rowid,facility_name,facility_id,address,city,state,zip,inspection_date,deficiency_tag,scope_severity,complaint,standard,eventid,inspection_text,filedate
2147,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-09-24,580,E,1,0,9CH711,"**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 medications were not administered. This is true for two (2) out of five (5) residents Medication Administration Record [REDACTED]. Facility census: 59. Findings included: a) Resident #2 A review of Resident #2's MAR indicated [REDACTED]. --Apixaban 5 milligrams (mg) twice a day at 9:00 AM and 9:00 PM --Aspirin 81 mg daily at 9:00 AM --[MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg twice a day at 9:00 AM and 9:00 PM - [MEDICATION NAME], a schedule IV medication, was signed off on the controlled substance book indicating the nurse had taken the medication out of the pack, but Nurse #1 signed her initial on the dates and times on the MAR indicated [REDACTED]. The medication [MEDICATION NAME] was not sign off with another nurse on the controlled substance book that the medication was wasted. This means the medication was not observed by another nurse the medication was disposed of properly. --Carvedilol 3.125 mg twice a day at 9:00 AM and 9:00 PM --[MEDICATION NAME] 25 mg daily at 9:00 AM --[MEDICATION NAME] 20 mg daily at 9:00 AM --[MEDICATION NAME] 10 mg daily at 9:00 AM --[MEDICATION NAME] 7.5 mg at 9:00 PM --[MEDICATION NAME] Chloride extended release 15 mg daily at 9:00 AM --[MEDICATION NAME] 20 mg daily for at 9:00 AM --Vitamin B 12 100 microgram (mcg) daily at 9:00 AM The Director of Nursing (DoN) stated the nurse who did not administer Resident #2's medication on 09/03/19 was Nurse #1. She further stated when a nurse circles her initals on the dates and times on the MAR, this indicates the nurse did not administer medication to the resident. Nurse #1 did not notify the physician why the medication were not administer to Resident #2. b) Resident #5 A review of Resident #5's MAR indicated [REDACTED]. When a nurse circles her initals on the date and times, this indicates the nurse did not administer these medication to the Resident #5. The Nurse did not notify the physician why they did not administer the following medication to Resident #5. On 06/01/19, 06/02/19 and 06/03/19 at 9:00 AM, Resident #5 was not administered the following medications: [REDACTED] --[MEDICATION NAME] Sodium 100 mg --[MEDICATION NAME] 1 mg On 06/01/19, 06/02/19, 06/03/19 and 06/05/19 at 2:00 PM, Resident #5 was not administered the following medication: --[MEDICATION NAME] 1 mg On 06/01/19, 06/02/19 and 06/03/19 at 2:00 PM, Resident #5 was not administered the following medication: --[MEDICATION NAME] ([MEDICATION NAME]) 1 mg - Resident #5's [MEDICATION NAME]- schedule IV medication was signed off on the controlled substance book on 06/01/19, 06/02/19, 06/03/19 to revealing the nurse had taken the medication out of the pack, signed their initial on the dates and times on the MAR indicated [REDACTED]. The medication [MEDICATION NAME] ([MEDICATION NAME]) was not sign off with another nurse on the controlled substance book that the medication was wasted. This means the medication was not observed by another nurse the medication was disposed of properly. On 06/01/19 and 06/02/19 at 9:00 AM, Resident #5 was not administered the following medication: --[MEDICATION NAME] 5 mg On 06/02/19 and 06/03/19 at 9:00 AM, Resident #5 was not administered the following medication: --[MEDICATION NAME] 24 mcg --[MEDICATION NAME] 0.5 mg Resident #5 was re-admitted on [DATE] at 11:12 AM. The physician (physician name) approved all admission orders [REDACTED] A review of Resident #5's MAR indicated [REDACTED]. The MAR indicated [REDACTED]. Resident #5 did not receive her medication [MEDICATION NAME] ([MEDICATION NAME]) 1 mg on 07/04/19 at 2:00 PM as ordered nor did the nurse notify the physician. A review of the controlled substance book to determine whether [MEDICATION NAME] - schedule IV medication to treat Resident #5's Anxiety had been removed on 07/04/19 at 2:00 PM, found no [MEDICATION NAME] ([MEDICATION NAME]) had been remove from the controlled substance pack. Therefore the [MEDICATION NAME] ([MEDICATION NAME]) one (1) MG by mouth was not administered to Resident #5. On 07/0419 07/07/19, 07/15/19 and 07/16/19, more than one nurse circled their initial on the dates and times for the following medication on the MAR, meaning the medication were not administered to the Resident #5. The nurses did not notify the physician why they did not administer the following medication to Resident #5. Resident #5 was not administered the following medication on 07/07/19 at 9:00 AM --[MEDICATION NAME] 24 mcg daily --[MEDICATION NAME] 5 mg --[MEDICATION NAME] 100 mg --[MEDICATION NAME] 2.5 mg Resident #5 was not administered the following medication on 07/1519 and 07/16/19 at 9:00 AM: --[MEDICATION NAME] 24 mcg was circled, indicating LPN #7 did not administer this medication. LPN #7 did write on the back of the MAR indicated [REDACTED]. Resident #5 was not administered the following medication on 07/15/19 and 07/16/19 at 9:00 AM: --[MEDICATION NAME] 5 mg --[MEDICATION NAME] 100 mg --[MEDICATION NAME] 2.5 mg --[MEDICATION NAME] 0.5 mg On 07/16/19 Resident #5 was sent to a Behavioral Health hospital (hospital name).The hospital performed a [MEDICATION NAME] Level on 07/17/19 in which the results were 15.5 ng/ml (A ng means- nanograms per ml - milliliter, which is abbreviated as ng/ml. This is the unit of measure most commonly used to express drug testing cut-off levels and quantitative test results. Normal range for [MEDICATION NAME] level range is from 50.0 - 240. The test detect presence of [MEDICATION NAME], a benzodiazepine sedative and anticonvulsant. A quantitative test tells you how much (the quantity) of an analyte is present. Hx benefits states [MEDICATION NAME] ([MEDICATION NAME]'s) half life is approximately 12 hours, which means that once you have taken your last dosage of [MEDICATION NAME] ([MEDICATION NAME]), it would take about 2.75 days for Lorazapam ([MEDICATION NAME]) to be full out of your body. A review of Resident #5's medical record finds on 09/24/19 at 11:40 AM, the physician was not notified Resident #2 and 5's medication were not administered as ordered. In an interview with the Director of Nursing (DoN) on 09/24/19 at 11:50 AM, she was shown the MAR'S for Resident #2 and #5. The DoN, stated that, the MAR indicated [REDACTED]. The DoN also revealed she could not provide evidence on whether the [MEDICATION NAME] ([MEDICATION NAME]) which is a (controlled Substance),( schedule IV)was given. The DoN stated all she can say is for Resident #2, the nurse took out the medication from the lock box, but what she did with the medication she cannot verify, because the nurse wrote the resident did not receive the medication [MEDICATION NAME] ([MEDICATION NAME]), and the medication was not wasted with another nurse on duty. On 06/01/19, 06/02/19 and 06/03/19 at 2:00 PM, the DoN confirmed the [MEDICATION NAME] ([MEDICATION NAME]) was removed from the pack and signed off as given, but the MAR indicated [REDACTED]. The DoN stated that on 07/04/19 Resident #5 did not receive her medication [MEDICATION NAME] ([MEDICATION NAME]) at 2:00 PM as ordered, because the medication was never taken out of the package when she should have received the medication. DoN revealed their policy is if a resident refuses the medication they are to circle their initals on that date and time and document the residents refusal of the medication on the back of the MAR, and if the medication is a controlled substance, the nurses must waste the medication with another nurse and sign off the resident refuses the medication. DoN stated her expectation would be if the resident refused any of their medication they should notify the physician. The DoN confirmed one (1) nurse did circle her initals, and wrote a rational for not administering the medication [MEDICATION NAME] on 07/15/19 and 07/16/19, but she did not notify the physician. The DoN stated, for the rest of the nurses they did not write on the back of the MAR, waste the [MEDICATION NAME] ([MEDICATION NAME]) with another nurse correctly and notify the physician the medication were not administered to Resident #2 and #5. The facility's policy for medication refused by resident, finds the nursing staff is to circle their initals, in the date and time space where that medication is ordered, and document patient's refusal of medication of the back of the MAR. The facility's pharmacy (pharmacy name) policy is to Wasted controlled substances should be destroyed with another appropriate observer and documented as a per facility policy. The pharmacy policy says to document omitted doses and why. A professional standard of practice of medication Administration -August 2013, reveals the nurse must notify the prescribing practitioner or supervisor when a resident refuses medication. RN. ORG finds that when controlled substances must be disposed of, the disposal should be witnessed by two (2) healthcare providers who are licensed to dispense drugs, such as two RNS, and the disposal documented with both healthcare providers signing. This should be done immediately after procuring the drug. The nurse should not carry the excess narcotic on a tray or in a pocket or place it in an unsecured medication drawer for later disposal because this increases the risk of diversion or errors in documentation but should immediately ask for a witness and dispose of the drug according to established protocol.",2020-09-01
