged victim (Resident #61) got into a fight with another female resident (Resident #88) resulting in a 1X1 incision to right palm of hand. Under the section titled, Immediate actions taken to protect residents it noted the physician was contacted and (typed as written), Treatment applied to residents hand after staff separated the two residents. An interview with the Social Service Director at 2:56 p.m. on 04/06/17, confirmed the facility did not report the incident between Resident #88 and Resident #61 to the appropriate State agencies within 24 hours. She stated, Sometimes I don't know about them. Then when (name of the Director of Nursing) sees them she will tell me, and I will report it. She agreed the facility did not report this allegation within the required timeframe.",2020-02-01
4220,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2016-08-11,225,D,0,1,1GMW11,"Based on resident interview, record review, staff interview, and facility policy review, the facility failed to report and investigate an allegation of abuse for (1) of one (1) resident reviewed. The failed practice had the potential to affect a limited number of residents reviewed for abuse prohibition. Resident identifiers: 73. Facility census: 84. Findings include: a) Resident #73 1. Resident interview During Stage 1 of the Quality Indicator Survey (QIS), on 08/09/16 at 8:25 a.m., Resident #73 replied, Yes when asked, Has staff, a resident or anyone else here abused you - this includes verbal, physical, or sexual abuse? Resident #73 also replied, Yes when asked, Did you tell staff? Resident #73, appeared extremely emotionally upset as she described an incident where she had been accused by staff of hitting another resident. Resident #73 stated, I was walking out of my door as another resident was being pushed in a wheelchair in the hall outside of my room, when I accidentally hit the ring on my finger against the wall rail and it made a noise. The next thing I know I got jumped by a nurse about hitting and smacking other residents. The whole time I was telling them I didn't hit anyone and I would never. But they never listened to me. They should have known better than that as long as I've been here. They made me feel awful yelling at me about it and thinking I would actually hit someone. I talked to Social Worker (SW) #40, and other staff a couple times but no one has ever told me they were sorry for falsely accusing me, or that they even believe me. Resident #73 appeared alert and oriented during the entire interview. 2. Record review On 08/09/16 at 12:54 p.m., review of records revealed Resident #73 was admitted to the facility in early (YEAR). Review of recent quarterly minimum data set (MDS), with an assessment reference date (ARD) 06/30/16, revealed the resident scored 15 on her brief interview for mental status (BIMS). A person who scores from 13 -15 on the BIMS is considered to be cognitively intact. On 08/09/16 at 3:08 p.m., review of records revealed a physician deemed Resident #73 to have capacity on 04/07/15. Review of facilities reporting forms and reports, on 08/09/16 at 1:43 p.m., revealed there were no reports for this resident. On 08/09/16 at 2:13 p.m., review of progress note dated 08/07/16 revealed .not demonstrate any worrisome behaviors. Progress note dated 08/05/16 revealed no behaviors. Review of progress notes for the prior six (6) month showed there were frequent documentation about the resident not having any behaviors. However, one (1) progress note dated 08/01/16 revealed, (typed as written) Resident was standing outside her room door and the other resident was being pushed up the hallway and this resident smacked the other resident on the arm (102A). Resident was ask about smacking the other resident and she stated she didn't smack her she hit her hand on the hand rail. Resident was educated on not smack other resident 3. Policy review Review of facility's abuse policy on 08/10/16 at 2:47 p.m., revealed All reports of resident abuse, neglect and injuries of unknown source shall be promptly and thoroughly investigated by facility management. 4. Staff interviews An interview with Nurse Aide (NA) #93, revealed NA #93 had always found Resident #73 cooperative, easy going, and easy to get along with. Denied ever seeing or hearing about resident having hit another resident. On 08/09/16 at 4:18 p.m., an interview with SW #40, revealed the SW talked to Resident #73 yesterday (08/08/16) for the first time about the issue of being accused of hitting a resident. Resident #73 reported to SW #40 that she did not hit the other resident. SW #40 stated Resident #73 was upset and was sensitive and her feelings could be hurt easily at times. When SW #40 was asked when she was aware of the incident occurring concerning Resident #73, the SW replied, Sometime last week when it happened, I knew Resident #73 was upset about being accused of hitting a resident. When asked the date the incident happened, the SW said she wasn't sure exactly, but she stated she knew about it before she went off work. SW stated she was off Thursday and Friday (08/04/16 and 08/05/16), so therefore she said she had to have at least known about it before 08/03/16 (Wednesday). SW #40, said she planned to take care of it when she returned back to work on Monday. The SW said she did not want to pass the incident onto the other SW, because they had been recently hired. SW stated she had interviewed Resident #73 yesterday, but had not yet written the resident's statement to be able to provide a copy to the surveyor. An interview with the director of nursing (DON) concerning the incident, on 08/10/16 at 12:27 p.m., revealed the DON was made aware of the incident at a clinical morning meeting. The incident was discussed as a side conversation and someone said Resident #73 didn't hit the resident (DON did not know who said it), therefore the DON stated she didn't go talk to Resident #73. The DON said she went and looked at the other resident and did not see any evidence the resident had been hit. On 08/11/16 at 2:54 p.m. interview with SW #40, revealed the SW agreed Resident #73 was deeply upset about being accused. The SW also revealed Resident #73 had previously been a nurse aid for a little while. SW #40 stated abuse was to be reported immediately, and abuse/neglect trainings and patient rights in-service were provided to all staff yearly or as needed, and when staff was hired. SW #40 agreed the incident had not been handled promptly. During an interview, on 08/11/16 at 3:45 p.m., the administrator stated the incident should have been reported to him immediately or his designee, which was the DON. At the time the incident occurred the administrator was on vacation.",2020-02-01
4260,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-10-07,225,E,0,1,310011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure incidents of repeated inappropriate physical contact and language displayed by a cognitively impaired resident toward other residents were reported to the appropriate State agency. This involved discharged and current male residents and had the potential to affect all residents and staff in the facility. Resident identifiers: #103 and #146. Facility census: 69. Findings include: Review of the clinical record of Resident #103 revealed the resident was originally admitted to the facility in (MONTH) 2014 and had the following Diagnoses: [REDACTED]. During an interview, on 10/04/16 at 4:10 p.m., Nurse Aides (NA) #66 and #82 revealed they monitored Resident #103 for any inappropriate behavior. The NA's stated they were to immediately intervene if they witnessed any inappropriate behavior and report it to the charge nurse. Review of the record revealed Resident #103 had a current care plan dated 09/30/16, related to him exhibiting sexual inappropriateness. The care plan included the goal for the resident not to exhibit any acts of sexually inappropriate behavior. Care plan interventions included: --to allow the resident time to vent feelings/needs; --approach resident in a calm friendly manner; --document interventions and resident's response; --encourage family involvement; --encourage resident to attend activities of choice; --adjust time spent in activities to resident's tolerance and attention span; --identify behavior triggers and reduce exposure to triggers; --observe and document the resident's activity and whereabouts every 30 minutes; and --obtain psychological evaluation as ordered. The resident also had a current care plan initiated on 09/30/16 and revised on 10/03/16 related to exhibiting or having the potential to demonstrate verbal behaviors related to cognitive loss/dementia, poor impulse control and psychiatric disorder(s). The care plan goals stated the resident would demonstrate effective coping skills related to verbal behavior by next review; resident would not exhibit verbal outbursts direct toward others by next review and resident would verbalize understanding of triggers that result in poor impulse control and effective coping mechanisms. The care plan interventions included to: --Monitor medications, especially new/changed/discontinued, for side effects and resident's/patient's response contributing to verbal behaviors, including: antipsychotics, [MEDICATION NAME], opioids, benzodiazepines (recent discontinuation, omission or decrease in dose) drug interactions, adverse drug reactions, drug toxicity, or errors. --Evaluate the nature and circumstances (i.e., triggers) of the (resistive behavior) with resident/patient and family members/caregivers, e.g., provoked/not provoked, offensive, defensive, purposeful, during specific activities, involvement of others, patterned, easily startled, etc. --Discuss findings with resident/patient and family members/caregivers and adjust care delivery appropriately. --Evaluate need for Psych/Behavioral Health consult. --Refer resident to Psych/Behavioral Health provider to develop a Behavior Contract, if appropriate. --Provide all effective interventions (e.g., non-pharmacologic, pharmacologic) for behaviors and/or psychiatric disorder(s), (remove resident from environment) to assist resident/patient in controlling physical behaviors. --Encourage resident to seek staff support for distressed mood. --Approach the resident in a calm, unhurried manner; reassure as needed. --Remove resident from environment, if needed. --Gently guide the resident from the environment while speaking in a calm, reassuring voice. --Listen to resident and try to calm. Review of the following Minimum Data Set (MDS) assessments indicated Resident #103 was independent with transfers, and was non-ambulatory and mobile in his room and on the unit using a wheelchair: --Significant change MDS with an assessment reference date (ARD) of 09/26/16; --Quarterly MDS with an ARD of 08/11/16, 05/12/16, 08/20/15, and 05/20/15; and --Annual MDS with an ARD of 02/12/16. During interview on 10/05/16 at 9:27 a.m., the Administrator and DON revealed five (5) incidents of sexually inappropriate behavior by Resident #103 towards other residents: --On 10/29/15, Resident #103 was witnessed by staff putting his hand in the pants of a cognitively impaired resident. --On 11/12/15, Resident #103 was involved in an incident of resident to resident inappropriate physical contact with a now discharged resident. Resident #103 was reported to have rubbed the resident's leg toward the resident's groin area. --On 01/28/16, Resident #103 was involved in an incident of resident to resident physical contact with an alert and oriented resident who is now discharged . During that incident Resident #103 was noted rubbing the back of the resident's neck. --On 09/18/16, Resident #103's roommate reported the resident was playing with his toes and attempt to get into bed with him. --On 09/29/16, Resident #103 kissed the back of another resident's hand, stroked his beard and asked him to come to his room later for a kiss. The Administrator and DON verified Resident #103 had a history of [REDACTED]. The Administrator confirmed the incidents of inappropriate resident to resident physical contact were not reported to the State agency. During an interview on 10/05/16 at 11:33 a.m., Social Worker (SW) #31 stated she was working on 09/18/16 when she was informed by a Nurse Aide (NA) (she did not recall name) that Resident #103's roommate (Resident #146) reported Resident #103 had touched his toes and attempted to get in his bed. SW #31 stated she went and spoke with Resident #146 who verified the allegation. She stated Resident #146 was not upset and did not express fear of Resident #103. Resident #146 stated they had been friends for a long time and he did not feel it was a big deal. SW #31 stated she notified the Administrator immediately of the incident due to Resident #103 allegedly attempting to get into Resident #146's bed. SW #31 stated Resident #103 was moved to another room with an alert and oriented resident. Review of General Notes by Registered Nurse (RN) #40 dated 10/29/15 at 9:35 a.m., revealed after exiting Resident #103's room, RN #40 observed Resident #103 reaching in the front of another resident's pants. The notes documented RN #40 asked Resident #103 what he was doing and Resident #103 pulled his hands out of the other resident's pants, looked at RN #40 and said What? The notes documented RN #40 re-directed the resident to his room and advised him to keep his hands off of other residents. The notes documented RN #40 assisted the other resident to nursing station and advised the physician of Resident #103's behavior. Review of General Notes, dated 11/12/15 at 3:39 p.m., revealed RN #40 interviewed Resident #103's former roommate (now discharged ) as she had been advised by a staff member Resident #103 may have had inappropriate sexual contact or conversation without the former roommates consent. The notes documented Resident #103's former roommate stated about a month after he became roommates with Resident #103 he was asked by Resident #103 how big his penis was. The notes documented Resident #103 proceeded to advise his former roommate he had oral copulation with 12 to 15 men in his lifetime. The former roommate also stated that around this time he was scheduled to have a colonoscopy procedure. It was during this time, he was awakened one night by Resident #103 rubbing his bare leg and advancing toward his groin. The former roommate told Resident #103 to stop to which Resident #103 replied, But, I love you. The notes further documented the former roommate reported he told Resident #103 to stop and go away again and Resident #103 returned to his side of the room. Per the notes, the former roommate went on to report on another night around the same time he was awakened again by Resident #103 rubbing his feet. He told Resident #103 to stop and Resident #103 started kissing his former roommate's feet. The former roommate told Resident #103 to stop or he would tell the administrator and Resident #103 returned to his side of the room. The notes documented Resident #103 had not touched his former roommate since that incident. The notes further documented the former roommate stated he noticed daily when Resident #103 exited their bathroom he watched his former roommate through the cracked hinged part of the bathroom door. The former roommate stated he tried to keep his curtain pulled so that Resident #103 could not see him when he exited the bathroom. The notes documented RN #40 notified the physician, the Director of Nursing and administrator of her interview results. The notes documented Resident #103 was moved to a private room, multiple laboratory test were ordered, a geriatric psychiatry consultation and the psychologist had also been requested for consult. Review of Social Service Notes dated 11/13/15 at 12:58 p.m. revealed the Administrator, Director of Nursing (DON) and Social Worker met with Resident #103's medical power or attorney (MPOA) that same day. The notes documented the meeting was to discuss Resident #103's recent behavior which led to him being moved to a private room to protect his former roommate and also to protect Resident #103 from possible negative reactions from other resident's toward him. It was discussed the resident was scheduled to see the psychologist that weekend and he would be asked to explore with the resident the extent to which he understood why he is in a different room and make an effort to counsel the resident in regards to his behavior and to gather his recommendations for medication, ongoing counseling and possible inpatient placement. The notes documented the resident's family member advised Resident #103 now verbalized and demonstrated affection toward her (hugs, kisses, etc.) which was in stark contrast to the majority of his life. The DON advised that Resident #103 requested that morning to not have male aides work with him. Review of a Report of Consultation by the psychologist, dated 11/14/15, revealed the consult documented Resident #103 had a significant increase in sexual behaviors towards male residents. Review of a Psychiatric Consultation Log indicated an interview was conducted with Resident #103 on 11/16/15 due to the resident being referred for inappropriate behaviors of touching male residents and male staff. The Consultation findings documented Resident #103 asked if he was in trouble and if he was even capable. The findings documented Resident #103 had capacity to make medical decisions and that he denied inappropriate behaviors. The documentation revealed Resident #103 stated he is a Christian and at his church people shake hands and pat each other on the shoulder. He stated he was just joking and people took the behaviors the wrong way stating, I was just kidding them. They did not take it that way. I think that is why I am here. Review of a Report of Consultation by the psychologist, dated 11/24/15, revealed the resident was seen for a follow-up and he did not have capacity since 11/25/14. The psychologist documented he had seen the resident on several occasions and that he had a recent inappropriate sexual behavior incident that was uncharacteristic of him. The psychologist documented Resident #103 did not appear to recall his behavior and that his [MEDICATION NAME] was increased on 11/12/15 with appears to have had positive results. Review of General Notes, dated 01/14/16 at 9:45 p.m., found at approximately 7:15 p.m. Resident #103 was propelling in his wheelchair down the 200 hallway towards another resident's room (resident now discharged ) when he attempted to open the other resident's door. The notes documented the nurse interfered and informed Resident #103 he could not go into that room, that if the other resident wanted a visitor then he would seek him out. The notes documented Resident #103 got angry and stated the other resident had invited him to his room at dinner time. The nurse again stated to Resident #103 if the other resident wanted a visitor he would come seek him. Resident #103 appeared very agitated and yelled, Who are you?! and, Are you the boss?! The notes documented the nurse re-educated Resident #103 again that he was not allowed in the room and he finally went back to his own room. General Notes, dated 01/15/16 at 2:56 p.m., documented Resident #103 again attempted twice to go in the other resident's room (same now discharged resident) by attempting to open the door to room. The notes documented Resident #103 was instructed to please go to his room or another area of the facility. The notes documented Resident #103 stated he was invited to the other resident's room. The notes document the other resident was interviewed and stated no invitation was made. The notes documented Resident #103 stated he was tired of you people treating me like dirt, but he complied and went back to his room. General notes indicated staff were to continue to monitor and re-educate the resident as necessary. General Notes, dated 01/15/16 at 5:15 p.m., documented Resident #103 was found in the other resident's room (same now discharged resident) by a N[NAME] The notes documented Resident #103 was asking the other resident for his address. The NA then asked the other resident if he wanted Resident #103 to have his address to which the other resident stated no. The notes documented the NA then tried to redirect Resident #103 out of the resident's room and Resident #103 told the NA, Leave me alone you [***] ! and as the NA was escorting Resident #103 out of the room he swung and tried to hit her. The notes documented the nurse and nursing supervisor tried to talk to Resident #103 and redirect and Resident #103 stated, You are a[***]y supervisor! The notes documented Resident #103 was redirected to his room shouting, I will have your jobs! The physician was notified and ordered an antipsychotic medication ([MEDICATION NAME] 5 mg) intramuscularly once at that time for combative behavior and agitation. Review on 10/05/16 revealed a General Late Entry Notes, dated 01/28/16 at 3:40 p.m., documented Resident #103 was following another male resident to his room and was asked and re-directed to his room on another hall. The note documented, less than 5 minutes later, Resident #103 went into another resident's room in his wheelchair and the nurse was observing. The notes documented Resident #103 was gently rubbing the back and neck of the resident in the room and the resident stated. No, no, no, and was trying to get away from Resident #103. The nurse then removed Resident #103 from that room and hall, and re-directed him to the hall he resided on. The notes documented Resident #103 raised his voice yelling, Don ' t tell me what I can and don ' t tell me what I can and can ' t do! The incident was reported to the DON. Review of General Notes, dated 01/29/16 at 2:26 p.m., revealed Resident #103 followed another male resident around the facility and wanted to know if he could be roommates with that resident. The notes stated Resident #103 wanted to know if he could go to his room with him. The notes stated Resident #103 was re-directed four times that shift. Review of General Notes, dated 01/29/16 at 2:52 p.m., revealed Resident #103 was sticking his finger down his throat and gagging in hallway and when asked if he was okay, Resident #103 stated, Yeah can I go to his room now? The notes stated Resident #103 was referring to another male resident (noted in the General Notes on 01/29/16 at 2:26 p.m.) and Resident #103 was redirected. Review of the Physician Determination of Capacity, dated 05/10/16, revealed Resident #103 was assessed to lack sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The document indicated the [DIAGNOSES REDACTED]. The nature of the incapacitation was indicated as evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the resident's incapacity was indicated as long term. Review of General Notes, dated 06/01/16 at 2:54 p.m., revealed orders were written for Resident #103 to have a consultation with the psychiatrist due to predatory behavior. A Report of Consultation, dated 06/3/16, documented the psychologist saw Resident #103 on several occasions due to similar concerns, most recent 12/22/15. The psychologist documented inappropriate sexual behavior (ISB) is not uncommon with dementia. Resident made inappropriate comments to residents. Review of General Notes by Social Worker #31, dated 09/18/16 at 3:08 p.m., revealed she was approached by a NA who stated Resident #103's roommate alleged Resident #103 was inappropriate with him. SW #31 documented she interviewed Resident #103's roommate who stated Resident #103 played with his toes and attempted to get in bed with him. The roommate indicated Resident #103 had displayed inappropriate behaviors. Review of the licensed social worker's psychiatric consultation log revealed Resident #103 was referred due to sexually inappropriate behaviors and was interviewed on 09/20/16. The consultation findings revealed Resident #103 was having sexually inappropriate behaviors and was moved to another room. The documentation stated Resident #103's new roommate was oriented and Resident #103 sleeps most of the day and is then up and out at night. He was reported by a peer that he touched him. Per staff report Resident #103 stated this did occur. Review of another psychiatric consultation log by the licensed social worker (LSW) from the local hospital behavioral department also with an interview date of 09/20/16, revealed the findings of the interview documented Resident #103 stated he was sorry. He stated it would not happen again. He stated it is, over with and that his roommate is not his type. He stated that it had not happened before. LSW documented it was charted he had past events. The LSW documented in the findings Resident #103 stated he could control his feelings. Review of a Physician Determination of Capacity form, dated 09/27/16, revealed the psychologist certified the Resident #103 lacked sufficient mental or physical capacity to appreciate the nature and implication of health care decisions. The documentation indicated the nature of the incapacity was evidenced by cognitive loss, inappropriate answers to questions and inability to understand or make medical decisions. The expected duration of the incapacity was indicated as long term. Review of Care Plan Evaluation Notes, dated 09/28/16 at 9:06 a.m., revealed a significant change assessment was completed for Resident #103 for behaviors of sexual inappropriateness with previous roommate and nursing staff since last review on 08/11/16. Review of Social Service Late Entry Notes, dated 09/29/16 at 2:26 p.m., revealed SW #31 was told Resident #103 had made inappropriate advances to another resident. SW #31 interviewed the other resident who stated Resident #103 kissed the back of his hand, stroked his beard and asked him to come to his room later for a kiss. The other resident stated he didn't feel violated. SW #31 documented she brought Resident #112 to her office to discuss this allegation and while pushing the resident's wheelchair to the front of the facility Resident #103 asked this same male resident to come see him in his room. Resident #103 told the other male resident he had the room to himself and was lonely. The other resident told him he wasn't interested. SW #31 documented that within minutes Resident #103 asked the same resident again to come see him in his room. SW #31 and the DON spoke with Resident #103 regarding these allegations. SW #31 documented Resident #103 did not deny or admit to the allegations. SW #31 documented they explained to Resident #103 his behavior wasn't appropriate and advised him to refrain from touching and propositioning other residents. Review of General Notes, dated 09/29/16 at 6:30 p.m., revealed Resident #103 was noted to be alone in his room with his roommate while his daughters were present in facility but visiting another resident in their room at that time. The notes documented Resident #103 was noted to be holding/patting his roommate's left hand and his roommate told him to, go visit with your daughters and repeatedly told Resident #103, thank you, ok, goodbye. The notes documented Resident #103's due to a medical condition the roommate was unable to remove his left hand from Resident #103's reach. The notes documented Resident #103 was redirected to the restorative dining room with both his daughters. The DON and administrator notified at that time with recommendations to move Resident #103 to another room. According to facility documentation of Resident #103's activity and whereabouts on 09/29/16, Resident #103 was in the dining room with family at 6:00 p.m., in his room alone holding his roommate's hand at 6:15 p.m. and in the restorative dining room with family at 6:30 p.m. There was no evidence the resident's level of supervision was increased beyond the every 30 minute checks after he was again noted displaying unwanted resident to resident physical contact. Review of General Notes, dated 09/29/16 at 6:45 p.m., revealed RN #40 spoke with Resident #103's family inquiring if they were aware of Resident #103's behavior that day related to him being inappropriate with two alert and oriented residents. The notes stated that during this meeting a nurse came to staff and the family that Resident #103 was asking his roommate at that very moment about the size of his penis. Review of General Notes, dated 09/29/16 at 7:20 p.m., revealed Resident #103's roommate reported to a NA that Resident #103 asked him, how big is his penis and if, he could see it. The note revealed the roommate was interviewed at that time and he reported, (Resident #103's name) always asks me how big ' it ' is and if he can see it. Review of the Change in Condition Notes, dated 09/29/16 at 11:04 p.m., revealed Resident #103 had a change in condition or behavior. The notes indicated onset and duration as the Resident had increased episodes of inappropriate sexual behavior. A nurse witnessed him rubbing on his roommate's arm and body. The roommate also stated that Resident #103 asked him, how big it was and can he see it. The previous night, another resident complained Resident #103 attempted to kiss him on the mouth. The notes documented the roommate was moved to another room, and Resident #103 was by himself in his room and being monitored every 30 minutes around the clock for his behaviors. The note further revealed Resident #103's level of consciousness as alert, the same as previous state and orientation to person, place, and time. Review of the facility's abuse prohibition policy, with a revision date of 9/01/16, provided by the Administrator, revealed sexual abuse includes but not limited to, sexual harassment, sexual coercion or sexual assault. The policy further revealed the definition of mental abuse is includes but not limited to humiliation, harassment, threats of punishment or deprivation. The policy indicated upon receiving information concerning a report of suspected or alleged abuse the Center Executive Director (CED) or designee would enter the allegation into the Risk Management System (RMS) and report to OHFLAC Long Term Care Department of Health and Human Resources using the Immediate Reporting Allegations form.",2020-02-01
4317,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2016-06-29,225,E,0,1,EOL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to immediately report and thoroughly investigate allegations of abuse, neglect, and misappropriation of funds. This was found for five (5) residents during review of incident reports and complaint/grievance reports for the previous three (3) months and had the potential to affect more than a limited number of residents residing in the facility. Resident #124 reported missing money. On two (2) occasions, Resident #49 did not receive her meals. Resident #182's son expressed concerns that his father did not have water, was not receiving pain medication prior to therapy, and had not had ammonia levels drawn. Resident #68's son expressed concern about the resident not receiving oral care, not taken to the bathroom, and not being ambulated. Resident #66 told a nurse that staff had twisted her ankle when placing her on the toilet. Resident identifiers: #124, #49, #182, #68, and #66. Facility census: 118. Findings include: a) Resident #124 On 06/28/16 at 8:00 a.m., review of twelve (12) grievances filed in the last three (3) months found three (3) were allegations of neglect and one (1) was found to be an allegation of misappropriation of funds. There was a complaint/grievance form dated 05/25/16 at 10:30 a.m. from Resident #124. He stated his sister brought him $40.00 cash on Saturday, 05/21/16, he placed it in his wallet in his room, and now he is unable to find it. There was evidence of an investigation by the facility and a follow up to the concern, but the facility never reported the allegation of possible misappropriation of funds to the required State agencies. b) Resident #49 A complaint/grievance form dated 05/01/16 at 12:30 p.m., initiated by Licensed Practical Nurse (LPN), #99, stated Resident #49 did not get a tray and received no dinner the evening before, on 04/30/16. The investigation notes supported Resident #49 received no dinner tray, on 04/30/16. The documentation included a statement from the resident's roommate. Her roommate said staff finally offered Resident #49 a grilled cheese sandwich around 9:30 - 10:00 p.m., but she was upset, crying, and said, It's too late, I'm tired. The facility did not report this allegation of neglect as required by law. c) Resident #182 A complaint/grievance form dated 05/24/16 at 4:00 p.m., made by Resident #182's son, included the son's concerns he found on two (2) occasions his father had no water pitcher in his room. He said the pain medication supposed to be given before his father had therapy to help with any pain, was not given to him until after therapy was over. He stated he had said in a care plan meeting that his father's ammonia levels should be drawn if he exhibited increased confusion and this was not being done. The facility did not report these allegations of neglect to the appropriate State agencies as required by law. d) Resident #68 A complaint/grievance form dated 05/08/16 with the time designated as afternoon noted the resident's son expressed concerns that included he felt his mother was dehydrated every time he visited her and there was no water pitcher available in her room. He was concerned his mother was incontinent because staff did not assist her to the bathroom. He was concerned staff were not providing oral hygiene and she was not being ambulated. The facility did not report these allegations of neglect to the appropriate State agencies as required by law. e) During an interview with Social Workers #200 and #134 on 06/28/16 at 3:00 p.m., they confirmed the allegations of neglect contained in the four (4) complaint/grievance records were not reported. f) Resident #66 Review of sixty-nine (69) incident reports for the previous three (3) months on 06/28/16 at 1:00 p.m., found a report from 06/05/16 at 10:00 a.m. that documented Resident #66 approached Licensed Practical Nurse (LPN) #165, and wanted the nurse to look at her ankle. The resident was complaining of pain and told the nurse the night before last, the girls put her on the toilet and twisted her ankle. The nurse looked at the resident's ankle, described it as [MEDICAL CONDITION] with no redness or bruising, and obtained physician orders [REDACTED]. The report described Resident #66 as oriented to person, place, time, and situation. The report said a predisposing situation factor was during transfer. There was no evidence the facility reported or investigated this allegation of possible abuse and/or neglect as required by law. In an interview with LPN #165 on 06/28/16 at 12:09 p.m., she confirmed she had not reported the allegation, and had not spoken to any staff regarding any possible issues with a transfer. g) Social Worker #134 said during an interview on 06/28/16 at 2:00 p.m. that all incident reports and complaints received for the preceding day were reviewed each morning during management meetings to determine if any might require reporting and/or investigation.",2020-01-01
4474,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2016-10-13,225,D,1,0,D9EI11,"> Based on record review, review of facility policy and procedures, and staff interview, the facility failed to thoroughly investigate and/or report an incident of possible abuse and/or neglect by a staff member to the appropriate State agencies. This occurred for one (1) resident of nineteen (19) residents reviewed for unexpected events from 06/12/16 to 10/08/16. Resident identifier: #19. Facility census: 64. Findings include: a) On 10/12/16 at 4:30 p.m. and 10/13/16 at 8:30 a.m., review of incident/accident reports revealed the following: 1. Resident #19 On 08/30/16, Resident #19 sustained a 16-centimeter (cm) by (x) 4.5 cm wide imprint/abrasion to her left thigh. The description of the circumstances of the event was (typed as written): --CNA (certified nurse aide) roller resident over to take lift pad out from underneath resident (room number) and one of the straps was under her left thigh. CNA had reported to this nurse that she might have a bruise on left thigh @ (at) 0930 (9:30 a.m.) this morning. When resident was lifted back in bed with lift pad, and when changing Resident (room number) CNA's noticed that resident had a 16 cm x 4.5 cm wide imprint/abrasion on left thigh. The record was silent for witness statements. A review of Resident #19's medical record on 10/13/16 at 9:18 a.m. revealed she was totally dependent on staff for bed mobility, transfers, toilet use, personal hygiene, and other activities of daily living (ADLs). b) On 10/13/16 at 9:00 a.m., a review of the facility's Abuse Prohibition policy/procedure, with a revision date of 09/01/16 found it included: -- (Name of corporation) will prohibit abuse, neglect, involuntary seclusion and misappropriation of property for all patients through the following: .Identification of possible incidents or allegations which need investigation; --Investigation of incidents and allegations; -- .Reporting of incidents, investigations, and Center response to the results of their investigations. --Abuse is defined as the infliction or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult or facility patient. This also includes the deprivation by an individual, including caretaker, of goods or services that are necessary to attain or maintain physical, mental, and psychosocial well-being. This presumes that instances of abuse of all patients, even those in a coma, cause physical harm, or pain or mental anguish. -- .Neglect is defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. -- .5. Staff will identify events--such as suspicious bruising of patients, occurrences, patterns . .5.1 .report the incident to his/her supervisor immediately. -- .6. Upon receiving information concerning a report of suspected or alleged abuse, neglect, .the CED (Center Executive Director) will: 6.2 Report as follows: to the appropriate state agencies. -- .6.3.1 conduct interviews using the Alleged Perpetrator/Victim Interview Record and Witness Interview Record. c) After reviewing the incident/accident reports with Social Services Director #65 on 10/13/16 at 9:30 a.m., she stated, I am not involved with these unless they tell me it is a reportable. It is not considered a reportable unless it causes harm or discomfort, but I was not involved with either of these incidents. The Administrator did these investigations because she is also a social worker with a master's degree. d) During an interview on 10/13/16 at 9:45 a.m., the Administrator stated she had witness statements for Resident #19. She stated, I did not report the incidents because it was not intentional and did not harm the residents. The CNA told the nurse about leaving the lift strap under Resident #19's and it may cause a bruise. The strap had only been under Resident #40's leg that morning. The administrator was unable to provide any evidence confirming this statement. She did not reply when asked why a large imprint/abrasion measuring 16 cm x 4.5 cm was not considered possible harm. She also did not reply when asked about an injury or an unexpected event of staff causing injury to a resident whether intentional or unintentional was not reported to the appropriate State agencies as outlined in the facility's policy and procedure for abuse prohibition. The Administrator did agree the resident had received an injury from staff members during care.",2019-10-01
4534,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2016-04-21,225,D,0,1,OVQ111,"Based on review of the facility's reportable allegations of abuse/neglect, staff interview, and review of the facility's abuse policy, the facility failed to immediately report allegations of abuse/neglect to the appropriate State authorities as required by State law. This was true for one (1) of five (5) investigations of abuse/neglect reported by the facility within the past year. Resident identifier: #10. Facility census: 36. Findings include: a) Resident #10 Review of the facility's reportable allegations of abuse/neglect on 04/20/16 found the following documentation: On 05/02/15, Registered Nurse (RN) #11 completed a resident complaint/grievance form from Resident #10. The nurse documented on the grievance/concern form: Resident #10 said, . staff are making her feel bad when they come to change her after having bowel movements. She was able to describe 2 workers and denies any other problems with other staff. On 05/03/15, a second staff member, the Director of Nursing (DON), spoke with the resident regarding the complaint received on 05/02/15. The DON wrote the following statement on 05/03/15 (typed as written): This nurse to resident's room to speak with her concerning complaint she filed on 5/2/15. (Name of resident) had stated that two staff members 'made her feel bad' when she they come to her room to change her after having she had bowel movements. (typed as written). (Name of resident) stated that it had been happening for about a month or so. I reminded (name of resident) of the conversation I had with her regarding reporting instances such as this to me and she stated she 'hated to say anything.' (name of resident) stated 'When they diaper me, they go on and one about how I've pooped.' (Name of resident) stated 'the colored girl in the morning told me to quit taking my medicines because they make me have diarrhea.' (name of Resident) also stated she 'told the colored girl that I didn't want to take any more of that medicine and she that I didn't have to do anything I didn't want to do.' (Name of resident) stated, 'that colored girl didn't make me feel bad.' (name of resident) stated that the other staff member was a fat lady with blond hair that limps and that lady told her 'I'm not getting anybody up today because there's not enough people here' and 'shoo, you've done it now, you need to stop that' when (name of resident) had a bowel movement. (Name of resident) stated 'I cried all the time.' (Name of resident) stated that 'fat lady' also told her 'they can't fire anyone', that it was 'no use to talk to anyone', and that she was 'going to quit anyway.' The immediate fax reporting to the Nurse Aide Registry, completed by the facility social worker, was not completed until 05/04/15. Two (2) days after the resident's initial allegation. At 12:54 p.m. on 04/20/16, the DON said the incident was not reported when the initial statement was taken because the facility did not have enough information. The resident only said staff made her feel bad and the resident did not elaborate. She said the incident was reported two (2) days later after the facility received more information and identified the employees. At 10:00 a.m. on 04/21/16, RN #11, who took the initial statement on 05/02/15, stated she did not report the incident because she was waiting for the DON. Review of the facility's policy, entitled Abuse Investigation, found: . An initial report is made to OHFLAC (Office of Health Facility Licensure and Certification). While we have 24 hours to notify OHFLAC, the immediate report should occur as quickly as events will allow. Waiting 24 hours to report should not be the norm The facility should have reported the allegation staff became aware of the situation. The initial report should have been made to OHFLAC. When the facility identified the employees, the allegations could have then been reported to the Nurse Aide Registry. The guidance to surveyors defines immediately as, means as soon as possible, but ought not exceed 24 hours after discovery of the incident",2019-10-01
4586,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2016-01-14,225,D,0,1,325Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, staff interview, medical record review, and policy review, the facility failed to ensure that all alleged violations involving neglect were thoroughly investigated and reported immediately to appropriate officials through established procedures, including the State survey and certification agency. Resident #200's medical power of attorney (MPOA) alleged the resident did not receive prompt medical attention when the resident experience a change in mental status. The MPOA voiced this concern to the administrator and to the corporate office, but the facility did not complete a thorough investigation and/or report the allegation of neglect. This was found for one (1) of three (3) Stage 2 sampled residents reviewed for abuse and neglect. Resident identifier: #200. Facility census: 117. Findings include: a) Resident #200 Medical record review, on 01/11/15 at 1:30 p.m., found Resident #200, an [AGE] year-old female, came to the facility on [DATE], following a hospitalization for urinary tract infection, altered mental status, and dehydration. Facility [DIAGNOSES REDACTED]. During her stay at the facility, she received treatment for [REDACTED]. The fifth urinary tract infection was diagnosed on [DATE]. In an interview with the resident's medical power of attorney (MPOA) on 01/11/16 at 5:00 p.m., she stated she became angry when she visited the resident at the facility on 06/27/15 at 5:30 p.m. She said she found the resident not acting right, was barely responsive, and was unable to open her eyes. She feared the resident had another urinary tract infection, but said nursing staff dismissed her concerns, did not notify the physician of her concerns or of the change in the resident's mental status, and did not check the urine for infection at that time. She said she finally insisted the resident be sent out to the emergency room , which was done at approximately 10:40 p.m. on 06/27/15. During the 01/11/16 family interview, the MPOA said she called the facility's corporate office, probably on Monday 06/29/15, and voiced complaints about the resident's lack of care. The MPOA was concerned about the nurse not doing anything about the resident's change in condition, and the nurse not notifying the physician timely. She said she also met with administrative staff a couple of days later to discuss her concerns. She said that as a solution, the administrator told her he put out education to staff. On 01/13/16 at 8:45 a.m. and 10:15 a.m., interviews were conducted with the administrator. When reminded that the MPOA had called the corporate office on or about 06/29/15, then met with him a couple of days later, he acknowledged that occurred, and recalled that the MPOA felt there was an extended lag time after telling the nurse she wanted the resident to go out to the ER. He said he needed to check his notes to see what constituted an extended lag time. This information was not provided prior to exit. Upon inquiry as to whether the facility completed a grievance form or reportable to State agencies, and did an internal investigation, the administrator said he did not recall a grievance form. In addition, he did not interpret the concerns called in to the corporate office, and those the MPOA voiced to him, as neglect. The facility conducted an internal investigation, and determined the problem was not doing appropriate customer service. The facility presented in-service education to nursing staff on customer relations on 08/11/15. Upon inquiry as to why this complaint was not entered into the facility's grievance log, he said it was different when the complaint came in from corporate, so he did not think it should have been entered into the facility's grievance log. Review of the facility's grievance/concern policy on 01/13/16 at 10:45 a.m. found its policy, section three (3) under process, stated, Formal concerns may be registered by phone, mail, office visit, or direct outreach to staff or with the Corporate Compliance Department. Section 4.1 and 4.2 stated, If a grievance/concern is received by the Compliance Department, it may be forwarded to the center. These concerns do not need to be documented on the grievance/concern form, but must be included on Grievance/Concern log. The administrator provided a copy of the Compliance Line Investigation Template, which contained details of the customer's contact. Allegations presented by the MPOA (related to alleged events, which occurred on 06/27/15), were as follows: -The MPOA stated the resident was a diabetic who suffers from chronic urinary tract infections because she is not encouraged to drink more liquids, and she is not changed often enough. -The resident's increased sleeping, and change in condition, was reported to Licensed Practical Nurse (LPN) #131 earlier in the day, and the nurse did not assess the resident. -LPN #131 became argumentative when the MPOA requested the resident to be taken to the hospital, and mistreated an aide who agreed with the MPOA. In interviews with the director of nursing (DON) on 01/13/16 at 11:14 a.m. and 5:15 p.m., he said the MPOA filed the complaint with the corporate office on 06/30/15 at 9:58 a.m., with concerns the nurse did not give timely care. He said had the MPOA come directly to facility staff with the complaint, they would have completed a formal grievance. Upon inquiry as to whether they conducted a thorough investigation in order to ascertain what actually happened that night, he said he thought they had. He said they did not complete an immediate reporting to State agencies, because they did not substantiate neglect following the corporate investigation. Upon inquiry as to whether they obtained written witness statements from the complainant or from staff who worked that day, he replied in the negative, because they treated the allegations as a grievance, not a reportable allegation of neglect. He acknowledged the complaint was not entered into the complaint log. When evidence of a thorough investigation was requested, it was learned there were no witness statements that were taken at the time of the occurrence in (MONTH) (YEAR). On 01/13/16, the director of nursing provided the following statements: 1. A telephone witness statement, dated 01/13/16 at 1:53 p.m., provided by the director of nursing, was reviewed on 01/13/16 at 5:00 p.m. Nurse Aide (NA) #14 said she was asked by another staff person to help transfer Resident #200 from the wheelchair to her bed. She said the other staff member then obtained the resident's vital signs, because the resident did not look right. The time of the transfer to bed and vital sign check was around 6:00 p.m. Less than ten (10) minutes later, LPN #181 checked the resident's blood sugar, and NA #14 left. The daughter and granddaughter were at the bedside. She recalled that around 10:30 p.m. (on 06/27/15), the family came to the desk and asked to send the resident out to the hospital. 2. A witness statement by Registered Nurse (RN) #81, dated 01/13/16 at 2:20 p.m., found she worked 7:00 p.m. on 06/27/15 to 7:00 a.m. on 06/28/15. RN #81 stated she recalled the family was asking a lot from LPN #131. RN #81 said that while LPN #131 was at lunch, she spoke to them (the family) about a urinalysis and culture and sensitivity, after the family questioned her on it. Then, when LPN #131 returned from lunch, she (RN #81) returned to my assignment. 3. Another witness statement, dated 01/13/16 at 2:30 p.m. by LPN #131, noted she worked 3-11 on 06/2715. She admitted the daughter came to her and reported the resident was not right. LPN #131 said she checked the resident's blood sugar, which was up, but not high enough to call the physician. She stated she listened to the resident's lungs. While on lunch break, the aides came and got her. She said she overheard RN #81 talking to the family about urinary tract infections. She stated, We told her we could send her out. She (the daughter) agreed. We sent her to the ER (emergency room ). In a confidential interview, an individual said Resident #200 returned to bed on 06/27/15 around 6:30 p.m. The individual recalled it was about that time when the MPOA first asked LPN #131 about sending the resident out to the hospital. This individual corroborated the MPOA's concern that the resident was not acting right. The interviewee said typically the resident was alert, generally laughed, [MEDICATION NAME], made noises, and nonsensical talk, but that evening, the resident did none of those things. The interviewee said LPN #131 obtained a blood sugar reading in the 300's, and allegedly told the MPOA the resident was all right. The interviewee also recalled the MPOA approached Registered Nurse (RN) #81, about her concerns, and that RN #81 allegedly told the MPOA she would get insulin later that night at bedtime. Although the statements provided by the DON, and the confidential interview were obtained more than six (6) months after the alleged incident, the information obtained did support that neglect had occurred. The incident should have been thoroughly investigated and reported as an allegation of neglect to the appropriate State agencies at the time it occurred.",2019-09-01
4634,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2016-02-26,225,D,0,1,4CE211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, family interview, and policy review, the facility failed to report and/or investigate allegations of neglect for one (1) of seven (7) residents reviewed for allegations of neglect. Staff failed to identify allegations of neglect, consequently, the facility failed to report and/or investigate allegations Resident #83 did not receive adequate and timely incontinence care. Resident identifier: #83. Facility census: 117. Findings include: a) Resident #83 During an interview with the resident's daughter, who was also the resident's medical power of attorney (MPOA), on 02/23/16 from 2:30 p.m. to 3:00 p.m., she related she had entered the facility on 02/09/16 at lunchtime. The MPOA said she changed her mother and, There was no sign of stool in her brief, but when I wiped her vagina, there was a ball of stool with a little bit of blood. She related she looked for Registered Nurse (RN) #34, but as she was at lunch, she spoke with Licensed Practical Nurse (LPN) #72, who said she would pass it on. Resident #83's daughter added that her mother was hosptalized on [DATE] related to a urinary tract infection [MEDICAL CONDITION] related to E-coli (Escherichia coli - an organism found in the colon). She said her mother returned to the facility on [DATE], at which time she spoke with the director of nursing (DON) and RN #34 regarding her concerns about her mother not being cleaned. She added that on 02/18/16, she entered the facility at 7:00 a.m. and her mother was at breakfast. The daughter related her mother returned to the room around 8:00 a.m. and when providing incontinence care, again wiped stool from the resident's vagina, but there was no stool in the resident's brief. She said the infection control nurse entered the room and she showed her the washcloth with the stool on it. On 02/24/16 at 8:15 a.m., review of complaints, grievance logs, and incidents reported to State agencies, found no evidence that the MPOA's concern regarding feces in the resident's vagina on 02/09/16, which was reported to LPN #72; the MPOA's concerns about the resident not being kept clean that she voiced to the director of nursing and RN #34 on 02/16/16; or the finding of feces in the resident's vagina on 02/18/16 and reported to the infection control nurse, had been identified as allegations of neglect. None of these incidents were identified as possible neglect and reported to the administrator and required State agencies, or investigated. During an interview with Registered Nurse #34 at 2:08 p.m. on 02/26/16, the nurse related she had received the complaint on 02/16/16 related to Resident #83 not being cleaned properly and staff had not provided care when requested by the resident. The nurse related she had educated staff, but had not reported the allegation of neglect to the appropriate entities, including the administrator, director of nursing, or State agencies. RN #34 acknowledged she had not completed an investigation regarding the allegation. The nurse related she did not believe it to be an allegation of neglect and did not realize it should have been reported. RN #34 also confirmed a complaint/grievance/concern form had not been completed. On 02/26/16 at about 9:00 a.m., LPN #72 related she had not completed a grievance/concern form related to any of the complaints received from the resident's MPOA. The abuse prohibition policy, reviewed on 02/24/16 revealed the purpose was to ensure the Center staff were doing all that was within their control to prevent occurrences of abuse and neglect. The policy indicated staff would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent; clinical examinations for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The policy required the facility to ensure documentation of witnessed interviews were included.",2019-08-01
4699,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,225,E,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review and staff interview, the facility failed to thoroughly investigate and/or immediately report allegations of abuse and/or neglect, including injuries of unknown origin. This was found for four (4) of twenty-seven (27) residents reviewed in Stage 2 of the Quality Indicator Survey, and had the potential to affect more than a limited number residents. Resident identifiers: #48, #105, #75, and #37. Facility census: 92. Findings include: a) Resident #48 This [AGE] year-old resident, initially, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. Her physician determined she lacked the capacity to make informed medical decisions. The review of her record began on [DATE] at 10:00 a.m. On [DATE], Resident #48 was one (1) of eight (8) residents moved to the 500 wing, the former Assisted Living unit of the facility, in preparation for conversion of the unit to an Alzheimer's memory care unit. The facility considered these eight (8) residents appropriate for admission to a licensed Alzheimer's unit. There were references in the progress notes for Resident #48 having falls and being sent for x-rays. The facility sent the resident to a hospital emergency roiagnom on [DATE], and she returned the same day. She was sent to an out of state hospital on [DATE], and returned on [DATE] with diagnosed fractures to her hip and pelvis. Pertinent progress notes after her transfer to the 500 wing were found as follows (typed as written): -- [DATE] at 09:41 (9:41 a.m.) Clinical Meeting Note: Reason for Review: 3 falls over past week Summary of Resident Status: no injuries with fall except a bruise to shoulder and hand, xrays negative, Referral Physical therapy for evaluation. Outcome of IDT (interdisplinary team) Review/New Interventions: We will continue to maintain safe environment for resident, planned moved to memory unit/SNF (skilled nursing facility). Additional Information/Follow-up: Awaiting recommendations from PT (physical therapy) Careplan updated-if applicable: YES per (name) MDS Physician/Family Notified, if applicable: Physician and family notified. Pertinent information forwarded to direct care staff: Encourage rest periods as needed. -- [DATE] at 19:48 (7:48 p.m.) Order Note: X-ray RT (right) Femur & RT hip via Quality Mobile Imaging per Dr.(name). resident pain level increases upon supine position, there is a 4 cm (centimeter) lump top of rt (right) femur. -- [DATE] at 14:19 (2:19 p.m.) Nurse's Note: X-ray RT Femur & RT hip via (name) completed at bedside. -- ,[DATE]/ at 16 00:03 (4:00 p.m.) Nurse's Note: Up wandering the halls. Pleasant. Confused . Assisted to bed several times. Restless. -- [DATE] at 10:00 (10:00 a.m.) Nurse's Note: Resident had refused meds earlier. When CNA was doing AM (morning) care resident screamed that her hip/back was hurting and cried in pain -- [DATE] at 11:00 (11:00 a.m.) Nurse's Note: Resident up dressed and walked to the dining room with no issues. Ask resident about any pain, she denied having any. No signs of discomfort noted. Pleasant and cooperative. -- [DATE] at 00:23 (12:23 a.m.) Nurse's Note: Resident attempted to raise up in bed but yelled out and grabbed right hip. upon assessment, pain with passive ROM (range of motion) and abduction to right hip. per evening nurse in report, resident was seen limping. however now resident can't tolerate to raise up in bed due to pain, yelling out. PRN (as needed) [MEDICATION NAME] given. vitals obtained, BP (blood pressure): ,[DATE], pulse 101, temp (temperature) 97.4. daughter (name) notified of change in condition at 1130 p.m., she said she visited today and resident seemed okay and I told her we might be getting x-rays again and she agreed with that. doctor (name) notified of change and also of the recent x-rays to her right hip and femur on [DATE]; based on the resident's recent behavior, pain, independent ambulation, and baseline confused status, doctor (name) gave order to get STAT (immediate) x-rays of right hip and femur to rule out any acute fracture. he said to monitor condition, and if condition/symptoms worsen, to send resident to ER for further evaluation. STAT x-rays ordered -- [DATE] at 08:48 (8:48 a.m.) Nurse's Note: Large knot area noted on left hip with complaints of pain this AM (morning). Left resident rest in bed for breakfast waiting on mobile x-ray to come to facility. -- [DATE] at 12:29 (12:29 p.m.) Nurse's Note: Resident sent to (Local Hospital) via (local Squad). Complains of right hip pain. No bruising, redness noted. No prior fall awareness. Dr. (name) notified and new orders obtained. (Name), daughter notified of new orders to send to (local hospital). Report give to (name) at (local hospital) ER. -- [DATE] at 13:30 (1:30 p.m.) Nurse's Note: Received report from (name) at ER. X-rays of hips, pelvis and knees negative. Sending resident back to facility by (Local Squad). (Name), daughter notified at this time. No new orders. -- [DATE] at 17:00 (5:00 p.m.) Nurse's Note: Resident observed with bruise on right hip. repositioned to left side and applied ice, open area or st (skin tear) to rt elbow-[MEDICATION NAME] applied. c.n.a (certified nurse aide) stayed with resident for next 45 minutes to ensure her safety. discoloration to hands-?(question) due to lab draws during ER (emergency room ) visit this afternoon. -- [DATE] at 18:45 (6:45 p.m.) Nurse's Note: Resident took scheduled [MEDICATION NAME] at this time. Dr. (name) in facility and assessed resident. Right hip continues with bruising, very tender to touch. Bruising to bilateral hands and right elbow -- [DATE] at 05:36 (5:36 a.m.) Nurse's Note: Resident resting quietly in bed with eyes closed . Bruising continues to right hip, right elbow and bilateral hands. Resident moans when repositioned. No signs or symptoms of acute distress at this time. -- [DATE] at 09:30 (9:30 a.m.) Nurse's Note: Resident sat up on the end of the bed with therapy. Complained that hip was hurting. Ate and drank a small amount and laid back down after taking morning medications which included pain med. Resting in bed at this time. -- [DATE] at 12:47 (12:47 p.m.) Nurse's Note: Difficulty ambulating. In W/C at this time in the dining room eating lunch. Daughter in and sitting with resident. Updated her on new order for increasing [MEDICATION NAME] to three times a day. -- [DATE] at 13:16 (1:16 p.m.) Nurse's Note: Resident resting in bed. Tolerated therapy well. Bruising to right hip noted. Resident stated her hip hurt. Scheduled [MEDICATION NAME] given. -- [DATE] at 21:35 (9:35 p.m.) Nurse's Note: Awaiting call back from Dr. (name), resident is unable to bear wt on Rt side, excruciating pain in hip area. Bruise extends from top of femur to mid hip. R (right) foot pressure is not tolerated @ (at) all. This hip per daughter has a prosthesis which was placed 3 yrs ago. Notified (name) RN & instructed to call (name) FNP (Family Nurse Practitioner) to update. -- [DATE] at 19:58 (7:58 p.m.) SBAR Note: Unable to bear ANY WT (weight) on RT (right) leg The resident has orders for the following advance directives: DNR (Do Not Resuscitate). Spoke with daughter (Name) & request resident be taken to (nearby hospital) d/t (due to) the increase of falls over the past two weeks & the inability to bear wt (weight) on her Rt (right) leg. Dr (name) notified & order received to transport to (hospital). Spoke with (name) RN (Registered Nurse) & (and) gave report of all this resident's hx (history) for the past 2 wks. (The past two week period would have been from [DATE] - [DATE].) [DATE] at 20:58 (8:58 p.m.) Nurse's Note: Resident departed for (nearby hospital) via ambulance in (name) services. Two paramedics assessed resident who was a total lift from chair to stretcher. Guarded Rt leg with grimacing face d/t severe pain. (Name) daughter updated with this departure & the ETA (estimated time of arrival) @ (at) (hospital) Communicated last doses of all medications @ time of this departure. During an interview on [DATE] at 4:32 p.m., about her [DATE] note, Licensed Practical Nurse (LPN) #103, was asked about her note saying Resident #48 had an increase in falls in the past two weeks. She was asked if the resident began to have more falls after she was moved down to the 500 wing, and she said she (the resident) did. She said Resident #48 had good days and bad days. Sometime she could get around a bit with help, sometimes not. She said Resident #48 had three x-rays while she was on the 500 wing unit. When asked about the SBAR note, she said, That night was different. Something happened to her that night. She could not bear any weight, and had severe pain. She spoke with the resident's daughter and told her she felt even though she had been to the local emergency roiagnom on [DATE] and the x-rays were negative at that time, she was in need of more in depth assessment, and should be sent to the nearby out of state hospital. The daughter agreed. The resident was sent and subsequently admitted to the hospital where the fractures to the hip and pelvis were diagnosed . During an interview with Social Workers #117 and #25 on [DATE] at 11:45 a.m., when the description provided by the progress notes regarding injuries, pain, and calling the physician for orders for x-rays were discussed, they said they had never been informed and were not aware of the incidents. Social Worker # 117 pointed out that since no written reports of the incidents were completed, there would have been no discussion in the morning department head meetings. They agreed that the incidents should have been reported as injuries of unknown origin and investigated thoroughly. It was found no one could state categorically when the fractures to Resident #48's hip and pelvis may have occurred. What was clear was that while Resident #48 resided on the 500 wing unit, she presented on [DATE], [DATE], and [DATE] with pain, bruising, and/or inability to stand, and on each occasion, a nurse called the physician to obtain orders for x-rays to be done. Progress notes such as the one on [DATE] said, Per evening nurse in report, resident was seen limping, however now resident can't tolerate to raise up in bed due to pain, yelling out. The note on [DATE] at 8:35 p.m. said Awaiting call back from Dr. (name), resident is unable to bear wt (weight) on Rt (right) side, excruciating pain in hip area Even with the documented excruciating pain, she was not sent out to the hospital until [DATE] at 8:58 p.m There was no apparent investigation of how any of these incidents may have occurred, nor were they ever reported as an injury of unknown origin. b) Resident #105 1. On [DATE] at 4:40 p.m. a medical record review revealed this [AGE] year-old female was admitted on [DATE] and discharged on [DATE] when she was sent to the acute care hospital where she expired on [DATE]. Her [DIAGNOSES REDACTED]. A nursing progress note dated [DATE] stated (typed as written), bruise observed to left rib area by RNA (Registered Nurse Aide) tonight when taking resident to bathroom, this nurse attempted to notify POA (power of attorney) x (times) 2, busy signal. no complaints of pain. Another nursing progress note, dated [DATE] stated, Resident c/o (complained of) pain to left rib area, noted large bruise to left side/flank area which was documented on [DATE] Continued record review on [DATE] at 7:45 a.m., revealed an accident/incident report dated [DATE] describing, RNA observed bruise to left outer rib area, this nurse assessed area, dark and non-swollen. She told me she fell 3 days ago in the bathroom. Further review of incidents the facility had reported to State agencies did not find evidence the facility reported the resident's injury, which was unwitnessed, as an injury of unknown origin to the appropriate State agencies. In addition, there was no evidence of any investigation regarding this incident. After reviewing the incident/accident report on [DATE] at 11:10 a.m., Social Worker (SW) #117 stated, Yes I would have reported this because of the unusual location and an injury of unknown origin. I was not aware of this incident, but it should have been reported and investigated. 2. During an interview with Speech/Language Pathologist (SLP) #38 on [DATE] at 7:45 a.m., she provided copies of SLP Daily Notes. A review of the notes revealed a daily treatment on [DATE], Therapy services provided in pt (patient) room: .The patient's tongue appeared ,anchored, to the bottom on her mouth with almost no movement present at all. The patient's top and bottom dentures were removed with oral care provided. Oral care provided to soft palate/pharynx revealed thick brown build up on and around the patient's uvula. Following oral care one swallow was triggered by the patient with slight movement in the sound of her breathing. Another daily treatment note dated [DATE], documented, Therapy services provided in pt (patient) room during the early morning. Lemon [MEDICATION NAME] swabs and warmed wet wash cloth over gloved finger were used to clear dark thick residue which covered oral and pharyngeal structures anchoring them from moving appropriately for swallow. After significant clearing/cleaning residue was cleared and swallow was able to be triggered SLP #38 stated, The resident was seen on [DATE] and [DATE] and was seen prior to that on [DATE]. Due to the condition of her mouth, she could not have been provided with hydration or oral care except by us (SLP) during this time period. We talked with the nurses about this. The resident had declined in health, but there were four days from ,[DATE] to ,[DATE] that we did not see her and she had significant residue in her mouth that prevented her swallowing. After reviewing the SLP notes on [DATE] at 11:13 a.m., Social Worker (SW) #117 stated, This is bad, absolutely this requires an incident report, investigation and a reportable due to the incident because it borders on neglect. I did not have any knowledge of this incident. All of the staff including therapy have been educated on reporting things and I guess will have to have much more education. During an interview with the Administrator on [DATE] at 11:25 a.m., after reviewing the SLP notes, he did not reply when asked if an incident report and a reportable form should have been completed and the incident investigated. c) Resident #75 On [DATE] at 12:30 p.m., medical record review for Resident #75 (who resided on the 500 hall during this time period) revealed a nursing progress note dated [DATE] which stated (typed as written), During morning care (resident's first name) left wrist and thumb are noticeably swollen, purple in color and with discomfort on palpation. Dr. (doctor) notified order obtained for hand and wrist xray. Daughter notified. During a review of facility documents on [DATE] at 12:45 p.m., there was a report dated [DATE] identifying a fall with no injuries, but no report was found for [DATE] regarding the bruising and swelling of the resident's left wrist and thumb. Upon inquiry regarding an incident report for [DATE], Nurse Consultant #136 stated, An incident report was not done on [DATE] for the swelling of the left hand and thumb because she had fallen on [DATE]. After reviewing the progress notes and incident reports on [DATE] at 9:25 a.m., the Director of Nursing (DON) stated, There is not an incident report for the swelling of the left hand and thumb on [DATE]. I agree one should have been done and it should have been regarded as an incident since the report (incident/accident report) on [DATE] said no injuries. I guess they just thought it was from the fall on [DATE], but she could have had another fall after that causing this injury. After reviewing the incident report on [DATE] at 11:10 a.m., Social Worker (SW) #117 stated, Yes, I would have reported this because of the unusual location and an injury of unknown origin. I was not aware of this incident, but it should have been reported and investigated. d) Resident #37 Review of Resident #37's medical record on [DATE] at 1:20 p.m., found a nursing progress written by Licensed Practical Nurse (LPN) #130 on [DATE]. The note stated, RNA (registered nurse aide) came out of resident's room to get this nurse. She stated that resident rolled out of bed and was on the floor. Resident assessed and noted to have c/o (complaints of) pain to her left shoulder, wrist, knee, and hip. She had a slight nose bleed to left nares. The resident was urgently transferred to the hospital for evaluation. According to the minimum data set (MDS) assessment with an assessment reference date (ARD) of [DATE], Section G identified Resident #37 required the extensive assistance of two (2) persons for bed mobility and was totally dependent on two (2) people for transfers. The resident's care plan interventions, updated on [DATE], Plan of care per Kardex (a method used to communicate a resident's care needs to direct care staff). The nursing Kardex stated under the section titled Transferring . 2 staff for bed mobility, 2 staff for repositioning and incontinence care. Review of the incident reports on [DATE] at 9:00 a.m., revealed Resident #37 had rolled out of bed onto the floor on [DATE]. The witness's statement was, RNA (registered nurse aide) states that she was turning resident to change her bedding and when she turned her on her side she just kept turning and rolled out of bed. She was on the opposite side of the bed. Nurse Aide (NA) #49, interviewed on [DATE] at 9:00 a.m., reported Resident #37 required assistance with all of her activities of daily living (ADLS) including transferring and repositioning. The resident's needs were listed on the computerized Kardex system. Resident #37 had been a two (2) person reposition and lift since this NA started working in (MONTH) (YEAR). Review of the reportable files on [DATE] at 1:20 p.m., found no evidence this incident was investigated and/or reported in accordance with State law through established procedures. During an interview with Social Workers #117 and #25 on [DATE] at 10:45 a.m., they reported they were unaware of the this incident and agreed this should have been investigated and reported to the State.",2019-08-01