2148,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,583,D,0,1,8VRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure a Resident's Medication Administration Record (MAR) and a Nurse Report Sheet were secured in a manner that protected personal, medical, and health information. Personal identifiers including resident's names, room numbers, code status, medications, medical interventions, allergies [REDACTED]. This was a random observation. This practice affected a limited number of residents. Facility census: 59. Findings included: a) Observation An observation of the 100 Hall, on 10/22/19 at 9:30 AM, revealed the medication cart was in the hall. The Medication Administration Record (MAR) and a Nurse Report Sheet were on top of the medication cart open and visibly available for anyone to view. No staff members were at the medication cart at the time of the observation. The MAR and the Nurse Report Sheet contained the following resident information: -Names -Room numbers -Code Status -Medications -Medical interventions -allergies [REDACTED]. b) Interview An interview with Licensed Practical Nurse (LPN) #16, on 10/22/19 at 9:35 AM, revealed the MAR and Nurse Report Sheet are supposed to be covered before she leaves the medication cart unattended. The LPN stated she forgot to do so.",2020-09-01
2149,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,623,D,0,1,8VRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to notify the ombudsman of the Resident's transfer to the hospital. This deficient practice was found for 1 of 4 residents reviewed in the care area of hospitalization . Resident identifiers: #59. Facility census: 59. Findings included: a) Resident #59 Record review indicated Resident #59 was transported to local hospital on [DATE] at 8:14 AM for an unplanned transfer and never returned the facility. Notification to the Ombudsman for this transfer was not documented. During an interview on 10/22/19 at 2:37 PM Social Services Specialist #54 verified the facility did not notify the ombudsman of the transfer or discharge and the reasons for the move in writing. Social Service Specialist #54 stated, I was not aware I should be sending those notifications to the ombudsman until recently when corporate questioned me about it. Review of the facility's Discharge and Transfer Policy, subtitled OPS404 Discharge and Transfer, effective date 06/01/96 Review date 01/16/10, revision date 02/01/19 stated - For patients transferred to a hospital copies of notices for emergency transfers must also be sent to the Ombudsman, but they may be sent when practicable, such as in a list of patients on a monthly basis or per state requirements.",2020-09-01
2150,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,625,D,0,1,8VRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to provide the Resident with Bed Hold Notice upon transfer. This deficient practice was found for one (1) of four (4) Residents reviewed in the care area of hospitalization . Resident identifier: #59. Facility census: 59. Findings included: a) Resident #59 Record review indicated Resident #59 was transported to local hospital on [DATE] at 8:14 AM for an unplanned transfer. Evidence that documented a Bed Hold Notice was provided to the Resident or Resident's legal representative was not found. During an interview on 10/22/19 at 2:37 PM Social Services Specialist #54 verified the facility did not provide the Resident or the Resident's legal representative with a Bed Hold Notice. Social Services Specialist #54 stated, Unless nursing done it, it wasn't done because when she left on the 9/14/19 it was a Saturday and I was not here. On 10/22/19 at 2:55 PM, Social Services Specialist #54 confirmed the facility did not have any documentation anywhere within medical records that a Bed Hold Notice had been provided for Resident #59's transfer on 09/14/19. Review of the facility's Accounts Receivable Policies and Procedures Policy subtitled: AR102 Bed Holds - effective date 03/15/00, review date 04/15/16, revision date 05/01/16 stated when a resident is transferred out of the service location to a hospital or on therapeutic leave, the designee will provide the resident/family member the written Bed Hold Policy Notice & Authorization form regardless of the payer.",2020-09-01
2151,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,657,D,0,1,8VRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview, the facility failed to ensure a resident's care plan was revised based on the results of a comprehensive assessment. This failed practice had the potential to affect one (1) of 19 residents whose care plans were reviewed during the long term care survey process. Resident identifier: #53. Facility census: 59. Findings included: A record review for Resident #53 noted the resident was re-admitted to the facility on [DATE] with an order for [REDACTED]. A review of the comprehensive care plan dated 10/08/19, noted no problem or modality utilizing the oxygen therapy ordered to be administered to Resident #53. An interview, on 10/22/19 at 10:55 AM, with the Clinical Reimbursement Coordinator (CRC), revealed the oxygen therapy had been noted on the comprehensive assessment but not carried through to the care planning process. The CRC verified the oxygen should have been care planned but the facility missed that.",2020-09-01
2152,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,695,D,0,1,8VRQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to provide oxygen therapy in accordance with professional standards and practices. The failed practice had the potential to affect one (1) of seven (7) residents receiving oxygen therapy. Resident identifier: Resident #53. Census: 59 Findings included: A review of the policy, Oxygen Concentrator, revision date: 12/01/18. showed when oxygen was to be administered, the oxygen flow rate would-be set-in accordance with the physician's orders [REDACTED].>An observation, on 10/21/19 at 01:02 PM, revealed Resident #53 was receiving oxygen (O2) via nasal cannula at 2 liters per minute. An additional observation, on 10/22/19 at 08:15 AM revealed Resident #53 was receiving O2 at 1.5 liters per minute via nasal cannula. Medical record review for Resident #53 noted a physician's orders [REDACTED]. An interview, on 10/22/19 at 08:27 AM, with RN#7, verified Resident #53's O2 was set on 1.5 liters per minute but verified the order was for 3 liters per minute. An interview was conducted on 10/22/19 at 09:31 AM, with the Center Nursing Executive (CNE). When informed of the oxygen settings observed on 10/21/19 and 10/22/19, the CNE verified the oxygen was to be set at 3 liters per minute and verbalized understanding they were not set in accordance with physician's orders [REDACTED].",2020-09-01
2153,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,842,D,0,1,8VRQ11,"Based on record review and interview, the facility failed to maintain medical records on each resident that are complete and accurate. Resident #43's Nurses Notes included a fall with injury that occurred for Resident #11. This practice affected two (2) of nineteen (19) resident records reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #11 and #43. Facility census: 59. Findings included: a) Record Review A review of the Nurses Notes for Resident #43, on 10/22/19 at 11:17 AM, revealed the notes included a fall with injury that occurred on 09/03/19. No other indication of a fall could be found in Resident #43's record. b) Interview An interview with the Center Nurse Executive (CNE), on 10/22/19 at 11:30 AM, revealed Resident #43 did not have a fall on 09/03/19 with injury. The CNE stated a nurse mistakenly charted Resident #11's fall in Resident #43's Nurses Notes by mistake. The CNE stated she would ensure the mistake was corrected in both of the Resident's medical records.",2020-09-01
2154,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2019-10-23,925,E,0,1,8VRQ11,"Based on observation and interview, the facility failed to maintain an environment free from pests. The resident Dining Room and the 100 Hall was observed to have flies on multiple occasions. This practice affected a limited number of residents. Facility Census: 59. Findings included: a) Observations Multiple observations during the LTCSP on 10/21/19, 10/22/19, and 10/23/19, revealed flies in the Resident Dining Room and 100 Hall. b) Interviews Interviews with Resident #26 and #36, on 10/22/19 at 1:45 PM, revealed there are flies in the dining room daily. The Resident's stated they need fly swatters during meals. An interview with Administrator, on 10/23/19 at 8:15 AM, revealed the facility has a pest control company come monthly. The Administrator stated they noticed an increase in flies last week and had contacted the pest control company to come out and take care of the issue. The Administrator stated they have not showed up yet.",2020-09-01
2155,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,561,D,0,1,I3US11,"Based on medical record review and staff interview, the facility failed to ensure the resident's right to make choices about aspects of his/her life that are significant to the resident. Resident #38 said she was not offered the opportunity to vote in the mid-term election. This was evident for one (1) of fifteen (15) sampled residents. Resident identifier: #38. Facility census: 58. Findings included: a) Resident #38 An interview was conducted with the resident on 11/05/18 at 11:48 AM. She said she votes in every election. She said no one at the facility offered her the option of an absentee ballot and/or an on-site polling voting option for the 11/06/18 mid-term election. The medical record was reviewed on 11/07/18. The most recent minimum data set (MDS), with assessment reference date (ARD) 09/09/18, assessed her with a Brief Interview for Mental Status (BIMS) score of fourteen (14). A score of thirteen (13) to fifteen (15) indicates intact cognition. On 11/08/18 at 8:49 AM the licensed social worker (LSW) was interviewed. Upon inquiry, she said that the activities department takes care of finding out which residents wish to vote, and then assists them with voting. She said she has worked here only since April, and this is the first election since her hire date. She spoke awareness that one male resident went to the polls and voted in this week's mid-term election. An interview was conducted with the activity director on 11/08/18 at 8:52 AM. She said facility staff transported one (1) male resident to the polls to vote in the early voting period. She said no other residents in the facility voted this election either in person or by absentee ballot. Upon inquiry as to whether Resident #38 was given the option to exercise her right to vote in this year's election, she said they sometimes talk about the election in current events, but she could not recall if or when she spoke with this resident about her voting preference. She was asked if anyone canvassed the residents last month to see if anyone wanted an absentee ballot. She said they talked some about voting in current events, but she did not keep a record of it. She could provide no evidence that this resident had been asked about voting in this year's mid-term elections. She stated I did not ask her in (MONTH) or (MONTH) of this year. She said she does not know if this resident was registered to vote or not. She said someone will come to the facility upon request and register residents to vote. She said this resident stays in bed most of the time and most likely would not have gone out to the polls. She agreed that an absentee ballot can be obtained for a mostly bedfast resident. She said she could in the future fix something up on the activity participation record whereby she could ask residents individually about voting preference prior to the elections and record it. Upon inquiry as to whether they discussed in the morning meetings about residents voting in this year's mid-term election, she replied in the negative. She said that could have been added to the agenda, but it was not. An interview was conducted with the DON and the administrator on 11/08/18 at 1:30 PM. No further information was provided prior to exit related to this resident's desire to vote.",2020-09-01
2156,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,641,D,0,1,I3US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, resident interview and staff interview the facility failed to ensure one (1) of fifteen (15) residents, had an assessment completed that accurately reflected their status. Resident #4's assessment did not reflect the resident's status concerning speech. This had the potential to affect more than a limited number of residents. Resident identifiers: #4 Facility census: 58 Findings included: a) Resident #4 On 11/05/18 at 02:30 PM during the initial interview with the resident this surveyor had difficulty understanding the resident at times due to the resident's speech abilities. The resident was slow to form some words at times and had to repeat herself to help this surveyor understand what she was trying to communicate. Review of Resident #4's quarterly minimum data set (MDS) with an assessment reference date (ARD) 11/04/18, on 11/06/18 at 11:51 AM, revealed the MDS was marked the resident had clear speech. Pertinent [DIAGNOSES REDACTED].) On 11/07/18 at 09:20 AM, observation of Licensed Practical Nurse (LPN#61) providing Pressure ulcer wound care to Resident #4, revealed LPN#61 had some difficulty communicating with and understanding Resident #4 due to the resident's speech abilities. LPN#61 had to ask the resident various times to repeat herself so the LPN could understand the resident. The same observations were made, on 11/07/18 at 10:10 AM, when LPN#61 provided supra pubic catheter to Resident #4. Interview with the back-up clinical reimbursement coordinator (CRC, the nurse responsible for completing the resident's MDS), on 11/07/18 at 01:16 PM, revealed 'clear speech' being marked on the MDS was inaccurate. The back-up CRC said, The resident has been here a while. I am familiar with the resident, and she does not have clear speech. The MDS is not accurate.",2020-09-01
2157,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,655,D,0,1,I3US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a baseline care plan for one (1) of one (1) closed record reviewed for death. Resident identifier: #58. Facility census: 58. Findings included: a) Resident #58 Resident #58 was admitted to the facility on [DATE]. A copy of Resident #58's baseline care plan was requested and reviewed on 11/07/18 during the Long Term Care Survey Process. The baseline care plan included problems, goals, and interventions related to nutrition and skin breakdown only. The initial nursing assessment completed on 09/22/18 revealed that Resident #58 had a urinary tract infection [MEDICAL CONDITION], urinary and bowel incontinence, recent falls, moderate hearing difficulty with need for a hearing aid, and limited mobility with wheelchair use. Per his admission orders [REDACTED]. On 11/07/18 at 4:00 PM, Clinical Reimbursement Coordinator (CRC) #8 stated that a baseline care plan should include, at a minimum, information related to nutrition, activities of daily living, skin integrity, and advance directives. She reviewed Resident #58's baseline care plan and agreed that it was incomplete. She said she did not know where the rest of the care plan was.",2020-09-01
2158,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,656,D,0,1,I3US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation the facility failed to develop and/or implement a comprehensive care plan related to psychosocial needs, the use of medication for [MEDICAL CONDITION], nutrition and activities. Resident identifiers: #40 and #48. Facility census: 58. a) Resident #40 Intermittent observations of his room on 11/05/18 found it devoid of any personal effects. The room had no music or television. He wore a hospital gown at every observation. The medical record was reviewed on 11/06/18. This resident first came to the facility the preceding month. He and/or his guardian elected hospice services on 10/04/18. Review of the care plan found it was not person-specific in the care area of things that formerly brought him comfort/pleasure, or past interests. The care plan contained a focus which was initiated on 10/05/18, that he was at risk for alterations in comfort related to chronic pain. Interventions included to Evaluate resident's past coping mechanism to determine what measures work best (relaxation, diversional activities, visualization). However, his past coping mechanisms were not included in the care plan. An interview was conducted with the licensed social worker (LSW) on 11/06/18 at 2:42 PM. We discussed that the care plan was not person-centered in that it did not include things that brought him comfort/pleasure or past interests. Also, his room was absent of any personal memorabilia or connections to his past life that might bring him comfort. The LSW said that mostly he likes for people to talk to him, although that was not included on the care plan. She said he has two (2) grandchildren who visit sometimes. Upon inquiry as to whether they were involved in care planning things that have brought him comfort/pleasure in the past such as favorite pets, type of music preferred, hobbies, pictures from his home, past employment, religious preference, she said she did not know. She added that activities usually assesses those types of things, and she would reach out to hospice for more input in these areas. An interview was conducted with the DON and the administrator on 11/08/18 at 1:30 PM related to the care plan which was not person-centered. No further information was provided prior to exit. b) Resident#48 Review of records, on 11/07/18 at 02:39 PM, revealed a care plan focus of Hypo [MEDICAL CONDITION] Disease [DIAGNOSES REDACTED] disease created and initiated on 07/23/18. The goal is TSH ([MEDICAL CONDITION] Stimulating Hormone) will remain within normal range X 90 days (times ninety days), created and initiated on 07/23/18. An intervention, initiated on 07/23/18, included monitor TSH annually and as ordered by the physician. Review of records revealed no lab for TSH was ever obtained. Interview with the Director of Nursing (DON) revealed no TSH had been obtained by the facility nor had the hospital obtained a TSH during a hospitalization . The DON said, I will contact the physician for orders for TSH for the next lab day. The DON agreed Resident#48 care plan was not implemented concerning this focus area.",2020-09-01