4726,CLARKSBURG NURSING AND REHABILITATION CENTER,515166,801 DAVISSON RUN ROAD,CLARKSBURG,WV,26301,2015-04-07,225,D,0,1,75SC11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of five (5) newly hired employees whose files were reviewed. Employee identifier: #43. Facility census: 95. Findings include: a) Nurse Aide (NA) #43 A personnel file review, completed on 04/02/15 at 9:30 a.m., revealed that one (1) of five (5) newly hired employees did not have the required criminal investigation background check based on fingerprinting on file. The Bureau for Medical Services manual includes in part: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history for Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire . A memorandum from the Bureau for Medical Services, dated 02/15/13, provided policy clarification on 514.4.1. Per this memorandum, for any new hires in the nursing facility, the policy is effective for those individuals as of 01/01/13. On 04/02/15 at 9:30 a.m. during an interview with the administrator and the business office assistant (BOA), they said the facility did not complete fingerprinting prior to NA #43's initial hire date of 02/25/15. Instead, the facility scheduled an appointment for NA #43's fingerprinting for 03/11/15. However, the employee did not keep the appointment. Upon inquiry as to the re-scheduled date for fingerprinting, they said there was no note in the file indicating a make-up date. There was no evidence that a make-up date was secured. At 10:05 a.m. on 04/02/15, the administrator provided an e-mail verifying Employee #43's appointment for fingerprinting. Review of this e-mail found it was sent on 04/02/15 at 9:52 a.m. to the facility's business office supervisor. Within this e-mail, the company that conducts fingerprinting of employees stated that NA #43s appointment for fingerprint services has been scheduled and confirmed with (company name), on 04/08/12 at 12:00 p.m.",2019-08-01
4749,MADISON PARK HEALTHCARE,515021,700 MADISON AVENUE,HUNTINGTON,WV,25704,2016-02-12,225,F,0,1,PDOU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to ensure it did not employee individuals who had been found guilty of abuse, neglect, mistreatment of [REDACTED]. When the facility received the results of a Federal Bureau of Investigation (FBI) fingerprint criminal history record check, which revealed the individual may not meet qualifications for employment, the facility failed to ensure the individual was not prohibited from working in a nursing home. This was true for one (1) of ten (10) employees hired after 08/01/15. This practice had the potential to affect all residents at the facility. Employee identifier: #9. Facility census: 40. Findings include: a) Nurse Aide #9 Review of the personal record of Nurse Aide (NA) #9, at 11:00 a.m. on 02/12/16, found the NA was hired on 12/28/15. Further review of the personnel record found a letter, dated 01/25/16, which included, The Federal Bureau of Investigation (FBI) has completed a criminal history record check on the applicant listed below. Based upon the information furnished by your agency, the FBI background check results indicate that the applicant may not meet qualifications for licensing or employment . Pursuant to federal law, this information cannot be released directly to your agency. The applicant can request this information by completing the FBI Request for Rapsheet form At 11:15 a.m. on 02/12/16, Human Resources Director #58 was unable to provide evidence the facility had investigated the reasons NA #9 might not meet qualifications for employment. At 12:45 p.m. on 02/12/16, the administrator provided a copy of a West Virginia State Police rapsheet for NA #9. The rapsheet, dated 12/16/13, and the results of the rapsheet had been sent to another nursing home in the area, not this nursing home. When asked if the facility had a copy of this document prior to surveyor intervention, the administrator said, I am looking at this for the first time, same as you. At 1:00 p.m. on 02/12/16, Registered Nurse #74, chief nursing officer, provided a copy of NA #9's time card which showed the employee had worked twelve (12) days since the date of the letter indicating the employee might not be fit for employment: 01/27/16, 01/28/16, 01/30/16, 02/02/16, 02/03/16, 02/04/16, 02/05/16, 02/06/16, 02/07/16, 02/08/16, 02/09/16, and 02/10/16.",2019-07-01
4787,TRINITY HEALTH CARE OF MINGO,515069,100 HILLCREST DRIVE,WILLIAMSON,WV,25661,2016-01-20,225,F,0,1,V5RK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, medical record review, policy review, reive of personnel records, and the Affordable Care Act, the facility failed to ensuer they screened one (1) of ten (10) employees by not ensuring they completed crominal background checks. Additionally, they failed to throughly investigate and report allegations of abuse/neglect for three 93) of nine (9) residents reviewed for abuse and neglect. These practices had the potential to affect all residents in the facility. Resident identifiers: Resident #48, #77, and #106. Facility census: 81. Findings include: a) Resident #48 During a Stage 1 interview, on 01/19/16 at 11:53 a.m., Resident #48 related that he felt like staff did not want to come to his room at times. He related he believed he had been vervbally abused. The resident related the incidents occurred more than once over the past couple of months. Resident #48 also related he felt like some of the staff got rough with him, because they had to provide care for him. Additionall, the resident related he had been left in urine and poop and not enough staff was available. He related the licensed practice nurses or registered nurses would answer the call bell, but would not provide care, and he had to wait for thirty 930) minutes. He further added, It gets old. The resident related he told the supervisor. Upon inquiry, Resident #48 related he told Social Worker (SW #76). The minimum datea set (MDS) with an assessment reference date (ARD) of 10/20/15, reviewed on 01/14/5 at 8:08 a.m., revealed a brief interview for mental status (BIMS) score of 14, indicating Resident #48 was cognitively intact. The highest attainable score was 15. Further review revealed he was totally dependent upon staff for bed mobility, transfer, toileting, personal hygiene and bathing. Concern/complaint/grievance forms, and reportable allegations, reviewed on 01/13/15, revealed no evidence the facaility had filed/reported an allegation of neglect on Resident #48's behalf. During an inteview with SW #76 on 01/19/16 at 11:53 a.m., she related Resident #48 often called her into his room as she was walking down the hall. The SW said, the resident complained that his alarm would go off and he said he waited for someone to answer the alarm. She related resident told her he felt like staff did not want to come in there at times. SW #76 related the resident dold her he had been left in urine and feces, but denied neglect, and did not want it reported. She related, I told him, now you know I hace to report this, are you sure? The social worker related she would review tapes and interview staff. On 01/19/16 at 2:45 p.m., another interview with SW #76 revealed she tried to determine what actually happened prior to reporting incidents. The social worker related if a concern/complaint/allegation was made, she would say to the staff, This is what I was told and try to determine what actually occurred, and if deemed reportable, would report it. During an interview with Resident #48, on 01/20/16 at 8:35 a.m., the resident related the social worker had not visited him this week (Monday, Tuesday or Wednesday). He related he was not notified of the outcome of the concerns/allegations he had reported. Additionally, the resident related he did not know how to report to the appropriate state agencies, only the facility staff. A follow-up inteview with SW #76 on 01/20/16 at 3:30 p.m., confirmed no reports had been filed related to Resident #48's allegations, and the SW was unable to provide evidence the allegations were investigated. b) Residen #77 A review of reportable allegations, on 01/13/16 at 3:30 p.m., revealed a noted dated 11/21/15 at 7:14 p.m., and signed by the Licensed Practical Nurse (LPN) #93. The report indicated a family member had reported to LPN #101 that Resident #77 was out of the facility. Staff immediately contacted (local) Police Department and began searching in and out of the facility. LPN #95 and minimum data set (MDS) Nurse #78 reviewed the cameras, which indicated the resident was last seen walking toward the water tower and up the hill behind the facility at 11:24 a.m. Inspection of the courtyard revealed knee prints, and wires that were holding the fencing to the pole together were untwisted. The physical area was fixed to prevent further elopement. The report did not indicate what time the resident was reported as missing, nor did it provide any inforamtion regarding staffs lack of awareness that the resident was missing. The Immediate Fax reporting of allegation form indicated the time of the incident as 11:24 a.m. on the 440-hall west side courtyard. The reports indicated a search was inside and outside of the facility, and was found about one (1) mile away, heading back towards the facility. The form did not indicate the time the search was initiated, nor the time the resident was found. An interview with Licensed Practical Nurse #93 (LPN), on 01/13/16 at 3:59 p.m., revealed Resident #77 had eloped under the fence in the courtyard near the administrator's office. The LPN related another nurse had called and related someone had seen the resident and the facility transported him back. When asked how the facility identified how the resident eloped, the LPN related staff had watched the cameras. LPN #77 related she could not remember whether staff completed witness statements related to the event. LPN #93 related the 911 emergency lines, and the police were called to make sure the resident was safely found. LPN #93 reviewed the medical record and confirmed the record did not indicate at what time the resident was reported missing. nor the time of his return. She related she could not remember. Further inquiry, revealed she was the unit charge nurse at the time of the incident. The LPN related staff had not reported an inability to locate the resident prior to the family notifiying the facility. LPN #93 related she was unaware of any follow-up intervention related to staff oversight of residents. The nurse indicated staff had not reported the resident as unavailable during smoke breaks or for lunch. An interview with the 911 center, on 01/19/16 at 1:29 p.m., revealed the facility called in the elopement at 15:06 (3:06) p.m. on 11/21/15. Upon inquiry as to who completed the investigation, LPN #93 related she believed the social worker was responsible. Additionally, interviews, with the Activity Director (AD) on 01/12/16 at 2:42 p.m. and Registered nurse #18 (RN), on 01/13/16 at 9:50 a.m., also related the social worker completed investigation of abuse and neglect when she returned to work. On 01/13/16 at 8:40 a.m., review of the abuse and neglect policy. located in a binder at the nurses' station, revealed the chain of command reported to the immediate supervisor, and the facility would take whatever measures were necessary to protect the victim. It indicated the facility would review the work schedule and identify staff who had worked up to 72 hours prior to the event and each employee would be questioned individually. A form indicating the date, time reported, response and description of abuse was to be placed under the door of the social worker or administrator. An interview with Social Worker #76 (SW), indicated the incident occurred on a weekend. She relaled the director of nursing would have been notified first, and a registered nurse supervisor (RN #18) was present and informed her. She further related the facility fixed the areas right then and there. The SW related the fence was relatively new and had been built as a non-smoking area. During another interview with SW #76, on 01/14/16 at 9:29 a.m., the SW related the facility was not aware Resident #77 had been a flight risk. She did relate, however, the resident had blamed her and said she was keeping him hostage at the facility. SW#76 reviewed the reportable allegation and related she believed the resident returned to the facility earlier than the note, which was dated and times as 11/21/15 at 7:14 p.m. When asked how long the resident had been missing prior to staff's awareness. the social worker related she did not know. Further review of the medical record, on 01/14/16 at 9:51 a.m., revealed [DIAGNOSES REDACTED]. [MEDICAL CONDITION] (dizziness), diabetes mellitus, hypertension, and [MEDICAL CONDITION]. The brief interview for mental status (SIMS) score was eleven (11) which indicated cognitive impairment. The immediate five (5) day follow-up completed by SW #76 noted, Resident was/did elope from facility while staff not watching. Resident was found by staff and brought back to the facility safe with only minor redness and scrapes . The social worker confirmed no evidence was present to indicate staff had been interviewed, or the incident had been thoroughly investigated to ensure the resident had been adequately supervised at the time of the elopement. c) Resident #106 Review of concerns and grievances, on 01/18/15 revealed an allegation dated 11 123f15 by Licensed Practical Nurse #107 (LPN) which indicated a responsible party had called the facility on 11/22/15 alleging abuse of Resident #106. The allegation indicated Resident #106 had not received her medication ([MEDICATION NAME]) and was treated for [REDACTED]. The hospital told me she was overdosed, and you shouldn't (should not) be asking me if she's (she is) confused you should do your job and read through her chart A note. dated 11/23/15 indicated Assistant Director of Nursing #34 (ADON) had called the daughter to request a meeting. No evidence was present to indicate the allegation of abuse had been reported to the approoriate state agencies. An interview, with Social Worker #76 (SW) confirmed the event had not been reported to state agencies. She related the director of nursing (DON) had handled it, and that she had not reviewed it. d) Criminal background checks The Affordable Care Act and West Virginia Code Chapter 16, Article 49 required direct access employees of nursing facilities, at a minimum, to complete a State and Federal fingerprint-based criminal investigation background checks prior to hire. Personnel records. reviewed on 01/13/16 at 1:52 p.m. with Medical Records #70 (MR) revealed no evidence the facility completed a State and Federal criminal background check for Physical Therapist #108 (PT), prior to hire on 10/15/15. On 01/13/16 at 2:55 p.m., a review of the time sheet, on 3116 at 2:55 p.m., confirmed PT #108 had worked on 11/27/15, 12/19/15, 12/24/15, and 01/01/16. An interview with the administrator on 01/ at 3:20 p.m. revealed the contracted company was responsible for completing criminal background checks, and confirmed a fingerprint background check had not been completed. A review of the facility policy revealed the following in regards to screening employees: In order to protect all residents. during the hiring process a newly hired employee will be screened. This will be accomplished through the local law enforcement, state police and other agencies. Once the checks have been completed and show no evidence of abuse or neglect the emr:loyee will then be fingerprinted and a background check is then initiated. The employee will be allowed to work until the background check comes back to facility. If the report is unfavorable, the individual will be terminated immediately.",2019-07-01
4860,MAPLES NURSING HOME,515186,1600 BLAND STREET,BLUEFIELD,WV,24701,2016-07-29,225,D,1,0,G6NZ11,"> Based on record review, staff interview, resident interview, and policy review the facility failed to investigate and report an allegation of neglect for one (1) of six (6) residents reviewed. Resident Identifier: #52. Facility census: 58. Findings include: a) Resident #52 In an interview with Resident #52, on 07/28/16 at 10:17 a.m., she revealed a morning in (MONTH) (YEAR) she had rang her call light due to she was incontinent of bowel and bladder. Nursing Aide (NA) #97 entered her room to assist her with her care. The resident said the NA cleaned her and left. She stated that she did not feel like she was cleaned properly. The resident said she reached over and used one (1) of her wipes and wiped herself and she had bowel movement on the wipe. The resident said she saw NA #91 walking down the hall, and yell out to her to come into her room. She said she told NA #91, she was not cleaned properly. She said she showed her the wipe in which had bowel movement on the wipe. She said the NA reported this to the Licensed Practical Nurse (LPN) #18. LPN #18 came into her room and she showed her the wipe she used which had bowel movement present. The resident said she told LPN #18, I was not cleaned by NA #97 properly. The resident revealed LPN #18 told NA #91 to clean her up. During a record review on 07/25/16 at 3:00 p.m., the most recent Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of 07/15/16 found the resident scored a 15 on her brief interview for mental status (BIMS). The Brief BIMS is a test given by medical professionals that helps determine a patient's cognitive understanding. A BIMS score of 13-15 indicates a resident is cognitively intact. In an interview with NA #91, on 07/28/16 at 10:30 a.m., revealed Resident #52 yelled for her as she walked by the resident's room. She further revealed the resident showed her a wipe with bowel movement on it. NA #91 stated the Resident told her NA #97 did not clean her after incontinence care. NA #91 revealed she reported this to LPN #81. She said LPN #81 asked her to clean Resident #52 and write up a statement on the alleged neglect. NA #91 revealed Resident #52 had feces caked up the front of her peri-area. NA #91 stated she gave a written statement to LPN #81. In an interview with the DON and the Administrator on 07/28/16 at 12:30 p.m., revealed they had no knowledge of Resident #52 allegation. The DON on 07/28/16 at 2:00 p.m., revealed that she spoke to LPN #18 and the LPN confirmed that she was aware of the allegation, and the LPN asked NA #91 to place the statement in the DON's box. The DON said she never received a written statement from either staff member, nor was called and informed about this situation. The DON said the LPN did not identify this situation as abuse or neglect. The DON confirmed that this allegation was not reported correctly, therefore no investigation was conducted or reported to the appropriate places. A review of the facility's policy on 07/28/16 at 3:00 p.m., found the staff are mandated staff training/orientation programs that include such topics as abuse prevention, identification and reporting of abuse. The staff are educated on how to identify abuse, reporting and filing of accurate documents relative to incident of abuse, and a thorough investigations of all reports and allegations of abuse. The facility should provide a written report of the results of all abuse investigation and appropriate action taken to the state survey and certification agency, the local police department, the ombudsman, and other as may be required by state or local laws, within five (5) working days of the reported incident.",2019-07-01
4887,WAR MEMORIAL HOSPITAL,5.1e+151,1 HEALTHY WAY,BERKELEY SPRINGS,WV,25411,2016-03-11,225,F,0,1,LRMX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel file review, facility policy/procedure review, review of Chapter 514.4 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every 3 years there after throughout the remainder of employment to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for one (1) of ten (10) employees whose personnel files were reviewed. Employee identifier: #48. Facility census: 16. Findings include: a) Employee #48, Rehabilitation Physical Therapy Aide (Rehab PTA) Review of the personnel files on 03/08/16 at 3:50 p.m. with Senior Human Resources Director (SRD #159), revealed Rehab PTA #48's file lacked a criminal background check. SRD# 159 stated, I will not be here tomorrow but will research and provide the criminal background check. On 03/09/16 at 8:55 a.m., the Administrator provided copies of communication from the West Virginia State Police to Rehab PTA #48. A copy of an email sent to an employee in the Human Resources Department on 02/18/14 from WV Easypath-Morpho Trust with a letterhead from the West Virginia State Police. The FBI (Federal Bureau Investigations) has rejected the fingerprint submission and the employee must be re-fingerprinted. A review of the facility Resident Abuse/Neglect policy and procedure on 03/09/16 at 9:00 a.m. stated; .D. Miscellaneous Screening Efforts 1. as part of the pre-employment process, all applicants for employment on the long term care facility will have a criminal conviction investigation completed and a complete set of fingerprints. On 03/09/16 at 9:10 a.m. the Director of Nursing (DON) stated, We do not have anything on her (Rehab PTA #48) for any background checks. She has been working with out a background check on file since her hire date (hire date 06/26/1984). 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment ). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013",2019-07-01
4891,TEAYS VALLEY CENTER,515106,1390 NORTH POPLAR FORK ROAD,HURRICANE,WV,25526,2016-06-22,225,D,1,0,KG2T11,"> Based on a review of the facilities reportable allegations of abuse and neglect, policy review, and staff interview the facility failed to ensure they thoroughly investigated and reported allegations of abuse/neglect. During a four (4) month period, the facility failed to report three (3) allegations of neglect and failed to thoroughly investigate two (2) allegations of abuse/neglect. This had the potential to affect more than a limited number of people. Resident identifier: #23, #122, and #123, Facility census: 120. Findings include: a) Resident #123 A review of the grievance/concern forms on 06/22/16 at 12:43 p.m. revealed a grievance/concern dated 03/29/16 which stated, Resident reports staff cussing (sic), water hot and cold while in bath. The investigation contained a statement from Resident #123 which said Nurse Aide #47 and #99 gave her a bath and the water was pretty hot. The statement said NA #47 and #99 were asked to turn the water off three (3) times and they did not. Resident #123 also said in her statement that NA #99 told the resident she was nasty because she had a bowel movement in the bed. The resident said they were cursing in the room and she did not think it sounded very good. The only statement other than the statement from the resident was from NA #47. That statement dated 04/03/16 stated, I helped (NA #99) shower resident on 03/29/16. She had a bowel movement and we had to re-shower her. I don't (do not) know of anything that happened nor did resident complain during shower. There was no statement from NA #99. During an interview with Social Worker (SW) #14, on 06/22/16 at 1:30 p.m., she stated there were no other statement or documents to show a further investigation into Resident #123's concerns about water temperature, comments made after she had a bowel movement or cursing in her presence. SW #14 read Resident #123's statement and said she was not sure what the resident meant when she, Told them three (3) times to turn it off and they did not do it. SW #14 said she did not know if this meant they were adjusting it three (3) times or if they did not turn it off as the resident requested three (3) separate times. Social Worker confirmed the facility needed to obtain further statements in order to ensure a thorough investigation was completed. She also confirmed they did report these issues as allegations of neglect. Director of Nursing (DON) #8 was also present for the interview and confirmed there were no further investigative information and the issue was not reported to the appropriate outside State agencies as an allegation of neglect. A review of the facility's abuse prohibition policy revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy stated the facility would conduct a thorough investigation that focused on whether or neglect occurred and to what extent. It also stated the investigation would be thoroughly documented and recorded and that interviews would be conducted with the alleged perpetrators. b) Resident #23 A review of the complaint grievances at 12:50 p.m. on 06/22/16 also revealed a complaint dated 06/03/16 which stated, Resident stated that it often takes 40-60 minutes to get 'changed,' and when her call light is on, the 'aides' come in and turn it off without asking what she wants. I asked what they do when they come in and she said that they look in the trash can, drawers, and closets, but don't (do not) ask her what she needs and that it takes up to an hour for her call light to be answered. The grievance/concern contained a resolution of the grievance concern dated 06/06/16 which stated, Touch pad call light installed on 6/3/16. There were no further investigative information present. DON #8 and SW #14 both confirmed on 06/22/16 at 1:45 p.m. that there were no further investigative information and these issues had not been reported to the appropriate outside State agencies as allegations of neglect. c) Resident #122 On 06/22/16 at 12:55 p.m. a review of the grievances/concerns revealed a concern dated 04/04/16 for Resident #122. The concern form stated, Resident's son stated the resident had been left in bed all weekend. He found her Sunday (4/3) at 9PM lying on dirty/bloody sheets, and her clothes had not been changed. He is also concerned her wounds are not being cared for properly if she is being kept in bed. He is concerned she is not being fed properly, also, as she continues to lose weight. He is requesting she be sent out to acute care for evaluation. An interview with SW #14 and DON #8 at 2:00 p.m., on 06/22/16 revealed these issues were not treated as allegations of neglect and were not reported to the appropriate outside State agencies. d) Review of Facility's Abuse Prohibition Policy A review of the facility's abuse prohibition policy revealed neglect was defined as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy stated the facility would conduct a thorough investigation that focused on whether or neglect occurred and to what extent. It also stated the investigation would be thoroughly documented and recorded and that interviews would be conducted with the alleged perpetrators.",2019-06-01
4939,OAK RIDGE CENTER,515174,1000 ASSOCIATION DRIVE,CHARLESTON,WV,25311,2016-05-18,225,D,1,0,1MMH11,"> Based on review of the facility's reportable allegations of abuse, neglect, and misappropriation of resident's property, staff interview, review of the Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, and facility policy review, the facility failed to report an allegation of abuse to the appropriate State agencies immediately in accordance with State law. This was true for one (1) of six (6) reported allegations reviewed. Resident identifier: #23. Facility census: 72. Findings include: a) Resident #23 Review of the facility's reportable allegations of abuse/neglect and misappropriation of resident property on 05/10/16 at 9:25 a.m., found an alleged incident reported to the Nurse Aide Registry on 02/11/16. Resident #23's daughter stated her father's roommate told her, That black guy took him to the bathroom last night and slammed him down and talked to him like a dog. The staff member knocked his glasses off and stepped on them and his hearing aid was on the floor. The facility reported the allegation to the Nurse Aide Registry on 02/11/16 and listed the perpetrator as Unknown. The nurse aide reporting form (NAR-1) requires the facility to list the name of the alleged perpetrator, the registered nurse aide's eval-code (evaluation code), the home address, and telephone number. Therefore, an unknown perpetrator was not required to be reported to this agency. The facility's investigation found two (2) black male nurse aides worked on the day the alleged incident occurred. One (1) staff member worked on the afternoon shift and the other on the night shift. The facility's investigation found the black male nurse aide working on the afternoon shift did not work on Resident #23's hallway and this employee had no contact with the resident. The second nurse aide provided the following statement on 02/13/16: I did not see (name of resident's) glasses in the floor and accidentally stepped on them. I tried to repair them unsuccessfully. I tried to find (name of resident's) hearing aide as well. While providing care to (name of resident) I had to speak loudly in order for him to hear me because he didn't have his hearing aide at the time and he was asking about his hearing aide. It probably sounded like I was yelling at him but he couldn't hear me otherwise. The Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, revised (MONTH) 2011, requires, If the alleged perpetrator is suspected to be a nurse aide, but the identity of this individual is unknown, this allegation is to be reported to OHFLAC's (Office of Health Facilities Licensure and Certification) nursing home program. Allegations of resident abuse, neglect, and misappropriation of resident property, where the alleged perpetrator is a nurse aide whose identity is known, are to be immediately reported to OHFLAC's Nurse Aide Program and not to OHFLAC's nursing home program When initially reported, the facility should have reported the allegation to OHFLAC's nursing home program. When the facility discovered the identity of the nurse aide, the facility should have reported the nurse aide to the Nurse Aide Registry. An interview with Social Worker (SW) #83, at 11:10 a.m. on 05/10/16, confirmed the facility never reported the incident to OHFLAC. Once the investigation revealed the identity of the nurse aide, the facility did not report the name of the nurse aide to the Nurse Aide Registry. On the morning of 05/11/16, SW #83 provided a copy of the reportable allegation involving Resident #23, indicating the nurse aide was reported to the nurse aide registry on 05/10/16, after surveyor intervention. The facility's policy, entitled Abuse Prohibition, directs: .6.2.1.2 If the alleged perpetrator is a nurse aide whose identity is known, report it via fax to OHFLAC's Nurse Aide Program",2019-05-01
5006,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-04-20,225,D,1,0,06GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, family interview, staff interview, facility record review, review of facility policies, and medical record review, the facility failed to ensure all alleged violations concerning mistreatment, abuse, and neglect were reported immediately to the administrator and/or to State agencies. Additionally, the facility failed to provide sufficient evidence that all alleged violations were thoroughly and/or investigated timely, and failed to prevent further potential abuse while the investigation was in progress. This practice affected two (2) of three (3) sample residents. Resident identifiers: #33 and #27. Facility census: 57. Findings include: a) Resident #33 During an interview with Resident #33 and his wife, on 04/18/16 from 4:04 p.m. to 4:45 p.m., an inquiry as to whether the resident had experienced abuse or neglect revealed an incident involving the administration of [MEDICATION NAME]. Resident #33's wife recounted an incident on 04/05/16 concerning the administration of [MEDICATION NAME], and how it was actually a misunderstanding. His wife said Resident #33 thought he was receiving Tylenol, but was actually receiving [MEDICATION NAME]. She related Licensed Practical Nurse (LPN) #60 came to the room and said, We need to talk. Resident #33 and his wife related the nurse told the resident that she did not appreciate him reporting her to the administrator. His wife indicated the nurse spoke in an angry and confrontational manner and that LPN #60 thought Resident #33 should have known what he was receiving. She said the nurse came in again the next evening and asked, Do you know what this is? The resident had replied, Tylenol? and the nurse responded, No it's (it is) your [MEDICATION NAME]. The resident related his wife had apologized to LPN #60 for the misunderstanding. During the interview on 04/18/16, Resident #33's wife said she called her husband on 04/06/16, the evening after the confrontation with LPN #60. She related the resident informed her that he was up in his chair and they would not put him to bed. The resident had told her LPN #60's husband, Nurse Aide (NA) #82, who was a nurse aide on the 100 hallway, was helping on the 200 hallway and would walk by and glare, but would not come into the room and did not help put him to bed. Resident #33's wife further added, RN #20 had come to the room the date of the confrontation by LPN #60 and the LPN exited the room with the RN. Both the resident and his wife related no one had responded to their concern about the way they were treated by the nurse and the nurse aide. The wife related she had contacted the corporate office. Resident #33 and his wife related she had spoken with Registered Nurse (RN) #20 and the social worker on a three (3) way call on 04/08/16. The concern/grievance log book and reportable allegation log book, reviewed on 04/18/16 at 5:00 p.m., revealed no evidence of Resident #33's concerns. During an interview on 04/19/16 at 4:30 p.m., RN #20, acknowledged she was aware of Resident #33's allegations. She said it was a concern that was a mixture of things which were misinterpreted, and the complaint had come through the compliance line from the corporate office. RN #20 related she would check the administrator's office, and returned with the complaint reported on the compliance line. The RN related, It was all a big misunderstanding. She said Resident #33 thought he had not been given his medication and had reported it to administration. She related LPN #60 did speak with the resident about the incident on 04/05/16, and the next evening (04/06/16), and NA #82 was assigned to Hallway 100, but assisted the NA on Hallway 200, where Resident #33 resided. RN #20 stated the nurse aide had informed her he may have glanced at the room as he was passing by and related he did not assist to transfer the resident to bed. According to RN #20, the resident was not assisted to bed when requested, and was returned to bed about 8:10 p.m. She related when she had inquired, LPN #60 related she wanted him to stay up for two (2) hours after dinner, to prepare him for discharge. Review of the care plan, on 04/19/16, revealed no evidence of a care plan requiring the resident to stay up in his chair. The care plan indicated staff should encourage the resident, but that he should remain up in his chair as tolerated. The RN added that during this time, the social worker had called Resident #33's wife on 04/06/16 to set up a discharge-planning meeting and his wife had expressed to the social worker that she thought it was retaliation because of reporting the concern about the [MEDICATION NAME]. RN #20 related she had received the complaint from the compliance line on 04/07/16 and responded to corporate office on 04/08/16. She related she did not report the allegations because she believed it was all a misunderstanding. The compliance line information received by the facility on 04/07/16, reviewed with RN #20 at 4:40 p.m., revealed the caller stated her husband waited for over two (2) hours to be transferred to his bed after the dinner meal. The caller also stated that (LPN #60's name) jumped on her and the resident for reporting her (the nurse); and that (names of NA #82 and LPN #60) walked by the resident, staring at him to cause an uncomfortable situation. The complaint also indicated the social worker left her a message of a meeting on 04/11/16 to discuss Resident #33's discharge and that he was not ready to be discharged . RN #20's written response to the allegations made on the compliance line, dated 04/08/16, indicated she and the social worker contacted Resident #33's wife regarding her complaint. The report included, The nurse previously confirmed that the conversation had occurred Additionally, the report indicated RN #20 spoke with NA #82 regarding the incident and NA #82 acknowledged being on the hallway assisting another NA. The report indicated the facility would be observant of any behaviors exhibited by (names of NA #82 and LPN #60) which may be perceived as making (Resident #33 and his wife) uncomfortable. The incident details of the report noted Resident #33, Was gotten out of bed a few minutes after 5 pm to eat dinner. He was assisted back to be at 8:10 pm that evening. During the interview with RN #20 on 04/19/16 at 4:30 p.m., she acknowledged the facility failed to complete a thorough investigation, as only the alleged perpetrators were interviewed related to Resident #33's allegation of verbal abuse, mental abuse, and neglect. Additionally, she acknowledged the allegations of abuse and neglect had not been reported to the appropriate State agencies. While reviewing the written response to the compliance line with RN #20, on 04/19/16 at 4:40 p.m., she related she had not interviewed any staff on duty the night of the allegation of neglect (leaving the resident up for over two (2) hours after dinner), or regarding NA #82's demeanor. The RN related she did not realize the allegations required reporting, because the complaint was received on the compliance line. b) Resident #27 Reportable allegations, reviewed on 04/20/16, revealed a substantiated allegation of verbal abuse with an incident date of 03/19/16. The immediate reporting form indicated the facility reported the allegation late to the appropriate State agencies. According to the report, Nurse Aide #103 made derogatory remarks to Resident #27 and told her to Shut her damn mouth. The report noted the resident was resisting with transfers and (NA #103's name) said, You need to stop it or I will have to put your ass on the floor The report also noted Resident #27 was mentally incapacitated, elderly, frail, and in a wheelchair (w/c). Witness statements indicated the allegation was first reported to Licensed Practical Nurse #47, who was working as an NA on that date (03/19/16). The nurse's statement included that she did not feel it was her place to act, and that it should have been reported to the charge nurse on duty. Registered Nurse #49's statement noted she was informed of the allegation on 03/21/16, and after speaking with NA #71, informed DON (director of nursing) of what I had been told. The witness statement by the social worker indicated she became aware of the incident on 03/23/16, at which time she reported it. During an interview with the administrator on 04/20/16 at 11:42 a.m., she related, We marked it as reporting late didn't (did not) we? The administrator agreed the incident should have been reported when identified. NA #103's time card, reviewed with Bookkeeper #28, on 04/20/16 at 11:55 a.m. revealed the NA worked on: -- 03/19/16 from 5:58 a.m. - 2:06 p.m.; -- 03/20/16 from 5:59 a.m. - 10:30 p.m.; and -- 03/22/16 from 5:59 a.m. - 2:00 p.m. (a double shift). A follow-up interview with the administrator, on 04/20/16 at 1:30 p.m., confirmed NA #103 had worked during the interim when the allegation was first reported to LPN #47 on 03/19/16 and the date reported on 03/23/16. She confirmed the facility had not ensured the safety of the resident(s). During the interview with the administrator on 04/20/16 at 12:30 p.m., she acknowledged the facility failed to ensure Resident #27's safety by allowing NA #103 to work on 03/19/16, 03/20/16, and 03/22/16. The administrator acknowledged the allegation of verbal abuse should have been reported to the appropriate State agencies immediately.",2019-04-01
5036,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-09-18,225,D,0,1,IPN311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, staff interview and review of the abuse policy and procedure, the facility failed to immediately report and investigate injuries of unknown origin regarding two (2) of three (3) sampled residents reviewed for non-pressure skin conditions. Resident identifiers #33 and #99. Facility census: 72. Findings include: a) Resident #33 On 09/17/15 at approximately 3:30 p.m., the electronic medical record of Resident #33 was reviewed. The physician progress notes [REDACTED].#33 had severe cognitive impairment. Observation on 09/16/15 at 2:33 p.m. revealed Resident #33 was in the dining room by herself, seated in a ger-ichair/Broda chair. The middle finger of the resident's left hand was slightly swollen and had a purple bruise. On 09/17/15 at 9:38 a.m., the middle finger of the left hand remained bruised, but was not swollen. Observation on 09/18/15 at 8:13 a.m. revealed the middle finger on the left hand. was still bruised. At the time of the observation on 09/18/15, an interview was conducted with Licensed Practical Nurse (LPN) #18. She stated she did not know what happened or where the bruise came from. She stated Resident #33 was known to throw her hands around. LPN #18 reviewed the nursing progress notes and indicated there was nothing documented regarding the bruised middle finger on the resident's left hand. The skin audit, dated 09/14/15, did not have any bruising documented. LPN #18 checked for events in the electronic charting system, and found nothing was documented regarding the bruised finger. LPN #18 stated she would notify LPN #19 regarding the bruise. An interview with the Director of Nursing (DON), on 09/18/15 at 8:46 a.m., revealed once a bruise was found, an investigation should begin. At that time, an event was started in the electronic charting system (Matrix). The DON discussed the procedure staff should follow when an injury of unknown origin was discovered. She verified staff did not follow the policy and procedure when they failed to notify leadership staff, including the DON and Administrator, of the bruised finger, and failed to start an investigation. An interview with Nursing Assistant (NA), #49 on 09/18/15 at 10:00 a.m., revealed she notified LPN #9 (night nurse) of the bruise on 09/17/15. NA #49 stated she saw the bruised middle finger on the left hand on first rounds and notified the nurse. She stated she did not know how Resident #33 obtained the bruise. b) Resident #99 This resident was admitted on [DATE] with a [DIAGNOSES REDACTED]. Observations on 09/15/15 at 1:12 p.m., revealed a dressing on the left lower leg. On 09/17/15 at 4:19 p.m. the medical record was reviewed. The nurse's notes indicated the resident acquired a skin tear on 08/17/15 to the left lower leg. The skin tear measured 2.0 centimeters (cm) by 2.0 cm. The nurse's note indicated the skin tear was of unknown origin. According to the note, the area was cleansed and Seri strips were applied. The family and the physician were notified. The event in the electronic medical records indicated the event was closed on 09/11/15 and the skin tear was healed. Observation, on 09/17/15 at 4:00 p.m., found the resident sitting in the dining room with a dressing covering her left lower leg. Registered Nurse (RN) #7 took the resident to her room and removed the dressing on the left lower leg. A skin tear was observed underneath the dressing. There was also a healed skin tear above the wound. RN #7 was not aware of the injury, and indicated the skin tear may have been caused by the wheelchair leg rests. At 5:00 p.m., LPN #18 was interviewed. The LPN stated she identified the skin tear on 08/17/15. LPN #18 removed the dressing to the left lower leg. When she looked at the wound, she stated the skin tear that was there at that time looked like a new skin tear. As she observed the skin tear, she indicated there was a healed skin tear above the area on the left lower leg. She identified the healed skin tear was what she originally observed on 08/17/15. LPN #18 indicated the skin tears may have been caused by the resident's wheelchair leg rests. On 09/17/15 nurses' notes indicated a skin tear was identified, the physician was notified, and a treatment was ordered. On 09/18/15, the skin tear was assessed. It measured one (1) cm by one (1) centimeter and was V-shaped. On 09/18/15 at 8:30 a.m., Social Worker (SW) #65 was interviewed. The SW stated when injuries of unknown origin were identified by staff, they were to report it to her, the DON, or the Administrator. She said they were to start an investigation at that time. The SW indicated she was not aware of the skin tear to Resident #99's left lower leg. At 8:40 a.m., NA #48 was interviewed. The NA stated she was told approximately one (1) and half (1/2) to two (2) weeks ago, by a nurse, that the resident had a skin tear on her left lower leg. She could not remember who the nurse was. The NA stated if she identified a skin tear, she would report it to the nurse and the nurse follows through with reporting. At 9:00 a.m., the DON was interviewed. The DON stated it was the responsibility of nursing staff, injuries of unknown origin were identified, to report the incident to herself, social services, or the administrator. She verified there was a injury of unknown origin to the left lower leg on 08/17/15, and the nurse failed to start an investigation. She was not aware of the new skin tear to the left lower leg. She verified nobody investigated the new skin tear to the left lower leg. The DON stated she was not aware staff were aware of the injury from approximately 1-1/2 to 2 weeks ago. She stated the process begins once the nurse is aware and creates an event in the computer. The DON said she expected the nurse to start an investigation of the injury of unknown origin. At 10:15 a.m., LPN #18 was interviewed. She stated on 08/17/15, when she identified the skin tear, she did not have any red flags go up. She stated she was aware of how to begin an investigation on an injury of unknown origin, but she did not feel this was an suspicious event that needed an investigation. c) On 09/18/15 at 10:19 a.m., the policy on accidents and incidents was reviewed. The policy indicated the nurse shall promptly initiate and document an investigation of the accident or incident. The investigative documentation was to include the nature of the injury, circumstances, where the incident took place, account of injury, and notification. The facility's policy on Abuse stated the facility must ensure that all alleged violations of injuries of unknown source will be reported to the administrator of the facility as soon as possible. The facility failed to report injuries of unknown origin for Residents #33 and #99.",2019-04-01
5061,SUMMERSVILLE REGIONAL MEDICAL CENTER,515029,400 FAIRVIEW HEIGHTS ROAD,SUMMERSVILLE,WV,26651,2015-10-20,225,D,0,1,MDR211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, abuse/neglect policy review, and concern/complaint record review, the facility failed to ensure allegations of neglect and injuries of unknown origin were reported. Although investigated, one (1) allegation of neglect and one (1) injury of unknown origin were not reported as required. Resident identifiers: #18 and #55. Facility census: 50. Findings include: a) Resident #18 On [DATE] at 3:30 p.m., a concern report, written by Licensed Practical Nurse (LPN) #86 on [DATE], was reviewed. The report indicated the resident ' s family member voiced a concern that no facility nurse or nursing assistant had been in to check on the resident all day. On this same note of concern, an additional family member stated if she had not come to the facility when she did, the resident would have died . There was no evidence this allegation of neglect was reported. b) Resident #55 Review of a concern form, dated [DATE], revealed this resident's family member reported bruises on the resident's buttocks of unknown origin. There was no evidence this allegation of potential abuse was reported. c) Review of the facility's Abuse/Neglect policy revealed, Reporting will occur per WV Office of Health Facilities Licensure and Certification guidelines. The West Virginia (WV) guidelines emulate the federal requirements for immediate reporting of allegations of neglect, abuse, and injuries of unknown sources. d) On [DATE] at 1:15 p.m., the director of nursing confirmed the allegations regarding Residents #18 and #55 were not reported to the State agencies in accordance with State law.",2019-03-01
5081,CONTINUOUS CARE CENTER WHEELING HOSPITAL,515055,600 MEDICAL PARK,WHEELING,WV,26003,2016-03-03,225,D,1,0,CIVS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to report an allegation of neglect to State officials in accordance with State law along with the results of the investigation within five (5) working days of the incident for one (1) of three (3) complaints reviewed. Resident identifier: #8664. Facility census: 105. Findings include: a) Resident #8664 A review Resident #8664's closed clinical record at 1:00 p.m. on [DATE], revealed Resident #8664 was an [AGE] year-old male admitted to the facility on [DATE], following an acute hospitalization with a surgical procedure and an ensuing wound infection. Additional [DIAGNOSES REDACTED]. Resident #866s required extensive assistance for all activities of daily living (ADLs). The resident's family was present at his side most of the time. At 9:00 a.m. on [DATE], the Administrator received several complaints from the wife of Resident #8664 after the resident had been discharged from the facility to acute care on [DATE], where he expired. The administrator arranged a meeting attended by herself, the resident's wife, her son, the facility's medical director, and the resident's attending physician while he was at the facility. The four (4) concerns discussed in the meeting were recorded by the Administrator as follows: -- (Resident #8664)'s room was not clean and orderly upon his admission -- Did not have pain controlled during a 16-hour period of time of not getting pain medicine -- On-call physician did not call nurses back timely; and -- Poor communication regarding end of life care decisions. The concerns were investigated and a written reply of the findings and actions taken was sent to Resident #8864's wife on [DATE]. However, these allegations of neglect were not reported to the Nursing Home Program or to Adult Protective Services in accordance with State Law. During an interview with the Administrator and the Director of Nursing at 11:10 a.m. on [DATE], the administrator said she had not considered the concerns as allegations of neglect when they met with the family. She had no comment when told the allegations met the definition of neglect and should have been reported.",2019-03-01
5088,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2016-03-05,225,D,1,0,H9I211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on staff interview, confidential interview, review of reportable allegations, policy review, and review of concern/grievance forms, the facility failed to report and thoroughly investigate an allegation of neglect for one (1) of three (3) residents reviewed. A concern form identified an allegation that the facility failed to provide care and treatment for [REDACTED]. Resident identifier: #83. Facility census: 76. Findings include: a) Resident #83 Review of the concerns and grievances, on 03/02/16 at 9:50 a.m., and again at 3:52 p.m., revealed a concern form dated 12/01/15 which indicated Resident #83's spouse had expressed concerns indicating a coccyx wound might get infected. An education in-service record attached to the concern, also dated 12/01/15, revealed staff education included communication and replacement of treatment. The education required nurse aides must notify nurses of resident's wound dressing being off during care and reporting it to the nurse immediately. Then nurse to take care of re-doing the treatment/dressing immediately due to Concerns have been voiced by visitors & (and) this cannot happen!!! Reportable allegations, reviewed on 03/02/16 at 10:00 a.m., found no evidence an allegation of neglect related to wound dressings not being replaced and creating a potential for infection, had been reported to the appropriate State agencies. Confidential Iinterview (CI) #1, on 03/04/16, revealed Resident #84 exhibited pain, had to lie on her side, and the last week was really hard on her. The interviewee related the resident's spouse assisted with care and was concerned because the wound sometimes did not have a dressing on when he assisted and/or observed staff providing care. The interviewee related sometimes the dressing was completely off and sometimes in place but not intact and contaminated with feces. Confidential Interviewee #2, interviewed on 03/04/16, confirmed the dressing had been off and/or not intact several times when the wound was observed. The individual related the wound continued to get worse and thought it might have been because of contamination from the bowel movements. An interview with the social worker (SW) on 03/04/16 at 10:00 a.m., revealed the allegation, dated 12/02/15 alleging staff did not replace and/or changing Resident #83's coccyx wound dressing timely, had not been completed. The concern form noted, Resident's husband concerned wound on coccyx may get infected. The SW related it would have been reported if the concern had been an allegation of neglect, but nursing responded to the concern. The SW then reviewed the education, completed on 12/02/15 which indicated, CNA must: notify nurses of residents wound dressing being off during care and reporting it to the nurse immediately, then nurse must take care of re-doing the treatment/dressing immediately. Concerns have been voiced by visitors and this cannot happen! The social worker acknowledged the education referred to treatments not completed and/or completed timely and acknowledged they inferred an allegation of neglect. She related no investigation had been completed. During an interview with the director of nursing (DON), administrator, and social worker, on 03/04/16 at 10:15 a.m., the DON related the concern was more about the wound becoming infected with feces because of the location on the coccyx rather than the dressing not being replaced. She confirmed an investigation had not been completed related to the allegation. The administrator reviewed the concern form and in-service and said she was not aware of, nor been involved with the concern. The abuse prohibition policy, reviewed on 03/04/16 at 12:00 p.m., indicated the facility would immediately report all alleged violations to the administrator and to other officials in accordance with State law. The policy required all alleged violations be thoroughly investigated.",2019-03-01
5118,EASTBROOK CENTER,515089,3819 CHESTERFIELD AVENUE,CHARLESTON,WV,25304,2016-03-11,225,F,1,0,JBQ211,"> Based on personnel record review, the Affordable Care Act, West Virginia Clearance for Access: Registry and Employment (WV CARES), state nursing home licensure rule, and staff interview, the facility failed to ensure it did not employee individuals with a negative finding on his or her state and federal fingerprint-based background check. The facility failed to ensure one (1) of ten (10) employees was prohibited from working in a nursing home beyond the 60 day conditional period. The facility also failed to ensure one (1) of ten (10) employees was prohibited from working with a criminal background negative fitness determination. This practice had the potential to affect all residents at the facility. Employee identifier: #24. Facility census: 123. Findings include: On 03/10/16 at 2:00 p.m., Human Resource (HR) #96 provided the personnel file for Nurse Aide (NA) #24. The personnel file revealed a 12/18/15 hire date for NA #24. HR #96 provided a copy of a form from WV CARES. The form contained NA #24's date of birth, last four digits of the social security number and an application number. The form stated, This applicant does not require fingerprinting for employment at this time. This applicant has received a fingerprint authorization form and must be fingerprinted by 11/29/2015. Nothing else is required of you at this time. You will be notified if further action is required. According to HR #96, the nurse aide had probably applied for a position at another facility and was fingerprinted prior to her coming to apply at this facility. HR #96 said the employee was not fingerprinted at this time because it appeared based on this form that fingerprints were already taken. HR #96 provided a copy of a form that according to HR #96 was used by NA #24 to be fingerprinted for a second time. The form was dated 01/15/16. HR #96 said the facility elected to fingerprint NA #24 since they had not received any results from her previous fingerprints. HR #96 said the NA was suspended from work on 03/04/16. HR #96 provided a copy of a fitness determination letter that was dated 01/11/16 that stated NA #24 was ineligible for long-term care direct access employment. The form stated in handwriting Recvd (received) 03/10/16 and had HR #96's initials on it. This information was not present or handwritten on the form the first time it was presented to the surveyor. HR #96 acknowledged that NA #24 had filed a variance of the fitness determination dated 01/11/16. The administrator and HR #96 confirmed NA #24 was employed as a provisional employee for more than 60 days at their facility. According to West Virginia State Code 16-49-9 WV CARES, 6.1 a conditional basis of employment for no more than 60 days may occur when: 6.1.a. An applicant does not have a negative finding on a required registry or license database, and the employment fitness determination is pending the criminal history information On 03/11/16 at 1:00 p.m., the administrator and HR #96 both confirmed that representatives from MorphoTrust had come to the facility earlier in the week and fingerprinted all staff members including NA #24.",2019-03-01