2159,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,657,D,0,1,I3US11,"**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 revise a careplan for two (2) of fifteen (15) sampled residents. Resident #108's care plan was not revised when isolation was discontinued. Resident #5's care plan was not revised related to diet and nutritional supplements. Resident identifiers: #108 and #5. Facility census: 58. Findings included: a) Resident #108 The medical record was reviewed on 11/07/18. This resident was hospitalized for [REDACTED]. She returned to the facility on [DATE] and was placed on contact precautions. Review of the care plan provided by the facility found a focus for being at risk for complications of infection related to pneumonia. One of the interventions included Droplet Precautions, which was initiated on the current care plan with the date of 09/13/18, as it remains today. Observations found no evidence of any type of isolation set up for her room. On 11/07/18 at 4:00 PM an interview was conducted with the director of nursing (DON). She clarified that this resident is no longer on droplet precautions, nor has she been in droplet precautions for at least the past month. She said the care plan should have been revised to reflect that change, and it was not. b) Resident #5 During an interview on 11/06/18 at 3:16 PM, Resident #5 said he thought he was on a renal diet, but he was not sure because no one had explained his diet to him. He also stated that he was given a nutritional supplement via his feeding tube. A review of Resident #5's physician's orders [REDACTED]. Low sodium diet due to fluid overload. Another physician's orders [REDACTED]. A review of Resident #5's care plan revealed instructions to provide a pureed, no added salt (NAS) diet with a sugar substitute and no oranges, OJ, bananas, or tomatoes. Additionally, care plan diet instructions stated to provide double eggs at breakfast, double meats at lunch and dinner, and diet as ordered. Page seven (7) of the care plan instructed to give 720 cubic centimeters (cc) Glucerna. Page fifteen (15) of the care plan instructed to give one (1) can of Nepro (a nutritional supplement formulated for individuals with kidney disease) at 2:00 PM and at bedtime. A review of Resident #5's nutritional supplement orders revealed that he was to receive Nepro one (1) can at 2:00 PM and at bedtime daily, starting on 04/11/18. This order was discontinued on 05/16/18 and a new order was written on the same day to provide one (1) can of Glucerna 1.5 daily at 10:00 AM and at bedtime. Resident #5's Diet Order and Communication Form, dated 09/27/18, was used by the Director of Dining Services (DDS) to assist with preparation of Resident #5's meals. It stated that Resident #5's diet was to be Dysphagia Puree and NAS. It also indicated that the 2gm Sodium diet was to be discontinued. During an interview on 11/07/18 at 12:35 PM, the Director of Nursing (DoN) was asked about the diet the Medical Doctor (MD) had ordered for Resident #5. The DoN reviewed the paper chart and stated that Resident #5's ordered diet was a pureed two (2) gram sodium diet. When asked about the diet and supplement discrepancies between the physician's orders [REDACTED]. On 11/07/18 at 1:00 PM, the DDS was asked why Resident #5 was receiving a NAS diet when a 2 gm Sodium diet had been ordered by the physician. She stated that the facility's Registered Dietitian (RD) had recommended a NAS diet, so Resident #5's Diet Order and Communication Form was updated to reflect this. The DoN added that the diet order needed to be clarified with the MD and that the care plan needed to be updated accordingly.",2020-09-01
2160,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,684,D,0,1,I3US11,"Based on medical record review and staff interview, the facility failed to follow physician's orders for one (1) of fifteen (15) sampled residents. Resident identifier: #108. Facility census: 58. Findings included: a) Resident #108 On 11/07/18 the medical record was reviewed. On 09/19/18 the physician ordered an increase in supplements (house shake) from once daily at 10:00 AM to twice daily at 10:00 AM and 2:00 PM. A verbal order from (name of doctor) to licensed practical nurse #71 (LPN #71) was dated 09/19/18 stated House supplements BID (twice daily) at 10 a and 2 p. Review of the treatment administration record (TAR) found the supplement was offered and/or given only one time per day on 09/20/18, 09/21/18, 09/22/18, 09/23/18, 09/24/18, 09/25/18, 09/26/18, 09/27/18, 09/28/18, 09/29/18, and 09/30/18. The (MONTH) TAR contained directive for supplement twice daily as the physician ordered. On 11/07/18 at 4:00 PM the director of nursing (DON) agreed the physician's order for twice daily supplements was not placed on the TAR until 10/01/18, and that the twice daily supplements were not offered to her in September. She said the order was not transcribed on the (MONTH) TAR correctly as it should have been, and this error was not found until changeover of the monthly TAR occurred the beginning of October.",2020-09-01
2161,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,693,D,0,1,I3US11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, policy review, resident interview, and staff interview, the facility failed to ensure the administration of enteral nutrition is consistent with the physician orders. This was true for one (1) of one (1) residents reviewed for the care area of tube feeding status. This had the potential to affect more than a limited number of residents. Resident identifiers: #4 Facility census: 58 Findings included: a) Resident #4 On 11/05/18 at 02:31 PM the enteral feeding container of [MEDICATION NAME] HN was found hanging in the resident's room with no information filled out on the label as required. The 2000cal (calorie)/1000 ml. (milliliter) container had a considerable amount of residual sediment from the enteral feeding deposited on the inside top of the container, indicating the container had not been properly shook prior to being hung. Instructions on the container read, Shake well before each use. Hang product up to 48 hours after initial connection when clean technique and only when one new feeding set are used. Otherwise, hang no longer than 24 hours. On 11/05/18 the enteral feeding container had 900 ml. of [MEDICATION NAME] left in the container that had not been administered. The resident said she gets her feedings between 6:00 PM to 6:00 AM, but according to the resident the nurse hung the container now hanging at 3:00 AM that morning. There was nothing on the label to indicate the time it was hung. Review of Resident #4's quarterly minimum data set (MDS) with an assessment reference date (ARD) 11/04/18, on 11/06/18 at 11:51 AM, revealed the resident's Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident is cognitively intact. The resident is dependent for all activities of daily living. The resident has impairment in range of motion (ROM) in both sides upper and lower extremities. Resident #4 has a supra pubic catheter and is always incontinent of bowel. Pertinent [DIAGNOSES REDACTED]. The nutritional approach was a feeding tube. The proportion of total calories the resident was receiving through her tube feeding was marked 51% (percent) and more. On 11/06/18 at 01:13 PM, an interview with the unit manager nurse, RN#24, revealed nurses are supposed to label the enteral feeding container with the resident's name, room, date, start time, and rate each time a feeding container is hung. Observations, with RN#24, of the current enteral feeding container hanging in the resident's room revealed the container's label was left blank, it was not filled out with any required information. A layer of residual sediment was coating the inside top of the enteral feeding container and 300 ml. was left remaining in the container. This surveyor informed RN#24 this was the second day the container was found with the label blank and residue coating the inside top of the container. RN#24 said a nurse should not administer anything that was not labeled, especially when it did not indicate when it was opened or spiked. RN#24 said the container was going to have to be discarded and a new one hung at 6:00 PM. This survey requested all records on how the facility tracked the resident's enteral feeding that ensured the resident was receiving the nutrition that was ordered for her. On 11/06/18 at 01:33 PM, the unit manager nurse (RN#24) gave this surveyor (MONTH) (YEAR) Enteral Protocol sheet, the form RN#24 said was used for documenting and tracking the resident's feedings. The Enteral Protocol sheet was the (MONTH) orders for Resident#4's enteral feedings, and indicated the rate of the feeding, the time it was to be started and turned off (6:00 PM to 6:00 AM), and the orders for the total amount to be administered. Review of records did not indicate what the daily amounts of feeding were administer. It did not indicate the amount in the feeding container at the start or end times. It did not indicate if it was a new container bottle with 1000 ml in the container, or if the nurse administer part of what might have been left from the previous feeding before having to hang a new container. This surveyor observed 900 ml left in the container on 11/05/18 and on 11/06/18 observed 300 ml. remaining in the container. Review of orders revealed Two Cal PEG 16Fr (PEG stands for Percutaneous Endoscopic Gastrostomy, a procedure whereby a feeding tube is inserted orally into the stomach to feed patients that cannot swallow food. The size of Resident#4's tube is 16 French.) The rate, frequency, and duration of the tube feeding was ordered as seventy (70) ml per hour for twelve (12) hours a day. Run from 6:00 PM to 6:00 AM, down time was 6:00 AM to 6:00 PM. The total number of nutrients the resident is to receive is 840 ml. in a twenty-four (24) hour period. Flush with two hundred (200) ml. of water every four (4) hours. The total volume of flush is 1200 ml. in 24 hours (excluding medication flushes). The total volume of nutrient and flush is 2040 ml in 24 hours. On 11/06/18 at 02:40 PM, review of the resident's care plan revealed a focus area of Resident has an enteral feeding tube to meet nutritional needs due to TBI ([MEDICAL CONDITION]) and resulting dysphagia. (Definition of 'dysphagia' by Merriam-Webster dictionary is difficulty in swallowing.) The resident is NPO (nothing by mouth). Resident aspirates on all consistencies (indicating the resident breaths in or sucks in food into her airway no matter the texture or thickness). Review of Policy for Enteral feeding: Administration by pump, on 11/06/18 at 03:05 PM, revealed under #18 Set up feeding system instructions on how to set up a closed ready to hang system. Instructions in #18.1.2 were Fill in the information on the containers label (patient name, room number, date, start time, and flow rate). Instructions included in #18.1.3 were Label the administration set with start date and time. Instructions included in #18.1.4 were Turn container upside down and shake vigorously, using a twisting motion for at least 10 seconds. Under the instructions for documentation (#37) on enteral protocol (#24.1), instructions included #24.1.1 Formula and amount infused per feeding; and under #24.1.10 Enteral orders not administered and reason. Interview with the director of nursing (DON) and RN#24 concerning tracking Resident #4's nutritional intake, on 11/06/18 at 04:10 PM, revealed the DON spoke with the resident and was told the pump had been turned off awhile during the night due to the resident becoming sick. The DON said when she looked at the readings recorded on the pump, she was only able to view readings for the past 24-hour period. The DON said according to the pump's reading, it appeared the resident did not get about 100 ml of her prescribed feeding when it was last administered to the resident. This surveyor asked where that was documented in the resident's record, and how often did it occur when the pump might need to be turned off for any reason. The DON and RN#24 said the nurse should have charted that somewhere, and that they were going to have to look at how the facility tracked resident's tube feedings and make some changes. Review of Policy for Enteral feeding: Administration by pump, on 11/07/18 at 08:27 AM, revealed under #18 Set up feeding system instructions on how to set up a closed ready to hang system. Instructions included in #18.1.2 were Fill in the information on the containers label (patient name, room number, date, start time, and flow rate). Instructions included in #18.1.3 were Label the administration set with start date and time. Instructions included in #18.1.4 were Turn container upside down and shake vigorously, using a twisting motion for at least 10 seconds. Under the instructions for documentation (#37) on enteral protocol (#24.1), instructions included #24.1.1 Formula and amount infused per feeding; and under #24.1.10 Enteral orders not administered and reason. Observation and interview with LPN#61, on 11/07/18 at 09:35 AM, revealed a thick substance coating the inside top of the container. When LPN#61 was asked what she thought the substance was, LPN#61 replied that is sediment from the feeding where the nurse did not shake it and mix it up. LPN#61 confirmed the resident was not receiving the full nutritional value of the feeding with that much residual sediment clinging to the container. On 11/07/18 at 09:42 AM, observation with the DON present revealed the feeding sediment attached to the inside top of the feeding container. The DON agreed the resident was not getting full nutritional value with the amount of sediment present. There was also 350 ml left in the feeding container, which would indicate if the resident got a new 1000 ml container at 6:00 PM, then only 650 ml was administered, not 840 ml as ordered. RN#24 said the container was going to have to be discarded and so a new one hung at 6:00 PM due to the sediment to ensure the proper nutritional value. The DON said for tracking purposes they may have to start recording what the pump says was administered. The DON said, We need to track differently and not assume the resident is getting the correct amount just because nurses sign off the feeding is running 6:00 AM to 6:00 PM, because sometimes the feeding might be turned off for some reason and turn back on, like yesterday when the resident said it was turned off a while because she was sick.",2020-09-01
2162,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2018-11-08,838,E,0,1,I3US11,"Based on record review, activity calendar review, facility assessment and staff interview the facility failed to ensure facility wide assessment was conducted to thoroughly assess the needs of residents and to determine the required resources needed to provide activity programing. This issue has the potential to affect more than an isolated number of residents. Resident identifiers: Facility census: 58. Findings included: Review of the activity calendar for the month of (MONTH) (YEAR) revealed the following: Thursday 11/01/18 9:30 Meal choice (activity staff gets meal choice from each resident) 10:30 Sensory 11:30 News and Views (right before lunch while waiting in the dining room) 1:00 Meal choice 2:30 Missing Letter 4:30 TV Land ( a channel with old shows the residents are familiar with) Friday 11/03/18 9:30 Meal choice 10:00 One to One 11:30 News View a:00 Meal choice 2:30 Let's get physical 4:30 TV Land Saturday 11/03/18 9:30 Meal choice 10:00 One to One 11:30 News & Views 1:00 Meal choice 2:30 Bingo 4:30 Pre-meal social Sunday 11/04/18 9:30 Meal choice 10:30 Sensory 11:30 News and Views 1:00 Meal choice 2:30 Church 4:30 Pre meal social Monday 11/05/18 9:30 Meal choice 10:00 One to One 11:30 News and Views 1:00 Meal choice 2:30 Baptist Ladies group 4:30 TV Land Tuesday 11/06/18 9:30 Meal choice 10:30 Sensory 11:30 News & Views 1:00 Meal choice 2:30 Bingo 6:00 Singing with the Perry's (volunteer group) Wednesday 11/07/18 9:30 Meal choice 10:00 One to One 11:30 News & Views 1:00 Meal choice 2:30 Creative time 4:30 TV Land The activity calendar continues with the same pattern, with a few changes for the remainder of (MONTH) (YEAR). During the month of October, September, (MONTH) of (YEAR) there was only one scheduled evening activity each month Singing with the Perry's. The month of (MONTH) (YEAR) had no scheduled evening activities. The activity calendars did not have weekend activities outside of the activity listings mentioned. A request was made to the activity director on 11/08/18 at 11:40 AM concerning the lack of group variety and evening activities. The AD explained; she is currently the only activity staff and the facility has had difficulty keeping activity staff, the budget had been recently cut from a little over $200.00 a month to $132.00 a month, and the lack of availability to use the facility van. The van priority is doctor appointments and activities have had to be canceled in order for the van to be used to transport residents for medical needs. The AD also explained the budget does not allow for food activities. The AD explained it is becoming more difficult to get volunteers for activities, and explained that a local church had recently donated funding to buy residents CD players. The budget does not allow for providing residents with individual activity needs. The current facility assessment, section 2.1, resident support/care needs, includes Provide person-centered/direct care: Psycho/social/spiritual support, but does not refer to creating and providing activities to meet residents needs. During an interview on 11/08/18 at 10:30 AM the facility administrator was not sure of the activity budget.",2020-09-01
2163,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2017-12-06,583,E,0,1,BX2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to protect the personal privacy of residents including medical and health information. A resident's medication box and a nurse report sheet was left unattended on medication cart in the hallway. Personal identifiers including residents' names, medications, and other health information were viewable by any person in the hall. This practice affected nine (9) residents. Resident identifiers: #14, #17, #19, #38, #39, #42, #47, #53, and #205. Facility census: 60. Findings include: a) Medication Box An observation during medication administration on 12/05/17 at 9:35 a.m., on the 200 Hall, revealed Resident #53's medication box for eye drops was left on top of the medication cart in the hallway. The medication cart was unattended. The medication box for Resident #53 contained the following information: --Resident's name --Medication prescribed --Physician's name b) Nurse Report Sheet An observation during medication administration on 12/05/17 at 9:35 a.m., on the 200 Hall, revealed a Nurse Report Sheet was left on top of the medication cart. The Nurse Report Sheet contained the following: --Resident #14-Resident's name, room number, and [MEDICATION NAME] 4:15 am. --Resident #17-Resident's name, room number, and fall, evening, witness. --Resident #19-Resident's name, room number, and no caffeine. --Resident #38-Resident's name, room number, and increased [MEDICATION NAME]-redraw-Thursday. --Resident #39-Resident's name, room number, and 3:30 am-Tylenol. --Resident #42-Resident's name, room number, and 2:15 Neb tx. --Resident #47-Resident's name, room number, and change R heel-skin prep. --Resident #205-Resident's name, room number, and Dr. Safely, p/u 12. An interview with Licensed Practical Nurse (LPN) #18 on 12/05/17 at 9:45 a.m. revealed the LPN should have not left the Nurse Report Sheet and medication box unattended on the medication cart. The LPN stated she knows better. A review of the facility's policy, on 12/05/17 at 11:45 a.m., titled OPS209 Privacy Rights with a revision date of 11/28/16 revealed The patient has a right to personal privacy and confidentiality oh his/her personal and medical records. b) Resident #53 During the medication observation on 12/05/17 at 9:37 AM, LPN #18 left the eye medication [MEDICATION NAME] 0.2-0.5% box on top of the medication cart for Resident #53. The box contained the resident's name, doctor name, medication name. The nurse also left the report sheet out on top of the medication cart which contained multiple resident's information on it. Resident #4, #14, #17, #19, #38, #39, #42, #47, #205 had identifiable medical information on the report sheet including name, room number, and medical information. During an interview on 12/05/17 at 9:45 AM, LPN #18 stated she usually turns the report sheet over when she walks away from her medication cart. The LPN stated she knows not to leave medication boxes and containers on top of the medication cart when she walks away. The LPN stated it is definitely a privacy issues and that she knows better. Facility Policy Review-Titled OPS209 Privacy Rights: Patient Revision Date-11/28/16 confirmed the patient has a right to personal privacy and confidentiality of his/her personal and medical records. Personal privacy includes accommodations, medical treatment, written, telephone and electronic communications, personal care, visits, and meetings of family and patient groups. ,",2020-09-01