5136,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2016-03-09,225,D,1,0,K6OL11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based upon resident interview, staff interview and review of records, the facility failed to immediately report Resident #70's allegation of verbal abuse as required. This was found for one (1) random resident. Resident identifier: #70. Facility census: 95. Findings include: a) Resident #70 This [AGE] year-old woman, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. She was determined by a physician to possess the capacity to make informed medical decisions. She is acting as her own responsible party. When greeted during a tour of the facility on 03/08/16 at 10:00 a.m. Resident #70 said she had some concerns she wanted to discuss. She said two (2) nurse aides (NAs) had been really mean to her recently. She said within the past week the NAs had yelled at her and said they were not going to provide care for her, she had to do it herself. She said she considered this verbal abuse and she had reported it to one of the new social workers. In an interview on 03/08/16 at 11:55 a.m. with the two (2) new Social Workers, #38 and #55, when asked if Resident #70 had told them two (2) NAs had been mean to her recently, Social Worker #38 said she had spoken with her yesterday about her roommate and she had told her two NAs had been mean. She said the resident had given her their names. Review of the resident's record found a social services note that stated (typed as written): -- 03/07/16 at 3:57 p.m. Social Service Note: This SW spoke with (Resident #70) regarding a room change, she states her roommate keeps their room too hot and she can't stand it, especially with summer coming and the temperature outside will be warm too, and her room mate still keeps it hot in the room. SW asked if she was willing to move to (name of wing) side and she stated no. I explained that it has been looked at but anyone who does not have a room mate keeps their room hot also. Assured (resident #70) that it will continue to be looked into and not forgotten. There was no mention of the resident's allegation about the NAs. Review of facility's complaint files and abuse/neglect reporting records on 03/09/16 at 11:00 a.m., found no complaints had been documented from Resident #70 and no immediate report of an allegation of abuse/neglect had been submitted to the required State agencies within twenty-four (24) hours after it was received. In an interview with Social Worker #38 on 03/09/16 at 2:20 p.m., she said she had completed a report of the allegation today and the investigation was underway. She expressed understanding the allegation should have been reported within twenty-four (24) hours.",2019-03-01
5138,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-03-04,225,D,1,0,PZGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on incident/accident reports review, record review, policy and procedure review, resident interview, and staff interview, the facility failed to identify incidents as possible abuse/neglect, failed to immediately report and thoroughly investigate an incident of a resident's injury caused by an employee, and injuries of unknown origin as required by law to the appropriate outside agencies. This practice was found for three (3) of one-hundred forty-nine (149) incident/accident reports reviewed. Resident #98, #46, and #84. Facility census: 107. Findings include: a) Resident #98 On 03/01/16 at 11:00 a.m., a review of the incident/accident forms revealed an incident/accident for Resident #98 dated 02/14/16 at 7:20 a.m. The form stated (typed as written), CNA (Certified Nursing Assistant) was putting resident on hoyer pad while she was laying in bed, when assisting resident to turn to position on hoyer pad, the hoyer strap caught residents leg causing two skin tears. Both on lower right leg. Proximal skin tear v-shaped with skin flap intact 2 cm (centimeter) x 2 cm x The section Immediate action taken to safeguard the resident: (typed as written) Assessed areas and provided treatment. Educated staff members on safety positioning resident, and to monitor positioning of hoyer straps to prevent further injuries. The investigation form by the facility stated as a contributing factor--dry fragile skin. The investigation form did not identify whether the nurse aide was providing care alone or with assistance. No staff interviews were included in the investigation report. On 03/02/16 at 9:30 a.m., a review of the medical record revealed the quarterly Minimum Data Set Assessment with an assessment reference date of 12/07/16, identified the resident required the extensive assistance of two (2) staff for bed mobility and transfers. During an interview with Resident #98 on 03/02/16 at 10:45 a.m., she commented she gets bruises sometimes and is unaware of how they happen. She stated, the girl cut my leg with a strap, sometimes they try to rush doing things, but she apologized for doing it. She got the nurse and she (nurse) put stuff on my leg. Then the girl (CNA) finished putting the lift under me and got me up. My leg was sore for a while but is better now. b) Resident #46 On 03/01/16 at 11:05 a.m., a review of the incident/accident forms revealed an incident/accident for Resident #46 on 02/20/16. Circumstances of the event were (typed as written); skin assessment completed and small fading bluish in color bruise observed to right upper buttock. Appears to be in place where staff would apply pressure with hand to hold resident when doing peri care. Resident skin pale dry and fragile. The investigation form by the facility stated, Immediate action taken to safeguard the resident: Monitor bruise weekly and staff educated on safe resident handling. There was no evidence the facility attempted to identify when the bruise had occurred. No staff interviews were included with the investigation report. On 03/02/16 at 9:10 a.m., a review of the medical record revealed Resident # 46 was totally dependent for bed mobility, transfers, locomotion, dressing, toileting, personal hygiene, and bathing. She was unable to be interviewed due to her cognitive impairment. c) Resident #84 On 03/01/16 at 11:10 a.m., a review of the incident/accident forms revealed an incident/accident for Resident # 84 dated 02/15/16. Description of the event (typed as written), It was found by this nurse that resident has a 6.4 cm x 5 cm bruise to top of right forearm appears deep purple. Resident has a history of being combative with staff during care. Several reports from staff stating resident refuses care and becomes combative during attempts to provide care for resident. The section Immediate action taken to safeguard the resident: (typed as written) On 02/13/16 resident's [MEDICATION NAME] was increased from 0.5 mg (milligrams) q (every) hs (hour of sleep) to 0.5 mg po (by mouth) q 6 hours prn (as needed) due to increased agitation. Staff to re-approach resident when having combative behaviors. d) A review of the facility's policy and procedure entitled Abuse Prohibition Policies and Procedures on 03/01/16 at 1:30 p.m., found it included the following definitions of Abuse, Neglect and Injuries of Unknown Origin: ---Abuse is defined as the infliction or threat to inflict physical pain or injury . ---Neglect is defined as the failure to provide goods and services necessary to avoid physical harm . ---Injuries of unknown origin are defined as injury with both of the following conditions. 1. The source of the injury was not observed by another person . 2. The injury is suspicious because of the extent of the injury or location of the injury . e) During an interview with Social Worker (SW) #148 on 03/02/16 at 11:00 a.m., she stated, The incident/accident reports are reviewed daily in the IDT (interdisciplinary team) meetings. The Social Services department receives the directive from the Administrator as to which incidents are to be reported. After reviewing the three (3) described incident/accident forms she stated, Yes they should have been reported. They are suspicious regarding the bruises due to the residents being dependent for care and also the harm to a resident caused by a CNA. The Administrator joined this interview with the SW #148 at 11:10 a.m. After reviewing the incident/accident forms, the Administrator stated, but we investigated them. The Administrator did not reply when inquired if the incidents should have been reported due to a resident being injured by the CNA and bruising/injuries of unknown origin. The SW stated, Always report and then investigate because you don't know what the cause is initially, but it is better to err on the side of caution. f) There was no evidence these incidents were reported to the appropriate State agencies by the facility. These incidents were not identified as requiring thorough investigations to rule out abuse or neglect. There was a lack of witness statements included with each of the incidents to collaborate events and resident behaviors.",2019-03-01
5148,SISTERSVILLE CENTER,515131,"201 WOOD STREET OPERATIONS, LLC",SISTERSVILLE,WV,26175,2015-06-23,225,F,0,1,PDA311,"Based on resident interview, staff interview, clinical record review, review of facility records, and facility policy and procedure review, the facility failed to ensure allegations of abuse and misappropriation of personal property were reported and investigated for three (3) residents identified during the abuse prohibition review. This included an allegation of sexual abuse voiced by Resident #72 and allegations related to misappropriation of property voiced by Residents #2 and #59. In addition, based on personnel record review, staff interview, and review of the the Bureau for Medical Services (Medicaid) manual, the facility failed to perform a thorough investigation of the past history for one (1) of five (5) employees whose personnel files were reviewed. These practices affected Residents #72, #2, and #59, but had the potential to affect all residents. Facility census: 55. Findings include: a) Resident #72 Review of a nurse's note, dated 06/13/15 at 8:42 p.m., revealed Resident #72 . told me also this morning that another resident touched her boob. She said it was not the first. I educated her to please stay away from that resident. The nurse's note was written by Licensed Practical Nurse (LPN) #64. There was no evidence this allegation was immediately reported to the administrator or to other officials in accordance with State law, through established procedures (including to the State survey and certification agency). 1. In an interview, on 06/16/15 at 3:38 p.m., Social Worker (SW) #8 stated she became aware of the abuse allegation on 06/15/15 at the morning meeting. SW #8 stated Resident #72 reported to her during an interview, that Resident #79 touched her left breast on 06/13/15. The SW said Resident #72 stated she reported the incident to LPN #64 that same day. SW #8 stated she had not reported the allegation or completed any further investigation with any residents or staff regarding the allegation. 2. During an interview, on 06/16/15 at 4:20 p.m., the Administrator and DON stated LPN #64 should have reported the allegation immediately on 06/13/15. 3. Review of the facility's policy and procedure entitled Abuse Prohibition dated as revised 07/16/13, was conducted on 06/16/15 at 6:25 p.m. The policy stated the center would report all information regarding abuse or misappropriation of resident property via fax to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman within 24 hours. It required the facility to conduct an immediate and thorough investigation and to provide a follow-up report in five (5) days. 4. On 06/17/15 at 10:40 a.m., SW #8 confirmed she did not report the allegation of abuse when she was made aware of it on 06/15/15. She said she reported it the evening of 06/16/15. Review of facility records revealed a fax receipt to OHFLAC on 06/16/15 at 5:06 p.m. 5. During an interview on 06/17/15 at 11:15 a.m., Assistant Director of Nursing (ADON) #16 stated she was on call the weekend of Resident #72's allegation on 06/13/15. ADON #16 stated LPN #64 did not report the allegation to her as required by facility policy. 6. On 06/17/15 at 12:36 p.m., LPN #64 indicated she had been trained to immediately report any allegation of resident abuse to the supervisor or other management staff. At that time, the LPN confirmed she had written the 06/13/15 at 8:43 p.m. nurse's note in Resident #72's clinical record. LPN #64 stated, When you think of abuse, I think staff to resident and didn't think about residents with capacity not so much as abuse. I should have reported it immediately. b) Resident #2 Grievance/concern forms were reviewed on 06/17/15 at 4:47 p.m. A concern dated 06/02/15 indicated Resident #2 was missing $34 and 2 bears. The form indicated staff searched the room and were unable to locate the items. Reportable allegations, previously reviewed at 2:59 p.m., contained no evidence the facility investigated the allegation of missing items to determine whether an act of misappropriation may have occurred. c) Resident #59 On 06/17/15 at 4:47 p.m., review of grievance/concern forms revealed Resident #59 initiated a complaint on 06/02/15. The form, completed by the facility, indicated the resident was missing $200, $20 and $10 dollars at different times. The form indicated the resident said the money was kept on his person, and when he awoke, the money was missing. The form indicated staff looked for the money and were unable to find it. There was no evidence the facility thoroughly investigated the incident. Resident #59, interviewed on 06/17/15 at 5:30 p.m., revealed he lost money on different occasions, and indicated the amounts of $200, $20 and $10. The resident related he . couldn't prove the money was taken, otherwise, he would have pursued the issue. Resident #59 related he obtained the cash from his resident funds to purchase personal items. He said he was still upset over the losses. The resident's funds, reviewed on 06/18/15 at 10:02 p.m., revealed a resident statement which indicated the resident had debited money at various times as follows: -- 03/25/15 $150 -- 03/30/15 $400 -- 04/06/15 $20 -- 04/09/15 $60 -- 04/15/15 $15 -- 04/23/15 $80 -- 05/04/15 $50 -- 06/10/15 $20 -- 06/16/15 $35 Review of the abuse prohibition policy, on 06/16/15 at 7:00 p.m., revealed the facility would conduct an immediate and thorough investigation to determine whether abuse occurred and to what extent, and thoroughly document the investigation, ensuring documentation of witness interviews. It also said a representative from social services or designee would monitor the resident's feelings. An interview with the nurse practice educator (NPE), on 06/17/15 at 10:40 a.m., revealed staff were trained/educated on abuse, neglect, and misappropriation of property upon hire and annually. The abuse protocol required staff report immediately to their nursing supervisor, and required the facility report the incident to the appropriate State agencies within 24 hours. The NPE related any allegation of misappropriation was to be reported. The director of nursing (DON), interviewed on 06/17/15 at 5:00 p.m., indicated she did not know whether the incidents were investigated and would ask the social worker. At 5:12 p.m., the DON reported she spoke with the administrator, and . because the resident did not use the specific term stolen, the missing money was not reported and/or investigated. The social worker, interviewed at 5:10 p.m. on 06/17/15, confirmed the facility had not found the missing money, had not investigated the incidents, and had not reported the missing money to the required State agencies. d) On 06/19/15 at 3:30 p.m., a review of personnel files found one (1) of five (5) recently hired employees had no fingerprints, or criminal background checks based on fingerprinting, in his/her files. The files contained criminal background checks completed based on the employee's social security number. Nurse Aide #8 was hired on 12/30/14. There was no evidence of fingerprinting, as required for a statewide criminal background check in West Virginia (WV). In a discussion with Employee #24, the payroll scheduling coordinator, she confirmed the background check was not completed. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included, . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2019-03-01
5168,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2016-03-10,225,D,1,0,JN7X11,"> Based on review of reportable allegations, review of facility policy, and staff interviews, the facility failed to thoroughly investigate allegations of staff to resident sexual abuse for complaints received 12/17/15 and 02/25/16. Further, a five (5) day follow up report for an instance dated 12/17/15, with the determination of the findings, was not completed and submitted to the appropriate State agencies as required. This was evident for two (2) of sixteen (16) reports reviewed. Resident identifiers: #77 and #45. Census: 87. Finding include: a) Resident #45 An allegation of a female staff member touching a male resident inappropriately was reported on 12/17/15. There was no evidence this issue was thoroughly investigated at the time it was reported. Interview with Administrator #85 on 03/07/16 at 3:35 p.m., revealed the staff felt there was not enough information in the complaint for an investigation, therefore; one was not started at that point. An anonymous allegation was reported to the corporate hotline on 02/25/16, but did not contain specifics of resident or staff names. Another allegation was made to the hotline on 03/05/16. The complaint made on 03/05/16 included specific names and details and generated initiation of an investigation. There was no evidence an investigation was conducted on 12/17/15 or 02/25/16 when complaints alleging sexual abuse were reported. The facility did not initiate an investigation into the sexual abuse allegations until (MONTH) (YEAR). b) Resident #77 A review of a reportable instance dated 12/07/15, revealed there was an immediate reporting form in place for an allegation of resident to resident sexual abuse. There was no evidence that a thorough investigation, with a five (5) day follow up report, was completed. The incident had been reported immediately, but the investigation did not have any further details or summation of the findings in five (5) days. A five (5) day follow up form was included with the documentation regarding the incident, but was blank and contained no information. The facility had not followed the corporate abuse/neglect policy with a revision date of 10/15/15, which stated a five (5) day follow up was to be sent to the appropriate agencies. These issues were discussed and verified with the administrator and social worker on 03/09/16 at 10:20 a.m.",2019-03-01
5177,WILLOW TREE MANOR,515156,1263 SOUTH GEORGE STREET,CHARLES TOWN,WV,25414,2015-05-15,225,D,0,1,EP0S11,"Based on facility record review, resident interview, and staff interview, the facility failed to report allegations of abuse for three (3) of five (5) allegations of verbal abuse and/or neglect. A resident alleged a nursing assistant (NA) passed by her door three (3) times and did not respond to the call light. Another resident complained a Nurse Aide (NA) spoke to her in a verbally abusive manner. Resident #23's daughter alleged her mother's bed was saturated with urine. Resident identifiers: #84, #23 and #31. Facility census: 95. Findings include: a) Reportable allegations Review of concern and grievance forms on 05/13/15 5:00 p.m., found five (5) allegations reportable to State agencies. Further review of the reportable allegations on 05/14/15 at 8:30 a.m., found no evidence three (3) of the five (5) allegations were reported to the State agencies. 1. Resident #84 This resident reported an allegation on 04/24/15 related to potential verbal abuse. The resident alleged a nurse aide (NA) had assisted him to the shower room. He related the NA had requested he stand, but he was unable. Resident #84 stated the NA then told him, You just don't want to do anything, and returned the resident to his room, and provided a bed bath instead. The complaint was founded. 2. Resident #23 This resident's family member filed a complaint for an incident date of 04/21/15. The complaint alleged the resident was soiled with urine and feces, and a dried urine stain was present on the sheets. Additionally, the daughter indicated the nurse had a poor response when questioned about the incontinence. The nurse investigated and substantiated the allegation of potential neglect. 3. Resident #31 A resident grievance/complaint form, dated 02/25/15, indicated Resident #31 turned on her call bell about 5:30 a.m. The resident alleged a specific nurse aide walked by her room three (3) times and did not answer her call light. Resident #31 related another staff member answered it when arriving on duty at 7:00 a.m. The nurse aide admitted he passed by the room. The facility's interview with the NA confirmed the resident was upset. The complaint was founded. Review of the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 02/20/15, revealed a brief interview for mental status (BIMS) score of 15, which indicated the resident did not have cognitive impairment. b) During an interview the afternoon of 05/14/15, the social worker, director of nursing, assistant director of nursing, and administrator each confirmed the allegations of potential neglect and/or abuse were not reported to the appropriate State agencies.",2019-03-01
5193,MCDOWELL NURSING AND REHABILITATION CENTER,515162,150 VENUS ROAD,GARY,WV,24836,2016-03-31,225,D,1,0,22Y611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review, staff interviews, and review of the facility's policy, the facility failed to report injuries of unknown origin to the appropriate State agencies for one (1) of three (3) residents reviewed for abuse and neglect. Resident identifier: #61. Facility census: 97. Findings include: a) Resident #61 A review of the progress notes for this resident on 03/30/16 at 9:30 a.m., found that Resident # 61 was transferred to an acute-care hospital on [DATE]. On 12/05/15 at 2:15 p.m., clinical care coordinator-wound nurse (CCS-WN) was called to the shower room by a nurse aide (NA) on duty. The NA was present in the shower room with fell ow NA and a unit charge nurse (UCN). The UCN asked her to assess the resident's left lower extremity. The CCS-WN's observations identified Resident #61's left lower extremity was drawn up and flexed outwardly and swollen. The nurse wrote, Yelling out and moaning observed from resident when left hip and upper extremity touched gentle. The CCS-WN informed UCN-LPN (Licensed Practical Nurse) #25 at that time, they should call emergency medical services (EMS) for transport. The record revealed the resident required incontinence care, and the staff applied a brief in which they used the log rolling technique to put the brief on the resident. The staff also placed a gown on the resident. Once the EMS arrived, the resident was transferred from the shower gurney to the EMS transportation bed. CCS-WN noted that the left lower extremity was no longer flexed outward, and was rotated back to the same alignment as the right lower extremity, but she observed shortening of the left lower extremity compared to the right lower extremity. The family nurse practitioner (FNP) was aware at that time what had happened to the resident. The resident's guardian was notified of the resident's condition. No incident or accident report was found relating the resident had a fall or injury. Resident #61's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 11/19/15 was reviewed on 03/30/16 at 10:00 a.m. The MDS found under section G of the MDS, the resident was totally dependent for bed mobility, transfer, dressing, eating, toileting use, and personal hygiene. The MDS revealed the resident did not walk in her room or in the corridor (hallway) unit. Under Section C, Cognitive Patterns, the MDS indicated the resident could not be interviewed for a Brief Interview for Mental Status (BIMS). The resident was not coded as having a fracture or a fall. The review Resident #61's discharge MDS with the ARD of 12/05/15, on 03/30/16 at 10:10 a.m., found Resident's #61 continued to be totally dependent on staff for her activities of daily living. The resident was unable to walk in her room or in the corridor. The resident was still unable to be interviewed to determine her cognitive status. The resident did not have any falls or fracture upon discharge from the facility. A review of the resident's care plan on 03/30/16 at 10:15 a.m., found a care plan with an initial date of 07/20/10. The plan identified the resident was disoriented, had impaired speech, was not ambulatory, had a non-weight bearing status, had contractures of her hand, impaired hearing in both ears, left and right side paralysis, and was incontinent of bladder and bowel. The resident required a full body mechanical lift with the assists of two (2). A review of the shower record on 03/30/16 at 10:19 a.m., found Resident #61 was showered at 1:43 p.m. on 12/05/15. A review of the history and physical from an acute-care hospital revealed the resident was seen on 12/06/15. The report said the chief complaint was the resident was sent from the facility for evaluation of left leg pain. The x-ray report indicated Resident #61 had a comminuted (which means broken or crushed into small pieces) left femur fracture. The discharge summary, written on 12/14/15, noted the resident had a closed (meaning skin intact) non displaced comminuted [MEDICAL CONDITION] of the left femur (the femoral shaft runs from below the hip to where the bones begin to widen at the knee). In an interview on 03/30/16 at 3:14 p.m., when asked how Resident #61's left lower extremity became swollen, with her leg drawn up, and flexed outwardly on 12/05/15, Unit Charge Nurse-Licensed Practical Nurse (UCN-LPN) #25 stated, I do not know what happened to (resident's name) left leg. When asked whether the injury was observed, the nurse stated, No. She was then asked whether the resident could tell how she injured her leg. UCN-LPN stated, (resident's name), could not tell us what had happened to her leg. The nurse was asked whether she reported this as an allegation to the appropriate State agencies as an injury of unknown origin due to no one had witnessed the injury, the resident could not explain what had happened to her leg, and the extent and location of the injury. The UCN-LPN stated, No. Clinical care supervisor-wound nurse (CCS-WN) #87 overheard the discussion with UCN-LPN #25 about Resident #61 having to go to the acute-care hospital on [DATE]. The CCS-WN said that she was present that day. She revealed that she was called to the shower room to evaluate the resident's injury. The CCS-WN said she informed the staff to call 911 because the resident's left lower extremity was drawn up and flexed outwardly. There was swelling present and the resident was yelling out and moaning when the left hip and the upper extremity were touched gently. This nurse said they were unable to identify what caused the injury to the resident's left leg. The CCS-WN was asked since no staff witnessed any injury, the resident was incapable of telling staff what had occurred to her left leg, and due to the extent and location of the injury, did you report this injury of unknown of origin to the appropriate State agencies? The CCS-WN stated, I reported this to the family nurse practitioner and to the director of nursing. I did not report this. During an interview on 03/30/16 at 5:00 p.m., Social Services Supervisor (SSS) #95 was asked whether she had reported the resident's injury to the appropriate State agencies as an injury of unknown origin when the staff observed Resident #61's left lower extremities was swollen, drawn up, and flexed outwardly on 12/05/15. The social worker stated no one informed her that she needed to report this to the appropriate State agencies as an injury of unknown origin. She verbalized that she was aware of the situation that had occurred. The administrator on 03/31/16 at 11:10 a.m., stated they talked about what had happened to the resident, but they did not identify this as being an injury of unknown origin, so therefore they did not report this to the appropriate State agencies. @ A review of the facility's policy for abuse, neglect and misappropriation of resident property: protection of residents/reporting and investigation policy on 03/31/16 at 11:35 a.m., found the policy included that the facility would report allegation(s) to the appropriate State agencies for injuries of unknown origin if the source of the injury was not observed by any person, could not be explained by the resident, and the injury was suspicious because of the extent or location of the injury; or the number of injuries observed at one particular point in time; or the incident of injuries over time. The facility's policy stated the facility will report immediate as soon as possible after the event.",2019-03-01
5208,NELLA'S INC,51A010,499 FERGUSON ROAD,ELKINS,WV,26241,2015-03-03,225,C,0,1,NK8711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review and staff interview, the facility failed to ensure it did not hire employees who had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found to for five (5) of ten (10) employees whose personnel files were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifiers: #70, #96, #11, #35, and #61. Facility census: 86. Findings include: a) Employees #70, #96, #11, #35, and #61 A review of personnel files on 02/26/15 at 1:30 p.m., revealed the files of five (5) employees contained no evidence the State nurse aide registry was checked to determine whether the individuals had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. The employees were: 1. Maintenance Employee #70, 2. Tech Support Person #96, 3. Tech Support Person #11, 4. Dietary Manager #35, and 5. Licensed Practice Nurse #61. Office Assistant #5 assisted with the personnel record review. Upon completion of the review, she stated she did not complete State nurse aide registry checks on these employees. On 03/02/15 at 9:30 a.m., Employee #5 presented completed State nurse aide registry checks on all employees in question. There were no reportable issues noted.",2019-03-01
5220,NEW MARTINSVILLE CENTER,515074,225 RUSSELL  AVENUE,NEW MARTINSVILLE,WV,26155,2015-09-16,225,E,0,1,5JCO11,"Based on resident interview, staff interview, review of concern/grievance forms, review of abuse and neglect reporting files, and policy review, the facility failed to report and/or investigate allegations of abuse and/or neglect for four(4) of eleven (11) residents reviewed for abuse/neglect. Resident identifiers: #109, #28, #35, and #60. Facility census: 81. Findings include: a) During confidential resident interviews on 09/15/15, a resident related staff were verbally abusive to residents. The resident said staff spoke harshly with residents. In another confidential resident interview, on 09/15/15, the resident stated, staff . are not good to a lot of us in here. I'm not the only one. The resident also related hearing staff griping at other residents. These interviews triggered an abuse investigation. b) Resident #109 A review of grievance/concern forms, on 09/15/15 at 12:40 p.m., revealed Resident #109 reported an allegation of verbal abuse on 08/03/15 to a nurse aide. The resident alleged a staff member on midnight shift called her fat and said the resident could get up on her own. During a follow-up interview with the social worker, the resident related the staff member was rough with her. A third interview conducted with the resident, revealed the midnight worker tried to roll her out of bed. The social worker then interviewed the resident a fourth time. According to the concern form, the social worker called the alleged perpetrator, who denied the incident. The concern form indicated, because of the conflicting interviews and denial by the alleged perpetrator, no further action was taken. Review of the minimum data set (MDS) with an assessment reference date (ARD) of 07/28/15, revealed a brief interview for mental status (BIMS) which indicated the resident was cognitively intact. An interview with Social Worker (SW) #46 and Social Service Assistant (SSA) #100, on 09/15/15 at 3:10 p.m., revealed the facility did not report the allegation of abuse to the appropriate state agencies. The facility did not conduct interviews with other staff, other than the alleged perpetrator. Additionally the facility did not conduct interview with other residents, other than the complainant. The facility did not conduct a thorough investigation. c) Review of reportable allegations, on 09/15/15 at 2:30 p.m., revealed allegations of neglect and/or abuse were not thoroughly investigated for four (4) residents. 1. Resident #28 On 09/09/15, Resident #28's niece reported her aunt alleged physical abuse and neglect by an unknown person(s). Th immediate reporting for did not have a description of the alleged event or allegation. A general progress note, dated 09/09/15 at 11:00 a.m., indicated the niece visited and Resident #28 reported staff were mean to her and hitting her. The niece related the resident needed changed and could not find staff to change her. Additionally, the niece related the resident's eyes were matted. The narrative on the five (5) day follow-up form indicated the allegation was not substantiated because the resident did not report the same allegation the second time. The neglect allegation with eyes was not substantiated because the resident's eyes were clear and cleaned by staff with baby shampoo; however, medical record review revealed the order for baby shampoo was not obtained until after the conversation with the niece. Review of the allegation revealed no evidence of a thorough investigation, as there were no interviews with persons other than Resident #28 and the resident's niece. 2. Resident #35 An allegation of neglect, dated 08/06/15, indicated the Director of Environmental Services (DES) reported she observed Resident #35 outside the building. The witness statement indicated the DES observed the resident wheeling herself from back around the garage. I asked her what she was doing but she didn't answer me. Another resident was coming out of the building and that's when (Resident #35) reentered building on her own. She did not resist going into the building. The five (5) day follow-up indicated no abuse/neglect substantiated. Resident did go outside building but was easily re-directed and went back into building as another resident was opening door. Nursing assessment complete-no negative impact. The MDS with an ARD of 08/04/15, reviewed on 08/16/15 at 8:30 a.m., revealed a BIMS score of 02 which indicated the resident was severely cognitively impaired. There was no evidence an investigation was conducted to determine how the resident got outside. There were no interviews with staff who were on duty when the resident eloped. SW #46 acknowledged, during an interview on 09/15/15 at 3:10 p.m., no evidence was present to indicate the incident was thoroughly investigated. 3. Resident #60 An immediate fax reporting form, dated 06/24/15, indicated alleged verbal abuse. The report did not provide further description of the incident. The five day follow-up form indicated the allegation was not substantiated. The investigative narrative report noted, No psychological damage-resident wants staff to continue to work with this staff, and feels care for this staff are usually good - only this incident. The MDS with an ARD of 08/01/15 indicated in section C0500, the resident was cognitively intact. The facility had an in-service sign in sheet which indicated the staff member was educated on how to speak to residents appropriately. It indicated the staff member worked the 10:00 p.m. to 6:00 a.m. shift. No further information was present to indicate a thorough investigation of the alleged verbal abuse. The SW, interviewed on 09/15/15 at 3:10 p.m., confirmed no staff or other residents were interviewed. Additionally, the file did not even contain a statement from the alleged perpetrator, Nurse Aide (NA) #43. d) An interview with Registered Nurse (RN) #75, on 09/15/15 at 4:08 a.m., revealed it was difficult for staff to understand verbal abuse. The nurse related staff felt they were just being honest. e) RN #25, interviewed on 09/16/15 at 8:30 a.m., related staff get frustrated. The nurse related staff sometime got upset with the residents and would intervene to prevent an incident. f) The abuse prohibition policy, on 09/15/15 at 12:30 p.m., indicated the administrator or designee would report suspected or alleged abuse to the appropriate state agencies and conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent; clinical examination for injuries, as indicated; causative factors; and interventions to prevent further injury. The abuse policy also indicated the investigation would be thoroughly documented and recorded on the center log and ensure that documentation of witnessed interviews was included.",2019-02-01
5231,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2015-07-23,225,D,0,1,76WG11,"Based on resident interview, staff interview, and medical record review, the facility failed to ensure allegations of verbal and physical abuse were thoroughly investigated. Resident #163 made an allegation of neglect by a nurse aide. The facility did not thoroughly investigate the resident's allegation before a conclusion was reached that the allegation did not occur. This was found for one (1) of nine (9) reportable abuse/neglect allegations reviewed. Resident identifier: #163. Facility census: 160. Findings include: a) Resident #163 During the Quality Indicator Survey (QIS), Stage 1 interview, on 07/20/15 at 3:24 p.m., Resident #163 reported Nurse Aide (NA) #137 spoke to her harshly on several occasions. Resident #163 reported while NA #137 was assisting her with care, she (resident) fell and hit her head causing both eyes to become black. After the fall, NA #137 stated, You have got to learn to help yourself. Resident #163 continued to explain that on one occasion, she was having trouble having a bowel movement. NA #137 used a washcloth and said in a harsh manner, You are still having a bowel movement. On another occasion Resident #163 reported, NA #137 said in a harsh manner, Try to help yourself, and the nurse aide got hold of me by both shoulders and shook me. During other care, Resident #163 indicated NA #137 said, Why didn't you tell me while you were standing up, and when the resident could not hear the nurse aide said, Why don't you buy some new ones? This was in reference to hearing aids. During the Stage 1 interview at 3:29 p.m. on 07/20/15, NA #137 knocked on the resident's door, opened it, took a slight step into the room and asked the resident Are you ok honey, the resident answered, Yes, and NA #137 stepped out of the room. Resident #163 then stated, That is her, and went on to state, See, she was real nice, you was sitting here. On 07/22/15 at 10:45 a.m., review of the resident's medical record found the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/25/15, identified the resident scored 14 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact (the highest possible score is 15). Continued review of the facility neglect/abuse reportable files revealed an incident report made to the facility staff on 07/16/15 by Resident #163's son. The allegation was that NA #137 was speaking rude/harsh to Resident #163 and was handling the resident roughly. Further review of the facility reportable investigation packet revealed a statement by NA#137 dated 07/17/15. (Typed as written) I put (resident) on the bedside & she voided and was pooping she was getting up & wiping while still pooping I sit her back down & told her to wait until she finished before wiping. put my hands over hers on her legs and told her she was not going to be clean from wiping until she was finished so try to finish before wiping. The reportable file also revealed an additional statement, dated 07/17/15, made by Certified Occupational Therapy Assistant (COTA) #5, in which the resident confided the following; I had a rough night yesterday. Resident #163 went on to state, referring to NA #137, (typed as written) .was rough with me, she shook my arms and told me that I don't listen. She was upset because I had to use the bathroom three times. After I started crying she started petting me and I didn't want that. Resident #163 went on to state, I don't want to get anyone in trouble. According to the statement, this occurred around 9:00 p.m. on 07/16/15. Continued review of the neglect/abuse reportable incidents related to Resident #163 revealed NA #137 was placed on leave until further investigation. The reportable file revealed no additional interview/investigation notes until 07/20/15 (time not noted) in which Registered Nurse (RN) #119 interviewed Resident #163. (Typed as written) Interview with (Resident #163) this date regarding son allegation of CNA (nurse aide) being rude, harsh and rough. Resident #163 denies the allegation and states that no one has been rude, harsh or rough with her. She states that there are some that are in too big of a hurry but none have been rude or harsh or rough with her. When asked specifically about (Nurse Aide #137), the resident states that CNA 'has a brash tone but means no harm' States, 'I don't have any problems with anyone but my son is very protective of his Mommy and he tends to over react some. ''' At 5:07 p.m. on 07/20/15, the abuse allegation reported by Resident #163 was reported to the facility administrator, who immediately called RN #119 into the interview. The administrator and Registered Nurse #119 were both aware of the reportable allegation dated 07/16/15 concerning Resident #163 and stated Nurse Aide #137 was placed on leave during the investigation. They also stated they were not aware of all areas reported by the resident during the Stage 1 interview and would immediately open an additional investigation, and place NA #137 on leave again until a further investigation could be completed into the allegations revealed during the Stage 1 interview. In regards to the 07/16/15 allegation, Registered Nurse #119 stated she interviewed Resident #163 in the rehabilitation room during the morning on 07/20/15 and after interviewing the resident, failed to substantiate the allegation of abuse. Registered Nurse #119 indicated she allowed NA #137 to return to work, during the evening shift, on 07/20/15. The reportable file revealed no evidence Resident #163 was interviewed other than in the rehabilitation room the morning of 07/20/15. The file also did not indicate the facility interviewed any other residents who were provided care by NA #137. Other staff members who worked on the same shift and/or hall as NA#137 were also not interviewed. On 07/23/15 at 1:59 p.m., Administrator #126 stated Assistant Administrator (AA) #235 interviewed Resident #163 and received the same information the resident had reported during the Stage 1 interview on 07/20/15. Administrator #126 and AA #235 both agreed RN #119 had not completed a thorough investigation into the allegations made by Resident #163 on 07/16/15.",2019-02-01
5276,HOPEMONT HOSPITAL,5.1e+149,150 HOPEMONT DRIVE,TERRA ALTA,WV,26764,2016-02-29,225,D,1,0,HFVZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on facility record review, hospital record review, and staff interview, the facility failed to submit a timely report of allegations concerning abuse, neglect, or missing property to the appropriate State agencies, failed to provide evidence that a thorough investigation into each allegation was completed, and failed to report the result of the investigations to the same agencies. This was found for two (2) of seven (7) residents reviewed for whom allegations had been reported to the State offices. Resident identifiers: #2719 and #2828. Facility census: 60. Findings include: a) Resident #2719 A review of the resident's closed clinical record at 11:45 a.m. on 02/23/16, revealed Resident #2719, a [AGE] year-old female, was admitted to the facility on [DATE]. Review of a capacity assessment, completed by a Psychologist on 12/26/08, revealed she had a history of [REDACTED]. At the time of admission to the facility, her son was her designated MPOA (medical power of attorney). The psychologist's impression after a lengthy assessment was, . would not have capacity to live independently. Prior to her admission, the resident had resided with a boyfriend who continued to visit her at the facility. In (MONTH) 2009 a temporary Order of Protection was obtained by the MPOA to keep the boyfriend from visiting as the MPOA suspected him of supplying her with drugs and because of inappropriate sexual behavior. This information was verified in a letter written by the MPOA and included in the resident's clinical record. Throughout her admission, there were numerous entries made by nursing and social services documenting the resident's inappropriate sexual verbalizations and actions. She had a behavioral health plan indicating diversions when she exhibited these behaviors. During an interview with Assistant Administrator #10, who at the time of the complaint was a social worker in the facility, at 2:00 p.m. on 02/23/16, he said the MPOA intermittently attempted to interfere with the boyfriend visiting the resident without success. The resident was alert and agreeable to the visits. His last visit was the morning of 03/09/15. At 12:00 p.m. on 03/09/15, Health Service Assistant (HSA) #85 (health service assistant assigned to physical therapy) documented in an incident report, The resident was being pushed in wheelchair down the hall and put her feet down on the skid strip causing her to fall forward out of the chair on her head, knees, and hand. This behavior was confirmed as happening in other incidents by Assistant Administrator #10 at 2:00 p.m. on 02/23/16, Registered Nurse (RN) #148 at 2:45 p.m. on 02/23/16, and RN #8 at 10:00 a.m. on 02/24/16. After the incident on 03/09/15 the resident was assessed and transferred to an acute care hospital because she was more lethargic than usual. The MPOA was notified and went to the hospital. The emergency room (ER) physician ordered a drug screen because of the transfer assessment and a narcotic antagonist was administered. The hospital notified the facility of a preliminary finding of opiates in the resident's urine and of the absence of [MEDICATION NAME] for which she was prescribed 0.25 milligrams (mg) twice daily, and indicated on the MAR (medication administration record) as taken. A written copy of the Progress Note ER Note from the hospital was in the resident's closed record. The facility reported the fall and the findings to the Nursing Home Program and APS (Adult Protective Services) the same day. An investigation was made and a five-day follow-up submitted regarding the allegation of opiates in the preliminary findings. The ER progress notes indicated that due to her behavior in the emergency room , comments made by the resident, and information the boyfriend had visited earlier in the day, the MPOA requested a rape evaluation, which was done, although the physician documented, I did not see any obvious external signs of trauma in the genital, perineal or anal area at initial assessment yesterday. The exam was inconclusive due to the lack of cooperation of the resident, but a police report was filed with the WV State Police and APS (Adult Protective Services) was notified by the hospital. The facility did not mention the allegation of sexual assault or the absence of the drug, [MEDICATION NAME], in the report to the State agencies, and there was no evidence of an investigation being made and/or reported of those allegations. During an interview with the Interim Administrator and the Assistant Administrator at 2:30 p.m. on 02/23/16, they said they did not think they should report the alleged sexual assault as the resident had not made it to them and they knew the police had been notified. (An extensive record review failed to reveal any allegations of this type.) Neither had any comment about the allegation claiming there was an absence of a drug ordered by a physician, and that records indicate the resident was receiving on a daily basis. During an interview with the Director of Nurses at 1:00 p.m. on 03/24/16, she was asked why the resident's drug test had not indicated the presence of [MEDICATION NAME]. She stated they had immediately counted all the drugs on the cart and reported it to the pharmacy, but there had been no reason found. Documentation of the investigation had not been provided prior to the final exit from the facility at 6:00 p.m. on 02/29/16. b) Resident #2828 A review of the clinical record revealed Resident #2828, a [AGE] year old male admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. He had been determined by a psychological evaluation on 08/18/14, to have the capacity to form his own health-care decisions. During an interview with Interim Administrator #133 at 2:00 p.m. on 02/23/16, he said he knew the surveyors were there to investigate the resident's missing computer and continued to related that the resident had been claiming the loss of the computer since the room search on 02/03/16, while the resident was out of the facility for an appointment with an outside physician. He stated there had been several items confiscated, but they did not include a computer. Interim Administrator #133 said the resident had been hiding food in his room and it smelled so it was decided his room would be searched and cleaned. He was not sure of the date, but thought it had been a few months ago. He added that when searched, they had found facility eating utensils and other items, and the room had been crowded with boxes and locked duffle bags. The facility items had been returned to the kitchen and the excess items had been placed in storage. The resident was present during the first search, but admitted the other searches were conducted when the resident was out of the facility for various reasons. At 3:00 p.m. on 02/23/16, Assistant Administrator #10 provided the requested complaint/grievance reports, incident reports, and allegations reported to the State. Review of the documents found no documented forms related to Resident #2828 contained in these records. When Interim Administrator #133 and Assistant Administrator #10 were asked at 9:30 a.m. on 02/24/16, why there was no evidence of complaints/grievances or allegations of missing items in the supplied documents, Assistant Administrator #10 said the resident had complained ever since his admission and staff probably quit writing it down. Interim Administrator #133 said he thought there was a report for the missing computer and he would look for it. During an interview at 3:00 p.m. on 02/23/16, Assistant Administrator #10 related he had been the Social Worker when the resident had initially been admitted . He said the resident had arrived with several suitcases, boxes, trash bags, and duffle bags full of personal belongings. Most of the bags were locked with padlocks. Because of the locks and because of the amount of personal items, no inventory of his personal belongings had been made. At 1:00 p.m. on 02/24/16, Interim Administrator #133 said it was difficult to maintain an accurate inventory of the resident's possessions because he brought so many with him at admission and continuously purchased new items via the Internet. He stated the resident often alleged something was missing, but there was no way to determine if he ever actually had it. He was asked to provide documentation of any of these allegations, but had none at that time. During an interview at 12:30 p.m. on 02/29/16, Resident #2828 complained he had purchased a new computer and it had disappeared when his room was searched. When asked when this had happened he said it was last week, but later in the conversation he said it was last month. He did say that he had tried to get the facility to call the police to report the stolen computer and he had reported it to the Ombudsman. There was a computer present in the room, but he said it was his old one and not the one taken. RN #150, interviewed at 1:30 p.m. on 02/29/16, said the resident had told her his computer was missing after the room search on 02/03/16, but when she contacted Interim Administrator #33, he told her the computer was seen under the resident's bed and she relayed this to the resident. She said it was hard to tell because he had more than one computer. On reentry to the facility at 10:00 a.m. on 02/29/16, a copy of an Immediate Fax Reporting of Allegations - Nursing Home Program and the Five-day Follow-up were provided. The immediate report included, (Resident #2828) feels personal items have been stolen and nothing done. (Resident) says he is not properly nourished and has lost weight. Just learned of this on 2 PM 2/22/16. This report was dated 02/23/16 and signed by Assistant Administrator #10. There was a one-page hand-written unsigned statement attached which did not address the computer at all. The 5-day follow-up, completed and signed by Social Worker (SW) #107 stated, Upon thoroughly investigating unsanitary items have been removed from his room but his personal belongings has been put in a separate room with lock/key as he has too many items, suitcases, and duffle bags to put in his room. During an interview with SW #107 at 12:00 p.m. on 02/29/16, when asked why there was no evidence of a resident or staff interview, or even what was alleged to be missing in her reporting of the resident's allegation to the State, she replied, Oh, yes, nursing asked him. He was unable to tell them. It's all documented.",2019-02-01
5281,MAIN STREET CARE,5.1e+155,"189 SUMMERS HOSPITAL ROAD, SUITE 300",HINTON,WV,25951,2015-02-06,225,F,0,1,74FM11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for five (5) of five (5) employees whose files were reviewed. This had the potential to affect all residents. Employee identifiers: #8, #19, #33, #22, and #14. Facility census: 33. Findings include:a) Thorough Criminal Background ChecksOn 02/05/15 at 1:00 p.m., a review of personnel files found five (5) of five (5) employees hired by the facility had no fingerprints, or criminal background checks based on fingerprinting, in their files. The files all contained criminal background checks completed based on the employees' social security numbers. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: -- Employee #8, a nursing assistant (NA), hired 04/26/14; -- Employee #19, a licensed practical nurse (LPN), hired 07/14/14; -- Employee #33, a registered nurse (RN), hired 08/22/13; -- Employee #22 a NA, hired 05/28/13; -- Employee #14, a LPN, hired 12/19/14. In a discussion with the Administrator and director of nursing at 1:30 p.m. on 02/05/15, both denied knowledge of any regulations requiring criminal background checks based on fingerprinting. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included, . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2019-02-01
5285,HUNTINGTON HEALTH AND REHABILITATION CENTER,515007,1720 17TH STREET,HUNTINGTON,WV,25701,2015-05-12,225,C,0,1,ORJG11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview; the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of five (5) employee files reviewed. This had the potential to affect more than a limited number of residents. Employee identifier: #42. Facility census: 181.Findings include: a) Employee #42 On 04/27/15 at 4:21 p.m., a review of personnel files found one (1) of five (5) employees hired by the facility had no fingerprints, or criminal background checks based on fingerprinting, in their files. The file contained a criminal background check completed based on Nurse Aide #42's social security number. Employee #42 was hired on 03/16/15. In a discussion with the Administrator and director of nursing at 4:21 p.m. on 04/27/15, the administrator indicated Nurse Aide #42's fingerprinting had been scheduled and then rescheduled. On 05/12/15 at 11:00 a.m., the administrator provided evidence the nurse aide had fingerprints completed on 04/21/15. The facility received the results on 04/27/15. The administrator said Employee #42 had been scheduled to for fingerprinting prior to the hire date of 03/16/15. Employee #42 missed the appointment. The administrator and director of nursing said 04/21/15 was the earliest date the fingerprints could be rescheduled. However, the facility had no evidence that this was the earliest date the fingerprints could be rescheduled. On 05/12/15 at 2:15 p.m., the director of nursing provided timecard information that showed Nurse Aide #42 had worked 29 days from 03/16/15 through 04/26/15 prior to the facility obtaining the results of the criminal background fingerprint results 04/27/15. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID).",2019-01-01
5329,WILLOWS CENTER,515085,723 SUMMERS STREET,PARKERSBURG,WV,26101,2015-06-18,225,D,0,1,6BSN11,"Based on policy review, a review of the complaints/grievances, and staff interview, the facility failed to ensure an allegation of neglect was identified and reported to the appropriate State agencies. A grievance/complaint report identified Resident #96 was found with dried fecal matter up her back. The facility failed to identify this as an allegation of neglect, and failed to investigate and report the allegation. This was found for one (1) of nine (9) complaint/grievances that were reviewed. Resident identifier: #96. Facility census: 94. Findings include: a) Resident #96 A review of the grievance/complaints on 06/25/15 at 11:00 a.m., revealed the facility had not identified, investigated and reported one (1) allegation of neglect. The grievances/concerns contained an allegation of neglect dated 01/20/15. The allegation statement involving Resident #96 included, (name) reported to SSW-II (social service worker) that when he came in to visit Resident #96 on 01/17 (January 17, (YEAR)) and 01/18 (January 18, (YEAR)) between the hour of 3:15 pm and 3:30 pm, he found her soiled. He reported on Sunday that it was dried fecal matter up her back. He reported that he loves her care here, but was concerned over it being dried and how long it had been there. The resolution of the grievance/concern stated MPOA (medical power of attorney) is pleased with care overall, and that the appropriated staff who were knew (sic) to his wife's care, were individually educated by the NPE (nurse practice educator) on proper protocol and shift change checks. The grievance/concern contained a staff education form completed on 02/13/15 which stated Nurse Aide #63 (NA) and NA #136 were both educated on the need for resident care rounds to be completed every two (2) hours. The education also stated NAs must perform rounds together to ensure residents were clean. The facility's abuse prohibition policy, revised on 07/16/13, defined neglect as the failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The policy also stated, The administrator, or designee, is responsible for operationalizing policies and procedures that prohibit abuse, neglect, involuntary seclusion, injuries of unknown origin, and misappropriation of property for all patients. The policy went on to state the facility would report allegations to OHFLAC (Office of Health Facility Licensure and Certification) and DHHR (Department of Health and Human Resources Adult Protective Services (APS) the Ombudsman Program and the OHFLAC Nurse Aide Program if the allegation contained a nurse aide. An interview with Director of Social Services #65, on 06/25/15 at 11:30 a.m., revealed the facility had not investigated or reported this issue as an allegation of neglect. Employee #65 agreed this grievance/concern did contain an allegation of neglect and the facility should have reported it to the appropriate State agencies.",2019-01-01
5336,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2015-10-21,225,D,0,1,4PJF11,". Based on record review and staff interview, the facility failed to report all allegations of neglect to the appropriate outside agencies in accordance with State law for two (2) of sixteen (16) complaints reviewed. Resident #32 alleged she did not receive her eye drops for several days. An allegation was made regarding Resident #35's bed linens not being changed. Resident identifiers: #32 and #35. Facility census: 29. Findings include: a) Resident #32 Review of a complaint form at 9:00 a.m. on 10/21/15, revealed Resident #32 had complained to Licensed Practical Nurse (LPN) #9 on 12/13/14. Resident #32 said she had not had her eye drops administered at 9:00 p.m. for the last several days. This was documented and investigated by Director of Nurses (DON) #17 and Social Worker #37 on 12/15/14, but the allegation of neglect was not reported to the appropriate State offices. During an interview with Social Worker #37 and DON #17 at 11:00 a.m. on 10/21/15, they acknowledged Resident #32 was alert and oriented and able to make her needs known. After review of the complaint, they agreed it should have been reported. b) Resident #35 Review of a complaint form at 9:00 a.m. on 10/21/15, revealed the MPOA (Medical Power of Attorney) for Resident #35 contacted the Social Worker #37 on 02/19/15, with concerns over the resident's bed linens not being changed. This allegation of neglect was investigated by Social Worker #37 and Registered Nurse #19, but it was not reported to the appropriate State offices. During an interview with Social Worker #37 and DON #17, at 11:00 a.m. on 10/21/15, they acknowledged it should have been reported. c) A review of the facility's policy entitled, Mistreatment, Neglect, or Abuse including Injuries of Unknown Source, and Misappropriation of Resident Property, at 10:45 a.m. on 10/21/15, found it included the following definitions of Neglect: -- c) Lack of attention to physical needs ., and -- d) Failure to provide services that result in harm, such as not turning a bed-fast resident of leaving them in a soiled bed. The policy included: 7. Reporting/Response: All facility staff is considered mandatory reporters. Upon witnessing or learning of an allegation, staff must initiate reporting procedures in accordance with state and federal laws and regulations, and facility policies and procedures d) At 11:00 a.m., both the Director of Nurses and the Social Worker stated that this policy had been presented as part of each employees' orientation upon hire and reviewed annually at mandatory in-services.",2019-01-01
5345,PARKERSBURG CENTER,515102,1716 GIHON ROAD,PARKERSBURG,WV,26101,2015-01-28,225,E,0,1,11X211,". Based on review of allegations reported to the State, resident interview, staff interview, and record review, the facility failed to ensure an allegation of abuse for one (1 ) of two (2) residents reviewed for the area of abuse, during Stage 2 of the Quality Indicator Survey (QIS), was reported and investigated. In addition, the facility failed to ensure an inquiry was made to the State nurse aide abuse registry for one (1) of ten (1) employees whose personnel files were reviewed. This had the potential to affect more than an isolated number of residents. Resident identifier #74 Facility census: 64. Finding include: a) Resident #74 On 01/20/15 at 1:50 p.m., during an interview while conducting Stage 1 of the QIS, Resident # 74 stated a Nurse Aide (NA) had hurt his leg. He said he reported this to the social worker. Review of the facility's reported allegations of abuse, on 01/22/15 at 11:10 a.m., revealed no allegation of abuse regarding Resident #74 was reported to the State agencies. Employee #54, the Licensed Social Worker (LSW), was interviewed on 01/22/15 at 11:31 a.m. She said the resident told her the NA used a monotone voice when talking to him. The LSW confirmed the resident also told her, at that time, NA #20 hurt his leg when she was transferring him from the bed to the chair with the lift. She said the monotone voice was investigated and addressed. Upon further inquiry, the LSW said the allegation regarding the NA hurting the resident's leg was not reported, and There was no formal investigation. She said she thought the situation had occurred in the last few months. The LSW did not have any notes regarding the allegation. An interview with the administrator (NHA) and the director of nursing (DON), on 01/22/15 at 11:35 a.m., revealed neither had investigated the allegation of abuse. Further interview with the DON, LSW and NHA, on 01/22/15 at 12:40 p.m., revealed they did not feel the complaint was about the NA hurting the resident, but was regarding the tone of the NA's voice while providing care. They said this could be misconstrued as disrespectful and insincere. b) Employee #34 On 01/26/15 at 4:00 p.m., a review of Employee #34's personnel file revealed the employee, a registered nurse, did not have a nurse aide abuse registry check in the personnel file. The facility hired Employee #34 on 04/01/10. At 4:05 p.m. on 01/26/15, Employee #47 (payroll/human resources/accounts payable) confirmed the facility had not checked the nurse aide abuse registry for Employee #34. .",2019-01-01