2164,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2017-12-06,584,D,0,1,BX2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for one (1) of twenty seven (27) rooms observed during the Long Term Care Survey Process. The issue identified included a resident's bathroom with paint missing and hanging from the ceiling. Room identifier: #103. Facility census: 60. Findings include: a) room [ROOM NUMBER] The following observation was made on 12/04/17: --room [ROOM NUMBER]-The bathroom ceiling above the sink had paint missing as well as several large paint chips hanging from the ceiling. An interview with the facility's Administrator on 12/06/17 at 9:30 a.m. revealed the Administrator was not aware of the paint falling from the bathroom ceiling. The Administrator stated he would ensure that maintenance fixed the ceiling immediately.",2020-09-01
2165,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2017-12-06,689,E,0,1,BX2G11,"Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. Chemical substances, shaving razors, and skin treatments, were unsecured and accessible to residents in the 100 and 200 Hall Shower Rooms. This practice had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) 100 Hall Shower Room A tour of the 100 Hall, on 12/04/17 at 11:15 a.m., revealed the Shower Room did not have a lock on the door. The room contained the following items: --Two (2) containers of Medspa Shave Cream with the warning Keep out of reach of children. --One (1) container of Gold Bond Body Powder with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. b) 200 Hall Shower Room A tour of the 200 Hall Shower Room, on 12/04/17 at 11:25 a.m., revealed the Shower Room did not have a lock on the door. The room contained the following items: --One (1)-container of Soothe and Cool Inzo Barrier Cream with 5% Dimethicone with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Control Center. --One (1)-container of Medline Remedy Phytoplex Z Guard Paste with the warning Keep out of reach of children-If swallowed get medical help or contact a Poison Contact Center. --Two (2) containers of Medspa Shave Cream with the warning Keep out of reach of children. --Fifteen (15) uncapped razors in an unlocked biohazard infectious waste container. --Eight (8) capped razors in a bucket. An interview with the Director of Nursing (DON) on 12/04/17 at 11:30 a.m. revealed the shower rooms are never locked. The DON stated the razors and other care products should be secured away from the residents. The DON stated I had no idea the items in the shower rooms were there.",2020-09-01
2166,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2017-12-06,761,E,0,1,BX2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure expired medication and enteral feedings were removed after the expiration date. Twenty-two cans of enteral feeding supplies and a bottle of multivitamins were found expired on the shelves in the medication storage room. This had the potential to affect more than an isolated number of residents. Facility census: 60. Findings include: a) On [DATE] at 2:32 p.m. observations of the medication storage room revealed one bottle of stock multivitamins (Ondra One daily) had an expiration of date of (MONTH) (YEAR). The storage room also contained 20 cans of Glucerna and two (2) cans of Two Cal which had an expiration date of (MONTH) (YEAR). On [DATE] at 12:00 p.m. Center Nursing Executive Sr #13 confirmed the enteral feeding and multivitamins should have been discarded at the time they expired.",2020-09-01
2167,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2017-12-06,880,E,0,1,BX2G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to maintain an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection to the extent possible. During a random observation, a nurse was observed placing a bottle of lancets and a resident-shared glucometer directly onto a resident's overbed tray with no barrier, and in so doing contaminated the surface of the lancet bottle and glucometer. Prior to surveyor intervention, the nurse failed to disinfect the contaminated bottle of unused lancets before attempting to place the bottle back into the medication cart where some residents' medications were stored. Also, the nurse contaminated the clean surface of the medication cart by placing the contaminated glucometer and bottle of unused lancets directly onto the work area surface of the medication cart. This had the potential to affect more than a limited number of residents on the 100 hall. Facility census: 60. Findings include: a) On 12/04/17 at 12:24 p.m., Licensed Nurse #18 checked the blood sugar of a resident who received [MEDICAL TREATMENT] treatments three (3) times weekly. During the process, she laid the glucometer and a small bottle of unused lancets directly onto the resident's overbed tray without providing a barrier of any type. This contaminated the surface of the bottom of the glucometer and the outside of the bottle of unused lancets. After the blood sugar was completed, the nurse wiped the glucometer with an alcohol wipe, then left the resident's room. The nurse was asked if all of the residents used the same glucometer, and if all the residents used lancets from the bottle she held in her hand. The nurse replied that all of the diabetic residents on the 100 hall shared the same glucometer and the same bottle of unused lancets. She said they disinfect the glucometer with Micro-Kill bleach wipes after every patient use. She then entered the medication storage room, while still carrying the glucometer and the bottle of unused lancets. She accidentally dropped the glucometer onto the floor of the medication storage room. She picked up the glucometer from the floor, then placed both the glucometer and the small bottle of unused lancets directly onto the top of the medication cart. Those contaminated items were laid directly onto the area of the medication cart where nurses prepare medications to administer to residents on the 100 hall. The nurse obtained a Micro-Kill wipe and cleaned and disinfected the entire surface of the glucometer before returning it to the top drawer of the medication cart. However, she did not clean or disinfect the outside area of the bottle of unused lancets which had been in direct contact with the [MEDICAL TREATMENT] resident's overbed tray. She picked up the bottle of unused lancets off the top of the medication cart, and was in the process of laying the bottle of lancets in the top drawer of the medication cart, prior to surveyor intervention of stopping her. Upon inquiry as to what she should first do with the bottle of lancets before laying them in the top drawer of the medication cart, she was unable to say. When told that the bottle of lancets became potentially contaminated when she placed it directly onto the resident's overbed tray without a barrier, she agreed that she should have disinfected the outside of the bottle of lancets prior to returning it to the medication cart drawer. When told that she also contaminated the top of her medication cart when she laid the contaminated glucometer and bottle of lancets on it, she agreed that she had done so, but had not realized it. She then obtained Micro-Kill and disinfected the outside of the lancet bottle before returning it to the medication cart drawer. She also used Micro-Kill to disinfect the top of her medication cart. An interview was conducted with the director of nursing (DON) on 12/06/17 at 11:26 a.m. She said the nurse told her about not disinfecting the lancet bottle or medication cart, and not using a protective barrier in the resident's room. She allegedly told the DON that she was trying to recall all the correct steps and was nervous. The DON agreed that the nurse should not have placed the glucometer and bottle of unused lancets onto the unclean surface of the resident's overbed tray without a barrier. The DON agreed that the nurse should have disinfected the surface of the bottle of unused lancets before returning it to the medication cart drawer, and should have disinfected the top of the medication cart after she laid those potentially contaminated items on it. She said the facility has policies in place for preventing cross contamination of inanimate objects by using good nursing practices. She said the nurse knew better, but was nervous.",2020-09-01