5363,GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2015-06-11,225,E,0,1,2MMX11,"Based on personnel record review, review of West Virginia Code 69 CSR 6-8.1, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents. The facility failed to check for findings entered in the nurse aide abuse/neglect registry for three (3) of ten (10) employees whose files were reviewed. This had the potential to affect more than an isolated number of residents. Employee identifiers: #43, #52, and #53. Facility census: 46. Findings include: a) A review of ten (10) personnel files began on 06/09/15 at 4:15 p.m., and continued the morning of 06/10/15. The review found three (3) of ten (10) employees hired by the facility had no evidence of required nurse aide registry checks. The employees with no evidence of the required nurse aide registry check were: 1. Licensed Practical Nurse #43 2. Dietary Employee #52 3. Registered Nurse #53 b) West Virginia Code 69 CSR 6-8.1 describes the establishment of a statewide nurse aide registry for nurse aides found guilty of abuse, neglect, or misappropriation of property. Placement on the registry is intended to provide a mandatory process to prohibit facilities from employing those individuals. All employees are to be checked against the registry regardless of the individual's current job description. c) Human Resources Director (HRD) #40 was interviewed on 06/10/15 at 9:00 a.m. She said the nurse aide registry checks were to be completed by each department head when they made a hiring decision in their department. HRD #40 said the former director of nurses had routinely checked the employees for all the other department heads, but she was not sure the current director was aware of that. d) Facility Administrator #49 was interviewed on 06/11/15 at 10:16 a.m. She acknowledged the required nurse aide registry checks were not completed.",2019-01-01
5382,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,225,D,0,1,ZLZ811,"Based on review of accident/incident reports and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation. This was found for one (1) of fifty-three (53) accident/incident reports reviewed involving an injury of unknown origin. Resident identifier: #61. Facility census: 111. Findings include: a) Resident #61 A review of the accident/incident reports, on 08/20/15 at 9:00 a.m., revealed an incident report dated 06/18/15 identifying two (2) small bruises found on Resident #61's right breast. Record review noted the resident to be dependent on staff for transfers and required a mechanical lift. There was no evidence the facility documented this incident as an injury of unknown origin, nor was it thoroughly investigated or reported to the appropriate State agencies. b) After reviewing the the incident reports, on 08/20/15 at 2:30 p.m., the Director of Nursing (DON) agreed the incidents involving Resident #61, lacked a thorough investigation by the facility and absolutely should have been reported to the State agencies, according to the abuse prohibition policy for possible abuse and neglect.",2019-01-01
5404,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2015-05-14,225,F,0,1,NX8Z11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for two (2) of ten (10) employees whose files were reviewed. This had the potential to affect all residents. Employee identifiers: #32 and #83. Facility census: 127. Findings include: a) Thorough Criminal Background Checks On 05/13/15 at 9:40 a.m., a review of personnel files found two (2) of ten (10) employees hired by the facility had lived and worked in states other than West Virginia within the past five (5) years. Both employee files contained criminal background checks for the state of West Virginia, but neither contained evidence of the requisite federal background checks utilizing fingerprints through the national crime information database (NCID). Both employee files contained criminal background checks completed based on the employees' social security numbers. The employees with no evidence of the requisite federal background checks, utilizing fingerprints through the NCID, were: -- Nursing Assistant (NA) #32, hired on 02/10/15; Nursing Assistant #32 indicated in her employment application that her home address was in the state other than West Virginia, and she had resided at the address for the past one (1) and a half years. Employee #32's employment application also indicated, she had resided in a state other than West Virginia prior to residing at her current address. Further indicated in her employment application was previous employment in the health care field in a state other than West Virginia from (MONTH) of 2013 through the time of her application on file, dated 01/13/15. -- Licensed Practical Nurse (LPN) #83, hired on 07/06/11; LPN #83 indicated in her employment application that her previous home address was in a state other than West Virginia. The application indicated she had resided, and was employed in the health care field in a state other than West Virginia from (MONTH) of 2009 through (MONTH) of 2011. In a discussion with the Administrator at 10:40 a.m. on 05/13/15, he verified the federal background checks, utilizing fingerprints through the NCID, were unable to be located for either employee. b) On 05/13/15 at 11:00 a.m., upon further inquiry regarding the omission of the federal background checks for Nursing Assistant #32 and Licensed Practical Nurse #83, the Administrator verified only West Virginia criminal background checks had been obtained for both employees upon hire. He said in regards to Licensed Practical Nurse #83, she had been hired in 2011, and it had been the facility's understanding, federal background checks, had not been required at that time. He verified that under the current regulations, the federal background check for Employee #83, should have been obtained prior to (MONTH) 1, 2014. c) To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, the Bureau for Medical Services requires federal background checks utilizing fingerprints through the national crime information database (NCID). The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2019-01-01
5458,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2015-06-22,225,F,0,1,N2E611,"Based on personnel record review, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by the use of fingerprinting for one (1) of five (5) employees whose personnel files were reviewed for the care area of Abuse Prohibition. The facility did not perform a fingerprint based federal criminal background check for the employee, who had lived out of state. This had the potential to affect all residents currently residing in the facility. Employee identifier: #36. Facility census: 62. Findings include: a) Employee #36 At 8:32 a.m. on 06/17/15, a review of personnel files found one (1) of five (5) employees hired by the facility had no evidence a fingerprint based federal criminal background check was performed. Nurse Aide (NA) #36 was hired by the facility on 02/19/15. NA #36's application for employment revealed he NA lived in another state until (MONTH) 2014. Based on her hire date, the facility should not have allowed NA #36 to work past 04/18/15, her sixtieth (60th) day of employment, without the results of a fingerprint based federal background check. Review of NA #36's time card for the previous thirty days, from 05/17/15 through 06/17/15, found the NA worked twenty (20) of the thirty (30) days reviewed. The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included, . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2019-01-01
5469,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2015-03-27,225,E,0,1,HEH611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of grievance/concern forms, and staff interview, the facility failed to report allegations of mistreatment, neglect, misappropriation of property, and results of the investigations for these allegations to the appropriate state officials in accordance with State law 64-13-4.16.c.5, for six (6) of the twelve (12) Grievance/Concern forms reviewed. Resident identifiers: #90, #106, #75, #103, #14, and #9. Facility census: 64. Findings include a) Resident #90 A review of a Grievance/Concern Form, at 11:00 a.m. on 03/26/15, revealed Resident #90 reported a concern to Employees #65 (Recreation Director) and #27 (Social Worker) on 01/08/15. Resident #90 said, During therapy with OT (occupational therapy) she told (name of therapist) that her right arm was hurting and swollen and she would not be able to perform the task he was asking her to do. She further stated the therapist, . did not listen to her and continued to try the activity/exercise on her right arm. Resident #90 was an alert and oriented resident with [DIAGNOSES REDACTED]. Her comprehensive assessment described her as having clear comprehension and able to make herself understood. A review of the nurses' notes, for the days following the incident, revealed notations the resident had increased [MEDICAL CONDITION] in her right arm and had increased complaints of pain. The facility completed an investigation that included interviews with the named therapist (no longer at the facility) and Employee #66 (Physical Therapist in charge of the department). The therapist named by the complainant was removed from the resident's plan of care. The facility did not report this allegation of physical abuse to the appropriate State agencies. During a review of the incident with the Administrator and the Social Worker, at 2:15 p.m. on 03/26/15, they had no comment as to why they did not report the allegation. The social worker confirmed the documentation on the grievance was correct. b) Resident #106 1. A review of a Grievance/Concern Form, at 11:00 a.m. on 03/26/15, revealed Resident #106 reported, to the director of nurses (DON), she had not received her pain medication in a timely manner after she had requested it on 01/02/15. A review of the record revealed the resident was a [AGE] year-old female described in her comprehensive assessment as having clear speech, understanding others and understood by others. The facility completed an investigation, which included taking statements from the complainant and staff members that cared for the resident, but they did not report the allegation to the appropriate State agencies. The facility identified the social worker as the contact person for Abuse Prohibition Policies, Procedures, and Grievance Information. During independent interviews with the administrator and the social worker, on 03/26/15 at 2:15 p.m., a review of the incident revealed the social worker and administrator had no comment regarding why they did not report the allegation. The social worker confirmed the information on the grievance form was correct. 2. A review of a Grievance/Concern Form, at 11:00 a.m. on 03/26/15, revealed Resident #106 reported to the Social Worker, on 02/02/15, she was discharged home on[DATE] without discharge instructions which included her laboratory reports for tests completed while she was a resident at the facility. Those tests revealed she had an infection that the facility reported to the state health department, as required by law. She was being treated for [REDACTED]. She was unaware, until she was contacted by health department officials. The nursing department completed an investigation, resulting in a directive that in the future, nursing staff would provide education to inform residents when the health department was notified of an illness/infection regarding the resident. The facility did not report this allegation of neglect to the appropriate State agencies. During independent interviews with the administrator and the social worker, on 03/26/15 at 2:15 p.m., the social worker and administrator had no comment regarding why the allegation of neglect was not reported. The social worker confirmed the information on the form was correct. c) Resident #75 A review of a Grievance/Concern Form, at 11:00 a.m. on 03/26/15, revealed the daughter of Resident #75 reported, to the Social Worker on 02/02/15, she had not received instructions for the administration of the resident's insulin, and had arrived home with oral medication for [MEDICAL CONDITION] labeled as belonging to another resident. The DON performed an investigation of the claim, which included taking statements. The facility retrieved the medication sent in error; and counseled the two (2) nurses involved in the resident's discharge. This allegation of neglect was not reported to the appropriate State officials. During independent interviews with the Administrator and the Social Worker, on 03/26/15 at 2:15 p.m., a review of the incident revealed the social worker and administrator had no comment regarding why they did not report the allegation of neglect. They social worker confirmed the information on the form was correct. d) Resident #103 A review of a Grievance/Concern Form, at 11:00 a.m. on 03/26/15, revealed Resident #103 reported an allegation to the Social Worker on 01/26/15. The resident stated, On Saturday, (MONTH) 24 (nurse aide name - Employee #13) put her in bed to change her and then did not get her back up into her wheelchair and she had to wait until the next shift got her up. She also reported only one (1) staff member had gotten her into her wheelchair with the Hoyer lift. Resident #103's comprehensive assessment, completed on 12/16/15, described her as an [AGE] year old with clear speech who understood verbal instructions and was easily understood. The facility identified her as interviewable and alert. They indicated the resident required extensive assistance for transfer. An investigation was completed which included staff interviews regarding both the delay in getting the resident out of bed and why only one (1) staff member used the lift to transfer the resident, when the policy required two (2) staff members. The facility did not report this allegation of neglect to the appropriate state officials. During independent interviews with the administrator and the social worker, at 2:15 p.m. on 03/26/15, the incident was reviewed. When asked why it had not been reported, they had no comment. The social worker confirmed the information on the form was correct. e) Resident #14 A review of a Grievance/Concern Form at 11:00 a.m. on 03/26/15, revealed Resident #14 reported to Employee #83 (RN) that on 01/08/15, she had not received her 8:00 p.m. medications, including the finger stick check of her blood sugar and the insulin coverage necessary. RN #83 documented, at that time, the resident was alert and oriented. Resident #14's comprehensive assessment, with an assessment reference date of 12/18/14, indicated she had clear speech; understood verbal direction, was easily understood by others, and scoring 15 of 15 her Brief Interview for Mental Status examination. An investigation, including medical record review and statements from caregivers, was completed. It resulted in the discipline of two (2) nurses for the omission. The allegation of neglect was not reported to the appropriate state officials. During independent interviews with the Administrator and the Social Worker, at 2:15 p.m. on 03/26/15, a review of the above incident revealed they had no comment regarding why they had not reported the above allegation. The Social Worker confirmed the information on the form was correct. f) Resident #9 A review of a Grievance/Concern Form at 11:00 a.m. on 03/26/15, revealed Resident #9 reported to Employee #97 (LPN) on 02/04/15, she had money missing from her room. Resident #9's comprehensive assessment with an assessment reference date of 02/05/15, indicated she had clear speech, understood verbal direction, was easily understood by others, and scored 15 of 15 on her Brief Interview for Mental Status examination. Employee #97 referred the written allegation to Employee #27, who completed the investigation, but failed to report the allegation of missing money to the appropriate state officials. During independent interviews with the Administrator and the Social Worker, at 2:15 p.m. on 03/26/15, a review of the incident revealed they had no comment regarding why they had not reported the allegation. The Social Worker confirmed the information on the form was correct.",2019-01-01
5493,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2015-04-23,225,D,0,1,H66T11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, and staff interview, the facility failed to report an allegation of mistreatment/abuse for one (1) of one (1) residents reviewed for abuse allegations in Stage 2. The facility investigated an allegation made by Resident #13, but failed to notify the State agencies of the alleged incident. Resident identifier: #13. Facility census: 40. Findings include: a) Resident #13 During an interview on 04/20/15 at 9:48 a.m., Resident #13 stated one (1) nurse aide pulled her legs apart roughly when she provided care to her. She said she thought the nurse aide might have been mad or having a bad day. She said she reported the incident to the facility and the nurse aide no longer took care of her. During a follow-up interview, on 04/21/15 at 9:00 a.m., Resident #13 stated the staff member in question talked loudly with a rough voice. During this interview, Resident #13 stated she would not say the NA abused her, but she would say the care she provided was done in a rude and disrespectful manner. A review of the facility's abuse policy and procedure, on 04/21/15 at 9:15 a.m., revealed when a resident makes an allegation of abuse The facility will notify the Stage Agency within 24 hours. During an interview on 04/20/15 at 3:30 p.m., Director of Nursing (DON) #29 stated Resident #13 never complained any staff being rude, rough, or disrespectful while providing care. The DON stated the daughter reported an incident on 08/25/14 regarding a staff person being rough with her mother while providing care. The daughter had placed the completed complaint form under the DON's door. The DON received it on 08/26/14. The DON stated she conducted an investigation with regard to the allegation. She moved the staff member named in the grievance to work a different hall, and instructed the nurse aide she would not be providing care to Resident #13. On 04/21/15 at 10:05 a.m., review of the grievance form dated 08/25/14, revealed the daughter documented her mother needed to receive better treatment than she was getting. The daughter documented Nurse Aide (NA) #22 spoke rudely at times to her mother and moved her roughly at times when providing care to her. The investigation revealed DON #29 went to Resident 13's room to speak to her on 08/26/14 at 9:30 a.m., and the resident stated she wanted her daughter to be with her when she spoke to DON. The DON arranged a meeting with the resident and her daughter for 08/28/14 at 1:00 p.m. Review of the investigative notes from a meeting conducted on 08/28/14 between the resident's daughter and DON revealed: -- The daughter come to the facility to visit her mother on 08/25/14 at 5:00 p.m.; -- Her mother stated she was not being treated right by the a staff member; -- The daughter stated her mother told her she called out several times to be put back to bed at 3:00 p.m. on 08/25/14, but no one put her to bed; -- The daughter stated she went to get assistance for her mom at 5:00 p.m. and NA #22 was rude and had an attitude; -- The daughter stated NA #22 put her mom to bed at that time, but she felt the NA #22 had a loud and rude tone to her voice; -- The daughter stated when she changed her mom NA #29 told her mom to open her legs; -- The daughter told NA #22 her mom was not able to due to previous [MEDICAL CONDITION]; and -- The NA forcefully separated her mother's legs apart. The report documented the daughter and the DON went to Resident #13's room at 2:30 p.m. on 08/28/14. The DON interviewed Resident #13. The report indicated the resident stated the same events the daughter revealed about the NA being rude and pulling her legs apart when providing care. Further interview with DON #29 on 04/22/15, confirmed she had not reported to the State Agency. She stated as long as they investigate and determine within 24 hours that it was abuse, then they do not have to report it to the State. According to the regulatory requirement, The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The guidelines include, 'Immediately' means as soon as possible, but ought not exceed 24 hours after discovery of the incident, in the absence of a shorter state timeframe requirement. Conformance with this definition requires that each state has a means to collect reports, even on off-duty hours (e.g., answering machine, voice mail, fax).",2019-01-01
5514,MORGANTOWN HEALTH AND REHABILITATION CENTER,515049,1379 VAN VOORHIS RD,MORGANTOWN,WV,26505,2015-12-11,225,D,1,0,V8DE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure multiple unwitnessed falls requiring medical intervention for a resident were reported to the appropriate State agencies and thoroughly investigated. Resident #92 had unwitnessed falls without injury on [DATE] and [DATE]. After medical interventions another unwitnessed fall occurred on [DATE] with possible head injury requiring medical interventions and an admission to an acute care hospital. Resident identifier: #92. Facility census: 91. Findings include: a) Resident #92 On [DATE] at 2:30 p.m., a review of the accident/incident log revealed Resident #92 had a total of two (2) unwitnessed falls without injury, one (1) on [DATE] at 0245 (2:45 a.m.) and two falls on [DATE] at 6:00 p.m. and 7:00 p.m. Copies of the accident/incident reports were provided on [DATE] at 3:30 p.m. and found not to match the accident/incident log. The accident/incident reports identified an unwitnessed fall without injury on [DATE] at 0245 (2:45 a.m.) and one (1) report for [DATE] for unwitnessed falls without injury at 6:00 p.m. and 7:00 p.m. (This was found to be inaccurate, the resident only had one fall at 7:00 p.m.). On [DATE] at 09:30 a.m., a record review revealed Resident #92 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Transfer/Discharge Report, by an unknown author dated ,[DATE] 5:30 p.m. states, . Resident fell several times today. unable to calm, possible head injury . A review of the nursing progress notes on [DATE] at 09:45 p.m., revealed the following documentation: -[DATE] at 17:15 (6:15) of Resident had been having increased agitation .Notified MD. received order for [MEDICATION NAME] 1 mg IM (intramuscular) x 1 dose now repeat in 1 hr. (hour) if needed . -[DATE] at 17:59 (7:59 p.m.) IM [MEDICATION NAME] given as ordered at 1800 (6:00 p.m.) to (L) arm .There was no documentation of a fall at 6:00 p.m. -[DATE] at 01:58 (1:58 a.m.) Resident is alert and verbal with increased confusion. Resident received IM [MEDICATION NAME] 1 mg at 6p (6:00 p.m.), resident continued to have behaviors and was found on floor beside bed IM [MEDICATION NAME] 1 mg administered at 7P per MD orders . Resident continued to flail around and was unconsolable and was found on floor after second dose of [MEDICATION NAME]. Resident found with head against bottom bed bar, no visible injuries noted . Redness noted to back of head . Respirations even and labored . PA ordered to send resident to Mon Gen for eval . Resident left facility via Star city EMS (Emergency Medical Service) at appox 8 P (8:00 p.m.) . (note was made after Resident was transported to the hospital on [DATE].) There is no evidence in the record of the incident being reported to the appropriate State agencies or of an investigation by the facility of the unwitnessed fall which required medical intervention. During an interview with Licensed Practical Nurse (LPN) #11 on [DATE] at 11:40 a.m. she commented that she was the nurse going off shift on [DATE]. Resident #92 was aggressive on [DATE] and was trying to destroy the furnace in his room. LPN #11 had notified the Physician and received an order for [REDACTED].#92) daughter. I walked past as I was leaving about 6:30 p.m. and peeked in the room, he was in bed and no one was in his room with him. The Director of Nursing (DON) was interviewed on [DATE] at 12:20 p.m. and asked to explain the procedure for a resident following an aggressive episode that would require medical intervention. She stated, call the doctor, call the family, keep a close eye on for the next few hours and someone should stay in the room for the first (1st) hour after giving [MEDICATION NAME] or any emergent medication. On [DATE] at 9:00 a.m., a review of the acute care hospital records revealed Resident #92 was admitted on [DATE] with the chief complaint of agitation and combativeness, multiple falls and [MEDICAL CONDITION]. Resident #92 expired on [DATE] at 2:15 p.m. The cause of death on the Death Certificate was listed as (typed as written): a. Acute hypercapnic [MEDICAL CONDITION]. b. Benzodiazepines overdose. An interview on [DATE] at 9:20 a.m. was conducted with the Director of Nursing (DON) and the Assistant Director of Nursing (ADON). When asked if looking back at Resident #92's falls and interventions, should this have been reported and thoroughly investigated, they both stated, yes it should have been reported. Due to the resident being newly admitted to the facility, having unwitnessed falls with the latest fall needing medical intervention, the resident expiring in less than 24 hours of being transferred to the community hospital and due to the listed causes of death, it should have been reported to the appropriate state agencies and thoroughly investigated by the facility.",2018-12-01
5539,WORTHINGTON HEALTHCARE CENTER,515047,2675 36TH STREET,PARKERSBURG,WV,26104,2015-06-04,225,C,0,1,EDOZ11,"Based on review of personnel files, review of the West Virginia Bureau for Medical Services' policy manual and memorandum (memo), and staff interview, the facility failed to conduct a criminal investigation background check every three (3) years during employment for one (1) of ten (10) employees reviewed. Employee identifier: # 6. Facility census: 97. Findings include: a) Hospitality Aide #6 A review of personnel files, at 10:30 a.m. on 06/03/15, determined Hospitality Aide #6, hired on 09/19/11, had a WV statewide criminal background check on 11/01/11, but had not been rechecked as required by the WV Bureau for Medical Services. This was pointed out to Employee #46 (person designated by the facility as responsible for Personnel Files) at 1:30 p.m. on 06/03/15. Employee #46 provided a letter with an appointment for Employee #6 to be fingerprinted and a receipt of payment for the search, but admitted she could not locate the results of a current WV statewide criminal background check. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2018-10-01
5552,WELLSBURG CENTER,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2015-07-10,225,F,0,1,LX9B11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law for one (1) of five (5) employees whose files were reviewed. The facility did not make reasonable efforts to uncover information about any past criminal history by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This had the potential to affect all residents. Employee identifier: #27 Facility census: 52. Findings include:a) Activity Assistant #27 On 07/09/15 at 9:00 a.m., a review of personnel files found Activity Assistant (AA) #27 was hired on 01/29/15. There was no evidence of a criminal background check based on fingerprinting, as required for a statewide criminal background check in West Virginia. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.b) The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included, . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013. c) On 07/09/15 at 11:20 a.m., an interview with the Nursing Home Administrator confirmed this employee did not have the required criminal background check based on fingerprints.",2018-10-01
5561,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2015-02-12,225,E,0,1,7Y3Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of personnel files and staff interview, the facility failed to be thorough in their investigations of the past histories of four (4) of 15 employees reviewed. The fingerprints for a Statewide Criminal Background Check by the West Virginia (WV) State Police were not resubmitted as requested for Employee #30. An inquiry of the State nurse aide registry concerning abuse, neglect, mistreatment, or misappropriation of property was not completed for Employees #61, #12, and #64. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #61, #30, #12, and #64. Facility census 57. Findings include: a) Employee #30 A review of the personnel file for Employee #30 (nursing assistant), who was hired on 12/02/14, revealed the facility received notice from the WV State Police, on 12/08/14, stating her fingerprints could not be processed and; therefore, the criminal background check could not be completed. The facility was requested to resubmit the fingerprinting requirement. There was no evidence this had been done. During an interview with Employee #67 (Human Resources) at 4:30 p.m. on 02/10/15, she reviewed the letter and the employee's complete file. She stated she had telephoned L-1 (the national background check program) to ask them if they had any contact information after 12/08/14 (the date of the letter), but there was none. Employee #67 acknowledged there had been no resubmission of fingerprints for Employee #30. She also confirmed the employee was functioning in direct resident care on a full time basis. b) Employees #61, #12, and #64 A review of the personnel files for Employees #61 (registered nurse), #12 (maintenance worker), and #64 (registered nurse) failed to reveal evidence the facility made an inquiry to the State Nurse Aide registry concerning abuse, neglect, mistreatment of [REDACTED]. During an interview with Employee #67 (Human Resources), at 4:30 p.m. on 02/10/15, she acknowledged, after reviewing the employees' complete files, that the information was not there. She stated she had not realized this was necessary for these employees, as they were not nurse aides. c) The Administrator was notified of these findings at 4:45 p.m. on 02/10/15. She stated she would investigate further. No additional information was provided by the close of the survey on 02/12/15.",2018-10-01
5565,POCAHONTAS CENTER,515183,5 EVERETT TIBBS ROAD,MARLINTON,WV,24954,2015-02-11,225,C,0,1,II7711,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Affordable Healthcare Act, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility failed to ensure the results of the fingerprint based statewide and/or federal criminal background checks were received and/or reviewed prior to employees working in the facility longer than sixty (60) days. This was true for three (3) of five (5) new hire personnel records reviewed. Employee identifiers: #69, #22, and #31. Facility Census: 65. Findings Include: a) Employee #69 A review of Employee #69's personnel record at 12:30 p.m. on 02/10/15, found Employee #69 was hired as a Laundry Aide on 10/29/14. Her sixtieth (60th) day of employment was 12/27/14. Review of her application found she had lived outside of the state of West Virginia in the previous five (5) years. Further review of the personnel record found no results of a fingerprint based federal background check. Additional review found the facility had mailed Employee #69's fingerprints to the company completing the federal criminal background check on 10/29/14. An interview with Employee #36, bookkeeper, at 12:45 p.m. on 02/10/15, revealed the facility identified Employee #69 had lived out of state and needed a fingerprint based federal background check. She indicated she mailed the fingerprints to the company completing the background check on 10/29/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back She said they advised her not to call until after twelve (12) weeks. Employee #36 was asked if Employee #69 was still actively working at the facility. She replied, Yes she is. Review of Employee #69's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days, found she had worked on 01/11/15 through 01/13/15, 01/16/15 through 01/20/15, 01/22/15, 01/23/15, 01/26/15 through 01/28/15, 01/30/15 through 02/02/15, 02/04/15 through 02/06/15, 02/09/15 through 02/11/15. Which was twenty-three (23) of thirty (30) days. b) Employee #22 A review of Employee #22's personnel record, at 12:50 p.m. on 02/10/15, found Employee #22 was hired as a Dietary Aide on 11/20/14. Her sixtieth (60th) day of employment was 01/18/15. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 11/19/14. An interview with Employee #36, bookkeeper, at 1:00 p.m. on 02/10/15, revealed the she was aware the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 11/20/14. When asked if she had called to see why the results had not been returned she stated, No, because they told me it could take up to twelve (12) weeks to get the results back. When asked if Employee #22 was still actively working at the facility, she replied, Yes she is. Review of Employee #22's timecard on 02/11/15 at 1:25 p.m., from her sixtieth (60th ) day of employment, 01/18/15 to present, found she had worked on 01/19/15, 01/22/15, 01/24/15 through 01/27/15, 01/30/15 through 02/02/15, 02/05/15 through 02/09/15, which was fifteen (15) of twenty-four (24) days. c) Employee #31 A review of Employee #31's personnel record at 1:07 p.m. on 02/10/15, found Employee #31 was hired as a Registered Nurse on 08/18/14. Her sixtieth (60th) day of employment was 10/16/14. Further review of the personnel record found no results of a fingerprint based statewide background check. Additional review found the facility had mailed Employee #22's fingerprints to the company completing the statewide criminal background check on 08/29/14. An interview with Employee #36, bookkeeper, at 1:15 p.m. on 02/10/15, revealed the employee needed a fingerprint based statewide background check only. She indicated she mailed the fingerprints to the company completing the background check on 08/29/14. She further stated the company rejected Employee #31's fingerprints on 12/05/14. Employee #36 indicated the letter notifying them the fingerprints had been rejected was mailed to Employee #31 and not to the facility. Employee #36 stated Employee #31 did not bring in the rejection letter until two (2) weeks ago. Employee #36 stated she sent Employee #31 to have her fingerprints re-done today (02/10/15). Employee #36 was asked if Employee #31 was still actively working at the facility, and she replied, Yes she is. Review of Employee #31's timecard on 02/11/15 at 1:25 p.m., for the previous thirty (30) days found she had worked on 01/13/15, 01/14/15, 01/18/15, 01/21/15, 01/22/15, 01/29/15 through 01/31/15, 02/03/15, 02/04/15, 02/07/15, 02/08/15, and 02/11/15. Which was thirteen (13) of thirty (30) days. d) Review of Affordable Care Act Section 6201 Section 6201 (a)(3)(A) requires that long-term care facilities and providers obtain state and national criminal history background checks on prospective employees that utilize: a search of state-based abuse and neglect registries, state criminal history records, and national fingerprint-based criminal history record checks. Section 6201 (a)(3)(B) requires that participating states describe and test methods that reduce duplicative fingerprinting, including providing for the development of rap back capability by the State Section 6201 (a)(3)(C) requires that the background checks conducted under the nationwide program remain valid for a period of time as specified by the Secretary (not yet determined). Under section 6201 (a)(4)(A) and (B), participating states must also monitor compliance with the requirements of the nationwide program and have procedures in place to: - Conduct screening and criminal history background checks; - Monitor compliance by facilities and providers; - Provide for up to 60 days of provisional employment by the long term care facility/provider for a direct patient access employee, pending completion of the required criminal history background check or appeals process; . e) Review of Bureau of Medical Services (Medicaid) Services Manual The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). It is the responsibility of the employer to assure that the exclusion lists are checked monthly. The facility may employ an individual for a maximum of 60 days if a preliminary check is completed. The facility may choose to contract with a company that completes internet background checks use these results until the fingerprint results are received.",2018-10-01
5576,HERITAGE CENTER,515060,101-13TH STREET,HUNTINGTON,WV,25701,2014-12-12,225,E,0,1,VNJW11,"Based on review of the facility's reported allegations to proper state authorities, staff interview, review of grievance complaint forms, and resident interview, the facility failed to ensure all alleged violations involving neglect and misappropriation of resident property were reported to the proper state authorities and/or failed to ensure each allegation was thoroughly investigated for seven (7) of eight (8) allegations of alleged abuse, neglect and misappropriation of resident property. In addition, allegations of neglect were not reported for two (2) of two (2) allegations of neglect discovered during a review of thirty-four (34) grievance / complaint forms reviewed. For Resident #9, the facility failed to immediately report two (2) allegations of misappropriation of property. For Resident's #193 and #170, the facility failed to immediately report alleged allegations of neglect. For Residents #47, #211 and #76, the facility failed to report allegations of misappropriation of personal property to local law enforcement agency. For Residents #9, #4, #217 and #220, the facility failed to conduct a thorough investigation allegedly providing the statements. Resident identifiers: #9, #47. #4, # 193, #211, #76, #217, #220 and #170. Facility census: 154. Findings include: a) Resident #9 On 11/05/14, the nursing home reported, to the nursing home program (on OHFLAC form 225), Resident states she is missing $70.00 from her purse. Attached to the report was a statement from Employee #128 (nursing assistant) and Employee #95 (registered nurse). These statements were signed and dated 11/01/14, indicating the misappropriation of personal property was not immediately reported. According to Employee #128's statement, he was the employee who found the resident's purse on the bathroom floor. He helped the resident look through her purse when she discovered the money was missing. Employee #95's statement acknowledged she was aware the resident had reported $70.00 missing from her purse. There were six (6) additional witness statements from facility staff attached to the allegation. None of these statements were signed or dated by the staff members as required on the facility ' s interview documentation form. The six (6) statements were all written by Employee #52, the social service director. It could not be determined when and/or if the employees actually provided the statements. Employee #52 was interviewed at 3:55 p.m. on 12/03/14. She was asked why the allegation was not reported when discovered on 11/01/14. She was also asked why the staff providing the witness statements did not sign and date their statements as indicated on the form. She said she reported the incident when she knew about it. Employee #52 said she obtained the statements from the witnesses; however, when asked, she did not comment on why the witness statements were not signed by the employees allegedly providing the statements. The resident was interviewed at 2:15 p.m. on 12/04/14. She said someone had stolen her money and she reported the missing money to staff. She said Employee #128 had discovered her purse in the floor of the bathroom. She had this employee help her search her purse and she found $70.00 was missing. When asked if she had any other occasions of missing money or personal items, the resident replied someone took her makeup bag with $6.00 in it after her $70.00 was stolen. She explained she received the makeup from her sister as a birthday present, for her birthday on (MONTH) 4. She said she kept the bag on her over-the-bed table. She said she had placed $6.00 in the bag and now it was all gone. She said she reported the incident to the night shift nurse, Employee #45. At 9:30 p.m. on 12/09/14, Employee #45, a licensed practical nurse, said the resident had reported the missing make up bag and the missing six (6) dollars. She did not recall the exact date, but said she had told the registered nurse supervisor, Employee #179, about the missing money and the missing makeup. Employee #179 was interviewed at 9:45 p.m. on 12/09/14. She acknowledged she talked with the resident and was aware of the missing makeup bag and money. She said she reported the situation to the social services director by e-mail as she was required to do. Employee #179 said she also searched for the lost items when it was reported by the resident. When asked if she remembered the date she reported the situation, she said she could look at her e-mail and find the date. Employee #179 provided a copy of the e-mail, dated Sunday 11/16/14 at 12:32 a.m., addressed to Employee #52, the social services director, the director of nursing (DON) and Employee #65, a registered nurse. The contents of the e-mail were: It was reported to me by the 2nd floor nurse that (name of resident) has a makeup case missing from her room that she stated had $6.00 in it. She says it is red on one side and black on the other. I went to laundry and looked in there to see if possible it was in some linens that were taken out of the room. No luck. On the morning of 12/10/14, Employee #52, the social services director, stated she had no knowledge Resident #9 was missing a bag of makeup which also contained money. When shown the e-mail from Employee #179, she had no comment. The director of nursing recalled the e-mail when interviewed, at approximately 11:00 a.m. on 12/10/14. She said she thought the social services director had taken care of the situation. b) Resident #47 Review of the immediate fax reporting of allegations to the nursing home program found an allegation, dated 09/15/14. The resident reported she left her tablet (computer tablet) debit card, and about $80 on her bed. When she got back from therapy it was gone. The allegation was also reported to the ombudsman. There was no evidence the allegation was reported to the local law enforcement agency. The five (5) day follow-up was completed on 9/19/14 and was faxed to the OHFLAC office on 09/19/14 at 1:25 p.m. It said, We are unable to determine what happened to residents belongings. Resident did have a visitor and was in the room alone while resident was (symbol for at) therapy and roommate was out on the room. The five (5) day follow up report did not indicate the allegation was reported to the local law enforcement agency. According to the Abuse/Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities, revised (MONTH) 2011, the local law enforcement agency is to be contacted for, Reasonable suspicion of a crime against a resident. The administrator and the social services director, were interviewed at 10:28 a.m. on 12/04/14. The administrator was not in agreement this resident ' s personal property, which was removed from her room while she was at therapy, required reporting to the local law enforcement, because the resident did not say the items were stolen, she said they were missing. c) Resident #4 On 11/04/14 the facility completed an immediate fax reporting of allegations to the nursing home program. The resident stated she was missing $17.00. Employee #52, the social services director, completed the reporting form and completed interview statements from three (3) nursing assistants (Employees #176, #42, and #48) and two (2) licensed practical nurses (Employees #13 and #133). The facility interview documentation form required employees to sign and date their statements; however, none of the statements were signed or dated. Beginning at 10:00 a.m. on 12/08/14, Employees #176, #13, #133, #42, and #48 were interviewed individually. They were asked if they had provided statements regarding the theft of Resident #4's money. Only one (1) employee (#176) said she thought she was asked to give a statement. All of the other four (4) employees denied they provided any statements to the social services director regarding Resident #4 The administrator, social services director, and the director of nursing were interviewed on 12/09/14. The interview started at 10:19 a.m. and concluded at 10:49 a.m. No further information was provided regarding the employee statements. d) Resident #193 Review of the grievance/complaint forms found the resident's daughter initiated a complaint on 07/28/14, States res. (resident) waited 40 minutes to get call light answered, she has a red area on her R (right) ankle that looks like it is getting ready to breakdown. Wants her feet and in between her toes washed better during showers and lotion applied to them. This complaint was not reported as an allegation of neglect. In addition, there was no evidence the facility did a thorough investigation of the allegations. In the area of the complaint form which indicated action taken, only the following was documented: -- The family was unsure of the specific date regarding the call light. A call light audit was done 8/01/14 - 8/03/14. (Attached to the complaint was only one (1) call light audit, dated 8/01/14.) -- Wound treatment was started on the ankle on 07/2814. (Review of the skin integrity report, completed by the facility on 07/28/14 after the family's complaint, found the resident already had a Stage II pressure ulcer to her right ankle that required treatment.) -- Shower given 7/26/14, 8/02/14 - bed bath given. The administrator and the social services director were interviewed at 10:28 a.m. on 12/04/14. Both were asked why this allegation of alleged neglect was not reported to the proper state agencies. The administrator disagreed this was an allegation of neglect. He confirmed it was not reported to any state agencies. e) Resident #211 Review of the immediate fax reporting of allegations to the nursing home program found the resident reported she had $15.00 (3 - $5.00 bills) stolen from her pocket book on 10/03/14 at 12:00 p.m. The facility made a referral to the Ombudsman, but did not contact the local law enforcement agency. The five (5) day follow-up report faxed to OHFLAC, on 10/08/14, listed only the ombudsman was contacted. The follow-up report noted the facility was unable to determine what happened to the resident's money. The facility ' s investigation was not thorough. It only contained statements from two (2) licensed practical nurses (LPNs). The statements obtained from the LPNs were not signed or dated by the employees; therefore, it could not be determined when and/or if the employees actually provided the statements. The statements were completed by the social services director. There were no statements from any nursing assistants or other staff members who worked on 10/03/14. At 10:19 a.m. on 12/09/14, the administrator and Employee #52 were asked why the facility did not obtain statements from other staff members, and why the LPNs did not sign and date their statements. Neither provided an answer to these questions. The administrator stated he felt the incident did not require reporting to the local law enforcement agency. No further information was provided by the close of the survey on 12/12/14. f) Resident #76 Review of the facility's immediate fax reporting of allegations to the nursing home program found an incident, reported by the resident, who said she had $15.00 her daughter gave her for the beauty shop and someone took it. The resident was unsure of the date and time of the incident. According to the report, the social services director called the daughter and confirmed the daughter had given her mother $15.00 (three (3) - five (5) dollar bills). Statements were obtained from two (2) nursing assistants and one (1) licensed practical nurse. The statements were not signed or dated by the employees who allegedly provided the statements, although this was directed by the facility's interview documentation form. The facility also failed to report the incident to the local law enforcement agency. At 10:19 a.m. on 12/09/14, the administrator and Employee #52 were asked why the facility did not report the incident to local law enforcement authorities and why staff members did not sign and date their statements. Neither provided an answer to these questions. The administrator stated he felt the incident did not require reporting to the local law enforcement agency. No further information was provided by the close of the survey on 12/12/14. g) Resident #217 Review of the immediate fax reporting of allegations of abuse/neglect and misappropriation of resident property to the nursing home program found the resident reported he had $100.00 taken. The report was dated 11/07/14. Review of the investigation documentation found the social services director, Employee #52, completed interview documentation forms for three (3) employees: a housekeeper, and two (2) nursing assistants. The statements were not dated or signed by any of the employees; therefore, it could not be determined when and/or if the employees actually provided the statements. Employee #52 signed each statement, but did not date the statements. The above situation was discussed with Employee #52, the administrator and the director of nursing. The interview started at 10:19 a.m. on 12/09/14 and concluded at 10:49 p.m. on 12/09/14. h) Resident #220 Review of the immediate fax reporting of allegations of abuse, neglect and misappropriation of residents property to the nursing home program found the resident said he had $90.00 taken from him. He did not know the date or the time. The allegation was reported by the facility on 11/07/14. Review of the investigative documentation attached to the report found Employee #52 obtained statements from three (3) nursing assistants and a licensed practical nurse. The statements were not signed or dated by the employees allegedly providing the statements. Employee #52 had signed the statement but she had not dated the statements. The failure to have signed and dated statements from employees was discussed with the administrator, social services director, and the director of nursing on 12/09/14 during an interview that started at 10:19 a.m. and concluded at 10:49 p.m. No further information was provided. i) Resident #170 Review of the grievance/complaint reports found an allegation of neglect made by the resident ' s daughter on 08/05/14: Daughter showed LPN (licensed practical nurse) bed as it was all wet The CNA (certified nursing assistant) (symbol for changed) her brief but not the sheets. Attached to the complaint report was a statement from a registered nurse unit manager: When you change a resident and they are in the bed please do not leave the resident with wet sheets on the bed. We have found this MESS during shift rounding and during just the nursing rounds that we do every day. Now you could use the excuse Well, I didn't see it, or, you could use this one, Well I changed her/him about 10 minutes ago and why he/she is wet I have no idea. This is considered to be poor patient care and is unacceptable!! So, please keep the resident and the bed dry. If you need help with trying to make a bed with a resident still in it feel free to stop by my office Further review of the reportable allegations of abuse, neglect and misappropriation of resident property found the facility had not reported the allegation of neglect to the proper state agencies as required by law. During an interview with the administrator, social services director, and the director of nursing, which started at 10:19 a.m. and concluded at 10:49 p.m. on 12/09/14, the administrator stated he did not believe the family member was making an allegation of neglect. He said he did not believe this complaint should have been reported as an allegation of neglect.",2018-09-01
5610,MONTGOMERY GENERAL HOSPITAL,515081,401 6TH AVENUE,MONTGOMERY,WV,25136,2015-03-04,225,C,0,1,KF9N11,"Based on personnel record review and staff interview, the facility failed to ensure it did not employ individuals who found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for one (1) of ten (10) employees reviewed. This had the potential to affect more than an isolated number of residents. Employee identifier: #51. Facility census: 38. Findings include: a) Criminal Background Checks Review of personnel files on 03/04/15 at 1:30 p.m., found Nurse Aide (NA) #51, originally came to work at the facility in (MONTH) 2008. The facility completed a criminal background check with fingerprints at that time. NA #51 came back to work at the facility in (MONTH) 2011. The facility completed another criminal background check with fingerprints at that time as well. The employee came back to the facility to work for a third time on 12/30/14. The facility did not complete a statewide criminal background check with fingerprints at the time of the individual's rehire. On 03/04/15 at 2:15 p.m., Human Resources Employee #62 verified the facility did not complete a criminal background check with fingerprints when they rehired NA #51 on 12/30/14.",2018-09-01
5647,PIERPONT CENTER AT FAIRMONT CAMPUS,515155,1543 COUNTRY CLUB ROAD,FAIRMONT,WV,26554,2015-07-29,225,G,0,1,DSPZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon resident interview, family interview, staff interview, record review, and review of facility documents, the facility failed to ensure residents were free from abuse and neglect, resulting in actual harm to Resident #120. The facility failed to immediately report all allegations as required by law, failed to consistently conduct thorough, complete investigations, failed to consistently follow its past practice for the protection of residents during investigations, and failed to identify an allegation of neglect. This was found for four (4) of twenty-two (22) allegations of abuse/neglect reviewed. Resident identifiers: #120, #183, #14, and #90. Facility census: 99. Findings include: a) Resident #120 Abuse/neglect reports submitted by the facility were reviewed on 07/22/15 at 1:00 p.m. There were three (3) reports of alleged abuse/neglect perpetrated against resident #120 between 02/01/15 and 07/06/15. Another allegation initially took place on 07/23/14. Resident #120's Brief Interview for Mental Status (BIMS) score, as assessed on 09/27/13 was 15. This indicated he was cognitively intact. He was determined by a physician to possess the capacity to make informed medical decisions and act as his own responsible party. His [DIAGNOSES REDACTED]. He was partially paralyzed and ambulated in a motorized wheelchair. He was being followed by a consultant psychiatrist for his anxiety, depression, and post-traumatic stress disorder ([MEDICAL CONDITION]). The review of reportable allegations found Resident #120 made allegations of verbal and emotional abuse by a physician and a nurse practitioner. Resident #120 was initially interviewed on 07/20/15 at 2:00 p.m. During this interview, he voiced both those allegations documented in the facility's abuse investigation files and had several other complaints as well. Two (2) of the reported allegations were reviewed and are described separately: 1. Allegation #1: The facility's report of alleged abuse documented Resident #120 claimed he was a victim of verbal/emotional abuse by a nurse practitioner on 07/23/14. Review of the facility's investigative documentation found a Follow-Up Summary of their investigation which stated in part the nurse practitioner initiated an interaction with the resident by stopping in his doorway and telling him that He needed to grow up. The summary statement says she did this because Resident #120 had kept his new roommate up all night yelling and cursing at him. The Social Services Director (#154) was actually in the room at the time attempting to address the events of the previous night. Following her statement at the door, the situation escalated immediately with Resident #120 followed the nurse practitioner to the hallway outside his room, cursing and screaming at her. The summary statement said the nurse practitioner instead of removing herself from the situation . remained in the hall and continued to engage the resident in an argumentative tone. This allegation was reported as required in a timely manner. An extension of the investigation past the usual five (5) day follow-up deadline was requested and granted on 07/25/14 because administration has requested direction from the corporate RVP (regional vice president) regarding this incident since it involved a NP (nurse practitioner) and the RVP is currently on vacation. The nurse practitioner was employed by the parent governing corporation rather than by the facility. There were eleven (11) written signed statements included with the investigative documents. These generally supported the summary or said they did not witness the incident. There was no statement from the nurse practitioner in the record. There was a witness statement signed by the activities director and her assistant that said in part (Resident #120 was cussing & yelling at (nurse practitioner) and she was yelling and then started laughing at him continuously which appeared unprofessional. (Administrator) intervened and had (nurse practitioner) to remove herself from the situation which she continued to laugh and made comment that he is an a______ (expletive) as she walked away. (Administrator) and (Social Services Director) continued to talk with (Resident #120) trying to calm him down. Resident #120 was interviewed on 07/20/15 at 2:00 p.m., again on 07/22/15 at 1:30 p.m., and on 07/23/15 at 1:20 p.m. He stated he was verbally and psychologically abused by the nurse practitioner. He was in his room talking with the Social Services Director and she stuck her head in the door and told him to grow up. She screamed at him, laughed at him, cursed at him, called him a drug addict, and said you're all messed up. He said she continued to mock him and make faces at him and he has isolated himself to his room to avoid her. There was a Report of Consultation in the medical record dated 07/09/15 by a local Psychiatrist treating Resident #120. The report said in part (typed as written): Agitation D/T (due to) some issues at the nursing home with (symbol for with) a Physician and a nurse practitioner. Speech pressured and rapid . The situation at the nursing home is causing some flashbacks, sweats & nightmares. Not on every day or night but just when he sees these people . This is impacting his recovery. In an interview on 07/27/15 at 3:00 p.m., Nurse Practitioner #217 said she was out of line because she should have just walked away when the incident began, but she did not curse and she did not yell at Resident #120. She said he continued to make unfounded accusations against her and other residents, staff, and Physicians as well. Activities Director #198, was interviewed on 07/27/15 at 11:27 a.m. She was asked about the incident and her written statement. She said she stood by what was written. She said the nurse practitioner yelled back at Resident #120, laughed at him loudly and continually, called him an a______ (expletive), and he heard it. Activities Assistant #201, who co-signed the written statement with activities director #198, was interviewed on 07/28/15 at 9:00 a.m. She said the activities director had written the statement, but she was there with her and she agreed with what was written. She said the nurse practitioner yelled back at Resident #120, laughed at him, and called him an a______ (expletive). Administrator #153, was initially asked on 07/22/15 at 1:05 p.m. why there was no written statement from the nurse practitioner in the investigative record. She said the parent corporation had interviewed her (the nurse practitioner) and obtained a written statement, but the facility was not provided the document. She was asked to obtain the statement. The statement was provided on 07/23/15 at 3:05 p.m. The statement recounted she had gone to the room around 9:45 a.m. She asked the newly admitted resident, who was her patient, how he was feeling. He said he needed to get out of here right away. He described being cursed and taunted all night by Resident #120 and being chilled because Resident #120 turned the thermostat way down. She observed him to have six (6) blankets on him. She went to get the medical record and upon her return, the Social Services Director was in the room attempting to deal with the issues of the previous night. She told (Resident #120) he had to act like an adult. Before she could finish her statement, Resident #120 began yelling, cursing, and coming toward her. She felt extremely threatened and turned and walked down the hall toward the lobby. He followed her cursing and screaming until the Administrator intervened at the main desk and told her to just keep walking. The summary document stated Although we validate that (Nurse Practitioner #217's) interaction was unprofessional, the resident's allegation of verbal abuse is not being substantiated. Per a follow-up with (corporate) HR (human resources) manager, and administration, (Nurse Practitioner #217) has received formal counseling regarding this incident and was instructed she may return to work on Monday 07/28/14. It was verified that Nurse Practitioner #217 was suspended pending the conclusion of the investigation for the protection of residents in accordance with the facility's past practice and procedure. Documentation of the counseling received by Nurse Practitioner #217 showed she had been counseled by facility administration, and also by a corporate director. She was reported to the West Virginia Licensing Board of Examiners for Registered Nurses. The referral to the board included the statement that the allegation was unsubstantiated and counseling was provided, and the facility did not feel any action from the board was necessary. There was no evidence of documentation in the investigative record of any corporate questioning or speaking with witnesses or discussing the investigation findings with the Social Services Director or the Administrator. During an interview on 07/28/15 at 9:30 a.m., Administrator #153 said the investigation of the allegation was conducted partly at the facility level and partly at the corporate level because the nurse practitioner was not an employee of the facility. She acknowledged the ultimate responsibility for reporting, investigation, protection and resolution of allegations of abuse/neglect rested with the facility management regardless of who the alleged perpetrator might be. She said corporate had some of the investigative documents, but not all. She was asked if corporate staff had interviewed any of the witnesses (other than the nurse practitioner) and she said they did not. She again confirmed that the facility did not have the nurse practitioner's written statement. She said the facility staff normally involved in investigations, such as the Social Worker, did not speak with any corporate persons to clarify any issues or offer any opinions regarding the decision whether to substantiate the allegation. Social Services Director #154 was interviewed on 07/28/15 at 9:48 a.m. She said the investigation was handled differently than most. It was not handled exclusively by the facility. The action to be taken was ultimately determined at the corporate level. There was sufficient evidence to indicate the facility did not thoroughly investigate the allegation of abuse made by Resident #120 against Nurse Practitioner #217 before reaching a conclusion that the allegation was unsubstantiated. All of the available information was not fully investigated and considered by all parties in a comprehensive manner. 2. Allegation #2: The facility's report of alleged abuse documented Resident #120 claimed he was a victim of psychological/emotional abuse by a physician on 07/02/15. The immediate report stated Resident (#120) feels the facility's in-house Physician (Physician #218) is deliberately mocking him. According to the resident, (Physician #218) makes faces, smirks, and makes fun of him when he passes him in the halls. Review of the facility's investigative documentation found the allegation had not been reported to all applicable agencies until 07/06/15. Reporting of allegations of abuse/neglect are to be immediately, not to exceed twenty-four (24) hours. A written statement submitted on 07/02/15 by Social Worker #145, stated in part, (Administrator #153) told (Resident #120) that she is going to wait until Monday to discuss issue with (corporate regional vice president of operations). (Administrator #153) feels this needs reported but wants to speak to (corporate regional vice president of operations) first. There was a Follow-Up Summary that stated (typed as written): After an investigation we do not substantiate abuse or any type of mistreatment toward (Resident #120). On 07-2-15 the resident alleged that the facility's in house Physician, (Physician #218) was deliberately mocking him/trying to cause him psychological distress AEB (as evidenced by) smirking at him while he was trying to have a conversation with another staff member. Per a statement obtained from (#213), Guest Services Director while having a conversation with (Resident #120) in the front lobby around 4:15 p.m. on 072/2/15, (Resident #120) stopped mid-sentence and yelled out I'm talking to (Guest Services Director #213), not you. When she turned to see what was going on she reports that she saw (Physician #218) going around the corner toward the social service office. According to (Guest Services Director #213), while talking to the resident she did notice the doctor looking around the comer several times and smirking prior to leaving the building. In a statement obtained from SW #145, she indicated she did hear the resident yelling and cursing at (Physician #218) on the date/time in question. She reported that at the time of this incident (Physician #218) had been joking with her about something else and was laughing when he left the office. (Physician #218) confirmed that when walking past the resident in the front lobby, (Resident #120) yelled an offensive profane comment toward him, but indicated that he did not respond. In a follow up interview with the resident, he acknowledged that (Physician #218) did not make any verbal comments toward him, but continued to indicate that he was offended by his smirking and planned to sue both the Doctor and the facility secondary to this incident. Please note that this resident had a long history of exhibiting open conflict/paranoid behaviors which were being addressed on his plan of care. A written statement was submitted by Social Worker #145. This statement contained both a typewritten section and a handwritten section below it. The typewritten section stated (typed as written): (Resident #120) complained that when he was in the lobby around 4:15 he was talking to (Guest Services Director #213) when (Physician #218) walked by and was mocking him. (Resident #120 is upset because this has happened in the past and feels (Physician #218) deliberately makes faces, smiles, smirks, and makes fun of him when he walks past (Resident #120). (Guest Services Director #213) did witness (Physician #218)'s actions in the lobby today. SS (Social Services), GS (Guest Services), ADM (Administrator) met with (Resident #120) afterwards and he is planning on taking legal action against (Physician #218) since he has a witness. (Administrator #153) told (Resident #120) that she is going to wait until Monday to discuss incident with (corporate regional vice president). (Administrator #153) feels this needs to be reported but wants to speak with (corporate regional vice president) first. The statement was signed. Below this was a handwritten statement that said (typed as written): I did hear (Resident #120) cussing and calling (Physician #218) names (inserted a reference to a profanity) when the Dr. (doctor) was in my office. We were joking about something else when (Physician #218) left my office and he was laughing when he left the door. This second statement was also signed. There was a written statement from Resident #120 which stated Physician #218 walked past him in the lobby and smirked at him, then went to the social services office and peeked around the corner four or five times and smirked at him, then opened the front door, turned around and walked out backwards facing him and kept smirking at him. Resident #120 was interviewed on 07/20/15 at 2:00 p.m., again on 07/22/15 at 1:30 p.m., and on 07/23/15 at 1:20 p.m. He confirmed his written statement, and said (Physician #218) said he would put something on my record to make it look like nothing is wrong with me and I'm a bad patient. He stated (Physician #218) and (Nurse Practitioner #217) also, play mental games with me such as being cordial and friendly to other staff around, but ignore him. He said he has been diagnosed with [REDACTED]. He said he has resided at the facility for two years and he is tired of being treated this way. There was a Report of Consultation in the medical record dated 07/9/15 by a local Psychiatrist treating Resident #120. The report says in part (typed as written): Agitation D/T some issues at the nursing home with (letter c with a horizontal line above.) a Physician and a nurse practitioner. Speech pressured and rapid . The situation at the nursing home is causing some flashbacks, sweats & nightmares. Not on every day or night but just when he sees these people . This is impacting his recovery. There was a written statement submitted by Guest Services Director #213, which stated she was talking with Resident #120 in the lobby when Physician #218 walked past them. She did not see him make any facial expressions as he passed by them. She said Resident #120 said to (Physician #218) I'm talking to (Guest Services Director #213), not you. She saw Physician #218 go toward the social work office. Three more times while she was speaking with Resident #120, Physician #218 came around the corner smirking at Resident #120. The resident asked her to go to the social work office because she witnessed these things. As they were going to the office, Physician #218 walked out the doors backwards and smirked at Resident #120. Guest Services Director #213 was interviewed on 07/27/15 at 11:05 a.m. She confirmed the events in her written statement. She was asked to describe the facial expression she saw and called a smirk. She said it was an exaggerated fake smile, which she interpreted as (Physician #218) mocking Resident #120, especially since #218 peeked around the corner three separate times while she was speaking with the resident and then backed out the automatic front door making the same face. She said she felt it was deliberate, intentional, and directed at Resident #120. There was a written statement in the record from Physician #218, which stated in part (typed as written): I am responding to (facility)'s (Resident #120)'s unfounded and fabricated complaint about me to (corporate) administration. A resident at (facility) (Resident #120) has complained that I had a facial expression of a 'smirk' toward him and he is going to file suit against (corporation) and me over my said 'smirk'. He admitted that I uttered no actual words toward him but that I looked back at him and 'smirked' and he feels this was offensive. I was however offended when he told (#213) of guest services very loudly in the (facility) lobby 'I hate that (profanity)' after he felt that I had looked back and smirked at him. I did not respond to his offensive profane comment . (Resident #120 is well known for his almost daily fabricated written complaints about employees and residents alike, and I have overheard him multiple times stating to other residents 'I wonder who I can get fired this week.' . It is concerning to me, due to (Resident #120)'s well known track record of fabricating stories to his liking that we continue to embolden him by catering to all of his demands and complaints without any proof, as well as refuse to place another resident in his room due to the fear that he will bully the other resident, as he has done in the past every time he acquires a roommate. Physician #218 was interviewed on 7/27/15 at 3:14 p.m. He said he questioned Resident #120's ability to interpret facial expressions. While he was in the vicinity of Resident #120 and the Guest Services Director, he heard him talking about his patient (Resident #129) and saying he had the ability to hurt him. Being concerned, he was trying to listen to protect his incapacitated dependent resident. He said he was also lingering in case Guest Services Director #213 needed protection. He said Resident #120 terrorizes staff and residents and no one protects them. He expressed frustration with being advised not to talk to Resident #120 and just walk away, feeling it hinders his ability to perform the functions of his position. Administrator #153 was asked if there was any documentation available at the corporate level regarding their involvement in the investigation. She subsequently furnished a copy of an email from the corporate vice president of operations dated 07/27/15. It stated in part (typed as written): This email is to verify that on (MONTH) 8, (YEAR) at 4:00 p.m. Dr. (Senior vice president of medical affairs) and I held a telephone meeting with (Physician #218) concerning the allegation made by (Resident #120). 1. Initially, I reviewed the allegation with the group. (Physician #218) denied the allegation (in agreement with the statement that he supplied to the center). 2. Secondly, I reviewed the Abuse and Neglect regulations and the (corporate) policy. 3. In addition, I reviewed policy on Resident's rights with specific emphasis on the right to register complaints. 4. We also discussed the general difficulty in finding appropriate discharge arrangements for residents with unusual circumstances or behavioral issues. Administrator #153 was asked whether there was any documentation of counseling or disciplinary action at the corporate level. She subsequently furnished an email from the corporate vice president of operations dated 07/28/15 that stated (typed as written): Our conversation was not a formal counseling in a disciplinary manner but more of a re-education in regard to the areas I listed. This decision was made for several reasons. 1. (Physician #218) denied that he 'smirked' - he indicates that he may or may not have smiled (he simply cannot recall) but did not smirk or verbalize anything to (Resident #120). 2. Dictionary.com defines 'smirk' as 'to smile in an affected, smug, or offensively familiar way.' 3. Per this definition, in order to substantiate the concern, one would have to conclude that (Resident #120) could, in some way, accurately determine the intent of any smile that (Physician #218) may or may not have expressed. There was simply no way to prove that. The conclusion was that the allegation was unsubstantiated but that (Physician #218) should avoid any unnecessary contact or interaction with (Resident #120). Dr. (Senior vice president of medical affairs) did not document in addition to what I provided in the summary and he validated. There was no evidence of documentation in the investigative record of any corporate questioning or speaking with witnesses or discussing the investigation findings with the Social Services Director or the Administrator. Administrator #153, was interviewed on 7/28/15 at 9:30 a.m. She said the investigation of this allegation, like the one involving the nurse practitioner, was conducted partly at the facility level and partly at the corporate level because the physician was not an employee of the facility. She acknowledged the ultimate responsibility for reporting, investigation, protection and resolution of allegations of abuse/neglect rests with the facility management regardless of who the alleged perpetrator may be. She said corporate had some of the investigative documents, but not all. She was asked if corporate staff had interviewed any of the witnesses (other than the nurse practitioner) and she said they did not. She was asked if Physician #218 had been suspended pending the outcome of the investigation and she said he was not. She acknowledged this was contrary to her expectation and facility past practice for its policy to protect residents during an investigation. She said the facility staff normally involved in investigations, such as the Social Services Director, did not speak with any corporate persons to clarify any issues or offer any opinions regarding the decision whether to substantiate the allegation. Guest Services Director #213 was again interviewed on 07/29/15 at 9:14 a.m. She was asked whether facility staff or corporate staff had interviewed her following her submission of her written statement which appeared to support to some degree the allegations of Resident #120, to clarify anything, ask her opinion about any of the events she witnessed, etc. She said no one had spoken to her at all. She was asked to write a statement, which she did. No one followed up with her in any way, so she never informed anyone of her belief the Physician was mocking Resident #120. Social Services Director #154, was interviewed on 07/28/15 at 9:48 a.m. She said this investigation, like the one involving the nurse practitioner, was handled differently than most. It was not handled exclusively by the facility. The action to be taken was ultimately determined at the corporate level. There was sufficient evidence to indicate the facility failed to thoroughly investigate the allegation of verbal abuse made by Resident #120 against Physician #218. The investigation was not fully investigated and considered by all parties in a comprehensive manner. The allegation was not reported in a timely manner as required by law, and the alleged perpetrator was not suspended pending the outcome of the investigation for the protection of residents which the Administrator confirmed was the standard of practice in such situations. b) Resident #183 1) Resident #183 was admitted to the facility on [DATE]. The next morning she made an allegation she was treated roughly by two (2) nursing assistants when they took her off the bedpan the night she was admitted . Review of the reporting and investigation found the immediate reporting of the allegation was not made to all applicable agencies as required by law until 05/12/15. Social Services Director (SSD) #154 was interviewed on 07/28/15 at 9:48 a.m. She acknowledged the allegation was not reported in a timely manner as required. She said facility staff did not report the allegation, which the resident made on Saturday, 05/09/15. SSD #154 waited until she returned to work on Monday 05/11/15 to inform her of the allegation. She then completed the required referral forms and faxed them to all applicable agencies. c) Resident #14 1) On 06/27/15 at 9:00 a.m., Resident #14 made an allegation to nursing staff that a nursing assistant had stolen $32.00 from a drawer in her room. Review of the reporting and investigation found the immediate reporting of the allegation was not made to all applicable agencies as required by law until 06/29/15 at 4:45 p.m. Social Services Director #154 was interviewed on 07/28/15 at 9:48 a.m. She acknowledged the allegation was not reported in a timely manner as required. She said facility staff did not report the allegation as reported on Saturday, 06/27/15. She reported it on Monday, 06/29/14 when the resident repeated it to her. She then completed the required referral forms and faxed them to all applicable agencies. She also reported the allegation to the police, and an officer met with Resident #14 on 06/29/15. d) Resident #90 Review the past six (6) months complaints, on 07/27/15 at 3:30 p.m., found a complaint dated 01/19/15 regarding Resident #90's bed sheets being brown ringed, a condition where the sheets had a dried brown circular area, presumably of old urine. This matter was discussed with Social Worker #145 on 07/27/15 4:30 p.m. She said she did not know this was a matter that should have been reported to the State, nor did she understand why it should have been reported, therefore, she did not report it. During an interview with the responsible party of Resident #90, on 07/28/15 at 11:00 a.m., she said she had complained many times in the past about Resident #90's bed being wet at various times of day. She said one (1) weekend, Resident #90's bed was so wet, she went to nursing staff and told them it was neglect. She was unable to provide a date or names for this particular incident and no reportable documentation was found describing any incident regarding urinary incontinence of Resident #90 during a record review on 07/27/15 at 3:30 p.m.",2018-09-01
5665,PINE VIEW NURSING AND REHABILITATION CENTER,515184,400 MCKINLEY AVENUE,HARRISVILLE,WV,26362,2015-01-21,225,F,0,1,XRGM11,"Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual and certification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, staff interview, and review of facility policy, the facility failed to ensure criminal background investigations were completed for all employees prior to hire and every three (3) years thereafter throughout the remainder of employment. Eight (8) of fifteen (15) employees reviewed were found to not have required criminal background checks. The facility failed to complete criminal background investigations for two (2) employees (#10 and #42) at the time of hire. The facility also failed to incorporate in its policy a requirement for criminal background checks every three (3) years throughout the remainder of an individual's employment as required by BMS to meet the requirements of the Affordable Care Act. Six (6) employees (#46, #62, #68, #26, #69 and #13) who had worked in the facility for more than three (3) years, were found to not have had a criminal background check repeated by (MONTH) 1, 2014 as directed by BMS. This practice had the potential to affect all residents. Employee identifiers: #46, #62, #10, #42, #68, #26, #69, and #13. Findings include: a) On 01/20/15 at 11:00 a.m., a review of personnel files for new and tenured employees with Bookkeeper #20, identified the following: 1. Nurse Aide (NA) #46 A review of the personnel file for Nurse Aide (NA) #46, hired on 12/06/09, revealed a background check dated 11/14/10. The 11/14/10 background check was not timely, and no repeat background check had been conducted by (MONTH) 1, 2014 as required by BMS to meet the requirements of the ACA. 2. Activities Director #62 Review of the personnel file for Activities Director #62, hired 01/27/97, revealed no evidence of a statewide criminal background check completed since her date of hire. 3. Housekeeper #10 A review of the personnel file of Housekeeper #10, hired by the facility on 12/29/14, found no evidence of a statewide criminal background check completed at the time of hire. 4. Housekeeper #42 A review of the personnel file for Housekeeper #42, hired 10/29/14, found no evidence of a statewide criminal background check completed at the time of hire. b) On 01/21/15 at 8:20 a.m., review of additional personnel files with Bookkeeper #20 identified the following: 1. Licensed Practical Nurse (LPN) #68 Review of the personnel file of LPN #68, revealed she was hired 08/17/11. The date of her last background check was 09/24/11. The employee file lacked any evidence of a current statewide criminal background check. 2. NA #26 A review of NA #26's personnel file revealed she was hired 12/01/09. The file contained an initial background check dated 01/13/10. There was no evidence of an up to date statewide criminal background check. 3. Registered Nurse (RN) #69 Registered Nurse (RN) #69's record indicated her date of hire was 01/27/11 and her initial background check was 01/18/11. Review of her personnel file found no evidence of a current statewide criminal background check. 4. NA #13 A review of the personnel file for NA #13, hired 05/17/10, found no evidence of an up to date statewide criminal background check since the initial background check dated 06/08/10. c) In interviews with Bookkeeper #20 on 01/20/15 at 2:00 p.m., and again on 01/21/15 at 8:20 a.m., she confirmed the statewide criminal background investigations were not up to date for all of the facility's employees. She agreed the facility was not in compliance with the required state, federal, and Centers for Medicare and Medicaid Services (CMS) regulations. d) On 01/21/15 at 10:30 a.m., review of a copy of the facility's current policy titled Resident Abuse (Prohibition) provided by Bookkeeper #20, found Segment 3 under the section titled Implementation states: A statewide background check will be conducted for all potential new employees through the state police department or other capable private entity. A background check will also be completed in any other state the applicant is known to have lived in or held employment. The policy was silent in regards to the current requirements of the Affordable Care Act and completing criminal background investigations on current employees every three (3) years thereafter throughout the remainder of their employment. e) The Bureau for Medical Services Manual (BMS) includes: 5.14.4.1 Employment Restrictions. Criminal Investigation Background check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a finger-print based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of the state within the last five (5) years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on 02/15/13. The memo included .at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every three (3) years thereafter throughout the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow nursing facilities until (MONTH) 1, 2014, to have all current employees up to date with criminal background checks .For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2018-09-01
5672,NELLA'S NURSING HOME,5.1e+35,"200 WHITMAN AVENUE, CRYSTAL SPRINGS",ELKINS,WV,26241,2015-02-19,225,D,0,1,VV3811,"Based on record review and staff interview, the facility failed to complete thorough investigations into the past histories for two (2) of five (5) employees whose personnel files were reviewed. Background checks through the Nurse Aide Registry program were not completed upon hire. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #52 and #55. Facility census: 68. Findings include: a) The personnel file of Employee #52, maintenance employee, was reviewed on 02/18/15 at 4:00 p.m. Employee #52 was hired on 10/30/13. There was no evidence a Nurse Aide Registry search was performed. b) The personnel file of Employee #55, laundry employee, was reviewed on 02/18/15 at 4:00 p.m. Employee #55 was hired on 06/04/13. There was no evidence a Nurse Aide Registry search was performed. c) This matter was discussed with Employee #20, secretary, on 02/19/15 at 1:00 p.m. She stated she could not find evidence of a Nurse Aide Registry search on either employee.",2018-09-01
5693,PINE LODGE,515001,405 STANAFORD ROAD,BECKLEY,WV,25801,2015-01-29,225,F,0,1,WCKU11,"Based on staff interview and review of employee personnel files, the facility failed to conduct a thorough investigation into the criminal background of one (1) of five (5) employees hired within the past five (5) months. Employee #126 lived out of the state of West Virginia in the previous 5 years. The facility did not complete a fingerprint based criminal background check in the state in which the employee lived. This had the potential to affect all residents residing at the facility. Employee identifier: #126. Facility census: 108. Findings include: a) Employee #126 Review of the personnel files with Employee #27, identified as the bookkeeper, at 3:50 p.m. on 01/26/15 found Employee #126, a nurse aide, had lived in another state from 2007 to 2014. Employee #27 confirmed a criminal background check had not been completed in the other state.",2018-08-01
5713,CLARY GROVE,515039,209 CLOVER STREET,MARTINSBURG,WV,25404,2014-11-19,225,E,0,1,H5V711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of facility records of investigations into allegations of abuse, neglect, mistreatment of [REDACTED]. to the designated representatives of the State survey and certification agency when requested as required by section 483.13 (c)(2) and (4) of the facility's reporting requirements. This decision was made based on the lengthy and unnecessarily secretive method of discovery for review of the facility's investigation documents during the survey. This had the potential to effect any resident who made an allegation of abuse, neglect, mistreatment of [REDACTED]. Resident identifiers: #23, 92, 43, 20, 26, 29, 24, 34, 65, 6, 83, 233, and 81. Facility census 110. Findings include: a) A primary purpose of the Quality Indicator Survey (QIS) is to ensure the facility's compliance with the residents' rights and quality of life requirements. On 11/10/14 during entry into the facility, a written request was made to the Administrator for Evidence that the facility, on a routine basis, monitors accidents and other incidents, records these in the clinical or other record, and has in place a system to prevent and/or minimize further accidents and incidents. The facility provided the surveyors with 48 files of incidents which they had identified, reported to the State, and investigated. At 10:30 a.m., on 11/13/14, a review of these files had resulted in questions regarding the investigative findings for six (6) of the seventeen (17) files already reviewed. When this concern was expressed to the administrator, she explained the (facility name) office had changed their policy regarding the accessibility of the facility's investigations of accidents/incidents and of allegations of abuse, neglect, mistreatment of [REDACTED]. The facility now retained two (2) separate files on reportable events. The files presented for survey review contained: the Immediate Fax Reporting of Allegations (NAR-1); the Five Day Follow-up Report (NAR-2); and a facility name Investigation Report generated by the social worker, who was identified as the contact person regarding abuse prohibition policies and procedures / complaints / Grievance Information. This report was her summary of the investigation and its outcome and stated: -- This report reflects information and data collected by or at the direction of the Quality Assessment & Assurance Committee. This report should not be shared with outside third parties. If a state or federal agency requires evidence of an investigation, this report may be made available for review subject to the following cautionary statement. Cautionary notice: This report was prepared by or at the direction of the Quality Assessment & Assurance Committee. It is provided to you for review purposes under state and federal laws and is confidential pursuant to those laws. The Administrator stated a second file which was protected as part of the Quality Assurance process was maintained and contained all original documentation generated during the investigation of an incident. In order for the surveyor to view the second file the surveyor was required to request each one from the Administrator/Social Worker who would contact the corporate office for permission and, if granted, they would bring the 2nd file; stay while the information was reviewed; and then remove it. If a copy of any document was requested, the same procedure was repeated for each document. b) A review of the reportable incident investigations based on the files provided by the facility for review on 11/11/14, revealed the following concerns: 1) 11/08/14: An allegation of abuse by Resident #34 which was reported to Nurse Aide Registry (NAR) on 11/10/14. The five day Follow-Up Report included in the Narrative Investigation: Resident stated that the aide was not rough with her or her roommate At 3:25 p.m. on 11/18/14, the surveyor requested a copy of the interview statement made by Employee #102 and of the incident report filed on 11/08/14 by Employee #128 to verify both the date of the initial allegation to a nurse and the aides observation of the resident at the time of the incident. The Social Worker returned at 3:50 p.m. stating that permission for copies was denied. At 9:40 a.m. on 11/19/14, after communication with the Office of Health Facilities Licensure and Certification (OHFLAC), the Administrator provided a copy of the incident report, but stated per corporate instructions she could not release the employee statement. 2) 10/30/14: Investigation Report of an allegation regarding Resident #20 stated employee statements had been taken, but did not state the content and the reason for the stated outcome was unclear. 3) 10/28/14: Five-Day Follow-up Report of an incident involving Resident #65 having a injury of unknown origin attributed to her wheelchair and stated only it had been referred to therapy, but did not include therapy's findings. 4) 10/19/14: A review of the Immediate report to OHFLAC (office of health facility licensure and certification); the Five-Day Follow-up Report. The Investigation Report indicated statements were taken from Employees #62, #7, and #126 (aides), but they were not present in the file. 6) 10/18/14: Five-Day Follow-up Report of an incident involving Resident #6 indicated the allegation was Substantiated and the nurse received Counseling, but there was no evidence of proof or content of the counseling. 7) 10/18/14: Five-Day Follow-up Report of an incident involving Resident #24 indicated the allegation was Substantiated and the nurse received Counseling, but there was no evidence of proof or content of the counseling. 8) 10/06/14: An allegation of a missing hearing aid for Resident #23 included a list of people interviewed, but the Five-Day Follow-up Report was unclear as to Outcome and the Corrective Action was undetermined. 9) 09/27/14: An allegation of missing money by Resident #83 was confusing and did not state if it was substantiated or not although the Five-Day Follow-up Report did indicate a Safe as the Corrective Action. In an interview with the Social Worker at 3:00 p.m. on 11/17/14, she provided additional information, including the original allegation by Resident #83 naming another resident as stealing the money, which was not included in the Immediate Report to OHFLAC. 10) 09/28/14: Five-Day Follow-up Report of an an allegation of physical abuse by Resident #29 listed no outcome. 11) 09/26/14: An allegation was received from the Nursing Home Program of statements from two (2) nurse aide students that an aide (Employee #18) in the facility had made inappropriate comments to Resident #92 in their presence on 09/26/14. The Investigation Report indicated eight (8) people were interviewed regarding the allegation, but only one (1) of the eight (8) people interviewed was present during the incident and that person was the accused. There was no evidence in the report the resident, who had been determined by his attending physician to have the capacity to form his own medical decisions and scored 15 out of a possible 15 correct responses on his Brief Interview for Mental Status (BIMS) examination on 08/06/14 (indicating he was cognitively intact), was asked for a statement. There was no evidence in the report the two (2) students who reported the incident were interviewed. During an interview with the Administrator and the Social Worker (SW) at 3:00 p.m. on 11/17/14, the SW was asked why the students who were present in the room and reported the incident were not interviewed, but had no answer. On the afternoon of 11/18/14, the SW produced a statement she had located from the Nurse Aide Instructor who had also been reported by the students for participating in the same inappropriate comments, but while the statement acknowledged her part in the inappropriate treatment, she did not mention Employee #18 at all. --8/28/14: During an interview by the SW Resident #26 Reports that nurse does not give him his pain medications during med pass. The only interviews indicated on the Investigation report were with the resident and the Director of Care Delivery (DCD) nurse for the unit. There were no interviews with the direct care team. The Five-Day Follow-up Report stated the resident was educated on orders on 08/28/14 and, under Outcome: res (resident) receives routine pain and has an order for [REDACTED]. --8/13/14: An allegation was made that Resident # 43 was over medicated. The Investigation Report indicated there were interviews with the resident, 2 aides, and 1 nurse. It also stated the MD reviewed previous and current medication regimen. There was no information regarding medication administration or nursing assessments in the file. The Five-Day Follow-up Report stated: Allegation unsubstantiated per facility investigation. -- 09/23/14: A Complaint of missing clothing was made by Resident #43, was reported timely, search was unsuccessful, and clothing was replaced. The Investigation Report documented interviews with three (3) staff, which surveyors were not given access to in the file presented. Housekeeping and laundry supervisor #75 was listed, with no date or time given. Nursing assistant #62 was listed, date was given as 10/7/14. Licensed practical nurse, #109 was listed, date was given as 10/7/14. The five day follow up was completed on 09/24/14. The Investigation Report documented interviews with two (2) residents. These residents were #34, and #37. They were all supposedly interviewed on 10/7/14. The five day follow-up was completed on 9/24/14. Although the purpose and content of the staff and resident interviews could not be investigated by the surveyors, and it is unclear why so many were interviewed several days after the allegation was unsubstantiated, per report, there was sufficient documentation found to determine the investigation was sufficient to determine the item was gone, it was unknown why, and it was replaced Summary: Review of 48 reported incidents, provided to the survey team, revealed 17 would require additional documentation to determine if the facility's investigation was thorough, complete, and appropriate. Even if the content of interviews were summarized on the Investigation Report , it would not ensure the summaries were accurate and complete accounts of pertinent information. Therefore without access to investigative source documents it cannot be determined all investigations were thorough, pertinent to all allegations, and if the conclusion was appropriate. During an interview with the Administrator at 8:30 a.m. on 11/19/14, she was informed of the surveyors concern that it was not acceptable to base our decisions solely on the files presented to us and the facility's practice of requiring individual requests for additional information that was slowed by requiring communication with a distanced corporate office for decisions was both time consuming and questionable as the documents in the protected files were handed to the surveyor individually from the file and removed immediately when the staff person left the room. This process for only 6 reviews required 8 separate staff interviews and over 4 hours. The administrator replied that her hands were tied as the decision had been made at the corporate level. A supplemental random review of four (4) allegations of abuse/neglect/misappropriation of property on 11/19/14 at 10:07 a.m. as part of teh abuse prohibition review revealed: 1. Resident #43: Date of allegation 9/23/14. Complaint of a missing bra was reported to HRD. Was reported timely, search was unsuccessful, bra was replaced. The Investigation Report documented interviews with three (3) staff, which surveyors were not given access to. Housekeeping and laundry supervisor #75 was listed, with no date or time given. Nursing assistant # 62 was listed, date was given as 10/7/14. Licensed practical nurse, #109 was listed, date was given as 10/7/14. The five day follow up was completed on 9/24/14. The Investigation Report documented interviews two (2) residents, which surveyors were not given access to. These residents were #34 and #37. They were all supposedly interviewed on 10/7/14. The five day follow-up was completed on 9/24/14. Although the purpose and content of the staff and resident interviews could not be investigated by the surveyors, and it is unclear why so many were interviewed several days after the allegation was unsubstantiated, there was sufficient documentation found to determine the investigation was sufficient to determine the item was gone, it was unknown why, and it was replaced. 2. Resident #43 date of allegation 08/25/14. Complaint of $5.00 in change missing. Reported to RN DCD. The facility was unable to substantiate misappropriation, but replaced the money and provided resident with a lockbox. No interviews were documented. The room was searched and the money was not located. There was sufficient evidence to determine the money was gone, it was replaced, and preventive measures were implemented. 3. Resident #81. Date of allegation 09/14/14. She reported not receiving her pain medication and that no one in the facility is nice to her. The Investigation Report documented the following: Medical Record Review. The people interviewed were listed as Resident #105 who was interviewed on 09/07/14 at 11:00 a.m. Resident #81 who was interviewed on 09/07/14 at 11:30 a.m. Resident #7 who was interviewed 09/07/14 at 11:15 a.m. The allegation unsubstantiated per facility investigation. Resident now requests stronger pain medication and nurse contacted MD who ordered [MEDICATION NAME]. The five day follow up stated, Allegation unsbubstantiated per interviews with resident, like residents, nursing documentation. Access to the witness statements was denied. It could not be determined if the investigation was thorough, pertinent to all allegations, and if the conclusion was appropriate. 4. Resident #233. Allegation date 08/31/14. Alleged not receiving medications timely. Also her daughter expresses concern stating that her mom requested pain pill and the nurse said she would have to look at the books. She said she pressed the call button seven separate times for an aide. The investigation report stated, Documents reviewed 1. Medical record review 2. Staff interview. Under People interviewed a nursing former nursing assistant was listed as interviewed on 09/03/14 at 3:00 p.m. Resident #233 was listed as interviewed on 09/03/14 at 10:30 a.m. Resident #1 was listed as interviewed on 09/05/14 at 11:00 a.m. The Summary of critical information included: .unable to obtain statement from Nurse (name).educated on use of call light. unable to substantiate untimely administration of pain medication. PCC (point click care) documentation indicated frequent toileting. Resident reports no further issues. Access to the witness statements was denied. It could not be determined if the investigation was thorough, pertinent to all allegations, and if the conclusion was appropriate. Investigation found two (2) of four (4) allegations required review of the actual witness statements and other documentation in order to determine whether the facility ' s investigation was thorough, complete, and appropriate. Even if the content of interviews were summarized on the Investigation Report , it would not ensure the summaries were accurate and complete accounts of pertinent information. Therefore without access to investigative source documents it cannot be determined all investigations were thorough, pertinent to all allegations, and if the conclusion was appropriate. g) A reported allegation of neglect for resident #81 was reviewed on 09/19/14 at 11:30 a.m. The date of the allegation was 09/14/14. She reported not receiving her pain medication and that no one in the facility was nice to her. The Investigation Report summary documented: 1. Medical Record Review 2. People interviewed were listed as Resident #105 on 09/07/14 at 11:00 a.m. Resident #81 was interviewed at 11:30 a.m. on 09/07/14. Resident #7 was interviewed on 09/07/14 at 11:15 a.m. 3. The allegation unsbustantiated per facility investigation. Resident now request stronger pain medication and nurse contacted MD who ordered [MEDICATION NAME]. 4. The five day follow-up stated, Allegation unsubstantiated per interviews with resident, like residents, nursing documentation. Access to the witness statements was denied. Because of this, based only upon the provided summary, It could not be determined if the investigation was thorough, pertinent to all allegations, and if the conclusion was appropriate. h) A reported allegation of neglect for resident #233 was reviewed on 11/19/14 at 11:50 a.m. The date of the allegation was 08/31/14. She alleged not receiving medications timely. Also her daughter said (typed as written): expresses concern stating that her mom requested pain pill and the nurse said she would have to look at the books. She said she pressed the call button seven separate times for an aide. The Investigation Report stated, 1. Documents reviewed 1. Medical record review 2. Staff interview People Interviewed The people interviewed were listed as a former nursing assitant on 09/03/14 at 3:00 p.m. Resident #233 on 09/03/14 at 10:30 a.m. Nursing assistant #136 on 09/03/14 at 11:00 a.m. Resident #1 on 09/05/14 at 11:00 a.m. 3. Summary of critical information included: .unable to obtain statement from nurse (name). .educated on use of call light. Unable to substantiate untimely administration of pain medication. PCC (point click care) docuementation indicated frequent toileting. Resident reports no further issues. Access to the witness statements was denied. Because of this, based only upon the provided summary, It could not be determined if the investigation was thorough, pertinent to all allegations, and if the conclusion was appropriate. The investigation found two (2) allegations required review of the actual witness statements and other documentation in order to determine whether the facility's investigation was thorough, complete, and appropriate. Even if the content of interviews were summarized on the Investigation Report, it would not ensure the summaries were accurate and complete accounts of pertinent information. Without access to all investigative source documents it cannot be determined all investigations were thorough, pertinent to all allegations, and if the conclusion was appropriate.",2018-08-01
5731,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2015-08-21,225,D,1,0,Z9U411,"Based on record review and staff interview the facility failed to ensure all allegations of neglect were reported to appropriate State agencies and thoroughly investigated. This was true for one random opportunity for discovery during a complaint survey. A nurse aide's personnel file contained an individual performance improvement plan (IPIP) which included allegations of neglect. There was no indication these allegations of neglect were ever reported and/or thoroughly investigated by facility staff. Employee identifier: #84. Facility census: 117. Findings Include: a) Employee #84 A review of NA #84's personnel file, at 1:30 p.m. on 08/18/15, found an IPIP dated 02/12/15. The incident date on the IPIP was 02/11/15. The description of event was, . resident found in wet bed with dried stool on the resident, therapy baths reported that they were complete, were not. The IPIP contained NA #84's signature with a date of 02/12/15. The IPIP was also signed by Registered Nurse (RN) #128 who was NA #84's supervisor, with a date of 02/12/15. Review of the incidents from 02/01/15 through 08/17/15 found no record this incident was reported. At 2:30 p.m. on 08/18/15, a discussion was held with the Director of Nursing (DON), Nursing Home Administrator (NHA), and Social Worker (SW) #69, in regards to this allegation of neglect. The NHA reported he did not work here in (MONTH) so he was not aware of this allegation. The DON and SW #69 both stated they worked at the facility at the time, but were unaware of this incident. The DON indicated RN #128 should have given her the IPIP at which time she would have given it to SW #69 and an investigation would have begun. They indicated they did not know who the resident was that was in the wet bed with dried stool. They went on to say they would not be able to determine which residents were documented as receiving baths when they did not. They both confirmed the incident was not reported, nor was it investigated due to their lack of knowledge of the incident. The DON indicated this was the first time she was made aware of this incident. The DON said RN #128 no longer worked at the facility, so it would be difficult to investigate. She said the facility would never be able to determine which residents were affected.",2018-08-01
5740,DUNBAR CENTER,515066,501 CALDWELL LANE,DUNBAR,WV,25064,2015-10-20,225,F,0,1,30IW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to thoroughly investigate the past histories of potential employees to ensure they were eligible for hire based on potential past criminal histories. Employees #100, #105, #125, #124 and #122 each lived in a state other than West Virginia (WV) in the previous five (5) years. The facility did not complete a fingerprint-based criminal background check in the other states in which the employees previously lived. This practice had the potential to affect all residents (census 117) currently residing in the facility. In addition, based on record review, resident interview, family interview, and staff interview, the facility failed to report and/or investigate allegations of abuse and neglect to State agencies as required. This was found for five (5) of twenty-five (25) resident complaints filed with the facility, and for one (1) of five (5) residents reviewed for dignity during Stage 2 of the Quality Indicator Survey. Residents #41, #170, #107, #212, #4, and #98. Facility census: 117 Findings include: a) Thorough Criminal Background Checks 1. License Practical Nurse #100 Review of Licensed Practical Nurse (LPN) #100's personnel record, at 8:45 a.m. on 10/14/15, found it contained an application for employment. According to the application, LPN #100's hire date was 06/10/15. She lived in another state from (MONTH) 2007 until (MONTH) 2014. LPN #100's personnel record contained no evidence a fingerprint-based criminal background check was completed in the previous state prior to, or upon, her employment with the facility. 2. Physical Therapy Assistant (PTA) #105 PTA #105's personnel record, reviewed at 8:55 a.m. on 10/14/15, revealed an application for employment for PTA #105, with a hire date of 05/20/15. The application identified he worked and lived in another state from (MONTH) 1992 until (MONTH) (YEAR). Review of PTA's #105's personnel record revealed no evidence a fingerprint-based criminal background check was completed in the previous state prior to, or upon, his employment with the facility. 3. Nurse Aide (NA) #125 At 9:15 a.m. on 10/14/15, review of NA #125's personnel record found it contained an application for employment indicating NA #125's hire date was 09/24/15. She lived in another state from (MONTH) 2013 until (YEAR). NA #125's personnel record contained no evidence of a fingerprint-based criminal background check completed in the previous state prior to, or upon, her employment with the facility. 4. NA #124 Review of NA#124's personnel record, at 9:45 a.m. on 10/14/15, found an application for employment, with a hire date as 08/07/15. He lived in another state from (MONTH) 2000 until (MONTH) 2011. The NA's file contained no evidence of a fingerprint-based criminal background check completed in the previous state prior to, or upon, his employment with the facility. 5. NA #102 NA #102's personnel record, reviewed at 10:15 a.m. on 10/14/15, found the NA was hired on 02/04/15. She lived in another state from (MONTH) 2014 until (MONTH) 2014. NA #102's personnel record contained no evidence of a fingerprint-based criminal background check in the previous state prior to, or upon, her employment with the facility. 6. An interview with Bookkeeper (BK) #84 at 10:30 a.m. on 10/15/15, confirmed LPN #100, PTA #105, NA #125, NA #124, and NA #102 had each lived and/or worked in another state. She said the facility did a fingerprint-based criminal background check for LPN #100 on 06/03/15 and repeated it on 08/28/15, but had still not received results of the background check. The facility provided no evidence LPN #100's fingerprints were mailed to the appropriate agency, and/or were processed. BK #84 said the facility did not do a fingerprint-based background check in the states in which PTA #105, NA #125, NA #124, and NA #102 previously resided. She stated their corporate office did a nationwide background check based on the employee's social security number, but it was not fingerprint-based. 7. The Bureau for Medical Services (the State Medicaid Agency) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees . For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013. b) Reporting of Grievances and Complaints The facility's grievance and complaint files were reviewed on 10/19/15 at 10:00 a.m. Twenty-five (25) complaints, covering the period from 05/01/15 through 10/01/15, were reviewed. Five (5) of these complaints were allegations of abuse and/or neglect, which should have been immediately reported to the appropriate State agencies. 1. Resident #41 Resident #41 voiced a concern to Social Worker (SW) #98 on 08/17/15. The social worker's narrative documentation described the concern as (typed as written): Resident felt as though therapy staff pressured her to complete therapy. Under the section Investigation, SW #98 documented, Spoke with (Resident #41) about the therapist attempting to motivate resident, situation discussed and customer service in-service completed 2. Resident #170 Review of Resident #170's concern, voiced to SW #98 on 08/21/15, found the SW's narrative documentation described the concern as (typed as written): Resident felt as though therapy staff pressured her to complete therapy. Under the section Investigation, SW #98 documented, Spoke with (Resident #170) about the therapist attempting to motivate resident and customer service in-service completed 3. Resident #107 Review of Resident #170's concern voiced to Admissions Director #79 on 09/11/15, found the AD's narrative documentation described the concern as (typed as written): Patient states that last evening (9/10) (September 10, (YEAR)) the nursing assistant caring for her acted as if she 'patient' was an imposition and it took 1/2 hour for call light to be answered. Also, she was having chest discomfort and told her nursing assistant. According to patient, the nursing assistant told her the nurse was at lunch. Son present at time concern expressed. Under the section Investigation, SW #98 documented, Reeducation completed. 4. Resident #212 Review of Resident #212's concern voiced to SW #98, on 07/17/15, found the SW's narrative documentation described the concern as (typed as written): Rude nursing assistant (NA) on midnight shift; unable to identify nursing assistant. Under the section Investigation SW #98 documented, Customer service in-service completed. 5. Resident #4 Review of Resident #4's concern voiced to SW #98, found the SW's narrative documentation described the concern as (typed as written): Nursing assistant (NA) rude on day shift (05/31/15); unable to identify nursing assistant. Under the section Investigation it was documented SW #98, Spoke with the Nurse Practice Educator (NPE), Director of Nursing (DON) and Unit Manager (UM). NPE to review customer service with all nursing staff in nurse's meeting on 06/22/15. 6. An interview was conducted with social worker, Employee #98, on 10/19/15 at 10:15 a.m. She acknowledged the five (5) complaints were allegations of neglect and/or abuse which should have been reported immediately, but were not. c) Resident #98, Reporting and Thorough Investigation of an Allegation of Abuse During Stage 1 of the Quality Indicator Survey (QIS), at 3:38 p.m. on 10/12/15, when asked if staff treated her with dignity and respect, Resident #98 stated, No, I had a little disturbance when I first came here. The resident stated a nurse aide (NA) came into her room to get her breakfast tray. She said she allowed her (the NA) to take the tray, but she (the resident) kept her cereal bowl in her room to finish eating her cereal. She said when she finished the cereal, she took her bowl and silverware out into the hallway and placed them in an empty wheelchair in the hallway. She stated, I didn't know any better and I saw other people doing that. I put it out there so they would know I was done with it. The girl (NA) came into my room with the bowl and threw it at me yelling, this is your trash and you need to pick it up. I am not here to pick up after you. The resident said it really upset her when the girl yelled at her. She did not know the name of the staff member. Medical record review, at 2:00 p.m. on 10/13/15, revealed the resident was admitted to the facility on [DATE]. Review of the reportable incidents of abuse/neglect and grievance/concern forms found no evidence the incident was reported or thoroughly investigated. During an interview with the resident at 2:30 p.m. on 10/13/15, the resident was asked if anyone from the facility had talked to her about the incident. She stated, No, but I told my cousin about it when she visited and I think she (the cousin) talked to someone about it, you should ask her. An interview with the resident's Licensed Practical Nurse (LPN) #83, at 3:04 p.m. on 10/13/15, found she remembered the incident. She stated, (the name of the nurse aide) yelled at the resident and stated something about, 'Don't put your garbage in this hall anymore.' I heard the yelling and went down to (Resident #98's) room to see what was going on. LPN #83 stated she reported the incident to Social Worker (SW) #34. A telephone interview at 3:04 p.m. on 10/14/15, with the resident's cousin, found the resident told her about the incident. the cousin said, I told a person in charge about it, but I don't remember her name. She stated, If you knew (name of resident) you would understand why she was so upset. (Name of resident) is very neat and she can't stand anything laying around, she has to put everything in its place. She was just cleaning up her room and the way she was talked to, really hurt her feelings. During an interview, at 8:30 a.m. on 10/15/15, SW #34 stated, I remember getting statements - it was a big deal. It was reported, let me look for it. She said she would call the nurse aide program and obtain a copy, if she was unable to find the facility's copy. At 9:01 a.m. on 10/15/15, SW #34 stated, I thought we reported it, but we didn't. I did take statements, but they said they were going to handle it as a personnel issue because the nursing assistant was rude. SW #34 said the former administrator said she would take care of the situation. The SW provided copies of three (3) statements, which she said she obtained on 06/09/15. Review of the statements found one (1) statement from a nurse aide working with the alleged perpetrator, a second statement from the alleged perpetrator, and the third statement from the licensed nurse on duty the day the alleged incident occurred. There was no statement from the resident. SW #34 verified the alleged perpetrator no longer worked at the facility, but stated the reason she was no longer there had nothing to do with the allegation. SW #34 also stated the alleged perpetrator continued to work at the facility after the incident. The statements the facility obtained from staff included: a. Nurse Aide (NA) #73, statement dated 06/09/15. I heard (name of nurse aide) take (name of resident) items into her room. She told (name of resident), I am going to set your trash in here . (name of resident) was in her doorway and upset over someone coming in room and calling her stuff trash. (Name of nurse aide) said well it is trash. That was all she said, but it was the tone she used and the approach. Kind of with an attitude b. Licensed Practical Nurse (LPN) #83, statement, dated 06/09/15. (Typed as written) While passing meds this am (morning) (name of resident) brought a bowl and cup from her room to put on the tray cart and the cart had been taken around and she sat them on the w/c (wheelchair). The CNA (certified nurse aide) (name of nurse aide) came out of a room and picked the dishes up and took them back to the room and yelled at resident saying heres your trash you can't put your trash in the hallway. (name of resident) tried to explain to her why she put them in the w/c and (name of nurse aide) continued to say you can't put trash in the hallway and (name of resident) began to cry. c. Alleged perpetrator statement, dated 006/09/5. The nurse aide denied the allegation, stating, . (name of resident) started going off so I left 8. An interview with the administrator, at 9:16 a.m. on 10/21/15, found he was aware of the incident involving Resident #98. He stated he would now be reviewing all allegations of neglect/abuse and all grievance concern forms. He said any allegations of abuse/neglect would be reported to the proper State authorities, and added, This will no longer be a problem now that I am here. He stated he could not comment on why the incident was not reported because he was not the administrator of record when the alleged incident occurred. .",2018-08-01
5767,MANSFIELD PLACE,515129,95 HEALTHCARE DRIVE,PHILIPPI,WV,26416,2015-02-10,225,E,0,1,8Z8911,"Based on personnel record review and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty, by a court of law, of abusing, neglecting, or mistreating residents. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions which occurred in a state in which the employee had formerly lived and/or worked within the past five (5) years prior to employment at the facility. THis practice had the potential to affect more than an isolated number of residents. Employee identifier: #36. Facility census: 59. Findings include: a) Nurse Aide #36 On 02/05/15 at 10:00 a.m., personnel records of employees hired within the preceding four (4) months were reviewed with Human Resource Employee #110. Nursing aide (NA) #36, was hired by the facility on 10/04/14. Personnel record review found this employee had lived and/or worked in another state within the past five (5) years prior to hire by the facility. Upon inquiry, Employee #110 said the facility was unaware that a criminal background check needed to be completed in the former state in which the employee resided. Employee #110 said a fingerprint background check by the West Virginia State Police was completed in West Virginia for Employee #36. Also, the facility checked the nurse aide registry in the former state in which the resident had resided to see if there were any findings of abuse or neglect for Employee #36's nursing assistant certification. Employee #10 said she thought that was all that was necessary for the background check for Employee #36.",2018-08-01
5780,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2015-08-05,225,D,1,0,5S9P11,Deficiency Text Not Available,2018-08-01
5785,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2015-07-10,225,F,0,1,0TIA11,"Based on employee personnel file review and staff interview, the facility failed to ensure all employees were thoroughly screened for histories that would indicate the individual was unfit for service in a nursing home through the use of a Statewide criminal background check. This was true for one (1) of five (5) newly hired employees reviewed for Statewide criminal background checks. This had the potential to affect all residents. Employee identifier: #32. Facility census: 19. Findings include: a) Nurse Aide #32 On 07/09/15 11:00 a.m., after reviewing personnel information received from the facility, there was no evidence found to verify Nurse Aide (NA) #32 had a Statewide criminal background check. The individual's hire date was 05/04/15. At 12:45 p.m., on 07/09/15, after attempting to find the statewide background check documentation for Employee #32, the facility administrator stated there was no record of the statewide background check being completed. The Affordable Care Act includes: (3) REQUIRED FINGERPRINT CHECK AS PART OF CRIMINAL HISTORY BACKGROUND CHECK -The procedures established under subsection (b)(1) of such section 307 shall- (A) require that the long-term care facility or provider (or the designated agent of the long-term care facility or provider) obtain State and national criminal history background checks on the prospective employee through such means as the Secretary determines appropriate . The procedures established under subsection (b)(1) of such section 307 shall- (A) require that the long-term care facility or provider (or the designated agent of the long-term care facility or provider) obtain State and national criminal history background checks on the prospective employee . provide for a provisional period of employment by a long-term care facility or provider of a direct patient access employee, not to exceed 60 days, pending completion of the required criminal history background check and,",2018-08-01
5789,WEIRTON GERIATRIC CENTER,515037,2525 PENNSYLVANIA AVENUE,WEIRTON,WV,26062,2014-10-07,225,D,0,1,U60O11,"Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual, review of a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure a thorough evaluation of each employee to determine if each employee was fit to work in the facility. One (1) of ten (10) employees reviewed, who had been employed by the facility more than three (3) years, had no fingerprint-based state level criminal investigation background check results, as required every three (3) years. Employee identifier: #30. Facility census: 132. Findings include: a) On 10/02/14 at 8:05 a.m., a review of the personnel files for tenured employees was conducted with Employee #63, the Human Resources representative. This review identified the following: 1. Employee #30 A review of the personnel file for Employee #30, a Nurses Aide (NA), who was hired on 10/16/2006, revealed no evidence an up to date statewide criminal background check was completed since her hire date. The review also revealed Employee #30 had a criminal background/fingerprint check that was rejected on 11/13/13 which was not acknowledged or repeated by the facility until another background check/fingerprints was sent on 04/27/14. These results were unavailable in the employee personnel file for review during the survey. On 10/02/14 at 8:15 a.m., an interview was conducted with Employee #63. She verified the NA's fingerprints were sent on 04/27/14, and verified the results or rejections were not available at the time of the QIS survey. Employee #63 acknowledged the receipt of the letter received by the facility requiring all current employees to be in compliance with up to date background checks/fingerprints by (MONTH) of 2014. She also commented the rejection of the criminal background check dated 11/13/13 should have been acknowledged and repeated in a more timely manner. b) The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on (MONTH) 15, 2013. The memo included .at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until (MONTH) 1, 2014, to have all current employees up to date with criminal investigation background checks . For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013.",2018-07-01
5813,PUTNAM CENTER,515070,300 SEVILLE ROAD,HURRICANE,WV,25526,2014-10-21,225,F,0,1,VUH711,"Based on record review and staff interview, the facility failed to thoroughly investigate the criminal background of all employees. Employee #16 and Employee #45 had both lived out of the state of West Virginia in the previous five (5) years. The facility did not complete a fingerprint based criminal background check in the states in which they had lived. This practice had the potential to affect all residents currently residing in the facility. In addition, the facility failed to report all allegations of abuse and neglect to State agencies as required. Resident #65 made an allegation of neglect which was not reported to the required State agencies. This was found to be true for one (1) of fifty-one (51) facility complaints and concerns reviewed during Stage 2 of the Quality Indicator Survey. Employee Identifiers: #16 and #45. Resident Identifier: #65. Facility Census: 115. Findings include: a) Criminal Background Checks 1. Employee #45 Social Worker (SW) #45's personnel record was reviewed at 8:25 a.m. on 10/15/14. It contained an application for employment which indicated SW #45 had lived in another stated from (MONTH) 1990 until (MONTH) 2012. SW #45's personnel record revealed no evidence a fingerprint based criminal background check was completed in the previous state prior to, or upon, her employment with the facility. 2. Employee #16 Nurse Aide (NA) #16's personnel record was reviewed at 8:55 a.m. on 10/15/14. It revealed an application for employment which indicated NA #16 had worked and lived in another state from (MONTH) 2010 until (MONTH) 2013. Review of NA #16's personnel record revealed no evidence a fingerprint based criminal background check was completed in the previous state prior to, or upon, her employment with the facility. 3. An interview with Bookkeeper #106, at 10:33 a.m. on 10/15/14, confirmed SW #45 and NA #16 had each lived and/or worked in another state. She said the facility did not do fingerprint based criminal background checks for employees who had lived out of state. She indicated their corporate office did a nationwide background check based on the employee's social security number, but it was not fingerprint based. b) Resident #65 The facility's grievance and concern forms for the previous six (6) months were reviewed at 4:48 p.m. on 10/14/14. A grievance/concern form, dated 08/21/14 was completed after Resident #65 reported to staff (typed as written), She was not changed (briefs) from 7:30 p.m. on 08/20 (2014) to 5:30 a.m. on 08/21 (2014) after she asked the CNA (Certified Nursing Assistant) to change her. A review of the facility's reportable incidents, at 5:15 p.m. on 10/14/14, revealed no evidence this allegation of neglect was reported to Adult Protective Services (APS) or The Office of Health Facilities Licensure and Certification (OHFLAC) in accordance with State law. (Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, revised 10/2011). An interview with Social Service Director (SSD) #92, at 11:26 a.m. on 10/15/14, confirmed this allegation of neglect was not reported to the appropriate State agencies. She reviewed the concern and stated the reason it was not reported was because the Director of Nursing (DON) had spoken to Resident #65 and the staff members involved on 08/22/14. The DON concluded the resident did not remember the staff checking on her during the night because she was asleep and did not need to be changed. The SSD agreed Resident #65's original concern was an allegation of neglect. Allegations of neglect are reportable. At 5:00 p.m. on 10/15/14, the SSD provided a copy of an Immediate Fax Reporting of Allegations - Nursing Home Program form which had been faxed to OHFLAC at 2:28 p.m. on 10/15/14. The date of the incident was listed as 08/20/14-08/21/14. On the section titled, Brief description of the incident, the following was written (typed as written), Resident stated she was not changed from 7:30 p.m. on 08/20/14 to 5:30 a.m. on 08/21/14 after she had asked to be changed. Allegation addressed as a concern/grievance on 08/21/14, however, after review by facility staff we have determined concern should be reported. The SSD indicated, they had decided to report this concern as an allegation of neglect.",2018-07-01