4390,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,241,D,0,1,B8Y111,"Based on observation and staff interview, the facility failed to ensure the dignity of residents during the dining experience. This was evident for two (2) random observations. Resident #27 was fed by nursing staff while the staff member stood over her. The same was true for resident #52. Both residents were cognitively and physically impaired, and unable to feed themselves. Resident identifiers: #27, #52. Facility census: 59. Findings include: a) Resident #27 On 10/31/16 at 12:22 a.m., an observation revealed Resident #52 lying in her bed. Nurse Aide (NA) #76 stood by the resident's bed, and spoon fed her pureed meal. She stood over the resident through the entire meal. The resident was unable to be interviewed due to cognitive impairment. Review of the quarterly minimum data set (MDS), with assessment reference date (ARD) 08/03/16, revealed moderate cognitive impairment. She required extensive assistance of two (2) for bed mobility, and extensive assistance for eating. b) Resident #52 On 11/01/16 at 12:25 p.m., Registered Nurse #35 stood by the resident's bed, and spoon fed her meal. She stood over the resident while she fed her, rather than obtaining a chair and sitting down by the resident in a more dignified manner. The resident was unable to be interviewed due to cognitive impairment. Review of the quarterly minimum data set, (MDS) with assessment reference date (ARD) of 10/03/16, revealed severe cognitive impairment. She was totally dependent on staff for eating her mechanically altered diet. On 11/01/16 at 5:15 p.m., an interview was conducted with the director of nursing (DON) to ascertain if she felt the practice of standing over residents while feeding them was an acceptable standard at this facility. She replied in the negative. She said it is their practice at the facility to sit down beside the residents while feeding them, rather than standing over them. She said that standing over a resident while feeding them is undignified. She said she would speak to nursing staff about this finding. On 11/01/16 at 6:09 p.m., NA #62 said she often feeds Residents #27 and #52. She said she always pulls up a chair and sits down beside them as she feeds them. She was observed earlier this evening sitting down by a different resident as she fed her. NA #56 said staff are supposed to sit down and feed the residents casually and talk to them, and are not supposed to stand over residents as they feed them.",2019-11-01
4391,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,246,D,0,1,B8Y111,"Based on observation, staff and resident interview, it was determined the facility failed to provide Resident #24 an alternative to call for assistance due to the inability to always push the call light button. This practice affected one (1) of thirty (30) Stage 1 sampled residents for reasonable accommodation of individual needs. Resident identifier: #24. Facility census: 59. Findings include: a) Resident #24 When Resident #24 was asked, during Stage one (1) of the Quality Indicator Survey(QIS), to push the call bell button to test to see if it was functioning properly, Resident #24 replied, If I can. When asked what she meant by, If I can, the resident replied, I can't always push the button to make the call light work. Sometimes I just can't. The resident was asked what she did when she was unable to push the call light button. The resident replied, I get my roommate to push her call light. During the time of the interview the resident was alone in her room, the roommate was not present. The resident was then asked, What do you do when your roommate is not here? The resident replied, I holler for staff or just wait until somebody comes by. When asked if the resident had ever told any staff she had a problem pushing the call light button, the resident replied, Yes, several times. Resident #24 was unable to give any names of the staff she had told. An interview with Licensed Practical Nurse (LPN) #52, on 10/31/16 at 4:25 p.m., revealed Resident #24 had talked her about having difficulties pushing her call light button. LPN #52 stated, It has been a while ago since she talked to me about it. I did not know it was still a recent problem. The Director of Nursing (DON) was notified about the issue and was informed that the resident had informed the facility staff that she was unable at times to push the call light. The facility promptly provided a touch pad call bell for the resident. This occurred after surveyor intervention and after the facility confirmed the problem with Resident #24.",2019-11-01
4392,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,280,D,0,1,B8Y111,"Based on observation, record review, and staff interview the facility failed to revise the care plan to reflect the resident's current status. This failed practice had the potential to affect one (1) of twenty one (21) sampled residents. Resident identifier: # 57. Facility census: 59. Findings include: a) Resident #57 Interview with Nurse Aide (NA #50), on 11/02/16 at 11:05 a.m., revealed Resident #57 required total care and was dependent for activities of daily living (ADL). NA #50 said, We reposition her (Resident #57) every two (2) hours and check her briefs and change her. We use to get her up to the toilet, but not for a good while, she's not able. On 11/02/16 at 1:04 p.m., review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/16/16 revealed a Brief Interview for Mental Status (BIMS) score of 3 indicating severe mental status impairment. Resident #57's MDS showed Resident #57 was dependent for care, including toileting, bathing, personal hygiene, and is always incontinent of bowel and bladder and is not on a toileting program. Review of the care plan, on 11/07/16 at 3:47 p.m., revealed a focus area which stated, Resident requires a limited assist to extensive at times with ADLs. She does have cognitive loss secondary to dementia. Resident does transfer and toilet herself independently at times . Other focus areas noted were, Resident is occasional incontinent of urine with potential for improved control or management of urinary elimination, and, Resident is occasional incontinent of bowel with potential for improved control or management of bowel elimination. Interventions included: --Assist resident to toilet at scheduled times --Discuss and plan voiding schedule with resident --Maximize physical activity to enhance general muscle tone, functioning of lower GI (gastrointestinal) tract, and ability to mobilize to bathroom in response to urge to defecate On 11/07/16 at 4:29 p.m., an interview with Registered Nurse (RN ) #38, revealed resident was dependent for care. RN #38 agreed Resident #57's care plan has not been revised to match her current status.",2019-11-01
4393,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,309,D,0,1,B8Y111,"Based on observation, record review, and staff interview, the facility failed to provide the necessary care and services to ensure residents attained or maintained good body alignment and comfortable positioning while the resident was lying in bed. This was true for one (1) of twenty one (21) sampled residents. Resident identifier: #57. Facility census: 59 Findings include: a) Resident #57 Observation of Resident #57, on 11/02/16 at 11:05 a.m., revealed she was lying on her bed in poor body alignment. After Nurse Aide (NA) #50 completed her peri-care, she assisted and positioned Resident #57 to lie on the resident's back. Both of the resident's legs were observed with the knees bent in an upright position perpendicular to the bed, with the soles of both feet laying flush on the bed. The resident stated she was cold, and NA #50 covered Resident #57 with a blanket. When the blanket was placed on the resident, her bent upright legs started to tilt to the right and the resident grimaced. NA #50 started to leave, the surveyor asked NA #50 if she would look at the resident and see if there were any issues. NA #50 acknowledged, after surveyor intervention, that Resident #57 needed a pillow to support her legs, and proceeded to reposition the resident with a pillow supporting both legs. On 11/02/16 at 1:04 p.m., review of quarterly Minimum Data Set (MDS) with an assessment reference date (ARD) of 10/16/16 revealed a Brief Interview for Mental Status (BIMs) score of 3 indicating severe mental status impairment. Resident #57's current MDS showed resident was dependent for care, including toileting, bathing, and personal hygiene. Review of the care plan, on 11/07/16 at 3:47 p.m., revealed she was to maintain good body alignment and she was at risk for alterations in comfort with an intervention to assist resident to a position of comfort, utilizing pillows as appropriate positioning device.",2019-11-01
4394,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,431,E,0,1,B8Y111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and policy review, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. A multi-dose vial of purified protein derivative (PPD), a medication injected beneath the skin to aid in the detection of exposure to [DIAGNOSES REDACTED], was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication, and had the potential to affect any resident who might receive an injection of medication/serum from this vial. Facility census: 59. Findings include: a) On 11/01/16 at 1:52 p.m., the facility's only medication room refrigerator was observed, accompanied by licensed practical nurse #41. An opened and partially used multi-dose vial of Aplisol purified protein derivative (PPD) was stored in the medication room refrigerator. When full, this vial held ten (10) doses. The vial was about half full, indicating that approximately five (5) doses remained. The vial contained no date to indicate the time interval since it was first opened. Nurse #41 said she believed the vial could only be used for thirty (30) days after opening it. She said since the vial was undated, it could not be determined when it was first opened, or when the thirty (30) day period was over. She disposed of the vial immediately. Review of the facility's policy entitled 3.8 Accessing a Multi-Dose Vial, with revision date 07/01/12, stated under section 7 that multi-dose vials are to be discarded if open and undated. It also stated that multi-dose vials are to be discarded within twenty-eight (28) days of opening, or as specified by the manufacturer for an open vial. On 11/01/16 at 5:15 p.m., the director of nursing (DON) was interviewed. She said that licensed nurses are supposed to date multi-dose vials when initially opened, then dispose of the vial thirty (30) days after first opened. She agreed that their policy was not followed in this case.",2019-11-01