5862,HILLCREST HEALTH CARE CENTER,515117,462 KENMORE DRIVE,DANVILLE,WV,25053,2014-11-17,225,D,0,1,LO0C11,"Based on medical record review and staff interview, the facility failed to conduct a thorough investigation of an injury of unknown origin to rule out abuse or neglect for one (1) of thirty-two (32) Stage 2 residents. The resident was found with swelling and bleeding of her nose, bruising to the left eye and to the right side of the nose. The facility was unable to provide evidence a thorough investigation was conducted to determine the cause of these injuries to the resident. Resident identifier: #31. Facility census: 87. Findings include: a) Resident #31 Observations of Resident #31, on 11/10/14 at 3:20 p.m., found the resident in bed. Her arms and legs were pulled in towards her inner body in a fetal-like position. The resident had yellow bruising beneath both eyes, extending over the bridge of her nose. Review of Resident #31's medical record, on 11/14/14 at 11:00 a.m., revealed a quarterly minimum data set (MDS) assessment with an assessment reference date of 08/02/14. This MDS indicated Resident #31 required extensive assistance with activities of daily living, had impairments of upper and lower extremities with a contracture of the right hand, limited range of motion in upper and lower extremities, and was non-ambulatory. Further record review, on 11/14/14 at 11:30 a.m., revealed an incident report completed by Licensed Practical Nurse (LPN) #103. It included, 10/28/14 at 7:30 a.m. This nurse called to resident's room by NA (nursing assistant). I observed resident in bed while NA was performing routine care for resident. The right nostril had some bleeding. I got a wash cloth and cleaned blood from the nostril. I had also observed nose to be swollen but no deformity seen but area to nose appeared to have bruising. Resident had bruising noted to left inner corner to eye. Bruising measured to left eye as 7 cm in length and approximately 3 cm in width. Bruising noted to right side of nose 1.5 cm in length and 0.5 cm in width. On the incident report, under the section labeled Notes was an entry by the Director of Nursing (DON). The entry was dated 10/28/14. The DON wrote she was notified of the incident and entered the building to conduct an investigation on 10/27/14. -- The DON listed the names of Employees #66, #80, #89, #65, #37, #18, #20,#103 and #4. -- The note indicated Employee #66, a registered nurse (RN) fed the resident her dinner (the night before) and stated there were no skin integrity issues to the resident's face at that time. -- The DON stated Employee #80, a nursing assistant (NA), took the resident to her room and Employee #80 and Employee #4, a NA, transferred the resident to bed. According to the note, the transfer was completed without incident and the resident was positioned in bed for comfort. -- The DON's note indicated Employee #80 returned to the resident's room about 30 minutes after putting her to bed and noted there was a nose bleed from the right nare. Reportedly, the resident was found lying in the same position as when she was assisted to bed 30 minutes prior. According to the note, Employee #80 brought LPN #103 to the resident's room for an assessment. -- The note indicated the DON, upon entering the building, assessed the resident and found no bleeding, but noted a small raised area to the upper nose with bruising extending to inside of the right eye. The DON stated the nose was in alignment and the resident did not facial grimace or show any signs and symptoms of pain, such as crying. -- The note's concluding statement was, All staff interviewed made no report of any incident. A review of progress notes found no entries for 10/28/14 by any staff. On 11/14/14 at 2:15 p.m., review of the reportable incident found written statements from only Employees #80, #18 and #4, all NAs. No other statements were provided. An interview conducted with the DON, on 11/14/14 at 3:00 p.m., revealed she felt she had conducted an investigation, but was unable to provide any further written statements or any further information pertaining to the facility's investigation into the cause of the injury of unknown origin.",2018-07-01
5885,MEADOWBROOK ACRES,515134,2149 GREENBRIER STREET,CHARLESTON,WV,25311,2014-11-04,225,D,0,1,WN6C11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, mistreating residents, or misappropriation of their property. The facility failed to conduct a criminal background check using fingerprints for one (1) of five (5) employees whose personnel files were reviewed. Employee identifier: #37. Facility census: 59. Findings include: a) Employee #37 On 10/02/14 at 10:15 a.m., a review of the personnel record for Employee #37, a nursing assistant (NA), hired on 07/27/12, found it did not contain any evidence of fingerprints being completed as required for a West Virginia criminal background check. In West Virginia, the only method to ensure an individual has not been found guilty of abusing, neglecting or mistreating residents in a court of Law. West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. By failing to conduct criminal background checks with fingerprinting, the facility failed to ensure all employees were thoroughly screened for criminal histories. An interview with Employee #93, the Administrative Assistant, on 10/02/14 at 10:45 a.m., verified there was no criminal background check completed for this employee.",2018-07-01
5898,GRANT COUNTY NURSING HOME,515151,127 EARLY AVENUE,PETERSBURG,WV,26847,2015-07-01,225,D,1,0,LIFD11,"Based on record review, review of incident/accident reports, and staff interview, the facility failed to thoroughly investigate and report an injury of unknown source to the appropriate State agencies for one (1) of six (6) residents reviewed for incidents involving injuries. Resident identifier: #11. Facility census: 104. Findings include: a) Resident #11 On 06/29/15 at 3:30 p.m., review of an incident report filed by Director of Nurses (DON) #149 revealed the resident's daughter/Power of Attorney reported to the nurse an injury to her mother's right wrist at 4:15 p.m. on 03/28/15. The incident report described it as .discolored area on residents Right Medial wrist. area 8cm X 4.5cm. no c/o (complaint of) pain. The incident report had no other information. The areas for Resident Description and Action Taken were both blank. The nurses' notes on 03/28/15, also described the incident as identified in the DON's report. On 04/02/15, a nurse's note indicated the physician examined the resident's wrist and on 04/10/15, an X-ray was ordered after complaints of pain and visible swelling to the wrist. There was no evidence in the record of any investigation into the source of the discoloration and the incident was not reported to the required State agencies as an injury of unknown source. In an interview with the director of nurses at 10:30 a.m. on 07/01/15, she agreed, after reviewing the record, the incident had slipped through the cracks and was not reported, although she stated it was treated and x-rayed.",2018-07-01
5900,FAYETTE NURSING AND REHABILITATION CENTER,515153,100 HRESAN BOULEVARD,FAYETTEVILLE,WV,25840,2015-07-02,225,D,1,0,DYHB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the reportable abuse/neglect allegations, staff interview, and abuse/neglect policy review, the facility failed to ensure it thoroughly investigated one (1) of the three (3) allegations of abuse/neglect reviewed during a complaint investigation. Resident #37 alleged the facility did not provide incontinence care timely and did not remove a lift pad from underneath him after he was transferred. Resident identifier: #37. Facility census: 54. Findings include: a) Resident #37 On 07/02/15 at 10:20 a.m., a review of the facility's reportable abuse/neglect allegations revealed the facility completed an investigation into an allegation of neglect involving Resident #37. The allegation was made on 05/02/15 and the facility completed the investigation on 05/07/15. The immediate reporting of the allegation by the facility to the Nurse Aide Program stated Resident #37 did not receive care in a timely manner. A review of the investigation revealed the facility collected statements from fifteen (15) direct care staff members. - Nurse Aide (NA) #7 provided a statement dated 05/06/15, which said, At approximately 8 am (8:00 a.m.) (Name of Resident #37) yelled out for assistance. CNA (certified nurse aide) (name of nurse aide) and I went into room. We found him soiled and with a lift pad beneath him, we cleaned him up and removed the lift pad. Later during the day around 2 (2:00 p.m.) during rounds we went into his room. He was wet and soiled but stated he wasn't and did not need assistance. We asked to change him. At first he said 'no' 'I'm fine' and then allowed us to change him once we checked and explained how to him how soiled he was. There was no indication on the statement as to what date NA #7 referred to in this statement. There was also no indication the facility had taken a statement from the other nurse aide who was mentioned in this statement as assisting NA #7 in providing care to Resident #37. - A statement from Licensed Practical Nurse (LPN) #51, dated 05/02/15, stated, (typed as written) Approximately 0800 am (8:00 a.m.) two CNA's (nurse aides) came to report to me that (name of Resident #37) stated that he had not been changed all night when I approached resident he still had a lift pad underneath him. Me and co-nurse assessed resident for reddened areas and break down. Residents skin was free of breakdown. Resident had minimal redness to bilateral inner gluteal folds with no open areas. [MEDICATION NAME] was applied to reddened area. - The facility identified Nurse Aide (NA) #14 as the alleged perpetrator. However, in the statement provided, NA #14 did not address whether or not she used a lift pad with the resident or whether she provided incontinence care during her shift of work. - SW #10 obtained a statement from the alleged victim (Resident #37) on 05/04/15. The statement said, This social worker met with (name of Resident #37) on 5/4/15 to discuss care and services. (Resident #37) states he was very satisfied with his care. I asked if he was given care as often as he felt he needed it and he said he 'always gets good care.' He said there was only one incident that had occurred over the weekend. When I asked him to tell me about it he said that over the last weekend (5/1-5/3) on one night the nurse had left a lift pad under him after providing care. I asked him if he had requested that someone else remove it. He said 'Honey I forgot to even mention it when they came back in' The facility collected statements from fifteen (15) direct care staff members. Ten (10) staff members wrote in their statements that they were in the resident's room, but did not address the issue of whether or not they saw a lift pad under the resident, or if they noticed if the resident had been incontinent. During an interview with Social Worker (SW) #10, on 07/02/15 at 12:00 p.m., she reviewed the allegation and the statements the facility collected. She confirmed she had not asked all direct care staff that were interviewed about whether or not they had used a lift pad on the resident or noticed a lift pad under the resident. The statements also did not reflect if they noticed, or did not notice, the resident to be incontinent when they had been in his room. A review of the statements taken from the fifteen (15) staff who provided statements revealed the staff did not always clarify the date/time they were referring to when they wrote their statements. The SW commented that she had not noticed that. The SW further stated that when investigating the issue of incontinence care, she had not checked the documentation completed by all nurse aides who worked on the date the allegation occurred to determine how many different times incontinence care was provided and who provided the care to the resident on 05/02/15. The five-day follow -up form completed by the facility stated, Unsubstantiated. Investigation showed that care was provided to this resident in a timely manner. A review of the facility's policy for abuse/neglect, dated 03/01/14, revealed on page 4 of 10 included, a. The Executive Director or his/her designee will complete a chronological narrative of the investigation describing the allegation, the investigation and the conclusion based on the facts of the situation. The conclusion should state the reasons the determination was made, whether or not the allegation was substantiated or unsubstantiated, any external reporting that was completed in conjunction with the investigation, any employee education that occurred as a result of the investigation, any system changes that were made due to the investigation. The narrative should become part of the internal investigative file and be signed and dated by the investigation. The facility did not have a chronological narrative for this investigation. The chronological narrative would have given the reasons why the facility determined the allegation was unsubstantiated.",2018-07-01
5903,CAREHAVEN OF PLEASANTS,515191,506 RIVERVIEW ROAD,BELMONT,WV,26134,2014-12-18,225,E,0,1,MWZR11,"Based on personnel file review, policy review, and staff interview, the facility failed to ensure criminal background checks were completed on all employees who worked within their facility. One (1) of ten (10) employees did not have an updated background check completed as required. The facility could not easily access proof that one (1) of ten (10) employees had a criminal background check completed. In addition, six (6) months of complaints reviewed contained one (1) complaint that had an allegation of abuse. The allegation of abuse was not reported to the State agency or thoroughly investigated. Employee identifiers: #89, and #90. Resident identifier: #82. Facility census: 63. Findings include: a) Employee #89 The personnel file review on 12/15/14 at 9:00 a.m. revealed Employee #89 (physical therapy assistant) began working on 11/07/14. The employee's personnel file listed her residence as in a state other than West Virginia. The facility office manager (Employee #76) said the physical therapy assistant worked for a contract company and not for the facility. Employee #76 said she did not have access to the criminal background check for Employee #89, but would try to get it from the contracted therapy company. On 12/16/14 at 5:00 p.m., the administrator provided a copy of a criminal background check completed by the West Virginia state police on 12/05/14. The administrator said she did not know if the employee had a federal criminal background check or just a state criminal background check. On 12/17/14 at 12:58 p.m., the director for contracted therapy company (Employee #105) said the therapy company did not do a federal background check for the employee. He said the company only does a criminal background check for employees in the state in which they are going to work. On 12/17/14 at 4:00 p.m. Employee #103 (registered nurse consultant) provided a form which showed a credit card number and an application for the employee to have a criminal background check. The form was dated in inked pen for 11/13/14. On 12/17/14 at 5:00 p.m., the administrator said the facility relied on the contracted therapy department to conduct background checks and alert them if any issues were found with the checks. They had to contact the therapy company to get the results and in the case of Employee #89, the results were not readily available when requested by the surveyor. b) Employee #90 On 12/15/14 at 9:20 a.m. the employee file for Employee #90 (physical therapy assistant) hired on 03/13/10 revealed this employee had not had the updated criminal background check completed in 2014. The Bureau for Medical Services manual Includes: 514.4.1 Employment Restrictions Criminal Investigation Background: Check (CIB) Results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check using fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities, 02/15/13. The memo included, At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer, prior to hire and every three (3) years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility, until 03/01/14, to have all current employees up-to-date with criminal investigation background checks . For any new hires in the nursing facility, the policy is effective for those individuals as of (MONTH) 1, 2013. On 12/18/14 at 3:00 p.m., the administrator confirmed the facility did not have an updated criminal background check for Employee #90. c) Resident #82 On 12/16/14 at 10:00 a.m., the concern files revealed a file regarding Resident #82. The concern file was dated 08/30/14. The concern revealed the following: Resident states 'Employee #100 was rough with me. He gave me a bruise on my leg and hurt my fingers' When asked what day this took place resident states '3 nights ago now.' Incident was witnessed by this nurse involving (Employee #103). The facility responded by stating Statements gotten by witness and (Employee #100). No bruising noted per nursing staff. Resident alert with memory loss and decision making problems. The facility abuse policy dated 2012 stated, Components of an investigation include: Interview the involved resident if possible and document all responses. If resident is cognitively impaired, interview the resident several times to compare responses. Interview all witnesses separately. Include roommates, residents in adjoining rooms, staff members in the area and visitors in the area. The information contained in the concern revealed two (2) statements. One (1) statement was made by the licensed practical nurse (Employee #16) and the alleged perpetrator (Employee #100) made the other statement. There was no other information in the complaint regarding an investigation into the alleged abuse. The social worker (Employee # 82), on 12/16/14 at 10:45 a.m., indicated the administrator had handled this situation. On 12/16/14 at 11:00 a.m., the administrator said she did not report this as an allegation of abuse to the State agency. She said Employee #16 witnessed the event, and therefore she did not feel she needed to conduct further investigation or report to the State agency. A review of the facility policy dated 2012, on 12/18/14 at 2:00 p.m., revealed that when abuse was suspected the State agency and local ombudsman agency would be contacted to report the alleged abuse.",2018-07-01
5935,ELKINS REGIONAL CONVALESCENT CENTER,515025,1175 BEVERLY PIKE,ELKINS,WV,26241,2015-01-07,225,E,0,1,RDRC11,"Based on resident interview, record review, staff interview, review of resident council meeting minutes, and policy review, the facility failed to report and investigate allegations of verbal abuse for two (2) of two (2) residents identified during a review of resident council meeting minutes. Resident identifier: #21 and #37. Facility census: 104. Findings include: a) Resident #21 On 12/30/14 at 3:40 p.m., a review of resident council minutes dated 10/20/14, revealed Resident #21 was one (1) of two (2) residents who alleged some of the night shift nurses were very rude and sassy with the residents. A departmental response form from the nursing department, dated 11/17/14 and stamped second notice given 11/10/14, indicated two (2) residents stated the night nurses were very rude and sassy with us. No specific names were given at the meeting. The response actions taken to resolve the issue identified was, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. There was no indication this allegation of abuse was reported or investigated. A review of the reportable abuse/neglect records, on 12/31/14 at 8:40 a.m., revealed no evidence that allegations of nursing staff verbally abusing Resident #21 were reported or investigated. On 12/31/14 at 11:43 a.m., review of Resident #21's minimum data set (MDS) with the assessment reference date (ARD) of 10/29/14, revealed resident scored 14 on the brief interview for mental status (BIMS). A score from 13 -15 on the BIMS indicated a person was cognitively intact. An interview with Resident #21 on 12/31/14 at 11:55 a.m., revealed .some of the night nurses can be a little rough speaking and rude .I am not sure of their names. I try not to deal with them when I can. It's not as bad now as it was since someone talked to them. Resident #21 requested to end the interview due to not feeling well. On 12/31/14 at 10:12 a.m., an interview was conducted with Employee #124 (resident council liaison) concerning the issue of resident council members stating some of the night nurses were 'very rude and sassy.' Employee #124 was asked, What did you do with that information? The response from Employee #124 was, I knew it was a nursing issue, so I took it to the director of nursing. I did not think of it as verbal abuse at that time or I would have also taken it to the social worker and filled out the paperwork . Now that I think about it, it may be considered verbal abuse. Employee #124 agreed if it had been investigated, it might have been discovered who the staff were that were involved in the allegation, or what occurred. An interview with the director of nursing (DON), on 12/30/14 at 5:15 p.m., revealed nursing had monthly meetings with agendas and sign-in sheets for the nurses and aides. The DON provided the agenda and sign-in sheets for the December monthly nursing meeting. It had an agenda item which stated, Reports from residents r/t (related to) rudeness/sassiness by staff to them -UNACCEPTABLE. During an interview with the DON, on 12/31/14 at 10:35 a.m., the nursing departmental response form dated 11/17/14 was reviewed. Under the section titled response/actions taken by department in reference to rudeness/sassiness by nursing staff, the DON had written in the response section, Complaint will be reviewed with nursing staff at scheduled meeting 12/2/14. When asked if the complaint had been investigated, the DON replied, No. I did not think of it as a complaint. It was pointed out that she had used the word complaint in her departmental response. The DON agreed it should have been investigated. b) Resident #37 On 12/30/14 at 3:40 p.m., review of resident council minutes, dated 10/20/14, revealed Resident #37 was the other of the two (2) residents that alleged Some of the night shift nurses are very rude and sassy with us. During an interview with Resident #37, on 12/30/14 at 4:37 p.m., when asked if nurses were ever rude to her, she stated, .some of them at night can be rude and grouchy, not all of them, some treat you real good. She said other council members also agreed the night nurses were rude. A review of reportable records containing allegations of abuse/neglect, on 12/31/14 at 8:40 a.m., revealed no evidence the allegation of nursing staff verbally abusing Resident #37 was reported or investigated On 12/31/14 at 11:43 a.m., review of Resident #37's minimum data set (MDS), with the assessment reference date (ARD) 10/21/14, revealed the resident scored 15 on her brief interview for mental status (BIMS). A score from 13 - 15 on the BIMS indicated a person was cognitively intact. c) Review of the facility's abuse policy, on 12/31/14 at 12:15 p.m., revealed Any staff member witnessing, receives a complaint of, or suspects mistreatment, neglect and/or abuse is to immediately report it to their immediate supervisor. All state specific requirements for reporting any allegation of abuse or neglect shall be followed. The allegation will be reported to the Administrator, DON, or designee and all other agencies as required by state law within twenty four (24) hours of the occurrence. An assistant administrator or social worker will complete the investigation and notify the required agencies in five (5) days of the allegation. The policy also directed staff to notify the executive director or social services supervisor. d) The allegations of abuse made by Residents #21 and #37 were not reported or investigated. The resident council liaison and the DON failed to identify that Some of the night shift nurses are very rude and sassy with us, as expressed at the resident council meeting, was an allegation of abuse that required reporting and an investigation.",2018-05-01
5974,TAYLOR HEALTH CARE CENTER,515057,2 HOSPITAL PLAZA,GRAFTON,WV,26354,2014-10-15,225,F,0,1,GZSS11,"Based on personnel file review, facility abuse/neglect policy and procedure review, medical record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum (memo), and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. This was true for five (5) of ten (10) employees whose files were reviewed. In addition, the facility failed to report and investigate an allegation of misappropriation of resident property. A nursing assistant (NA) removed Resident #15's personal beverage cup from the resident's room, even though the resident asked the NA not to take the cup. Employee identifiers: Employee #8, #9, #29, #45 and #11. Resident identifier: #15. This practice had the potential to affect all residents. Facility census: 59. Findings include: a) Criminal Background Checks for Employee #8, #9, #29, #45 and #11 On 10/08/14 at 10:00 a.m., a review of ten (10) personnel files revealed five (5) of ten (10) employees, who were employed by the facility between 06/10/08 and 04/03/12, had no fingerprints or criminal background checks based on fingerprinting in their files. On 10/08/14 at 3:20 p.m., the Human Resource Director stated employee criminal background checks had not been conducted for Employees #8, #9, #29, #45 or #11. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: - Employee #8, nursing assistant (NA) hired on 04/28/10; - Employee #9, NA hired on 06/22/10; - Employee #29, licensed practical nurse (LPN) hired on 06/10/08; - Employee #45, LPN hired on 06/20/11, and. - Employee #11, NA rehired on 04/03/12. In a discussion with the administrator (NHA), on 10/06/14 at 4:00 p.m., the NHA denied knowledge of any regulations requiring criminal background checks on all facility employees. She denied any knowledge of the memo issued to all Medicaid participating facilities on February 15, 2013. She stated this may have been received by the previous NHA, but she had no knowledge of the memo. To ensure the facility had not employed an individual who had been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, fingerprint-based State level criminal investigation background check must be conducted initially the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NICD). A policy clarification memo was issued to all Medicaid participating facilities on February 15, 2013. The memo included .at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau of Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. b) Resident #15 Interview with Resident #15, on 10/07/14 at 2:43 p.m., revealed a nursing assistant (NA), Employee #25, came into her room and the resident caught the NA going through her dresser drawers. Resident #15 said she had a red cup, part of a set that was a gift from her son. The resident said the NA started to take the red cup. The resident said she told the NA not to take the cup. Resident #15 said a few days later the cup showed up missing. She said the next time she saw the NA, she asked her (the NA) if she got the cup. The resident said at first, the NA denied getting the cup, but then admitted she had taken it because she did not have anything to drink out of that day. The resident said she was very upset and told the NA to go get the director of nursing (DON). The resident said she got her cup back after that. Review of a 09/24/14 nursing note, on 10/14/14 at 2:30 p.m., revealed a Late entry: on 9/23/14 this resident (#15) asked to speak to the DON (director of nursing) and the nurse manager. Resident extremely upset with CNA (certified nursing assistant) . Interview with the DON, on 10/14/2014 at 2:06 p.m., revealed she did not investigate the situation to rule out a potential misappropriation of property, even though the aide, Employee #25, informed the DON she had borrowed a resident's personal cup. When asked if staff were allowed to borrow items from residents, the DON replied No, absolutely not. They know better. The DON was asked if she was concerned about the fact the aide borrowed the resident's cup, when she should have known better. The DON shook her head in affirmative motion and stated, If I had known more about it then, I would have investigated it. The DON agreed if it had been investigated, she would have known more about it. The NA was not available to interview because she was off from work due to a death in her family.",2018-05-01
5990,PLEASANT VALLEY NURSING AND REHABILITATION CENTER,515064,640 SAND HILL ROAD,POINT PLEASANT,WV,25550,2014-09-18,225,F,0,1,7HHJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's abuse/neglect assessment and reporting policy, review of the complaint files, staff interview, and personnel file review, the facility failed to ensure all allegations of neglect and abuse were reported and thoroughly investigated for three (3) of seven (7) grievances/concerns reviewed. In addition, the facility failed to be thorough in their investigations of the past histories of five (5) of five (5) employees they hired. The facility did not check with the abuse registry and /or obtain required criminal background checks, including fingerprinting, for these employees. These practices affected Residents #52, #148, and #156, and had the potential to affect all residents. Facility census: 98. Findings include: a) Resident #52 Review of a grievance/concern form, at 4:00 p.m. on 09/17/14, revealed the resident reported allegations of neglect and verbal abuse on 07/14/14, regarding incidents which occurred on 07/12/14 and 07/13/14: 1. Resident reports Licensed Practical Nurse #19 is very rude and hateful, and she is untimely with medications and she thinks she gave her two [MEDICATION NAME] instead of her pain medication. 2. Staff didn't provide a bed pan in timely manner. A notation on the form, under findings of the investigation, revealed the facility found the employee was perceived by the resident as rude and hateful. The corrective action was: Instructed to be mindful of how she is being perceived by resident when giving care. There was no evidence of a thorough investigation into the complaints. There was nothing which indicated how the facility determined the resident's complaint was only a perception that the employee was rude or hateful. There was no evidence of an thorough investigation regarding the resident's medication concerns or the timely provision of a bedpan. In addition, these allegations of verbal abuse and neglect were not reported to the required state agencies. During an interview with the Administrator, at 4:30 a.m. on 09/17/14, the administrator was asked why the allegations were not reported as allegations of neglect and verbal abuse. She stated she had not considered the concern to be a reportable. The administrator agreed that the grievances should have been thoroughly investigated and reported to the required state agencies. b) Resident #148 A review of a grievance/concern form, at 4:05 a.m. on 09/17/14, revealed several allegations made by the resident's daughter, on 08/11/14, regarding incidents which occurred on 08/09/14 and 08/10/14: 1. Resident #148's daughter stated She was upset to find her mother in her bed with the head of bed way down and her mother's butt was up in the air. (She said blood was rushing to her head)? Sat nite she said that her pants were down below her butt and side rails were down. The daughter said that she did not understand why they would have her in that position in her bed. 2. Daughter stated that her mother told her They are mean to me. Daughter said that when she asked her mother what they were doing mean to her she just shut up. 3. The daughter stated a friend had come to visit with her mother and her mother told her friend They are mean to me. The friend stated while visiting with her mother on Sunday night (08/10/14), she heard a nurse speak grouchy to a resident that was requesting eye drops. The daughter is concerned that since she has reported the incident that people will be mean to her mother now. The administrator assured the daughter that would not be tolerated by administration. A notation on the form, under findings of the investigation, indicated the facility checked the resident frequently, staff had found the resident positioned properly, she appeared to be in no distress, and was resting comfortably. There was no date or time the check occurred. The corrective action was: Educated all staff regarding positioning and communication skills. Will continue to maintain communication with family and address concerns whenever. The facility did not investigate the complaint regarding the resident stating, They are mean to me. There was no evidence of a thorough investigation regarding these allegations of verbal abuse and neglect. In addition, these allegations were not reported to the required state agencies. During an interview with the Administrator, at 4:45 p.m. on 09/17/14, she was asked why the allegation was not reported as allegations of neglect and verbal abuse. She stated she thought it was only a concern and did not consider the concern to be reportable. The administrator agreed that the grievance should have been thoroughly investigated and reported to the required state agencies. c) Resident #146 A review of a grievance/concern form, at 4:10 p.m. on 09/17/14, revealed the resident voiced an allegation of neglect on 07/03/14, for an incident on 07/02/14: 1. The resident stated she asked for a whenever needed (PRN) pain pill. Allegedly she was told it was change of shift, and then it Took over three hours for the nurse to bring it. The resident's alert and oriented roommate confirmed the verbal report. A notation on the form, under findings of the investigation, revealed [MEDICATION NAME] was administered at 2210. The form indicated the licensed practical nurse (LPN) #19 denied the resident's request; however the resident and her roommate both verified the resident asked for pain medication around 7:00 p.m. (shift change). Nursing assistant (NA) #64 reported telling the charge nurse (CN) #30 and licensed practical nurse (LPN) #19 around 9:00 p.m. that Resident #146 had told the NA that she had been waiting two (2) hours for a pain pill. The NA stated the LPN was doing her routine medication pass on the hall and the LPN told NA #64, I'll be there when I can. NA #64 stated the LPN Waited until she got to Hall 4. According to the form, LPN #19 received education regarding responding to residents' requests for pain management; however, there was no evidence a thorough investigation was completed. In addition, these allegations of neglect were not reported to the required state agencies. During an interview with the Administrator at 5:00 p.m. on 09/17/14, the administrator was asked why the allegation was not reported as an allegation of neglect. She stated she had not considered the concern to be reportable. The administrator agreed that the grievance should have been thoroughly investigated and reported to the required state agencies. d) In an Interview with social worker (SW) #93, on 09/18/14 at 11:46 a.m., she was asked to review the grievance/concern forms for Residents #52, #148 and #146. When asked if these grievance/concern forms contained allegations of neglect and verbal abuse, she replied yes. When the SW was asked if the allegations regarding Residents #52, #148, and #146 were thoroughly investigated and reported to the required state agencies, she stated No. e) A review of the facility's abuse /neglect assessment and reporting policy, on 09/17/14 at 1:53 p.m., revealed directives for investigation and reporting of all abuse and neglect allegations, and The facility will utilize the Abuse/Neglect Reporting Requirement for WV Nursing Homes and Nursing Facilities to determine reporting requirements. f) Abuse Registry Checks Employees #15, #22, #63, and #73: A review of personnel files found the facility had not completed thorough abuse registry checks for Employees #15, #22, #63 and #73. These employee was involved in direct resident care. An Interview was conducted with the assistant director of nursing, at 3:00 p.m. on 09/17/14. She stated after searching the employees' files, there was no record the abuse registry was checked for Employees #15, #22, #63, and #73. g) State Wide and National Criminal Background Checks The Patient Protection and Affordable Care Act (Pub. L. 111 - 148, enacted March 23, 2010) and the Health Care Education Reconciliation Act of 2010 (Pub. L. 111 - 152, enacted March 30, 2010), together are known as the ACA. The legislation authorized long term care (LTC) facilities and providers to obtain State and national fingerprint based background checks from potential employees whose duties include direct access to residents and patients. To ensure the facility has not employed an Individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of Law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual Includes: 514.4.1 Employment Restrictions Criminal Investigation Background: Check (CIB) Results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check using fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities, 02/15/13. The memo included, At a minimum, a fingerprint-based state level criminal investigation background check must be conducted, initially by the employer, prior to hire and every three (3) years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility, until 03/01/14, to have all current employees up-to-date with criminal investigation background checks . For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. Employee #15, #22, #63, #65 and #73: 1. Licensed practical nurse (LPN) #15's personnel file was reviewed at 1:00 p.m. on 09/17/14. LPN #15 was hired on 08/25/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 2. LPN #22's personnel file was reviewed at 1:05 p.m. on 09/17/14. LPN #22 was hired on 05/05/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 3. Nursing assistant (NA) #63's, personnel file was reviewed at 1:08 p.m. on 09/17/14. Nurse Aide #63 was hired on 08/25/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 4. NA #65's personnel file was reviewed at 1:10 p.m. on 09/17/14. NA #65 was hired on 09/08/14. The personnel file did not contain any evidence of fingerprinting as required for a West Virginia criminal background check. 5. NA #73's personnel file was reviewed at 1:10 p.m. on 09/17/14. Nurse Aide #73 was hired on 08/11/14. The personnel file did not contain any evidence of fingerprints being taken as required for a West Virginia criminal background check. An Interview was conducted with the assistant director of nursing, at 3:05 p.m. on 09/17/14. She stated after searching the employees' files, there was no record of a West Virginia (WV) state wide criminal background check on these employees.",2018-05-01
6011,SALEM CENTER,515071,255 SUNBRIDGE DRIVE,SALEM,WV,26426,2014-08-14,225,F,0,1,K1XR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on employee personnel file review, review of Chapter 514.4.1 of the Medicaid manual and a clarification memorandum from the Bureau for Medical Services (BMS) regarding the requirements for criminal background checks to meet the requirements of the Affordable Care Act, and staff interview, the facility failed to ensure individuals who had been employed more than three (3) years had had another criminal background check to determine whether the individuals had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. This was not completed for seven (7) of fifteen (15) employees whose personnel files were reviewed. This practice had the potential to affect all residents. Employee identifiers: #20, #35, #45, #78, #79, #87, and #104. Additionally, the facility failed to ensure all allegations of mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property, were reported immediately to the administrator of the facility and to other officials in accordance with State law. This was found for three (3) of forty-six (46) complaints reviewed, and had the potential to affect more than a limited number of residents. Resident identifiers: #42, #43, and #34. Facility census: 94. Findings include: a) On 08/06/14 at 11:05 a.m., a review of the personnel files for tenured employees was conducted with Employee #38, the payroll/human resources person. This review identified the following: 1. Employee #20 A review of the personnel file for Employee #20, a cook, who was hired on 06/09/11, revealed no evidence of an up to date statewide criminal background check completed since her hire date. 2. Employee #35 Upon a review of the personnel file for Employee #35, a NA, who was hired on 10/24/1994, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 3. Employee #45 Review of the personnel file for Employee #45, a nurse aide (NA) who was hired on 08/22/1988, found no evidence of an up to date statewide criminal background check was completed since her hire date. 4. Employee #78 During a review of the personnel file for Employee #78, a registered nurse (RN) who was hired by the facility on 11/03/03, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 5. Employee #79 The review of the personnel file for Employee #79, a licensed practical nurse (LPN), who was hired by the facility on 06/23/04, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 6. Employee #87 The review of the personnel file for Employee #87, a RN, who was hired by the facility on 04/16/09, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. 7. Employee #104 A review of the personnel file for Employee #104, a NA, who was hired by the facility on 09/25/07, revealed no evidence of an up to date statewide criminal background check was completed since her hire date. b) Employee #38 verified the personnel files for Employees #20, #35, #45, #78, #79, #87, and #103 did not contain evidence of an up to date statewide criminal background check completed since their hire date. She further stated, None of the tenured employees have an up to date statewide criminal background check that has been completed since their hire date. c) An interview was conducted with Employee #52, the Administrator, on 08/06/14 at 11:45 a.m. Upon reviewing the memorandum from BMS regarding background checks for employees, she stated, Oh, that is just for new hires. After further review, she stated, Oh, it is for all current staff, no we don't have that for any of them. d) The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. e) The facility's grievances and complaints files were reviewed on 08/12/14 at 10:01 a.m. There were forty-six (46) complaints reviewed covering the period from 05/01/14 through 07/31/14. The review found three (3) complaints were allegations of neglect, and should have been immediately reported. 1. Resident #42 This [AGE] year-old resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status (BIMS) score as assessed on 06/-4/14 was 15, indicating she was cognitively intact. She had spoken to the rehabilitation manager, contracted Employee #121, on 07/10/14. The therapist's narrative documentation described the concern as follows (typed as written): During tx (treatment) today at 10:40 a.m. resident very tearful reporting 'CNA's made me sit up in my wheelchair on Tuesday for 6.5 hours and wouldn't listen when I wanted to go to bed!' Resident reports this is a frequent response when requesting to return to bed. Under the section Investigation it was documented the director of nursing, Employee #17, Spoke with (Resident #42) about CNA's she felt were not doing their jobs. 2. Resident #43 This resident was admitted to the facility on [DATE], and discharged on [DATE]. Her [DIAGNOSES REDACTED]. Her Brief Interview for Mental Status (BIMS) score as assessed on 06/23/14 was 15, indicating she was cognitively intact. She had spoken to the social worker, Employee #61, on 07/01/14. The narrative documentation described the concern as follows (typed as written): Resident c/o (complained of) aide who 'has attitude' and states she has to wait a long time (30 - 60 min) for light to be answered by Aide. Also c/o Nurse who waits 1 - 2 hours sometime to give pain meds when she asks for them. Under the section Investigation it was documented the director of nursing, Employee #17, took action described as Staff reeducated - 2 specific staff counseled/Reeducated (see personnel file). 3. Resident #34 This resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. She had spoken to the rehabilitation manager, contracted Employee #121, on 06/23/14. The therapist's narrative documentation described the concern as follows (typed as written): I was providing treatment to resident at 2:30 pm on 6/23/14 and asked resident if there was a reason why she did not get to sleep until 5 am (as reported to me by nursing). Resident replied that she had 'been sitting in my own pee for like hours and the aides kept turning my light off.' Under the section Investigation it was documented the director of social services, Employee #61, on 06/24/14 Met with (Resident #34) 2x (two times) and she denied any complaints or concerns. Stated 'they are crazy in therapy.' f) An interview was conducted with social worker, Employee #61, on 08/13/14 at 3:14 p.m. She acknowledged the three (3) complaints were allegations of neglect and should have been reported immediately without waiting for any investigation to assess whether the allegations could be substantiated.",2018-05-01
6057,GLENVILLE CENTER,515103,111 FAIRGROUND ROAD,GLENVILLE,WV,26351,2015-01-16,225,E,0,1,5KNT11,"Based on record review and staff interview, the facility failed to ensure a thorough investigation of the past history for one (1) of ten (10) employees whose personnel files were reviewed. A background check through the State Nurse Aide Registry was not completed upon hire. Employee identifier: 26. Facility census: 62. Findings include: a) Employee #26 A personnel file review was performed on 01/15/15 with the assistance of the facility bookkeeper, Employee 36. Ten (10) files were reviewed. The file for Employee 26, a registered nurse, indicated her date of hire was 09/10/14. A scan was run of the Adult Abuse Registry on 09/09/14. The facility bookkeeper, Employee 36, stated this Adult Abuse Registry did not include the information used by the State Nurse Aide Registry until 12/01/14, which was after the scan was run on Employee 26. No scan through the State Nurse Aide Registry was performed to ensure the nurse had no finding which indicated unfitness to work in a nursing facility.",2018-05-01
6069,GLASGOW HEALTH AND REHABILITATION CENTER,515118,"120 MELROSE DRIVE, BOX 350",GLASGOW,WV,25086,2014-09-12,225,F,0,1,3Q4T11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure every three (3) years, to ensure a criminal background check in West Virginia. This was evident for four (4) of five (5) tenured employees whose files were reviewed. This had the potential to affect all residents. Employee identifiers: #25, #34, #76, and #27. Facility census: 93. Findings include: a) Thorough Criminal Background Checks. On 09/10/14 at 7:00 a.m., a personnel file review was conducted. Five (5) personnel files for tenured employees were reviewed. Four (4) of the five (5) employees had no updated fingerprints, or criminal background checks based on fingerprinting, in their files. The employees with no evidence of the fingerprinting, as required every three (3) years for statewide criminal background checks in West Virginia, were: -- Employee #25, a Nurse Aide (NA), hired on 02/01/11. This employee had an initial fingerprinting for statewide criminal background check in West Virginia on 02/11/11. There has been no updated fingerprinting. -- Employee #34, a Nurse Aide (NA), hired on 07/18/11. This employee had an initial fingerprinting for statewide criminal background check in West Virginia on 08/29/11. There has been no updated fingerprinting. -- Employee #76, a Nurse Aide (NA), hired on 04/27/11. This employee had an initial fingerprinting for statewide criminal background check in West Virginia on 03/23/11. There has been no updated fingerprinting. -- Employee #27, a Nurse Aide (NA), hired on 12/23/10. This employee had an initial fingerprinting for statewide criminal background check in West Virginia on 12/23/10. There has been no updated fingerprinting. In a discussion with the administrator on 12/09/14 at 7:30 a.m., she said the names of tenured staff who needed to have fingerprinting for a statewide criminal background check were posted in January 2014. In June 2014, the names of those employees who needed to have fingerprinting were again posted. The administrator and business office manager were given an opportunity to locate evidence. On 09/20/14 at 8:30 a.m. they were unable to provide further information verifying the background checks were completed. Upon inquiry as to whether the facility had a system in place to ensure that every tenured employee went no longer than three (3) years between fingerprinting for statewide criminal background checks, the administrator replied in the negative. She said the staff person who was in charge of compliancing staff with the required fingerprinting for statewide criminal background checks erroneously thought they had until the end of 2014 for completion. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history for Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three (3) years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five (5) years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 14, 2013. The memo included: . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire, and every three (3) years thereafter throughout the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau of Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks .For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013.",2018-05-01
6081,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2014-01-24,225,F,0,1,ZW4411,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy review, review of complaint files, review of incident reports, review of personnel files, and staff interview, the facility failed to ensure all allegations of mistreatment, neglect, injury of unknown origin, or abuse were reported immediately to the appropriate State agencies in accordance with this regulation and with Code of State Rules, Title 64 Series 13 - Nursing Home Licensure Rule for West Virginia. The facility also failed have evidence all allegations were thoroughly investigated. This was found for seven (7) of forty-three (43) documented grievances/concerns reviewed. Additionally, the facility had not ensured it did not employee individuals who had been found guilty of abuse, neglect, or mistreatment of [REDACTED]. Thirteen (13) of twenty (20) personal files reviewed did not have this information. These issues had the potential to affect all residents. Employee identifiers: #49, #15, #122, #119, #177, #178, #179, #180, #181, #182, #183, #184, and #187. Resident identifiers: #50, #148, #111, #47, #27, #71, and #25. Facility census: 100. Findings include: a) Resident #50 A review of a Concern Form revealed the son of Resident #50 made the following allegations during the course of a care plan meeting attended by both the resident and his son on 01/09/14: 1. Resident #50's trash can and/or phone were frequently not within the reach of the resident. 2. The resident was receiving poor nail care. 3. Resident #50 stated he gets poor response time to his call light. A written report was completed for each of these allegations on 01/09/14. The concerns were assigned to Employee #116 (RN and Director of Care Delivery) on 01/10/14, to be resolved by 01/15/14. Notices were distributed to All nursing staff in service on 01/10/14, instructing corrective action to be taken regarding the allegations and the following Resolution of Concern was written on the forms and signed by Nurse #116 - At this time, resident et (and) family are satisfied (sign for 'with') actions taken by facility to correct these concerns. Will cont. (continue) ongoing communication (sign for 'with') resident et family to ensure concerns are resolved. There was no evidence the allegations of neglect were reported to the appropriate State agencies as required, nor was there evidence the allegations were thoroughly investigated. b) Resident #148 Review of a facility Concern Form revealed Resident #148 had voiced a complaint to Employee #80 (Occupational Therapist) at 6:30 a.m. on 12/20/13, when she entered his room. His TED (antiembolitic) hose were on at that time. The resident told the therapist they had been left on for two (2) days and nights, when they were supposed to be taken off at night. He also stated he had asked someone to take them off and they said they would, but did not. An incident report was also filed and the resident's physician was informed. The form was signed by Employee #77 (Director of Nursing), but no one was assigned to take action on this concern. There was a partially completed State Report attached to the Concern form, but there was no evidence the resident's allegation of neglect was either reported to the appropriate State agencies, or that any type of investigation had been made. There was no indication the facility staff had notified the resident of any action taken to ensure this did not reoccur. c) Resident #111 A concern form, reviewed, at 10:00 a.m. on 01/14/14, included Resident (#111) found in bed (sign for 'with') wet sheet, dried brown urine circled on sheets. Resident's hair even saturated (sign for 'with') urine. Resident was cold, wet and shivering. The date on the form was 12/20/13 at 8:30 a.m., but it did not state who found the resident in that condition. A nurse (no longer at the facility) was assigned the concern for resolution on 12/21/13. There was no other indication of her involvement. A nurse, Employee #124, completed an incident report on 12/20/13, which noted the family was notified. Employee #77 (Director of Nursing) documented Interviewed LN & CNAS (licensed nurse and certified nursing assistants) caring for resident during shift prior to reported concern. Care provided prior to end of shift and Investigation completed. Care determined to be provided. The completion date on the form was 12/22/13. There was no attached evidence of an investigation. There was no evidence this occurrence was recognized as an allegation of neglect and reported to the appropriate State agencies. When questioned about the incident, at 11:15 a.m. on 01/14/14, Employee #77 confirmed there was no additional information filed, although she did say she talked to the nurse who was working at the time of the incident. d) Resident #47 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, found a concern form for this resident noted, Resident voiced that she has not been receiving CPM (continuous passive motion) machine (ordered therapy). The resident reported this to Employee #79 (Occupational Therapist) on 12/22/13, who filed the concern form. This allegation of neglect was not reported to the appropriate State agencies and a thorough investigation was not completed. Employee #116 (nurse) was assigned to take action on the concern. The record indicated his determination that the therapy had not been completed on 12/19/14, and Employee #88 (LPN) had confirmed this in a signed statement. Employee #116 indicated he had discovered four (4) missed treatments between 12/19/13 and 12/22/13 and stated in the report that the resident had confirmed the missed treatments. There were no other interviews or information collected. The resolution was education for the staff nurse identified for the single omission on 12/19/14. During an interview with Employee #116 at 1:00 p.m. on 01/14/14, he stated it was given to him as a concern only and he assumed the decision about reporting had already been made. e) Resident #27 Review of the facility Concern forms, at 10:00 a.m. on 01/14/14, revealed a concern reported to Employee #88 (LPN Supervisor) on 12/23/13, by Resident #27. Resident #27 stated Employee #49 (nurse aide) had not gotten her out of bed until late, had left sheets on her bed that were wet with urine, and had not set up her lunch tray. She did not want care from that aide again. The facility did not recognize this as allegations of neglect and did not report the allegations to the appropriate State agencies. The investigation contained only a follow-up interview with Resident #27 and interviews with three (3) other residents. One (Resident #141) had the same complaint about the same aide. f) Resident #71 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed staff reported a skin tear to the right knee and a large bruise on the left lower back of Resident #71 when he was bathed at 12:30 p.m. on 12/03/13. The resident denied any falls and staff documented, Unsure as to exact cause. The facility did not report this bruise of unknown origin to the appropriate State agencies and there was no investigation. There was an entry which stated, Res (resident) did sit down hard in w/c (wheelchair) one day last week when he almost missed the chair. At the time of discovery, no description of the bruise was documented to assist in determining the age of the bruise and no evidence that staff interviews had been done. g) Resident #25 Review of the facility Concern forms at 10:00 a.m. on 01/14/14, revealed the daughter of Resident #25 had reported a concern to Employee #88 (LPN Supervisor) on Monday, 10/14/13. The daughter visited on Sunday evening (10/13/13) and Resident #25 was wearing the same clothes she was dressed in on Saturday morning (10/12/13) and had no water. The cup in her room was labeled from the 11-7 shift on Saturday night. The facility did not report these concerns as allegations of neglect. There was no evidence of any investigation. e) The Administrator was asked to provide the facility's policies regarding abuse, neglect, and misappropriation and the policies regarding grievances/complaints at 10:00 a.m. on 01/14/14. She responded at 8:50 a.m. on 01/15/14 with the Patient Protection Practice Guide which stated in its opening paragraph, The information included within this guide does not relieve a business unit or center of the obligation to comply with all applicable (name of company) policies as well as federal and state regulations. She was asked if there was a policy instructing staff of who and how to report to in this facility. At 10:50 a.m. on 01/15/14, she provided a one page undated and unsigned paper with the heading Incidents involving any allegation or abuse or neglect must be reported immediately to all of the following and contained a list of agencies. She stated that she was the person ultimately responsible for reporting. The Administrator also provided a one-page instruction sheet, which accompanied the use of the concern form in use and a decision tree. She acknowledged that the decision tree for use with reporting concerns/grievances did not coincide with the decision tree in the abuse/neglect reporting guide. The Administrator stated there was no evidence to show that the facility's review and/or acceptance of these documents and she could locate no facility distinct policies. An interview with the Administrator, Employee #175 (Social Worker), and Employee #77 (Director of Nursing), along with the survey team, was conducted at 11:20 a.m. on 01/15/14, to review the above Concern Forms. The facility provided no additional evidence regarding these occurrences as of the time of exit. The administrator acknowledged that the lack of individualized policies to follow might have resulted in the allegations not being reported. g) Review of personnel files found the facility had not ensured thorough background checks and/or abuse registry checks had been conducted for all employees. These findings were verified on 01/13/14 at 11:00 a.m. by Employee #40, the human resource manager. The following issues were found: 1) Employee #49 The facility had no evidence of statewide criminal background check had been completed for this nurse aide. 2) Employee #15 The facility did not have evidence the abuse registry had been checked for this dietary employee. 3) Employee #122 There was no evidence the abuse registry had been checked for this social worker. 4) Employee #119 No evidence of a statewide criminal background check was found in this housekeeper's file. 5) Employee #187 There was no evidence this nurse had had a statewide criminal background check. h) On 01/21/14 at 1:30 p.m., it was discovered that contracted dietary employees were not included on the employee list. A list of contracted dietary employees was requested. Review of the eight (8) files for these staff found none of them had verification that they did not have findings of abuse, neglect, or misappropriation of funds prior to allowing them to have contact with residents. This was confirmed by administrator, Employee #120 on 01/21/14 at 2:00 p.m. These contracted employees were #177, #178, #179, #180, #181, #182, #183, #184, and #187 (a Registered nurse, 2 Cooks, and 6 Dietary Aides)",2018-05-01
6104,RIVER OAKS,515120,100 PARKWAY DRIVE,CLARKSBURG,WV,26301,2015-05-01,225,D,1,0,4ZJU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to conduct a thorough investigation of an unwitnessed fall resulting in a fracture for one (1) of five (5) residents reviewed with a history of recent falls. The facility viewed the incident only as an unusual occurrence, and failed to thoroughly investigate the incident to rule out neglect. In addition, the facility's report to the State agency was not a factual accounting of the situation. Resident identifier: #83. Facility census: 80. Findings include: a) Resident #83 A review of the medical record, at 9:00 a.m. on [DATE], revealed Resident #83 was a [AGE] year-old female admitted to the facility on [DATE], after a hospital stay. An admission note, entered at 7:30 p.m. on [DATE], by Licensed Practical Nurse (LPN) #153, indicated, Patient is oriented 3X (to person, time, and place), Patient is admitted from (name of hospital) [MEDICAL CONDITION] and pneumonia. Has VRE ([MEDICATION NAME] resistant [MEDICATION NAME]) in a wound on her coccyx. Patient can be alert and then just spaces out. An Immediate FAX Reporting of Allegations form was sent to the Nursing Home Program by Social Worker (SW) #6 on [DATE]. It stated, Resident was found on the floor of her room. She was sent to the hospital for evaluation. She was diagnosed with [REDACTED]. She returned to the Center with full weight bearing status. The discharge summary from the hospital did not correlate with the information the SW reported to the State agency. The discharge summary described the injury as a FALL WITH INOPERABLE FRACTURE OF HIP. Nothing in the medical record stated the fracture did not require surgery. Further, the physician's orders [REDACTED]. This did not correlate with a full weight bearing status as submitted to the State by the SW on the immediate reporting of allegations form. There was no information submitted to the State that described the accident, although a nurse's note was entered at 7:35 p.m. on [DATE] by Nurse #14. The nurse noted, This nurse was in resident room to complete nursing admission assessment. Resident was found lying on floor between bed and wall . After placement in bed; resident verbally voiced complaints of pain and states, 'I think I broke my hip.' A review of the Five Day Follow-up report to the State, also filed by SW #6, included a narrative summary of the Outcome/Results of Investigation as follows: Resident fell out of bed resulting in a [MEDICAL CONDITION]. There was no Corrective Action by the facility entered on the report to the State. The complete record of the investigation of the fall was requested from SW #6 at 8:30 a.m. on [DATE], and received shortly after. The following was hand copied verbatim from the investigation report, as the facility would not allow the survey team a photocopy: The resident is a [AGE] year old female with a history of [MEDICAL CONDITION] who was also a [MEDICAL TREATMENT] patient. She was a new admission on [DATE]. The incident occurred when the nurse was out of the room to obtain something in order to complete the assessment. The resident was sent to the hospital for evaluation and sent back. She was found to have an inoperable [MEDICAL CONDITION]. ACTION After a thorough investigation, it was determined that this was an isolated incident that was an unusual occurrence. CONCLUSION After a thorough investigation, it was determined that this was an unusual occurrence. The staff was attempting to do an assessment with this resident. They left the room momentarily to get something and she had fallen when they returned shortly thereafter. The resident was in end stage [MEDICAL CONDITION]. She was sent to the hospital the following day for another medical reason unrelated to the fall. She did not return to the center. She expired at the hospital. The investigation included only one (1) staff interview, with LPN #14, who was one of the two (2) nurses who were caring for the resident immediately prior to the fall. The statement read: I was doing her skin assessment on admission. I sent the other nurse out to get a dressing. Realized that I needed a Q tip to measure the depth. Stepped outside the door to say I needed it. When I went back in she was in the floor. During an interview with the Administrator and SW #6 at 9:00 a.m. on [DATE], the SW acknowledged this was the entire investigation record and that only one (1)interview statement was done. She also said, after review of the record, she had not indicated on the reports sent to the State what had been discovered about how the accident happened and that she had considered it to be an Unusual Occurrence as was entered into the investigation narrative. The Administrator indicated agreement, with a nod, that the investigation should have been more in-depth. The Director of Nurses (DON) and the Administrator were interviewed at 9:35 a.m. on [DATE]. The DON, who also reviewed the record and the investigation report, stated she was not aware of the total contents of the investigation. There was no evidence in the written investigation, or offered verbally by the facility during the survey, that the incident was identified as potential neglect at the time of the occurrence.",2018-05-01
6135,TRINITY HEALTH CARE OF LOGAN,515140,1000 WEST PARK AVENUE,LOGAN,WV,25601,2015-05-22,225,D,1,0,OI6D11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of reportable incidents and staff interview, the facility failed to investigate and report an allegation of neglect for one (1) of six (6) sample residents. A grievance report stated the facility did not provide care for the resident in a manner that prevented an infection, which ultimately resulted in hospitalization and surgery. The facility did not identify this as an allegation of neglect. Resident identifier: #64. Facility census: 114. Findings include: a) Resident #64 A review of grievance reports, the afternoon of 05/20/15, showed an allegation of neglect was reported by the resident's family on 05/06/15. The report stated Resident #64 was not given proper care in the treatment of [REDACTED]. There was no evidence this allegation of neglect was investigated or reported to the proper agencies as required. The situation was discussed with the social worker and quality assurance registered nurse on 05/20/15 at 2:30 p.m. They confirmed the allegation was not identified as neglect, was not investigated, and was not reported. Immediate reporting procedures were started after the discussion during the survey.",2018-05-01
6175,MILETREE CENTER,515182,825 SUMMIT STREET,SPENCER,WV,25276,2014-09-23,225,F,0,1,577211,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia (WV), review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia for two (2) of five (5) tenured employees whose personnel files were reviewed. This had the potential to affect all residents. Employee identifiers: #1 and #74. Facility census: 62. Findings include: a) Review of personnel files, on 09/18/14 at 3:30 p.m., found employees with no evidence of fingerprinting, as required for statewide criminal background checks in WV. These were: 1. Employee #1, a cook hired on 02/16/11; 2. Employee #74, a nursing assistant hired on 11/18/1996; Tenured Employees #1's and #74's personnel records revealed both were employed by the facility without the facility having evidence the required background checks were completed After the personnel files were reviewed the administrator provided evidence the required fingerprints were obtained in September 2013. The administrator stated the facility failed to ensure they received the results of the fingerprints in a timely manner. b) To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, the State of West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included .at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, The Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks .For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013.",2018-05-01
6203,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2015-05-14,225,F,0,1,5FNV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, review of West Virginia Code 69CSR6-8.1, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law, or who had findings entered in the nurse aide abuse/neglect registry. The facility did not make reasonable efforts to uncover information about past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia, for four (4) of thirteen (13) employees whose files were reviewed. Employee identifiers: #56, #34, #7, and #95. Additionally, the facility failed to perform the required check of the nurse aide registry for one (1) of those same four (4) employees whose files were reviewed. This had the potential to affect all residents. This practice had the potential to affect all facility residents. In addition, resident interview, medical record review, incident/accident report review, minimum data set (MDS) review, and staff interview, revealed the facility failed to conduct a thorough investigation and failed to implement measures to prevent further abuse related to an allegation of resident-to-resident abuse for one (1) of two (2) residents reviewed for abuse during Stage 2 of the survey. Resident identifier: #92. Facility census: 111 Findings include:a) Thorough Criminal Background ChecksOn 02/05/15 at 1:00 p.m., a review of personnel files found four (4) of thirteen (13) employees hired by the facility, whose personnel records were reviewed, had no evidence of timely required criminal background checks based on fingerprinting. The employees with no evidence of the required timely statewide criminal background check in West Virginia were: -- Employee #56, a nurse aide (NA), hired 04/04/12; -- Employee #34, a registered nurse (RN), hired 11/03/09; -- Employee #107, a licensed practical nurse (LPN), hired 02/17/11; -- Employee #95, a nurse aide (NA), hired 07/23/06. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.The Bureau for Medical Services (Medicaid) manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included, . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013. b) Nurse aide registry checks: On 04/28/15 at 11:49 a.m., a review of personnel files found one (1) of thirteen (13) employees hired by the facility, whose personnel records were reviewed, had no evidence of the required nurse aide registry checks. The employee with no evidence of the required nurse aide registry check was: -- Employee #34, a registered nurse (RN), hired 11/03/09. West Virginia Code 69CSR6-8.1 describes the establishment of a statewide nurse aide registry for nurse aides found guilty of abuse, neglect, or misappropriation of property. Placement on the registry is intended to provide a mandatory process to prohibit facilities from employing those individuals. c) Facility Administrator #2 was interviewed on 05/11/15 at 12:12 p.m. She acknowledged the required criminal background checks and nurse aide registry checks were not completed. d) Resident #92 During Stage 1 of the survey, on 04/21/15 at 2:35 p.m., when Resident #92 was asked, Have staff, a resident or anyone else here abused you, - this includes verbal, physical or sexual abuse, Resident #92 responded, Yes. The resident stated a male resident hit her on the right side of her face with his fist and caused her ear to bleed. When asked when this alleged incident took place, Resident #92 stated it was sometime around Christmas. She further indicated her ear was cleaned and medicine put into the ear. When asked if she could name the resident, she stated she was not able to name the resident, but she knew he still resided in the facility. A review of the medical record, on 04/27/15 at 11:43 a.m., revealed Resident #92 was admitted to the facility on [DATE]. Review of the annual minimum data set (MDS), with an assessment reference date (ARD) of 11/08/14, revealed a brief interview for mental status (BIMS) score of 15. This is the highest possible score and indicated the resident was cognitively intact. The BIMS score was the same on the quarterly MDS, with an ARD of 02/06/15. Review of the facility incident/accident log, on 04/27/15 11:46 a.m., revealed an incident report dated 12/23/14 at 12:00 p.m. related to Resident #92. Registered Nurse (RN) #43's note included, Noted to have dried blood in side of left ear. Upon direct observation with otoscope it was discovered that she had scratched her ear causing it to bleed. Resident statement on the incident/accident report on 12/23/14 at 13:42 (1:42 p.m.) I scratched it. On 04/27/15 at 11:55 a.m., a review of the nurse's note, dated 12/23/14 at 12:30 p.m., revealed, Dried blood noted in left ear canal. Stated it was from where (another resident number) hit her last night. The administrator (NHA) was notified of the allegation during the survey, on 04/27/15 at 2:30 p.m The (NHA) stated she was not aware of such an altercation. On 04/27/15 at 2:49 p.m., the assistant director of nursing (ADON) stated she was not aware of the allegation. At 2:57 p.m. on 04/27/15, upon request, the ADON identified Resident #50 as the resident Resident #92 alleged hit her. When asked about the facility's process when a resident voiced an allegation of abuse, she answered the question by stating there was no need for physician intervention, but the resident required first aid. In another interview, on 04/27/15 at 3:28 p.m., the NHA stated she would call the social worker to see if there was any information regarding the allegation in their old computer system. She stated the facility would investigate the allegation. By the end of the survey, on 05/14/15, the facility provided no evidence an investigation was conducted regarding the resident to resident abuse alleged by Resident #92 and no evidence measures were implemented to prevent further incidents.",2018-05-01
6250,GRANT MEMORIAL HOSPITAL,515045,117 HOSPITAL DRIVE,PETERSBURG,WV,26847,2014-02-21,225,D,0,1,CYPG11,"Based on record review, staff interview, and review of the Center for Medicare and Medicaid Services (CMS) S&C-05-09 letter, the facility failed to investigate and report an injury of unknown source to appropriate agencies. One (1) of one (1) resident reviewed for accidents had a fractured finger. The facility had not investigated the injury or reported the injury to the appropriate outside agencies. Resident identifier #8. Facility census: 11. Findings Include: a) Resident #8 On 02/18/14 at 10:27 a.m., an interview with Employee #9, Registered Nurse (RN), revealed Resident #8 sustained a fracture to the left little finger within the past 30 days. Resident #8's medical record, reviewed at 8:46 a.m. on 2/19/14, revealed the following nursing notes: -- 02/08/14 at 5:40 p.m., .Combative with staff during ADL (activities of daily living) care and bed bath. Scratched one of the CNA's in her right eye and caused her contact lens to come out -- 02/09/14 at 10:48 p.m., (typed as written): .Resident complained of her lt (left) hand hurting. Staff then called me into room to assess. Assessment of lt hand revealed bruising on outside of hand from wrist down to pinkie. Bruising wrapped around to both top and under side of hand. Resident refuses cold packs on hand. resident can not verify how or when she hurt her hand. -- 02/10/14 at 11:31 a.m., (typed as written): (L) (Left) hand 4th and 5th fingers swollen and very bruised. pt. (patient) c/o (complains of) pain in (L) hand. X-ray of (L) hand ordered A review of the X-ray report revealed Resident #8 had a non-displaced fracture involving the proximal phalanx of the little finger. On 02/19/14 at 9:04 a.m., Employee #8,the RN Nursing Manager of the Long Term Care Unit, reported she usually handled the reportable incidents if it happens during the day. She said if it happened in off hours, the nursing manager on call handled the reporting of the incident. Employee #8 stated they had a meeting about Resident #8 and the fracture she sustained to her left hand. She reported they discussed the injury and assumed it happened when Resident #8 was resisting care. She said the resident likely hit the side rail with her hand. She stated they were not sure this was what happened, but this was their best guess. Employee #8 stated she did not speak with the nurse aides, nor did she do an in- depth investigation into what could have happened to Resident #8's hand. She stated she did not speak to the nurse aide, who also received a scratch to the eye on 02/09/14. Employee #8 stated she never thought about talking to her about it. She confirmed she also had not talked to any other staff members to see if they recalled Resident #8 hitting her hand on the side rail during care. Employee #8 stated she did not report this to OHFLAC and APS as an injury of unknown source. She agreed that, due to the extent of the injury, the fact no one observed the injury, and the resident could not recall what happened that it did constitute an injury of unknown source. She stated the facility should have reported this as required. Employee #8 further agreed she should have spoken with nurse aides whom had worked with Resident #8 and she should have completed an in-depth investigation in attempts to determine what happened to Resident #8's finger. Review of the CMS letter S&C-05-09 dated 12/16/04 revealed the following: An injury should be classified as an 'injury of unknown source' when BOTH of the following conditions are met: 1. The source of the injury was not observed by any person OR the source of the injury could not be explained by the resident; AND, 2. The injury is suspicious because of the extent of the injury OR the location of the injury (e.g., the injury is located in an area not generally vulnerable to trauma) OR the number of injuries observed at one particular point in time OR the incidence of injuries over time.",2018-04-01
6269,HILLTOP CENTER,515061,152 SADDLESHOP ROAD,HILLTOP,WV,25855,2015-04-16,225,D,1,0,AU7811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and policy review, the facility failed to report potential neglect to the appropriate state agencies for one (1) of ten (10) residents reviewed. Staff failed to secure the lift pad when transferring Resident #11 with a mechanical lift, which resulted in a fall. Resident identifier: Resident #11. Facility census: 112. Findings include: a) Resident #11 During a medical record review, on 04/15/15 at 11:15 a.m., a progress note, dated 03/02/15, indicated Resident #11 required a total lift with transfers and activities of daily living (ADLs). The current care plan, reviewed on 04/15/15 at 11:41 a.m., indicated the resident required assistance with transfers and locomotion due to disease/compromising functional ability. It specified the use of a mechanical lift for transfers. The care plan also indicated Resident #11 was at risk for additional falls. The care plan falls history noted the resident had a change in condition, dated 03/09/15, related to a recent fall. A change of condition note, dated 02/18/15 at 7:25 p.m. indicated an accident/incident/fall in the past 72 hours. The note indicated the resident experienced back pain, which started after the fall. Further review of the medical record, on 04/15/14 at 12:45 p.m., revealed a progress note, dated 02/28/15 at 7:25 p.m. which indicated the resident was experiencing back pain and was sent to the emergency room for evaluation. Another progress note, at 7:57 p.m., indicated the resident sustained [REDACTED]. A progress note at 10:59 p.m. indicated the resident was transferred to the emergency room for a computerized tomography (CT) scan. The risk management report, supplied upon request on 04/15/15 at 1:45 p.m., indicated on 02/18/15, two (2) nursing assistants attempted to transfer Resident #11 from the shower chair to the bed, utilizing the mechanical lift. According to the report, the lift straps came off lift and resident fell to floor. The report indicated the nursing assistant partially caught the resident's upper body to keep her head from hitting the floor. The resident complained of back pain, and was sent to the emergency room for evaluation. The lift-transfer-repositioning evaluation completed on 02/12/15, reviewed on 04/15/15 at 3:45 p.m., indicated Resident #11 required a total lift for transfers. The facility's reportable allegations, reviewed initially on 04/14/15 at 3:30 p.m., and again on 04/15/15 at 1:00 p.m., provided no indication the fall was reported to the appropriate state agencies. The abuse/neglect reporting requirements for West Virginia (WV) nursing homes was provided by the facility. The reporting requirements were reviewed with the administrator on 04/14/15 at 4:00 p.m. The form indicated 42 CFR 488.301 required the facility to report to the Office of Health Facility and Licensure (OHFLAC), adult protective services (APS), and the ombudsman, of a failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness, regardless of whether the perpetrator actually meant or intended to cause harm. An interview with the director of nursing, on 04/15/15 at 3:15 p.m., confirmed the facility did not report the fall from the lift to the appropriate state agencies.",2018-04-01
6291,PINEY VALLEY,515122,135 SOUTHERN DRIVE,KEYSER,WV,26726,2014-04-15,225,E,0,1,ZU6S11,"Based on record review, review of staff training records, employee personnel file review, review of incident documentation, and staff interview, the facility failed to report and investigate an allegation of resident neglect. The resident was improperly lifted with a mechanical lift, resulting in a fall. In addition, the facility failed to ensure a pre-employment statewide criminal background check was completed for one (1) of five (5) newly hired employees. These practices had the potential to affect more than an isolated number of residents. Resident identifier: #30. Employee identifier: #35. Facility census: 105 Findings include: a) Resident #30 The resident's nursing progress notes were reviewed on 04/09/14 at 1:10 p.m. According to the notes, on 04/04/14, Resident #30 was being assisted to stand with the Sara lift and the resident slipped off the lift and onto the floor. When examined, a nurse noticed the resident's left leg was a different length than the right leg. The resident complained of pain in her leg, hip, and back when she was moved. The resident was transported to an acute care hospital. The hospital found no evidence of a fracture and there was no evidence the pain persisted. A review of an incident report, with an incident date of 04/04/14, for Resident #30, on 04/09/14 at 1:15 p.m., revealed the resident was being assisted to stand using the Sara 3000 lift to enable staff to perform incontinence care. She slipped off the lift and fell on to the floor. An interview was conducted on 04/09/13 at 1:45 p.m. with Employee #159, a nursing assistant (NA). During the interview, she stated she and Employee #33 were attempting to use the Sara 3000 lift to stand the resident. She stated she had put the sling around the resident's mid-torso region, and put the resident's feet on the platform. The NA said she applied the clips to the attachment on the lift. The device required the resident to hold onto the bars on the front of the lift. The NA said the resident took both hands off the bars, placed one (1) arm under the sling, and fell to the floor. Employee #159 was asked to explain the procedure for using the Sara 3000 lift. She stated they were to put the sling around the resident's mid-torso region and snap the buckles on the sling into place. She stated they then attached the clips from the sling to the attachment on the lift. During the interview at 1:45 p.m. on 04/09/14, Employee #159 stated there were no buckles on the sling to snap Resident #30 in place around the mid-torso region. She confirmed she knew she was supposed to snap the buckles to hold the resident in place. When asked if she had identified the buckles were missing while she was standing Resident #30, she stated she did not notice the buckles were missing from the sling. The NA stated she did not think Employee #33 knew either, because she did not say anything to her while they were attempting to use the Sara 3000 lift. An interview was conducted with Employee #16, the direct care delivery (DCD) nurse, on 04/09/14 at 2:00 p.m., regarding Resident #30's fall. She stated she was called to the room because the resident had slid out from under the sling while the NAs were attempting to stand the resident. Employee #16 stated the resident complained of pain in her right hip and the physician was notified. She said the resident was transferred to an acute care hospital for evaluation. Employee #16 said the resident returned at a later time that day with a recommendation to follow up with a CAT scan (Computerized Tomography (CT scan)) for her hip and her head. The DCD was asked what had caused the fall. She stated the buckles were cut off the sling so there was nothing to hold the resident in the Sara 3000 lift. The DCD was asked who trained the employees on the use of the Sara lift. She stated training was provided by the company from whom the facility purchased the lifts. The DCD stated upon hire, all nursing staff must watch a video on how to use the different types of lifts in the facility. She stated she did not know when the company may have been in to provide any training on how to use the Sara lift. The NA in-service records were reviewed on 04/09/14 at 2:00 p.m. The Sara lift in-services contained no evidence the NAs were evaluated for competency in the use of a Sara 3000 lift. The in-service records contained only signatures which represented the NAs had watched the videos. An interview was conducted on 04/09/14 at 3:38 p.m., with Employee #64, a registered nurse (RN). When asked how Resident #30 fell from the Sara 3000 lift, she stated the resident slid out of the lift. Employee #64 said an aide told her Resident #30 was lying on the floor. She said when she went to assess the resident, she observed Resident #30 lying on her back with her feet toward the window. The resident's assessment revealed she was having pain in her right hip. Employee #64 stated she called the physician, and the physician told her to send the resident to the emergency room for evaluation. Employee #64 said when her hip was touched, the resident said she was having pain. Employee #64 said she reported the fall to Employee #72, the director of nursing (DON). On 04/09/13 at 2:50 p.m., the DON confirmed she was told about Resident #30's fall. She said she looked at the sling, then asked Employees #33 and #159 to tell her how the resident could have possibly fallen out of the sling with the mid-torso buckles in place. She stated when she said this, Employee #159's eyes got real big and Employee #159 walked away. She said Employee #159 returned with the sling and said to the DON, They aren't there. The DON stated she asked the employees, Did you have the buckles hooked to her middle torso? The DON said Employee #33 and #159 stated No. The DON asked the employees why they would you use a sling that did not have the buckles in place. The DON said Employee #159 stated she did not realize the buckles were not there. The DON said she immediately reviewed, with the NAs, the need to check the integrity of all slings prior to putting them around or underneath a resident. She also said she reviewed the proper use of the Sara lift with the NAs. The DON stated she then took the Sara lift and the altered sling, which was used with Resident #30, to the administrator's office and described the accident and the circumstances surrounding the accident to the administrator. During an interview with the DON on 04/10/14 at 8:30 a.m., she was asked if this incident of neglect was reported and investigated as soon as the facility identified the buckles were missing and the NAs confirmed they used the sling without the required buckles. The DON said they they did not report this incident as required. She confirmed the incident was substantiated for failure to utilize the Sara lift sling appropriately on 04/04/14. b) Employee #35 On 04/09/14 at 11:30 a.m., a review of the personnel files for newly hired employees was conducted with Employee #157, the Director of Human Resources. Review of the personnel file for Employee #35, a social worker who was hired on 03/17/14, revealed no evidence of a statewide criminal background check. The Director of Human Resources verified the personnel file for Employee #35 did not contain evidence of a statewide criminal background check. At 12:30 p.m. on 04/09/14, the Director of Human Resources, provided an appointment slip indicating Employee #35 was scheduled for an appointment to obtain the statewide criminal background check on 03/28/14. She agreed this background check was not obtained prior to employment.",2018-04-01
6308,MARMET CENTER,515146,ONE SUTPHIN DRIVE,MARMET,WV,25315,2015-04-28,225,D,1,0,J5M711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reported allegations to state authorities, staff interview, resident interview, review of grievance/concern forms, and medical record review, the facility failed to ensure all alleged violations involving abuse and neglect were reported to the proper state authorities and/or failed to ensure each situation was identified and thoroughly investigated for two (2) of ten (10) sample residents. One (1) of two (2) resident's (Resident #72) grievances related to an allegation of verbal and physical abuse was not identified, reported, or investigated. In addition, the facility failed to identify and investigate an injury of unknown origin for Resident #87, to rule out neglect or abuse. Resident identifiers: #72 and #87. Facility census: 86. Findings include: a) Resident #72 On 04/22/15 at 1:00 p.m., review of the grievance/concern forms found Resident #72 voiced a grievance with the facility's social worker on 03/04/15. The grievance was (typed as written): Resident concerned about missing leg tx.'s (treatments) not being done. She also has concerns about staff she says they have been talking behind her back-yelling (symbol for at) her because she comes to the desk to get her cigarettes early and taking up space. She alleges that the staff complains about taking her outside because she is so heavy-they don't want to push her. The social worker (SW) signed the form as completed on 03/06/15. The SW noted the resident's grievance was discussed with the assistant director of nursing. Further review of the facility's grievance/concern form revealed staff were required to describe the actions taken to investigate the grievance/concern. It also directed staff to identify the method used to notify the resident of the resolution. This information was not completed on Resident #72's form. At 4:15 p.m. on 04/22/15, the SW stated she discussed the situation with the director of nursing and the assistant director of nursing. She stated she talked to the resident, but had no evidence of the conversation. The SW was also unable to provide evidence an investigation was conducted. Upon inquiry, she confirmed Resident #72's allegations were not reported to the proper state authorities, as required by law, when a resident alleges neglect and verbal abuse. On 04/27/15 at 10:00 a.m., the administrator stated he reported the resident's allegations, made on 03/14/15, to the proper state authorities on 04/23/15. He provided a copy of his report. Review of the information provided by the administrator found a nursing assistant (NA) was reported to the nurse aide registry for allegedly talking about the resident. The allegation indicated the NA stated the resident was too heavy to assist outside to smoke. The administrator also reported, as a result of his investigation into the 03/04/15 grievance/concern, a registered nurse for being rude to the resident. Further review of the resident's nursing notes, on 04/22/15, found a nursing note, written on 02/13/15 at 6:58 p.m.: . Res. (resident) needed a lot of assistance this day helping her go to the BR (bathroom) on the commode. Linens changed several times, from res. voiding in the bed. Very emotional, feelings are hurt very easily. Res. felt that she was misunderstood during her first night here by the staff d/t (due to) her incont. (incontinence) of urine. She says she goes through this everywhere she's admitted . Rude remarks, jerking on her arms/legs, etc. She spoke to the DON (director of nursing) and Social Worker re: (regarding) the incident. During an interview at 4:30 p.m. on 04/22/15, the SW and DON stated they were unaware of the nursing note. Both employees denied any knowledge of the resident's allegations. At 10:00 on 04/27/15, the administrator provided verification the incident found in the 02/13/15 nurse's note was investigated and reported to the proper state authorities on 04/23/15. b) Resident #87 Review of Resident #87's medical record, on 04/22/15 at 1:00 p.m., revealed the resident was admitted to the facility on [DATE] at 2:40 p.m. A nurse's progress note, dated 03/21/15 at 5:57 p.m. read . Resident was screaming and indicated she was having pain in her right upper quadrant. The nurse's evaluation revealed the resident had a knot located underneath her rib cage on the right side. She was sent to the emergency room (ER). The resident returned to the facility at 11:35 p.m. with documentation from the ER physician. It indicated Resident #87's chief complaint was right rib pain. The discharge [DIAGNOSES REDACTED]. Instructions for the treatment of [REDACTED]. The medical records contained no indication the knot underneath the rib cage, potentially an injury of unknown origin, was investigated. On 04/24/15 at 10:30 a.m., the medical record was reviewed with the Director of Nursing (DON). The DON verified the facility was unable to provide evidence the injury of unknown origin was investigated.",2018-04-01
6359,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,225,E,0,1,OMIN11,"Based on record review and staff interview, the facility failed to report allegations of abuse and neglect to required State agencies and/or failed to thoroughly investigate allegations of abuse and neglect for six (6) residents identified during a review of the past 12 months of reportable incidents. Allegations of abuse and/or neglect regarding Residents #3, #67, and #33 were not reported, and an allegation regarding Resident #63 was reported to the wrong agency. In addition, the allegations of abuse and/or neglect regarding Residents #3, #33, #59, #52, #63, and #67 were not thoroughly investigated. Resident Identifiers: #3, #67, #33, #63, #59, and #52. Facility Census: 61. Findings Include: a) Resident #3 Resident #3 had an occurrence note, dated 05/14/14, indicating the resident had a fall on 05/14/14. The resident was noted to have a 5 centimeter (cm) x (by) 7 cm bruise to her outer right antecubital area. An additional occurrence note, also dated 05/15/14, indicated the equipment involved in the fall was the sit to stand lift. The incident report regarding the fall contained a statement from Employee #25 (NA): While using sit to stand lift with resident, resident let go of hand handles of lift and lifted feet up and slid to the floor. Resident was over the bed at the time so she slid down side of bed. Resident #3's care plan was reviewed and revealed the following intervention, Transfer Self-Performance: (Resident Name) requires assist of 2. (Resident Name) uses a sit to stand mechanical lift and is able to hold onto the lift while in operation. May Need Full Body Lift - Consult OT. This intervention was added to the care plan on 01/20/14, with a revision date of 03/12/14. On 05/22/14 at 10:52 a.m., Employee #25, NA, was interviewed. Employee #25 was the NA who transferred Resident #3 on 05/14/14 when the resident fell from the lift. When asked what happened the night of the fall, Employee #25 stated she was assisting the resident to bed using the sit to stand lift. Employee #25 stated she was the only staff member in the room at the time of the fall. She acknowledged she should have had another staff member with her when operating the lift. Employee #25 said she did not ask anyone to help her because she was busy and did not want to make the resident wait to go to bed. She stated when she began lowering the resident to the bed, the resident let go of the handles and lifted up her feet and began to slide to the floor. Employee #25 said the resident's arms were tangled in the lift and she had to raise the lift a little to get her arms out of the sling. She stated she then got another NA and the Licensed Practical Nurse (LPN) to help her get the resident back to bed. In-service records for lift training were reviewed and found Employee #25 signed a Back Injury Prevention Program (BIPP) Resident Lifting/Transfer Policy on 08/28/12. This policy indicated that, as of 11/15/05, two (2) persons would be in attendance with all mechanical lifting episodes. Employee #56, Licensed Practical Nurse, (LPN) was interviewed at 3:14 p.m. on 05/22/14. She stated she was the nurse working the night Resident #3 fell from the lift. Employee #56 confirmed Employee #25 was the only aide assisting the resident with the transfer using a mechanical lift. She confirmed Employee #25 should have had another NA assisting her. On 05/29/14 at 3:40 p.m., Employee #70, the Executive Director, Employee #72, the Director of Nursing Services (DNS), and Employee #61, the Social Services Supervisor (SSS), were interviewed regarding this incident. They were asked why this incident of neglect was not reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS), and the Ombudsman. They stated it was not immediately known the incident happened with a lift. They also said they reviewed the incident report and did not see where it involved the lift. It was brought to their attention that the statement from the NA on the incident report was, While using sit to stand lift with resident, resident let go of hand handles of lift and lifted feet up and slid to floor. The DNS stated, We must have missed that, it should have been reported when it was known the incident involved a lift. She confirmed it was a reportable incident. b) Resident #67 The facility's grievance and concern forms were reviewed at 8:00 a.m. on 05/29/14. A grievance form, dated 03/20/14, revealed Resident #67 complained to Employee #61, SSS, that a male resident grabbed her breast as she walked by him in the dining room. The resident stated she asked him, What are you doing? and then left the room and told the nurse. The form revealed the action taken was for Resident #67 to avoid the male resident in the future, and nursing was notified to monitor the situation. Employee #67, SSS, was interviewed at 9:00 a.m. on 05/29/14. She stated she did not report this to OHFLAC, APS or to the Ombudsman. When asked if she felt this was resident to resident sexual abuse, she stated it was, because the touch was not wanted or welcomed by Resident #67. She reviewed her policy for abuse reporting and confirmed this incident should have been reported to OHFLAC, APS and the Ombudsman. Upon inquiry, Employee #67, SSS, said she had not investigated this allegation because Resident #67 was able to tell her what happened. c) Resident #33 The facility's grievance and concern forms were reviewed at 8:00 a.m. on 05/29/14. This review revealed a grievance form, dated 11/06/13, in which Resident #33's Medical Power of Attorney called the facility at approximately 12:30 p.m. with concerns about her mother. The MPOA's concerns included the resident being dirty (food dried on clothing, wet brief, etc.) when the MPOA visited around dinner time. The resolution for the grievance was for the nursing supervisor to educate and counsel CNAs (Certified Nursing Assistants) to tend to residents' hygiene and medical needs on a consistent basis. The resolution form was not dated to indicate when the concern was resolved. An interview was held with Employee #67, SSS, at 9:15 a.m. on 05/29/14. When asked if this concern was reported to OHFLAC, APS, and the Ombudsman as an allegation of neglect, she stated, No, I did not report this. She said they met with the MPOA at the resident's care plan meeting and told her (the MPOA) they would work on keeping her mother clean. Employee #67, SSS, was asked if she had investigated the allegation. She stated the she could not recall if she had investigated it or not. She stated she may have just talked to the NA about trying to keep Resident #67 clean. Employee #67, SSS, stated hindsight was always better, and she should have reported this concern as neglect and should have done a more thorough investigation. d) Resident #63 Review of the facility's reportable incidents for the previous 12 months, at 8:00 a.m. on 05/23/14, found a reportable incident dated 11/11/13. The 5-Day Follow Up Report indicated Resident #63 stated she had to get herself to the bathroom about 2 or 3 nights ago. The resident was not sure of the specific night or time frame when this occurred. She stated she pushed the call light and no one came. The resident said she got herself to the bathroom and back to her wheelchair. She said the NA came in and said, You got yourself up, then left. Resident #63 said she then got herself back to bed. The next day, 11/12/13, Resident #63 identified Employee #64 as the NA who failed to assist her. On 11/11/13 Employee #67, SSS reported the allegation to the OHFLAC Nursing Home Program. Since the NA had not yet been identified, this was the appropriate State agency to whom to report. When Resident #63 identified Employee #64 as the perpetrator the following day, the facility should have reported it OHFLAC- Nurse Aide Registry program, which is a separate unit. Employee #67, SSS, was interviewed at 11:34 a.m. on 05/23/14. When asked if this allegation was ever reported to the OHFLAC Nurse Aide Program, she said it had not been. She confirmed she should have reported it to the Nurse Aide Registry when the nurse aide was identified. Employee #67 stated she only took one (1) statement during the investigation. She stated she took a statement from Employee #64 and no one else. She stated that looking back on it, she should have taken statements from all the aides and staff who had worked the previous two (2) or three (3) days. e) Resident #59 Employee #29, Housekeeper, was interviewed at 8:17 a.m. on 05/22/14. He stated about three (3) of four (4) months ago he reported an incident of verbal abuse involving Resident #59. He stated Employee #27 mocked Resident #59's speech impediment. Review of the reportable incidents found an incident dated 02/25/14. The 5-day follow- up report indicated the incident was reported to Employee #67, SSS, on 02/25/14; however, the incident had actually occurred three (3) to four (4) weeks prior to Employee #29 reporting the witnessed abuse. The statement from Employee #29 noted he witnessed Employee #27 mocking the resident's speech impediment. He said Resident #59 had to go to the bathroom and an aide (who was not identified by the investigation) got Employee #27, NA, to assist her. When Employee #27 arrived, she asked Resident #29 what he needed. The resident replied, I need to go pee. Employee #29 stated Employee #27 used a mocking voice, mimicked Resident #59's speech impediment, and said I need to go pee. The facility took a statement from Employee #29 and Employee #27. Employee #27 stated, I may have mocked him a few weeks ago when providing care. Employee #27 was suspended, then brought back to work under supervision of the night shift supervisor. The facility did not take a statement from the other NA who had asked Employee #27 to assist her. An interview with Employee #67, SSS, at 11:45 a.m. on 05/23/14, revealed she had not taken a statement from the other aide who was present and was witness to the incident. Employee #67, stated she should have obtained a statement from the aide who asked Employee #27 to assist her. The SSS said she did not know why it took Employee #29 so long to report the allegation. She said Employee #29 was in-serviced on the immediacy of reporting. The SSS agreed it was the responsibility of all staff to ensure abuse was immediately reported when it was observed. f) Resident #52 Employee #29, Housekeeper, was interviewed at 8:17 a.m. on 05/22/14. He stated that about three (3) of four (4) months ago he had reported and incident of physical abuse involving Resident #52. He stated Employee #27 had picked up Resident #52 off the bed while changing her clothes and then allowed her to drop back down to the bed. A reportable incident for Resident #52, dated 02/25/14 was reviewed. The 5-day follow up report revealed, Employee #29 was putting clothes in Resident #52's closet, and witnessed Employee #29 performing a clothing change on Resident #52. Employee #29 stated he saw Employee #27 pick up Resident #52 by the bend of the knees and then let her drop back down to the bed. Employee #29 indicated Resident #52 was lifted high enough off the bed that her back was not touching the bed. The report also indicated this incident had happened about three (3) months ago. This report indicated Employee #67, SSS, spoke with multiple employees and had unsubstantiated the allegations. Although the investigation into the allegation of abuse was thoroughly investigated, the facility did not investigate the fact that Employee #29, a male housekeeper, was able to witness Employee #27 changing the clothes of Resident #52, a female resident. Employee #67, SSS, was interviewed at 12:00 p.m. on 05/23/14. She stated she did not even think about Resident #52's dignity. She stated she did not investigate anything as it pertained to the resident being seen by a male housekeeper during a garment change. The SSS confirmed Employee #29 was in-serviced on the immediacy of reporting. She said she did not know why he waited so long to report the allegation of abuse. The SSS agreed it was the responsibility of all staff to ensure abuse was immediately reported when it was observed.",2018-04-01
6381,GREENBRIER HEALTH CARE CENTER,515185,1115 MAPLEWOOD AVENUE,LEWISBURG,WV,24901,2014-06-27,225,F,0,1,35BV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, family interview, review of reportable allegations and review of personnel records, the facility failed to ensure allegations of mistreatment, neglect, and/or abuse were reported and/or thoroughly investigated for two (2) of five (5) residents reviewed for abuse and neglect. In addition, the facility failed to complete a thorough background investigation for one (1) of ten (10) employees (#103) whose personnel records were reviewed. This practice had the potential to affect all residents. Resident identifiers: #59 and #110. Employee identifier: #103. Facility census: 77. Findings include: a) Resident #59 Review of the resident's medical record, on [DATE] at 9:00 a.m., revealed the resident had a fall resulting in a head injury on [DATE]. On [DATE] at 2:30 p.m., the event summary report related to the resident's accident was reviewed. The summary indicated the resident fell on [DATE] at 8:20 a.m., hitting his head, resulting in a lump. He was sent to the hospital for an evaluation where a frontal lobe bleed was identified. Review of the nurse's notes, on [DATE] at 3:00 p.m., revealed a note dated [DATE] at 3:11 p.m. It indicated a nursing assistant (NA) was called to the resident's room to take the resident to the bathroom. The note described the NA had the resident holding onto a bar while she moved the wheelchair out of the way. The resident fell on to the bathroom floor, hitting the back of his head and his bottom. The resident complained of pain in the back of his head and the physician was notified. After the fall, it was noted the resident was in bed and was lethargic. He was also noted with a cough and congestion in his throat. At 11:45 a.m., the physician gave an order to send the resident to the emergency room (ER). The resident was sent to the ER for an evaluation regarding his changes in status, lung sounds, and bump on head. Further review of the resident's medical record found the most recent minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], found the Brief Interview for Mental Status (BIMS) was not attempted. The resident was noted to have short term memory problems, disorganized thinking was coded as continuously present and did not fluctuate, and he had trouble concentrating on things. According to the assessment, walking in his room only occurred once or twice in the look back period and walking in the corridor did not occur. For toilet use, he was coded as the extensive assist of one person and for balance, all areas were coded as Not steady, only able to stabilize with staff assistance. The assessment also identified the resident had active [DIAGNOSES REDACTED]. (No additional assessments were completed for this resident as he expired in the facility on [DATE].) During an interview with Employee #2, a registered nurse (RN), on [DATE] at 1:21 p.m., an inquiry was made regarding how many staff members were assisting the resident when he fell . She confirmed Employee #32, a NA, was the only staff member assisting Resident #59 at the time of the fall. Review of the resident's care plan on [DATE] at 9:20 a.m., found the ADL (activities of daily living) function / Rehabilitation Potential portion of the care plan indicated the resident required extensive assist of two (2) with transfers and total assist of two (2) with toileting. This problem was dated [DATE], three (3) days after the resident was admitted . It was reviewed by the facility on [DATE], and remained the same. Upon inquiry, on [DATE] at 1:48 p.m., Employee #1, the director of nursing (DON) said, The facility most always investigates occurrences such as this. She said Social Services kept the investigations and she would provide the investigation reports if they were completed. At 2:47 p.m. on [DATE], the DON reported, Social services reminded me we did not investigate the matter because the physician wrote a note that the resident was having a stroke prior to or during the fall. On [DATE] at 2:56 p.m., a review of the physician's note, dated [DATE], written two (2) days after the resident fell , stated (typed as written): pt (patient) has a cerebral hemorrhage dx (diagnosis) at (name of hospital). i talked to son and told pt may not survive this illness. talked to daughter and she also feels the bleed may have occurred before Tuesday and the fall. This did not negate the fact the resident was transferred by one (1) person instead of two (2). That part of the incident, neglect, required reporting and investigation. b) Resident #110 The resident's medical record was reviewed on [DATE] at 12:30 p.m. A nurse's note, written by Employee #8, a licensed practical nurse (LPN), on [DATE] at 3:39 p.m. noted (typed as written): Resident was sent to (name of hospital) at 1:45 p.m. to have a Rape kit done as she had stated that a male CNA (certified nursing assistant) had raped her. Review of the resident's quarterly MDS, with an ARD of [DATE], (the last assessment prior to her death in the facility on [DATE]) found this resident had severe cognitive impairment. According to her assessment, her speech was clear, she usually could be understood, and sometimes understood others. Her [DIAGNOSES REDACTED]. She also received scheduled pain medication for moderate pain that limited her activities. Review of the facility's reportable allegations of abuse/neglect revealed the incident was reported to the required State agencies; however, there was no evidence the allegation was investigated by the facility. On [DATE] at 1:20 p.m., during an interview with Employee #1, the Director of Nurses (DON), she stated she could not remember any details regarding the allegation of the rape, but she stated she knew the resident had not been raped. When asked how she knew this, she stated the Medical Director received a phone call from the hospital informing the medical director and herself the resident was not raped. When the DON was asked if the incident was reported or investigated, she stated she did not know. The DON said, Perhaps the social worker has that information. An interview with Employee #63, a Social Worker (SW), on [DATE] at 1:35 p.m., revealed the facility did not do an investigation of the allegation because the hospital report showed no evidence the resident was raped and the resident had no memory of the allegation. Upon inquiry, the SW confirmed she had not considered the possibility that something happened to the resident which required an investigation, even though it was not rape. The SW stated she did not think she had to investigate the incident since she had reported it. She could not remember any details concerning the alleged rape, such as how she found out about the allegation, what happened, how it happened, or who was involved. Employee #63 provided evidence that faxes were sent on [DATE] to the Office Health Facility Licensure and Certification and Adult Protective Services. The incident date on these faxes indicated the allegation of rape occurred on [DATE]; however, the resident was not sent to the hospital for the rape testing until 1:45 p.m. on [DATE]. c) Employee #103 On [DATE] at 1:20 p.m., the personnel file review revealed one (1) of ten (10) employees did not have a thorough criminal background check completed. Employee #103 (resident service provider) came to work at the facility on [DATE]. This employee listed on her application she had worked in a neighboring state until 2007. The facility had completed a criminal background check for the state of West Virginia at the time the employee was hired. The personnel file contained no evidence showing the facility had conducted a criminal background check outside of West Virginia. On [DATE] at 1:30 p.m. Employee #99 (bookkeeper) said the facility had not conducted a criminal background check in the neighboring state for Employee #103.",2018-04-01
6423,PRINCETON CENTER,515028,1924 GLEN WOOD PARK ROAD,PRINCETON,WV,24740,2015-03-06,225,D,1,0,S2LQ11,"Based on record review and staff interview, the facility failed to report an allegation of sexual abuse to appropriate State agencies, and failed to thoroughly investigate the allegation. This was discovered by a random opportunity for discovery while reviewing a resident's medical record. The medical record indicated an allegation of sexual abuse was made to a nurse aide and a licensed practical nurse (LPN). There was no evidence this allegation was reported to appropriate state agencies or thoroughly investigated. Resident Identifier: #59. Facility Census: 58. Findings Include: a) Resident #59 A review of Resident #59's medical record, at 4:00 p.m. on 03/04/15, found a nursing progress note, dated 07/15/14, written by Licensed Practical Nurse (LPN) #56. The note contained the following text (typed as written): Called residents room by CNA (Nurse Aide) to witness thing that the resident was stating. Resident stated that, 'Someone came in while I was asleep and was touching me down there and got me pregnant. They also took pictures of me naked. And since they touched me they made me start my period again. I went to the hospital last week and they had to remove a mass. It was a baby and it was born dead.' Charge nurse (Name of former employee), RN (Registered Nurse) was notified and so was social services. Resident was checked for bleeding and no bleeding noted. Resident will continue to be monitored. Call Bell within reach. An interview with the Vice President of Social Services, Employee #55, at 9:05 a.m. on 03/06/15, found this incident was not reported to the Office of Health Facility Licensure and Certification, Adult Protective Services, or the Ombudsman Program. She said she could not recall whether or not the allegation was reported to her by nursing staff. Employee #55 said she felt if it had been reported to her, she would have reported it immediately as an allegation of sexual abuse. She was asked about the process for situations in which a resident alleged abuse to nursing staff. Employee #55 stated nursing staff brought it to her attention, she reviewed it with the administrator, then a decision was made regarding whether it was a reportable allegation. She said to her knowledge, this process was not carried out for this allegation because she had no knowledge of the allegation Resident #59 made on 07/15/14. When asked if the allegation was investigated, Employee #55 stated the allegation of sexual abuse had not been thoroughly investigated.",2018-03-01
6495,VALLEY CENTER,515169,1000 LINCOLN DRIVE,SOUTH CHARLESTON,WV,25309,2014-06-23,225,F,0,1,3WT411,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by the use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for four (4) of ten (10) employees whose files were reviewed. This had the potential to affect all residents residing in the facility. Employee Identifiers: #133, #101, #91, and #48. Facility census: 123. Findings include: a) Thorough Criminal Background Checks Review of personnel files, on 06/17/14, between 1:00 p.m. and 1:24 p.m., found no evidence of fingerprints being taken as required for a West Virginia criminal background check for four (4) employees. These were: 1. Nursing Assistant (NA) #133, hired on 04/02/14. 2. NA #101, hired on 08/14/12. 3. NA #91, hired on 09/27/11. 4. NA #48, hired on 12/21/05. In a discussion with the Nursing Home Administrator (NHA) at 2:07 p.m. on 06/23/14, she confirmed Nurse Aides #133, #101, #91, and #48 did not have background checks completed using fingerprints in their personnel files. When asked what the process was to complete background checks for employees, she stated if they had not lived, worked, or gone to school out of state, they would submit the employees' fingerprints for a background check for the State of West Virginia. She also stated, if the employee had worked, lived, or gone to school out of state, they would submit the employees' fingerprints to the State of West Virginia and to the Federal Bureau of Investigations (FBI) for a background check. To ensure the facility had not employed an individual who had been found guilty of abusing, neglecting, or mistreating residents by a court of Law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police.",2018-03-01
6555,"MADISON, THE",515104,161 BAKERS RIDGE ROAD,MORGANTOWN,WV,26508,2014-03-06,225,E,0,1,3XP811,"Based on employee record review and staff interview, the facility failed to complete a thorough background history for two (2) of ten (10) randomly selected employees whose records were reviewed. The facility failed to obtain statewide criminal background investigations through the West Virginia State Police. This had the potential to affect more than a limited number of residents. Employee identifiers: #63, #20. Facility census: 58. Findings include: a) Employee #63 The employee record review, completed on 03/06/14 at 9:30 a.m., revealed the absence of a criminal background investigation report from the West Virginia state police. Employee #63, hired in October 2012 did not have a criminal background report from the West Virginia state police. Employee #23 (schedule manager/nurse aide) said a company (name) initially completed the fingerprinting; however, the request for the background check was rejected by this company. She said the facility did not receive a letter from the company to notify them of the rejection. b) Employee #20 On 03/06/14 at 9:35 p.m., an employee record review revealed the absence of a West Virginia state police criminal background investigation report. This employee was hired in May 2012. Employee #23 said the fingerprinting was initially completed, but the request for the background check was rejected. She said the facility did not receive a letter from the company assigned to complete the fingerprinting informing them of the rejection.",2018-01-01
6624,ROANE GENERAL HOSPITAL,515099,200 HOSPITAL DRIVE,SPENCER,WV,25276,2014-08-20,225,F,0,1,R6QV11,"Based on staff interview, record review, review of personnel files, and policy review, the facility failed to make reasonable efforts to complete thorough investigations of the past histories of individuals they hired. The facility failed to complete criminal background checks for eight (8) of ten (10) employees reviewed. In addition, the facility failed to check State nurse aide registries for two (2) of ten (10) employees who had resided in other states, and of which the facility was aware. The facility failed to prevent further potential abuse/neglect of all residents after neglect was identified for Resident #25. The facility failed to identify an occurrence of neglect for Resident #21. When notified of the neglect, the facility failed to report and investigate the allegation of neglect . These practices had the potential to affect all residents in the facility. Resident identifiers: #21 and #25. Facility census: 34. Findings include: a) Criminal background checks. Employee personnel files were reviewed, related to criminal background checks, with the executive director of human resources, Employee #70, on 08/14/14 at 9:00 a.m. Review of the records revealed no evidence a criminal background check was completed for Employee #29, a nursing assistant (NA), Employee #25 (NA), Employee #22 (NA/ward clerk), Employee #6 (NA), Employee #64 (NA), Employee #1, a licensed practical nurse (LPN), Employee #65 (NA), and Employee #9 (LPN.) Employee #70 related he was unaware the criminal background checks should have been completed. An interview with Employee #71(coordinator of clinical services), on 08/14/14 at 9:30 a.m., and Employee #27, executive director, on 08/14/14 at 10:00 a.m., confirmed no evidence was available to indicate the facility had completed the criminal background checks. The Patient Protection and Affordable Care Act (Pub. L. 111 - 148, enacted March 23, 2010) and the Health Care Education Reconciliation Act of 2010 (Pub. L. 111 - 152, enacted March 30, 2010), together are known as the ACA. The legislation authorized long term care (LTC) facilities and providers to obtain State and national fingerprint based background checks from potential employees whose duties include direct access to residents and patients. b) Nurse aide registry/licensing board Review of employee personnel files, with Employee #70, on 08/14/14 between 9:00 a.m. - 9:30 a.m., revealed no evidence the facility screened employees with the nurse aide registry in all states a staff member may have worked for two (2) employees reviewed. Review of the employee applications revealed Employee #3 (NA) and Employee #9 (LPN) had lived and worked in a state other than West Virginia. The director also related he was not aware the facility should check other state registries. An interview with Employee #71, on 08/14/14 at 9:30 a.m., revealed the nursing office did not complete screens, and had none on file. Employee #70 also confirmed no evidence was available to indicate the nurse aide registry or licensing boards were contacted to ensure fitness for service. Review of the abuse policy indicated the facility's policy was to screen and investigate the past histories of individuals considered for hiring. It indicated this included criminal background checks, office of the inspector general investigation, verification of licensure, certification or registration, and reference checks. c) Resident #25 A review of reportable allegations, on 08/12/14 at 10:00 a.m., noted an allegation reported to state agencies by the facility's previous social worker. The initial complaint was dated 06/06/14 at 3:30 - 5:45 p.m. It indicated Resident #25 was returned to her room by the shower aide, Employee #29, a nursing assistant (NA), and left in the shower chair for the floor NA to care for her. According to the report, the resident required assistance of two (2) for transfers. Employee #64 (NA) could not find immediate assistance, went to lunch, and forgot about the resident. Resident #25 was found at approximately 5:45 p.m., by the unit clerk, Employee #22 (NA/ward clerk), still in her shower chair, totally exposed, and had urinated and defecated. According to the report, the allegation was reported on 06/09/14. It indicated an extension request was made because the allegation of neglect was not made in a timely fashion by staff. The report indicated the social worker was not notified until three (3) days after the incident occurred, when she arrived to work and discovered the complaint form under the door. Review of the staffing schedule, for June 2014, revealed the alleged perpetrator(s) continued to work with residents after the date of the alleged neglect. According to the schedule, Employee #64 (NA) worked 3-11 on 06/06/14, 11-7 on 06/07/14, 06/08/14, and 06/09/14. Employee #29 (NA) continued to work. An interview with Employee #27 (executive director),on 08/14/14 at 12:30 p.m., confirmed staff did not protect residents from the alleged perpetrator(s). d) Resident #21 At 8:40 p.m. on 08/12/14, Resident #21 was observed asleep at the dining room table. He was sitting alone. His pants were visibly wet, as was the incontinence pad on which he was seated. On 08/12/14 at 8:45 p.m., the director of nursing (DON), Employee #27, was informed of the observation regarding Resident #21. She was made aware of the resident's visible incontinence, and positioning in the dining room. It was reported to the DON that Employee #14, a nursing assistant (NA) had verified, she was the NA assigned to provide care for Resident #21. Also reported to the DON was Employee #14's verification, that she had not provided toileting, incontinence care, or positioning for Resident #21, from 3:00 p.m. until 8:40 p.m. At 9:00 p.m. on 08/12/14, Upon inquiry, the DON was asked if the resident should have been toileted, provided incontinence care, and repositioned during the shift, to which she said, Yes, he should have. Review of the facility's abuse policy indicated the facility would identify, correct and intervene in situations in which abuse or neglect may occur, such as deployment of staff in sufficient numbers to meet the needs of residents, assure staff have the knowledge of individual resident's care needs, and assessment, care planning and monitoring of residents with needs which may lead to neglect such as those who exhibited behaviors, required heavy nursing care, and were totally dependent on staff. Although the allegations of neglect regarding this resident were reported to the DON on 08/12/14 at 8:45 p.m., at the time of exit, on 08/20/14 at 8:15 p.m., the allegations had not been reported or investigated",2017-12-01
6653,WELLSBURG CENTER,515123,70 VALLEY HAVEN DR,WELLSBURG,WV,26070,2014-04-04,225,D,0,1,Y7ME11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of incident and accident reports, policy review, and staff interview, the facility failed to ensure they reported an allegation of neglect for one (1) resident found during a review of 48 resident incident/accident reports. While transferring the resident, with two (2) nursing assistants and a mechanical lift, the lift tipped over. The resident landed on the floor on her right side, hitting her head, knee, and arm in the process. Resident identifier: #5. Facility census: 56. Findings include: a) Resident #5 An incident report, dated 01/25/14 at 4:30 p.m., was reviewed on 04/02/13 at 11:30 a.m. According to the report, Resident #5 fell to the floor during an assisted transfer from the bed to the chair by two (2) nursing assistants. Typed as written, While lifting resident into chair with Hoyer lift, Hoyer tipped over & (symbol for and) resident landed on right side on the floor hitting her head knee & arm. She sustained a red, lump R (symbol for right) head. She was transported to a local hospital for evaluation. During an interview with the administrator on 04/02/13 at 11:30 a.m., she said she did not report this incident to state agencies because no one alleged neglect, and both of the aides were experienced aides who knew how to use the Hoyer lift. The administrator said, for some reason as the aides tried to maneuver the Hoyer lift, the front end toed inward, and the lift tipped over. She deemed this to be an isolated incident. After this incident occurred, she said education was completed with all nursing staff on mechanical lift safety. On 04/03/14 at 9:00 a.m., the minimum data sets (MDS), with assessment reference dates (ARD) of 11/13/13 and 02/01/14, were reviewed. This review found that Resident #5 was totally dependent on staff for turning and repositioning while in the bed, and for all activities of daily living. Her bilateral upper and lower extremities were impaired. The medical record was also reviewed on 04/03/14 at 9:00 a.m. Because this resident was unable to transfer between surfaces, she required a mechanical Hoyer lift for staff to transfer her in and out of bed. The care plan addressed she had a potential for falls related to a previous [MEDICAL CONDITIONS], the inability to bear weight on her legs, and impaired balance. A care plan approach was for the use of a mechanical lift with two (2) person assists for all transfers. Several attempts were made to interview the resident, but each time she declined. During an interview on 04/03/14 at 9:15 a.m., the director of nursing (DON) said they did not report this incident to state agencies because the nursing assistants who were involved in the incident were seasoned staff, and there was no complaint of abuse or neglect from the resident. She said the aides involved should have known to keep the front end of the lift at a wider stance to provide more support, but for some reason the front end of the lift turned inward. She said the lift was able to accommodate the size and weight of the resident who fell . When asked on 04/03/14 at 12:00 p.m. for the facility's policy related to reporting abuse and/or neglect, the licensed social worker (LSW) said they follow a specific guide. She provided a copy of a table and guide for Abuse/Neglect Reporting Requirements for WV Nursing Homes and Nursing Facilities, revised October 2011. She said this is what the facility followed to determine if an incident should be reported to state agencies. Review of this guide on 04/03/14 at 12:00 p.m. found a definition of neglect as Failure to provide goods and services, necessary to avoid physical harm, mental anguish, or mental illness. This was regardless of whether the perpetrator actually meant or intended to cause harm. Reporting must be made to the Nurse Aide Program, adult protective service (APS), and the ombudsman. None of these programs were made aware of the incident of neglect that occurred on 01/25/14.",2017-12-01
6704,RIVERSIDE HEALTH AND REHABILITATION CENTER,515035,6500 MACCORKLE AVENUE SW,SAINT ALBANS,WV,25177,2014-11-05,225,D,1,0,YJ9E11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of abuse/neglect files, review of the facility's policy for Investigation and Reporting alleged violations of abuse/neglect, and staff interview, the facility failed to thoroughly investigate allegations of abuse/neglect. Two (2) separate incidents were reported to the State agencies, for one (1) resident, after the facility was made aware by adult protective services (APS) of allegations of abuse/neglect of which they were unaware until APS came in to investigate them. These allegations were reported to the State agencies, but were not thoroughly investigated by the facility. This was true for two (2) of the six (6) allegations of abuse/neglect reported to the State agencies that were reviewed. Resident identifier: #95. Facility Census: 94. Findings include: a) Resident #95 Review of the facility's abuse/neglect allegations and reporting files found two (2) allegations reported to the State agencies concerning Resident #95. Review of Resident #95's medical record identified she was alert and oriented and had capacity. She was able to answer questions appropriately and had good long and short term memory. 1) The first allegation on 08/22/14 had an immediate fax reporting sheet dated 08/22/14. This form described this incident as APS (adult protective services) in to investigate complaint they received regarding resident being dirty (dry feces) and not given pain medication timely at least once. The original report had the incorrect resident name and this was corrected and reported again for the correct resident which was Resident #95. This complaint investigation included four (4) interviews with staff members. There were three (3) nursing assistants and one (1) registered nurse interviewed regarding these allegations. They were asked the following two (2) questions : - Have you ever seen Resident # 95 in dry feces? - Has Resident ever complained of pain and indicated she could not get her medication? The statement/interview documents gathered for this investigation indicated three (3) of these interviews had not witnessed these things for Resident #95 and one (1) of the interviews was a nursing assistant who said I have never had this patient. The acting administrator/social worker (Employee #32) was questioned on 11/04/14 at 3:30 p.m. about the process for conducting this investigation. She stated they reviewed Resident #95's medication administration records to see if she had her pain medication when she ask for it and they interviewed staff. She verified there were only two (2) nursing assistants who took care of this resident interviewed and one (1) nurse. She was asked about the process for selecting which staff to interview when there was an allegation of abuse/neglect and she verified the ones she interviewed were the staff who were there the day she did this investigation. There was no evidence the schedule was reviewed to see who should be interviewed according to who had provided care for the resident during the time frame this abuse/neglect was alleged. Employee #32 was questioned at that time about interviewing this resident. She verified this resident was alert and oriented and could be interviewed, but she stated she did not interview the resident because she was out to [MEDICAL TREATMENT] at the time she conducted the interviews for this investigation. There was no evidence she attempted to discuss this incident with the resident when she returned from [MEDICAL TREATMENT] or talk to the family who visited daily to obtain more information about this incident and ensure the allegation was investigated thoroughly. The five-day follow up reported to the State agencies stated the outcome was No conclusive evidence of neglect. The corrective action simply stated continue to administer pain medication as ordered. 2) The second allegation of abuse/neglect for Resident #95 reported to the State agencies was dated 09/11/14. The description of this incident was, APS in on allegation that resident did not receive her pain medication and was wet. Reported to APS (adult protective services) on 09/05/14 and APS was in facility to investigate this 09/11/14. There was no evidence in this abuse/neglect file that the facility investigated this incident which was reported to them by APS. The administrator/social worker (Employee #32) stated, on 11/04/14 at 4:55 p.m., they had not known about this until the APS agency came in to investigate this and the facility then reported it. The Director of Nursing (Employee #35), in an interview on 11/05/14 at 9:00 a.m., verified the facility had not gathered any statements to investigate this allegation and did not have evidence of an investigation because APS (adult protective services) came in and investigated and was satisfied with it. The five (5) day follow up to the nursing home program stated, Unable to substantiate MAR (medication administration record) reflects medication has been administered PRN (as needed) and resident has no red areas or skin breakdown. b) A review of the facility's policy titled HR-408 Investigation and Reporting of Alleged Violations of Federal and State Laws Involving Mistreatment, Neglect, Abuse, Injuries of Unknown Source and Misappropriation of Resident's Property, effective/revised date 03/01/13, indicated in the section titled Investigation, The investigation shall include interviews of employees, visitors, residents, volunteers and vendors who may have knowledge of alleged incident. It was verified the facility did not include interviews with the resident, family visitors, or all staff that had provided care for the resident and may have knowledge of the alleged incident.",2017-11-01
6788,HARPER MILLS,515086,100 HEARTLAND DRIVE,BECKLEY,WV,25801,2014-11-21,225,D,1,0,X1Q611,"Based on a review of the concern log, a review of the reported allegations of abuse and neglect, and staff interview, the facility failed to ensure all allegations of neglect were reported to the required State agencies. A review of five (5) months of concern logs revealed two (2) concerns contained allegations of neglect, which were not reported as required. Resident identifiers: #142 and #146. Facility census: 145. Findings include: a) Resident #142 On 11/18/14 at 4:45 p.m., a review of the concern log and reportable allegations of abuse and neglect logs for June, July, August, September, and October 2014 revealed Resident #142's sister reported a concern on 10/07/14. The concern stated, Sister upset that resident was late for appointment citing that ambulance was called late and resident was inappropriately dressed. The concern log stated nursing was responsible for resolving the issue. Employee #148 (registered nurse) indicated, on 11/18/14 at 5:05 p.m.,she did not report this as an allegation of neglect. b) Resident #146 A review of the concern log and reportable allegations of abuse and neglect log, on 11/18/14 at 4:45 p.m., revealed a concern filed on 10/07/14. The concern stated, Son upset that walker was not moved with resident during room move yesterday and resident fell in the night. Concerned with resident's report this morning that no one answered call light for four hours. On 11/18/14 at 5:10 p.m., Employee #148 said the facility had investigated this issue but did not report it as neglect.",2017-11-01
6813,LEWISBURG CENTER,515144,979 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2014-02-20,225,F,0,1,SDOD11,"Based on personnel record review, review of the requirements for criminal background checks in West Virginia, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions by use of fingerprinting, which is a required procedure to ensure a statewide criminal background check in West Virginia. This was true for six (6) of ten (10) employees whose files were reviewed. This had the potential to affect all residents. Facility census: 85. Findings include: a) Thorough Criminal Background Checks On 02/18/14 at 9:00 a.m., a personnel file review was completed. Ten (10) personnel files were reviewed. Six (6) of six (6) employees hired after 01/01/13 had no fingerprints, or criminal background checks based on fingerprinting, in their files. The files all contained criminal background checks completed by Company #1. When asked, at 9:30 a.m. on 02/18/14, Employee #99, the individual responsible for human resources and payroll, stated they did not use fingerprinting with the Company #1. The employees with no evidence of the requisite fingerprinting, as required for a statewide criminal background check in West Virginia were: -- Employee#1, a licensed practical nurse (LPN), hired 01/07/14; -- Employee #121, LPN, hired 01/21/14 ; -- Employee #4, LPN, hired 01/07/14; -- Employee #122, a nursing assistant, (NA)m hired 02/04/14; -- Employee #20, LPN, hired 09/03/13; and -- Employee #27, NA, hired 05/28/13. In a discussion with the Administrator and Employee #99, at 4:00 p.m. on 02/18/14, both denied knowledge of any regulations requiring criminal background checks based on fingerprinting. They agreed the facility had not been performing such checks on their new hires. To ensure the facility has not employed an individual who has been found guilty of abusing, neglecting, or mistreating residents by a court of law, West Virginia requires submission of fingerprints to the agency contracted by the West Virginia State Police. The Bureau for Medical Services manual includes: 514.4.1 Employment Restrictions Criminal Investigation Background Check (CIB) results which may place a member at risk of personal health and safety or have evidence of a history of Medicaid fraud or abuse must be considered by the nursing facility before placing an individual in a position to provide services to the member. At a minimum, a fingerprint-based State level criminal investigation background check must be conducted initially by the employer prior to hire and every three years thereafter throughout the remainder of the employment. If the prospective employee has lived out of state within the last five years, the agency must also conduct a federal background check utilizing fingerprints through the national crime information database (NCID). A policy clarification memorandum (memo) was issued to all Medicaid participating facilities on February 15, 2013. The memo included . at a minimum, a fingerprint-based state level criminal investigation background check must be conducted initially by the employer prior to hire and every 3 years thereafter throughout the remainder of the employment. This policy pertains to new hires and current employees. Due to the magnitude of current employees in nursing facilities throughout the State of West Virginia, the Bureau for Medical Services will allow the nursing facility until March 1, 2014, to have all current employees up to date with criminal investigation background checks. For any new hires in the nursing facility, the policy is effective for those individuals as of January 1, 2013.",2017-11-01
6844,CRESTVIEW MANOR NURSING AND REHABILITATION,515160,199 COURT STREET,JANE LEW,WV,26378,2014-11-20,225,D,1,0,5L6B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of incident/accident reports, review of reportable incidents, and staff interview, the facility failed to investigate and report an injury of unknown source. Resident #6 was found with a large bruise to his left posterior flank area and was sent to an acute care center for evaluation on the same day. There was no evidence the facility investigated to determine whether the large bruise was a result of neglect, abuse, or mistreatment. One (1) of thirteen (13) residents on the sample was affected. Resident identifier: #6. Facility census: 61. Findings include: a) Resident #6 A review of the facility's incident/accident reports and abuse/neglect reports, on 11/17/14 at 1:00 p.m., found no evidence the facility had investigated and/or notified the required State agencies of an injury of unknown origin involving Resident #6 and a bruise found on his left flank on 10/25/14. Review of the resident's medical record, on 11/18/14 at 11:00 a.m., revealed this ninety-one (91) year-old male had [DIAGNOSES REDACTED]. The resident required assistance with all activities of daily living. On the morning of 10/25/14, a large bruise was found on his left flank, and he was transferred to an acute care center for evaluation as his medical power of attorney requested. During an interview, on 11/18/14 at 2:30 p.m., Nurse Aide (NA) #51 reported he had found the large bruise on the resident's left flank while giving the resident his bed bath and reported it to the nurse. The resident was transferred to the hospital for an evaluation the same day. The NA was unaware of the cause of the bruise. In an interview on 11/20/14 at 9:00 a.m., the director of nursing (DON) confirmed the facility had not investigated or reported the bruise of unknown origin found on Resident #6 on 10/25/14. The DON agreed it should have been investigated and should have been reported to the State agencies.",2017-11-01
6863,LOGAN CENTER,515175,55 LOGAN MINGO MENTAL HEALTH CENTER ROAD,LOGAN,WV,25601,2014-03-07,225,D,0,1,JZ4X11,"Based on record review and staff interview, the facility failed to ensure one (1) of ten (10)employees reviewed was eligible to work at the facility. The facility did not make reasonable efforts to uncover information about a possible criminal background for Employee #43. A criminal background check was not done in the state of Massachusetts, even though the facility had knowledge the employee worked in that state for multiple years. This practice had the potential to affect more than an isolated number of residents. Employee Identifier: #43. Facility Census: 62 Findings Include: a) Employee #43 Employee #43's personnel record was reviewed at 11:40 a.m. on 03/06/14. This review revealed Employee #43 was employed by the facility on 03/24/11 to fill the position of nurse aide. Employee #43's employment application was reviewed and revealed she had worked in the state Massachusetts from November 1988 until December 2002 as a nurse aide. Employee #43's personnel file included a criminal background in West Virginia, but did not include a criminal background check for Massachusetts. Employee #4, the bookkeeper, was interviewed at 11:49 a.m. on 03/06/14. She stated a criminal background check was not completed in Massachusetts for Employee #43. She stated the only background check they completed for this employee was in West Virginia. She confirmed Employee #43's application indicated she lived and worked in Massachusetts, and a criminal background check should have been completed in that state.",2017-11-01
6891,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,225,E,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reportable allegations regarding abuse / neglect (for the past three (3) months), medical record review, and staff interview, the facility failed to ensure all allegations involving neglect, or abuse, including injuries of unknown source and misappropriation of resident property were immediately reported to officials in accordance with State law (Abuse / Neglect Reporting Requirements for West Virginia Nursing Homes and Nursing Facilities, revised 10/2011). Allegations were not reported to the nursing home program and/or Adult Protective Services (APS) in accordance with West Virginia Code 9-6-9 for five (5) of nineteen (19) reportable allegations reviewed. -- Resident #145 was alleged to have worn the same brief, seeping with bowel movement, for two (2) hours and 40 minutes after it was reported soiled. The facility's investigation of this incident was not thorough and was not reported to APS in a timely manner, and was not reported on the correct form. -- Resident #26 was found with a urine saturated brief and draw sheet. He stated his brief had not been checked. It was mid-afternoon, yet he was still in his gown. The incident was not reported timely and the facility did not complete a thorough investigation of the incident. In addition, the allegation was not reported to APS on the State required form. -- Resident #151 reported she had to wait several hours to get out of bed and her call light was placed out of reach. The allegation was not reported timely to the nursing home program and the facility did not complete a thorough investigation of the incident. In addition, the facility failed to immediately report the allegation to APS using the correct mandatory reporting form. -- Resident #77's daughter made seven (7) complaints regarding her mother's care. Only one (1) of these complaints was reported and investigated. There was no evidence of an investigation into the other six (6) allegations. The allegation which was reported was not reported timely. -- Resident #18 A nursing note described neglect of this resident. The resident asked a nursing assistant (NA) to place her on the bedpan during a meal time. The resident was informed she could not be placed on the bed pan until she and everyone on her unit were finished with the meal. Resident identifiers: #145, #26, #151, #77, and #18. Facility census: 85. Findings include: a) Resident #145 Review of the facility's reportable allegations to proper State authorities found the facility's speech therapist, Employee #105, reported Resident #145 was observed at 8:00 a.m. on 01/03/14 with bowel movement seeping out of his brief. The therapist notified staff. The report noted the same brief was still on the resident two (2) hours and 40 minutes later, at 10:40 a.m. on 01/03/14. Staff members were again notified of the situation. Further investigation found the facility did not immediately report the allegation of neglect to the nursing home program as required by the State law. It was not reported until 01/06/14, three (3) days after the alleged incident occurred. Review of the immediate fax (form #225) to the Office of Health Facility Licensure and Certification (OHFLAC), found a brief description of the incident: The therapy dept. reported two concerns regarding this resident on 01/03/14. The first is that the resident appeared to have the same soiled brief on at 10:40 a.m. that they had noted at 8 a.m. At that time, resident was observed to have BM (bowel movement) seeping from his brief. The second concern is that the resident reported to therapy staff on 01/03/14 that he did not receive a breakfast tray. This was at 11:45 a.m. The therapist provided him with a snack and fluids. Review of the facility's investigation of the incident found the facility obtained three (3) statements from staff members. Two (2) of the staff members were not even working the day of the alleged incident. 1) Employee #71, a nursing assistant, provided a written statement on 01/10/14. I was not working this day, I know nothing of these incidents in question. 2) Employee #6, a registered nurse, provided a written statement on 01/10/14. The resident is not a regular patient of mine know nothing of the incident in question. This employee also stated she was not working on 01/03/14. 3) Employee #88, the facility social services worker, wrote a statement describing and interview with the resident on 01/10/14. The statement said the resident denied the allegations and had no complaints. Medical record review found the resident lacked capacity to make medical decisions as a result of a cerebral vascular incident ([MEDICAL CONDITION]) with a closed head injury. The resident was admitted to the facility, from the hospital, on 12/23/13, shortly after his [MEDICAL CONDITION]. His admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/30/13, identified the resident had long and short term memory problems. He could not recall the current season, location of his room, staff names and faces, or the fact he was in a nursing home. The brief interview for mental status (BIMS) could not be completed with the resident during his MDS assessment period with ARD of 12/30/13. His cognition was coded as severely impaired on the MDS. Review of the five (5) day follow up report to OHFLAC (form #225A), completed by the facility social worker on 01/10/14 found, Unable to substantiate neglect based on the investigation. Resident is noted to have cognitive deficits from a recent stroke but normally able to respond appropriately to questions. He did miss his breakfast tray on 01/03/14 but it was not a willful omission. The resident reported he believes he receives satisfactory nutrition and care. It was not possible to substantiate he was wearing the same brief on the morning of the incident. No skin breakdown. The facility's social worked was interviewed at 12:05 on 01/22/14. She stated the investigation involved everyone, not just herself, and she can not do everything. -- When asked why statements were not obtained from direct care staff who worked on 01/03/14, the social worker stated she had asked for statements from staff. She said, They would not provide them. -- When asked why the incident was not reported to OHFLAC until three (3) days after the occurrence, the social worker said it was because the incident occurred on a Friday and she did not work over the weekend. She also said the therapist put the statement in a box, which was not checked by herself until Monday, 01/06/14. -- When asked for evidence the incident was reported to adult protective services, the social worker was unable to provide evidence the incident was immediately reported to APS on the required reporting form. -- The social worker was interviewed regarding the five (5) day follow up report she sent to OHFLAC on 01/10/14. No response was received when the social worker was asked how the resident (who was coded as severely impaired in cognition) had memory of the incident when he was interviewed by her seven (7) days after the alleged incident occurred. b) Resident #26 Review of the facility's reportable allegations of abuse/ neglect and misappropriation of resident personal property found an incident recorded on OHFLAC's reporting form #225, entitled, Immediate Fax Reporting of Allegations - Nursing Home Program. The description of the incident was, The therapy department reported they found the resident in bed with a saturated brief and draw sheet at 3 p.m. on 01/03/14. The resident told the therapist he had only been given a bed pan once the entire day and no one had checked his brief. He was still in his gown and wanted to get out of bed and washed. The allegation was not reported until 01/06/14, three (3) days after discovery. The facility's Investigation of the incident consisted of two (2) handwritten statements. One from Employee #71, a nursing assistant. and the other from Employee #6, a registered nurse. Both employees stated they did not work on 01/03/14, the day the alleged incident occurred. The social worker (SW) was interviewed at 12:05 p.m. on 01/22/14. She verified the allegations were not reported immediately as required by State law. The SW also verified the investigation was not thorough, in that no statements were obtained from the resident's assigned care givers for 01/03/14, the date the alleged incident occurred. She was also unable to provide evidence the allegation was reported to Adult Protective Services (APS) on the required reporting form. c) Resident #151 Review of the facility's reportable allegation of abuse/neglect and misappropriation of resident property, on 01/22/14, found a copy of an immediate fax reporting of an allegation to the nursing home program (OHFLAC form #225) on 01/07/14 for Resident #151. According to a brief description of the incident, Resident reported to therapist in the rehab. dept. that she had to wait several hours to get out of bed. Then once she was out of bed, she was placed where she could not reach her call light. She reported that a CNA (certified nursing assistant) told her she would be right back but no one returned for several hours. She then began yelling for someone to assist her. She then reached her cell phone and called her family for assistance. She reported she thought she was being punished. According to the information on the OHFLAC form #225, the incident occurred on 01/05/14, the complaint was received on 01/06/14, and was reported on 01/07/14. Review of the five (5) day follow up report to OHFLAC (form #225A) found the incident was substantiated. There was no evidence the employee assigned to the resident when the incident occurred was interviewed. There was no evidence the nurse aide who was the alleged perpetrator was reported to the nurse aide abuse registry. On 01/22/14, at approximately 12:05 p.m., the social worked was asked how she substantiated the incident, yet failed to identify the nursing assistant responsible for the resident's care on 01/03/14. The social worker stated she was just one person and it took the whole team to investigate allegations of neglect/abuse. She was also unable to provide evidence the alleged incident was immediately reported to APS on the required reporting form. d) Resident's #145, #26, and #151 These residents each alleged neglect. The facility failed to use the adult protective services (APS) mandatory reporting form for reporting abuse/neglect and misappropriation of resident property. According to West Virginia Code 9-6, the APS reporting form should be received by APS within 48 hours. Any event being reported to APS must be reported immediately to the local office. If the immediate report must be made when the local office is closed, the facility is required to call the APS hotline. The social worker stated she had reported to APS using the correct form, during her interview at 12:05 p.m. on 01/22/14, but verification of this statement was never provided. At 2:35 p.m. on 01/22/14, the administrator confirmed the social worker had not used the correct APS reporting form. The administrator stated the allegations regarding Residents #145, #26, and #151 were not immediately reported to APS as required by State law. The administrator said, APS should have told us we were using the wrong form. The administrator had no explanation as to why the allegations were not immediately reported to OHFLAC. e) Resident #77 Review of the facility's Complaint / Concern / Grievance / Request Form found Resident #77's daughter made the following complaints on 11/18/13: 1. left at (illegible) with bed flat on Thursday 5:30 p.m. to be at 30 degree angle - told staff. 2. Same day - found mother with dry BM (bowel movement) 3. (typed as written) tube feeding hanging empty - rinsed out plastic container with 48 degrees for change 4. mother was out of breath breathing tx.( treatment) as PRN (as needed) - felt mother needed treatment. 5. Told her sister she is calling every 15 min. (minutes) and is upset. 6. Staff member told her that we can turn it off or give a bolus. 7. How long should she be in a geri - chair - for 4 hrs. (hours) with no pillows for comfort. The concern was signed by the administrator on 11/18/13. The administrator attached a handwritten note, dated 11/18/13, to the grievance concern forms with the following statements: 1. (name of resident) was put to bed when requested. She was up for a few hours. When (name of daughter) requested she be put to bed the situation was automatically corrected. 2. Stool is liquid due to tube feeding. Rd (registered dietician) / MD (medical doctor) to evaluate. 3. Staff was in-serviced regarding rinsing out bottle and proper tube feeding technique. 4. Breathing TX (treatment) needed scheduled will speak with MD. 5. (name of sister) only wants to be called. Staff did not say anything. 6. Can only give Tf (tube feeding) per bolus if ordered. Further review of the Immediate Fax Reporting of Allegation - Nursing Home Program (OHFLAC form #225) found the administrator completed the form on 11/20/13. The form listed the date of the incident as 11/19/13 (The complaint form, signed by the administrator, documented the date as 11/18/13). A brief description of the incident reported was: Daughter came to visit and found mothers concentrator off. O2 (oxygen) immediately replaced. Review of the Five Day Follow-Up - Nursing Home Program (OHFLAC form #225A), completed on 11/22/13 by the administrator, found the outcome / results of the investigation were: Investigation was completed on this issue of the O2 that was turned off and after talking to staff including therapists, we were unable to determine who turned off the concentrator. There was no negative outcome from the incident and the O2 was determined to only be turned off minutes based on the times she was taken care of by the aides and her therapy. There was no evidence any of the daughter's other complaints made on 11/18/13 were reported or investigated. According to the date on the facility's complaint form, only one (1) complaint was reported on 11/20/13. Further review of the investigation found the Adult Protective Services Mandatory Reporting Form was completed on 11/20/13. This form listed the allegation as: Daughter found oxygen turned off - no injury. According to the documentation on the form, the incident happened on 11/19/13; however, the grievance / concern form noted the allegation occurred on 11/18/13. The administrator was interviewed at 2:35 p.m. on 01/22/14. The administrator stated not all the complaints were reported because they had been addressed before. When asked about the conflicting dates on the forms, the administrator stated the daughter had made the same complaints on different occasions and some of her complaints were reported later in December 2013. The administrator was asked to provide evidence the other six (6) concerns were previously investigated and reported. At the close of the survey, on 01/23/14, no other information had been provided. f) Resident #18 Review of this resident's medical record, on 01/16/14, revealed a nursing note, dated 09/11/13 at 6:31 p.m. It described the resident asked a nursing assistant (NA) to place her on the bedpan during a meal time. The resident was informed she could not be placed on the bed pan until she and everyone on her unit were finished with the meal. During an interview with the director of nursing (DON), on 01/16/14 at 12:31 p.m., she verified she was unaware of the nursing note. The DON stated the staff member should have toileted the resident when the resident asked. The social services director, Employee #88, verified on 01/20/13 at 12:34 p.m., she was unaware of the nursing note. She said the situation had not been investigated or reported to the appropriate State authorities. On 01/20/14, after intervention during the survey, the facility's administrator reported the incident to the appropriate State authorities. Review of the five (5) day follow up investigation form (Office of Health Facilities Licensure and Certification-OHFLAC form #225A), dated 01/20/14, found the following: In talking to resident, she did recall an aide that was told not to toilet resident when meals were passed. She could not recall the aide. Resident was told that she can be toileted whenever she needed to and that nursing staff has been in-serviced regarding anytime a resident needs to be toileted the staff should toilet and use universal precautions.",2017-11-01
6925,PINERIDGE,515072,300 MILLER ROAD,KINGWOOD,WV,26537,2014-10-22,225,D,1,0,X43Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure injuries of unknown source were reported immediately to the administrator of the facility and to other appropriate officials in accordance with State law. The facility failed to report a bruise of unknown origin that was discovered on 09/03/14 and was not reported to the appropriate State officials and agencies until 09/08/14. This occurred for one (1) of eight (8) sample residents reviewed during the survey. Resident identifier: #25. Facility census: 115. Findings include: a) Resident #25 On 10/20/14 at 9:20 a.m. a review of the requested accident/incident reports, concerns and reportable occurrences for the last three (3) months did not reveal any concerns or problems with the provided facility reports. At 9:00 a.m. on 10/21/14 a record review was conducted for Resident #25, which revealed she had a bruise to her right hand on 09/03/14. Further review revealed the resident had documented [MEDICAL CONDITION] of her right hand, increased bruising from her right hand to her right forearm with tenderness to touch. An x-ray of her right hand on 09/06/14 revealed a recent [MEDICAL CONDITION] (4th) and fifth (5th) metacarpals. Review of the accident/incident report, facility investigative notes, and the reportable records, on 10/22/14 at 9:15 a.m., revealed Resident #25 had a bruise of unknown origin on 09/03/14, with an incident report completed. This was not it reported to the appropriate State agencies and officials until 09/08/14. During an interview on 10/22/14 at 10:40 a.m., the DON stated they were not made aware of the bruising until Monday 09/08/14 and it was reported as soon as she was aware of this having occurred. She also stated, Yes, we should have been notified sooner of the severity and extent of the bruise.",2017-10-01
6929,GOOD SAMARITAN SOCIETY OF BARBOUR COUNTY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2014-10-22,225,D,1,0,53PI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the complaint/grievances for the most recent three (3) months and staff interview, the facility failed to thoroughly investigate an allegation of neglect. A resident's family member found a resident very wet with urine, and was concerned about how long the resident may have been that way. There was no evidence this allegation of neglect was thoroughly investigated by the facility. This was evident for one (1) of seven (7) sampled residents. Resident identifier: #43. Facility census: 59. Findings include: a) Resident #43 On 10/21/14 at 9:30 a.m., a grievance report, dated 09/25/14, was reviewed. The family of Resident #43 came to visit in late afternoon on 09/25/14 and found the resident very wet with urine. The family was concerned about how long she may have been in this condition. The facility completed an immediate fax to the long term care program on 09/26/14, and indicated that an investigation would begin. On 09/30/14, the facility completed the required five (5) day follow-up to the long term care program. The outcome of the investigation was that no neglect was substantiated. This decision was based upon video review. There were no witness statements by any of the involved staff to try to determine what may or may not have occurred prior to the family's allegation of neglect. There was no witness statement from the resident who was named in the complaint. On 10/21/14 at 10:00 a.m., the medical record was reviewed. [DIAGNOSES REDACTED]. According to the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 09/18/14, her brief interview for mental status (BIMS) score was thirteen (13). A score of thirteen (13) to fifteen (15) indicates an intact cognition. She was not steady, and was only able to stabilize herself with staff assistance moving on and off the toilet. The assessment identified she required the extensive two (2) person assist for toileting and for ambulation, was occasionally incontinent of urine, always continent of bowel, and was on a toileting program trial. A toileting program was care planned for her to be toileted upon arising in the morning, before and after meals, and at bedtime. The care plan goal from 07/02/14 through 01/17/15 was for her to decrease the frequency of urinary incontinence from ten (10) to eight (8) times per week by the next review date. Progress notes addressed that Resident #43 was able to make her needs known. The resident had asked staff to take her into the bathroom. Review of the Documentation Survey Report revealed evidence that she had been continent of urine on 09/25/14 at 7:11 a.m. and 12:50 p.m. There was no evidence that she was toileted prior to the evening meal which was served around 5:00 p.m. daily. There was no further documentation of voiding on 09/25/14 until 8:57 p.m. At that time she was again continent of urine. On 10/21/14 at 1:15 p.m., an interview was conducted with the licensed social worker (LSW). He showed the video that surveyed the area where Resident #43 was located on 09/25/14 before, during, and after the family's expressed concern of her wetness. He said that in making his determination of no neglect having occurred, he mainly looked at the video leading up to the time before the 4:30 p.m. complaint was made by the family. He said he saw staff entering and exiting the resident's room that afternoon. Upon inquiry, he said he did not know what staff were doing while in the room of Resident #43. The resident also had a roommate. He said the resident's call light was not on all afternoon. The video showed staff wheeling the resident out of her room around 4:30 p.m. The family met the staff and resident a short distance down the hall at the solarium. Staff then turned the resident's wheelchair back toward her room again. The resident made a stop with the nurse to have the portable oxygen tank changed and her blood pressure checked. Two (2) staff persons then wheeled the resident into a large, common use restroom with a change of clothing. The LSW admitted that he should have gotten witness statements, and did not. At 3:45 p.m. on 10/21/14 the LSW provided a copy of a witness statement from the aide that allegedly worked with Resident #43 at the time of the complaint allegation on 09/25/14. Review of the document found the witness statement was not signed or dated. This witness said the resident was found wet on 09/25/14 when she went in to get the resident up in the chair. The witness alleged that she stripped the bed and dressed the resident in dry clothing. An interview with the resident was attempted on 10/22/14 at 1:30 p.m., but found she was not a reliable interviewee. On 10/22/14 at 5:00 p.m. the administrator acknowledged the investigation at the time of the 09/25/14 allegation was not as thorough as it should have been.",2017-10-01
6939,FAIRMONT HEALTH AND REHABILITATION CENTER,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2013-12-11,225,D,0,1,KCD511,"Based on facility record review, staff interview, resident interview, and policy review, the facility failed to report allegations of neglect and misappropriation. This was true for two (2) of four (4) complaints/concerns reviewed for 2013. Resident #33 complained the facility purchased clothing with his funds without his permission. The family of Resident #59 family alleged the resident was dehydrated. This practice had the potential to affect more than a minimal number of residents. Facility census: 115. Resident identifiers: #33 and #59. Findings include: a) Resident #33 On 12/03/13 at 9:45 a.m., Resident #22 stated the facility had purchased clothes for him that he did not want. Employee #5, a licensed social worker, stated the resident's clothes were too small and his butt would hang out of the back of his pants. She said spoke to the resident and told him that his funds were getting too high and he would lose his medicaid benefits when it got to $2000.00. She stated the resident did agree he needed some slippers. Employee #5 confirmed clothes were purchased for the resident and that she delivered them to the resident's room. She said the nursing assistants put the clothing away and completed the inventory sheet. Employee #5 stated that it was two (2) days before she knew the resident had an issue with the clothing and that the resident had refused to talk to her. When asked if anyone else attempted to speak to the resident, she stated Employee #13, a licensed social worker had also tried to speak to the resident. A review on the facility's complaint log, on 12/04/13 at 08:32 a.m., revealed there was no complaint regarding the purchase of clothing for Resident #33. The facility's concern log was reviewed on 12/04/13 at 8:50 a.m. A concern, dated 10/29/13, regarding Resident #33, stated he needed larger clothes and that he did not need shoes, but needed slippers. The resolution was that clothes were ordered. Another concern, dated 11/14/13, stated Resident #33 was mad over the new clothes and stated he did not want them. The outcome stated it was discussed with the resident. The follow up to this concern stated the resident would not discuss the situation with the recorder and the concern was marked as resolved on 11/14/13. The facility's reportable incidents were reviewed on 12/04/13 at 9:30 a.m. This incident was not documented as being reported. Resident #33 was interviewed again on 12/04/13 at 9:57 a.m. regarding his new clothes. He stated he did not want the clothes and that they had gotten rid of his old clothes. Resident was asked if he had picked out any of the new clothes. He stated he did not and he did not want the new clothes and that they were too big. The resident was asked if the facility staff had told him he was going to lose his medicaid benefits. He stated he still had four hundred dollars ($400.00) to go before he was going to lose his medicaid benefits and he said it would have never gotten that high. Employee #5 was interviewed on 12/04/13 at 4:17 p.m. When asked what had happened to the resident's old clothing, she stated she did not know as she only put the clothing in the resident's room. On 12/09/13 at 2:44 p.m., the facility's director of nursing (DON) was interviewed regarding reporting incidents to the State regarding abuse and neglect for Resident #33. She stated she was not in the facility the day the incident occurred. She stated the facility had purchased some new sweat pants for the resident in a size he had requested, and they had sent his clothing to the dry cleaner to be hemmed. In an interview, on 12/09/13 at 3:09 p.m., with Employee #13, a social worker, she stated she did not report the concern immediately, as she passed the concern on to the assistant director of nursing. However, she stated she did complete a concern report on 11/15/13, after the issue was reported to her by the state ombudsman. A review of the facility's policy regarding the procedure to prevention and reporting resident mistreatment, neglect, abuse, including injuries of unknown source and misappropriation of resident property stated centers were required to report these alleged violations to the Administrator and DON/designee immediately. Immediately meant as soon as possible, but not to exceed 24 hours after discovery of the incident, in the absence of a shorter state time frame requirement. b) Resident #59 A review of the facility's concern reports, on 12/04/13 at 8:32 a.m., revealed a concern was made by the family of Resident #59 on 09/26/13 regarding their family member being dehydrated. This allegation was not located in the facility's reportable incidents. The facility had investigated the allegation and had signed off on the concern in-house. A review of the reportable incidents, on 12/04/13 at 9:30 a.m., did not find any reported incidents regarding Resident #59. In an interview, on 12/09/13 at 2:44 p.m., with the DON, she stated this should have been reported to the state.",2017-10-01
6967,MAPLESHIRE NURSING AND REHABILITATION CENTER,515058,30 MON GENERAL DRIVE,MORGANTOWN,WV,26505,2013-11-12,225,D,0,1,X5R211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, family interview, staff interview, and policy review, the facility failed to ensure all alleged violations involving abuse were thoroughly investigated and reported immediately to the appropriate State agencies. Resident #164 reported her roommate, Resident #162, had been grabbed by her arms and forced to stand up causing a skin tear. She had reported this incident to a nurse on 11/03/13 and on 11/04/13 she had reported it to Employee #140, an Occupational Therapist (OT) and the social worker (SW). There was no evidence Resident #164, who had witnessed the incident, was interviewed as part of the facility's investigation. Resident #162's daughter, who was aware the resident had not had the injury on 11/02/13, but did have one when she visited on 11/03/13, had not been interviewed. In addition, the allegation was not reported to the appropriate State agencies by the facility until 11/07/13. This had the potential to affect more than a limited number of residents. Resident identifier: #162 and #164. Facility census: 95. Findings include: a) Resident #162 On 11/04/13 at 11:10 a.m., an interview was conducted with Resident #162 and her daughter during the initial tour of the facility. Resident #162 was noted to have a large bruise and a skin tear measuring six (6) centimeters (cm) in length with steri-strips intact on her left forearm. During the interview, Resident #162 commented the injury happened Saturday night on night shift, the nurses aides were rough and grabbed me by my arm when they helped me to the bathroom. The resident's daughter agreed her mother and her mother's roommate had told her this on Sunday when she had come to visit. The daughter stated her mother did not have the bruise or skin tear on Saturday, but they were present on Sunday morning when she came to visit her Mother. She said she had reported it to the nurse. On 11/11/13 at 8:10 a.m., an interview was conducted with Resident #164. She commented the SW had visited her roommate, but no one had interviewed her regarding the abuse allegation. She further stated she thought someone would have spoken with me since I was the one that told. On 11/05/13 at 9:15 a.m. an interview was conducted with Resident #164. During the interview, she stated I saw my roommate being abused. They forced her to stand up by grabbing her arms and they had caused her to hit her arm one night. She also stated she told the nurse and my roommate's daughter on Sunday the 3rd, then told my therapist and the social worker on Monday the 4th. On 11/11/13 at 10:30 a.m. a medical record review was conducted. The review revealed Resident #162 was admitted on [DATE] for short term skilled nursing. It was noted the resident had capacity as documented by the attending physician. On 11/11/13 at 12:30 p.m. a record review was conducted for Resident #164. She was admitted on [DATE] and documented to have capacity by her attending physician. She was also documented to have a Brief Interview for Mental Status (BIMS) score of 15 - indicating she was cognitively intact. On 11/11/13 at 12:01 p.m., a telephone interview was conducted with Resident #162's daughter. She commented she had a meeting with the SW on Thursday 11/07/13. The daughter stated the SW was unaware of the bruising but was aware of the skin tear. She further commented the skin tear and the bruising were both present on Sunday 11/03/13 and she could not understand how the facility could be unaware of both injuries. On 11/11/13 at 12:45 p.m. an interview was conducted with Employee #140- an OT. She commented she had completed the interdisciplinary communication form on 11/04/13 when Resident #164 had reported her roommate's alleged abuse and a copy was given to the SW and the Administrator. On 11/11/13 at 1:05 p.m., the Adminsitrator (Employee #4) provided a copy of the facility's Abuse Policy and Prevention and Reporting of Suspected Resident Abuse and Neglect Policy. Review of the abuse policy found it included When an alleged or suspected case of mistreatment, neglect, injuries of unknown source, or abuse is reported, the facility Administrator, or his/her designee, will notify the applicable persons or agencies of such incident (i.e. OHFLAC (Office of Health Facility Licensure and Certification), APS (adult protective services)). The policy also included, All reports of abuse must be reported to the Administrator and the Social Worker, OHFLAC, APS, Ombudsman, and other state agencies as required, within twenty-four (24) hours of the occurrence of such incidents. On 11/12/13 at 9:45 a.m. the survey team conducted an interview with the Administrator (Employee #4), the DON (Employee #17), and the SW (Employee #20). During the interview the Administrator agreed they did not report Resident #164's allegation of abuse regarding Resident #162, but the SW had investigated the allegation. Employee #20, the SW, commented she had spoken to Resident #162 regarding the allegation, but had not spoken to Resident #164, who had reported the allegation. She also agreed she had not reported the allegation of abuse that was reported by Resident #164 to the appropriate State agencies.",2017-09-01
6982,PENDLETON MANOR,515124,68 GOOD SAMARITAN DRIVE,FRANKLIN,WV,26807,2014-02-27,225,E,0,1,JUVV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon personnel file review, staff interview, and policy and procedure review, the facility failed to ensure they did not hire an employee who was unfit to work at the facility. The facility did not check the State nurse aide registry to ensure a prospective employee, Employee #146, staff nurse-licensed practical nurse, did not have a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. This was found for one (1) of five (5) employees whose files were reviewed. The had the potential to affect more than an isolated number of residents. Employee identifier: #146. Facility census: 83.Findings include:a) Employee #146A review of five (5) employee personnel files was conducted on 02/26/14 at 3:00 p.m. The personnel file of a licensed practical nurse (LPN), Employee #146, contained no evidence the State nurse aide registry was checked to determine whether the individual had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Review of the facility's policy and procedure, on 02/26/14 at 4:00 p.m., revealed the names of all new employees, regardless of positions would be checked through the State registry to ensure the potential employee, regardless of position, did not have a finding entered against him or her. During an interview, on 02/27/14 at 9:30 a.m., the contracted administrator, Employee #166, confirmed there was no evidence the required check was completed prior to permitting Employee #146 to provide care to residents. After intervention during the survey, on 02/27/14 at 9:34 a.m., Employee #5, the inventory control clerk, obtained verification through the State nurse aide registry for Employee #146 (LPN).",2017-09-01
6990,EAGLE POINTE,515159,1600 27TH STREET,PARKERSBURG,WV,26101,2013-12-18,225,D,0,1,EUXT11,"Based on review of the facility's reportable allegations of abuse/neglect, staff interview, and review of the facility's abuse policy, the facility failed to immediately report allegations of abuse/neglect to adult protective services as required by West Virginia Code 9-6-9. The facility also failed to prevent further potential abuse while the investigation was in progress by failing to suspend an employee, as required by facility policy, who was alleged to have been physically abusive to the resident. This was true for one (1) of ten (10) investigations of abuse / neglect reviewed during the survey. Resident identifier: #52. Facility census: 130. Findings include: a) Resident #52 During Stage I of the Quality Indicator Survey (QIS) a facility resident, (who wished to remain anonymous) answered, Yes, to the question, Have you seen any resident here being abused? Further investigation during Stage 2 of the QIS identified the resident, who was alleged to have been abused, as Resident #52. Review of the facility's reportable allegations of abuse/neglect found an immediate reporting of allegations to the nurse aide registry for two (2) nursing assistants, Employees #49 and #104, regarding an allegation of abuse/neglect reported by Resident #52. According to the written investigation material presented by the facility's social worker, Employee #66, on 12/10/13 at 7:54 a.m., Resident #52 accused two (2) nursing assistants, Employees #49 and #104, of being abusive. Review of the nurse aide registry immediate fax reporting of allegations on 12/10/13 found Resident #52 made the following allegation regarding Employee #49 on 11/27/13: Resident states CNA (certified nursing assistant) was mean to her, When I asked her for a pillow, she acted like it would kill her. Stated I've never been treated so bad before. Stated the CNAs told her not to put her light on again. On 11/27/13, Resident #52 provided the following statement regarding Employee #104 (identified by facility staff): Resident states CNA with long hair in pony tail hit me in the side, pointing to left side. States I've never been treated so bad and I don't know why they are so mean to me. Then the resident started crying. Upon assessment - no bruising or reddened areas noted. The facility reported the above allegations to the nurse aide registry on 11/27/13; however, the allegations made by Resident #52 regarding Employees #49 and #104 were not reported to adult protective services until 11/29/13. Review of Table 1 - Abuse/Neglect reporting requirements for WV nursing Homes and Nursing Facilities (revised October 2011) found, Any event being reported to APS (adult Protective services) must be reported immediately to the local office. If the immediate report must be made when the local APS office is closed, call the APS hotline at (telephone number). The 7-part APS reporting form should be received by APS within 48 hours of the event. Submission of the reporting form within 48 hours does not relieve the facility of the responsibility to complete the immediate reporting. All nursing home staff is a mandated reporter per WV Code 9-6-9. Continued review of the allegations of abuse/neglect made by Resident #52 on 11/27/13 found Employee #49 was suspended pending the the outcome of the investigation. Employee #104 who was alleged to have hit the resident was not suspended during the investigation. The facility's social service worker, Employee #66, was interviewed on 12/10/13 at 7:45 a.m. She stated the incident occurred on Wednesday night 11/27/13. This employee stated she did not work the next day which was Thanksgiving - 11/28/13. When she returned to work on Friday- 11/29/13 she realized Employee #104 had not been suspended. She stated she immediately spoke to the director of nursing (DON) about the situation. According to Employee #66, the nurse who called the DON on the evening of 11/27/13, to advise her of Resident #52's allegations, neglected to tell the DON Resident #52 had also accused Employee #104 of physical abuse. The nurse only told the DON about Employee #49. The social worker verified Employee #104 was not suspended as required by facility policy and the social worker was unable to provide evidence the allegations made by Resident #52 regarding Employees' #52 and #104 were immediately reported to adult protective services as required by law. During an interview with the DON at 8:42 a.m. on 12/10/13, she verified Employee #104 was not immediately suspended. She stated, I didn't have the whole story or I would have suspended her also. The DON further verified APS was not immediately notified of the allegation of alleged abuse. Review of the facility's policy entitled, Abuse, revised on 05/2012, (provided by Employee #66 on 12/10/13) found, section (6), Upon receiving reports of abuse, the resident's safety will be ensured first with the alleged perpetuator suspended, pending investigation of incident .",2017-09-01
7030,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2013-08-14,225,D,0,1,66WU11,"Based on review of personnel records and staff interview, the facility failed to ensure reasonable efforts were made to verify there were no past criminal prosecutions of a potential employee by not including a West Virginia (WV) statewide investigation for one (1) of ten (10) sampled employees prior to hire. Employee identifier: #67. Facility census 68. Findings include: a) A review of the personnel records at 02:00 p.m. on 08/07/13, accompanied by the Corporate Human Resource Consultant (Employee #94) revealed no evidence of a WV statewide criminal background check for Employee #67, a nursing assistant. Employee #67 had been working full-time since 04/02/13. During a follow-up interview with Employee #64 (Bookkeeper) at 9:00 a.m. on 08/13/13, she confirmed a WV statewide background check was not completed on Employee #67.",2017-09-01
7067,OHIO VALLEY HEALTH CARE,515181,222 NICOLETTE ROAD,PARKERSBURG,WV,26104,2014-07-14,225,E,0,1,U25211,"Based on personnel record review, policy review, and staff interview, the facility failed to ensure it did not employ individuals who had been found guilty of abusing, neglecting, or mistreating residents by a court of law. The facility did not make reasonable efforts to uncover information about any past criminal prosecutions in a neighboring state for one (1) employee who had listed working in another state on the employment application. In addition, the facility did not check three (3) employees against the nurse aide registry. This practice had the potential to affect more than a limited number of residents. Employee identifiers: #81, #32,#66, and #64. Facility census: 64. Findings include: a) Nurse Aide Abuse Registry On 07/14/14 at 1:00 p.m., a review of the personnel files revealed the facility had not completed a nurse-aide abuse registry check for three (3) employees. -- Employee #81 (licensed practical nurse), hired on 09/16/08, did not have a nurse aide abuse registry check completed at the time of hire. -- Employee #66 (licensed practical nurse), hired on 01/28/08, did not have a nurse aide abuse registry check completed at the time of hire. -- Employee #32 (registered nurse), hired on 08/08/08, did not have a nurse aide abuse registry check completed at the time of hire. In a discussion with Employee #52 (personnel) and Employee #55 (registered nurse) at 1:15 p.m., both agreed the facility did not have evidence the nurse aide abuse registry was checked for Employees #81, #66, and #32. b) Criminal Background Checks 1) Employee #64 At 1:30 p.m. on 07/14/14, a review of the personnel files revealed Employee #64 (nurse aide) who came to work at the facility on 03/17/14 had listed on his application he had worked in a neighboring state. The personnel file did not contain a criminal background check for the other state. Employee #52 and Employee #55 both agreed the personnel file did not contain a criminal background check for the other state where the employee had worked. c) Facility Policy A review of the facility policy for abuse revealed the following under the screening section: Potential employees will be screened for a history of abuse, neglect or mistreating individuals. This includes attempting to obtain information from previous employers and/or current employers, checking with appropriate boards and registries and criminal background check/central abuse registries.",2017-09-01
7097,CEDAR RIDGE CENTER,515087,302 CEDAR RIDGE ROAD,SISSONVILLE,WV,25320,2013-09-26,225,D,0,1,1ZMG11,"Based on staff interview, medical record review, abuse/neglect policy review, and concern/complaint review, the facility failed to ensure allegations of neglect were reported to outside State agencies. Concerns were reviewed for a six (6) month period. Three (3) allegations of neglect were not reported to the required outside State agencies. The facility handled these three (3) allegations of neglect as resident/family concerns instead of allegations of neglect. Resident identifiers: #147, #53, and #66. Facility census: 118. Findings include: a) On 09/23/13 at 2:00 p.m., a review of the facility's concerns/complaints for a period of six (6) months and medical record review revealed the facility had not reported three (3) allegations of neglect to the appropriate outside State agencies. 1) Resident #147 A care plan meeting note for Resident #147, dated 09/11/13, stated . (Medical power of attorney name) reports, 'Every time I visit she had crusty two day old food on her clothes.' He reports he visits on Saturdays and Sundays and this is when he finds her in soiled clothing. (Second medical power of attorney) reports visiting through the week and does not find the resident in soiled clothes 'very often.' Both medical powers of attorney report resident often not in her own clothing, but in room mates (sic). Reviewed process for bringing in clothing and getting it labeled. Will notify ADON (assistant director of nursing) of concerns . On 09/23/13 at 2:30 p.m., the social worker (Employee #5) stated she passed this issue along to the assistant director of nursing (Employee #128). On 09/23/13 at 3:00 p.m., Employee #128 said she had looked into the medical power of attorney's concern of finding the resident in soiled clothing on the weekend but had not reported the issue as neglect. 2) Resident #66 A concern form, dated 05/16/13, involving Resident #66 stated, Family member reports that he took resident to car and didn't know until he was getting him into car that resident had feces up his back and same clothes on as yesterday. On 09/23/13 at 4:00 p.m., the director of nursing (Employee #103) stated she had not reported this issue to outside state agencies as an allegation of neglect. 3) Resident #53 A concern form, dated 09/17/13, involving Resident #53 stated, Alleges not receiving showers weekly. The director of nursing said the resident had a cast on her leg and this prevented the facility from showering her. She said the facility did not report this as an allegation of neglect. b) The facility's abuse prohibition policy, with a revision date of 07/16/13, defined neglect as, The failure to provide goods and services to avoid physical harm, mental anguish, or mental illness.",2017-08-01
7116,HIDDEN VALLEY CENTER,515147,422  23RD STREET,OAK HILL,WV,25901,2013-09-25,225,D,0,1,K4W611,"Based on record review, staff interview, and policy review, the facility failed to identify an allegation as verbal abuse and consequently failed to report the allegation immediately (within 24 hours of learning of the incident) to the appropriate State agencies. On 06/17/13 there was an allegation of verbal abuse made against a former employee of the facility. The allegation was not reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Services (APS) or the ombudsman, until 06/19/13. This was true for one (1) of twenty (20) incidents reviewed. Resident Identifier: #71. Facility Census: 76. Findings Include: a) Resident #71 The facility's incident reports were reviewed at 10:45 a.m. on 09/23/13. This review revealed an incident which was reported to OHFLAC, APS, and the Ombudsman on 06/19/13. Further review of the incident revealed the date of the incident was 06/17/13. The immediate fax reporting of the allegations to OHFLAC on 06/19/13 revealed the following allegation, Charge nurse notified dementia program manager of a verbal conflict between a resident, (Resident #71's name) and activities director (former activities director name).' Employee #101, the Dementia Program Manager, was interviewed at 10:22 a.m. on 09/24/13. Upon inquiry, she reported the reason this incident was not immediately reported was because she had spoken to Employee #113, the former Nursing Home Administrator (NHA), on 06/17/13. Employee #101 said the NHA felt this was not verbal abuse, but instead, an approach issue between the then activities director and Resident #71. Employee #101 stated she received more witness statements on 06/18/13 which led to her to believe this was an incident of verbal abuse. She said when she called Employee #114, the vice president of operations, and told her about the situation. She was instructed to make the reports to OHFLAC, APS, and the ombudsman as required. Employee #101 confirmed the incident happened on 06/17/13 and was not reported until 06/19/13. The facility's policy titled Abuse Prohibition, with an effective date of 06/01/96 and revision date of 11/01/09, was reviewed at 11:15 a.m. on 09/24/13. The policy, under section five (5) contained the following statement. 5.1 The notified supervisor will report the suspected abuse immediately (not to exceed 24 hours) to the administrator or designee and other officials in accordance with state law. The facility failed to identify the occurrence as verbal abuse and failed to follow their own policy to report suspected abuse immediately.",2017-08-01
7139,WELCH COMMUNITY HOSPITAL,51A009,454 MCDOWELL STREET,WELCH,WV,24801,2013-10-10,225,E,0,1,LV1R11,"Based on personnel file review and staff interview, the facility failed to ensure a thorough criminal background check was completed for one (1) of five (5) employees reviewed. Employee #64 had listed prior work experience in a state other than West Virginia. The facility had not checked for a criminal history in that state. This practice had the potential to affect more than an isolated number of residents. Employee identifier: #64. Facility census: 39. Findings include: a) Employee #64 On 10/10/13 at 9:30 a.m., the personnel file review for five (5) newly hired employees revealed one (1) employee had listed prior work experience in another state. Employee #64 began working at the facility as a nurse aide on 08/16/13. The personnel record review revealed the facility had completed a criminal background check in the state of West Virginia. However, it did not complete a criminal background check in the state where the individual had worked previously. On 10/10/13 at 9:45 a.m., Employee #81, in human resources, said she did not know if the facility had completed a criminal background check in the other state. At 2:50 p.m. on 10/10/13, the administrator (Employee #78) did not have any further evidence to show the facility had completed a criminal background check in the state where Employee #65 had previously been employed.",2017-08-01