4395,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-11-09,441,E,0,1,B8Y111,"Based on observation and staff interview the facility failed to provide a safe and sanitary environment, to help prevent the development and transmission of disease and infection. Resident care equipment was stored improperly in two (2) separate instances. Two (2) hoyer lift cloth slings were observed lying directly on an unclean surface, and a plastic cart used to store resident's personal care items inside its storage drawers, was observed under a sink resting directly on the floor. A breach in infection control principal and practices was also observed while staff was providing peri-care for Resident #57. These practices had the potential effect more than a limited number of residents in the facility. Resident identifier: #57. Facility census: 59 Findings include: a) Hoyer lift slings On Unit 1, during the initial tour on 10/31/16, hoyer lift cloth slings were observed hanging on hooks mounted to the wall beside the hoyer lifts. Each cloth sling was meant to be hung by the sling's strap and buckles on both sides of the sling, leaving the slings hanging half way down the wall. Two (2) hoyer lift cloth slings were observed with only one side of the slings hung on a hook. The two (2) slings hung by only one side, dangled all the way down the wall, leaving their other side's buckles, straps, and area of the cloth lying directly on the floor. On 10/31/16 at 11:40 a.m., Registered Nurse Unit 1 Manager (RN) #38, accompanied this surveyor and observed the two (2) hoyer lift cloth slings resting on the floor. RN #38 agreed this was an infection control issue, and the slings were not supposed to be on the floor. RN #38 stated, I will have them removed, and have to have them washed. b) Storage drawers On 11/02/16 at 11:05 a.m., a plastic cart, used to store resident's personal care items inside its storage drawers, was observed under a sink resting directly on the floor in Resident #57 room. An interview with Registered Nurse/Nurse Practice Educator/Infection Control (RN #29), on 11/02/16 at 11:18 a.m., verified the plastic cart with storage drawers should not be resting on the floor, and did not know why the wheels had been removed. RN #29 confirmed this was an infection control issue. c) Resident #57 (peri-care) Observation of Nurse Aide (NA) #50 providing peri-care to Resident #57, on 11/02/16 at 10:49 a.m., revealed a breach in infection control practice. During the provision of peri-care, NA #50 removed the soiled brief and placed it directly on the foot of bed without a barrier. An interview with RN #29, Nurse Practice Educator/ Infection Control, on 11/02/16 at 11:18 a.m., revealed RN #29 agreed a used soiled brief should never be placed directly on a resident's bed. RN #29 stated, The NA should not have placed a soil brief on the bed, it was a breach in infection control practice.",2019-11-01
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
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
5007,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-04-20,226,D,1,0,06GH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on resident interview, staff interview, facility record review, and policy review, the facility failed to implement its written policies prohibiting mistreatment, neglect, and abuse of residents. The facility failed to conduct a thorough investigation, failed to report occurrences, and failed to ensure residents were protected from harm during an investigation. This affected two (2) of three (3) residents reviewed for allegations of abuse. 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. An interview with the social worker, on 04/20/16 at 9:00 a.m., revealed she had participated in the phone conversation related to the issue about medications, but could not remember exactly what was discussed. She related she did not follow-up on the allegations, and did not handle that situation. During an interview with Unit Manager (UM) #58 and the administrator, on 04/20/16 at 9:50 a.m., the administrator related, Yes, I see where you are going with this. We did not report it and should have. 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). 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. 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). c) The abuse prohibition policy, reviewed on 04/20/16 at 8:45 a.m., indicated the center staff would do all that was within their control to prevent occurrences of abuse, neglect . Section 4.1 indicated the facility would provide patients, families, and staff with information on how and to whom they may report concerns, incidents, and grievances without fear of retribution and provide feedback regarding the concerns that have been expressed. Section 5 indicated 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 employee alleged to have committed the act of abuse will be immediately removed from duty, pending investigation Section 6 noted the facility would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury and Ensure that documentation of witnessed interviews is included.",2019-04-01
5008,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2016-04-20,253,E,1,0,06GH11,"> Based on observation, resident interview, staff interview, family interview, facility record review, and policy review, the facility failed to provide housekeeping services necessary to maintain a sanitary, orderly, and comfortable interior. Curtain tracks were coated with dust/grime, garbage was overflowing on to the resident's floor, and floors were dirty. This practice affected eight (8) residents. Resident identifier: #33. Rooms: 200, 201, 204, and 208. Facility census: 57. Findings include: a) Resident #33 1. During an interview and observation on 04/18/16 at 4:04 p.m., Resident #33 related the curtain track over his bed was filthy. Observation revealed a layer of dust/grime along the track. The resident and his wife pointed to a dark pink mark on the wall/window border about midway down the window area. Resident #33 also related the floor on the right side of his bed, between the bed and the window was dirty, and pointed to dark brown/black areas. The resident said the areas had been there for at least three (3) days. Resident #33 and his wife stated staff only mopped every two (2) to three (3) days. She related staff buffed, but only from the entry across the room and bathroom. Another observation on 04/19/16 at 9:05 a.m., revealed the dark areas on the floor on the far side of the bed by the window remained. An interview with the housekeeping supervisor, on 04/19/16 at 10:50 a.m., revealed she only had two (2) housekeeping staff, one (1) from 8:00 a.m. to 4:00 p.m. and one (1) from 11:00 a.m. to 7:00 p.m. She said the housekeeper who came on duty at 11:00 a.m., was the one who completed the detailed cleaning of the rooms, and upon completion, she assisted with cleaning other rooms. During rounds with the supervisor she confirmed the floor area on the right side of Resident #33's bed was dirty, and the curtain guide over the bed was coated with grime and dust balls. 2. While reviewing information about the admission process and residents rights with Resident #33 and his wife on 04/20/16 at 1:30 p.m., his wife retrieved an admission folder from the night stand bottom drawer. The folder belonged to the resident who had resided in that room just prior to Resident #33's admission. An interview with the administrator immediately following the observation confirmed the folder would have been removed from the drawer had the housekeeper cleaned the nightstand. b) Rooms 204 and 208 Additionally, rooms 204 and 208 also had curtain guides covered with grime and dust. The supervisor confirmed the guides should have been cleaned during room detail. The supervisor related the room scheduled was accurate and rooms had been detailed. c) The maintaining/detail/cleaning calendar, dated (MONTH) (YEAR), reviewed on 04/19/16 at 9:15 a.m., indicated Room 200 A/B (Resident #33's room) had been cleaned on 04/11/16, Room 204 A/B had been cleaned on 04/16/16 and Room 208A/B had been cleaned on 04/18/16. The supervisor reviewed the schedule and confirmed all rooms had not been cleaned as scheduled. d) During an interview on 04/20/16 at 9:20 a.m., Housekeeper #105 related each room was mopped once a day and might be mopped more often when there were spills. She confirmed Resident #33's room had not yet been cleaned. The housekeeper also acknowledged only the walking area from the doorway to the bathroom was mopped. e) The detail cleaning policy, reviewed on 04/19/16 at 11:36 a.m., indicated the purpose was to ensure an optimal level of cleanliness of resident/patient rooms and to enhance the overall appearance of their environment. f) Waste management An observation on 04/19/16 at 8:30 a.m., revealed garbage overflowing onto the floor in Room 201, and garbage on the floor in the bathroom of Room 200. Other observations at 9:05 a.m. and 10:30 a.m., found the garbage remained on the floor. An interview with Housekeeper #105 revealed the housekeepers were responsible for disposing of garbage and cleaning the rooms. Upon inquiry, the housekeeper related nursing staff did not assist with garbage disposal. Housekeeper #105 related she was the only housekeeper on duty from 8:00 a.m. until 11:00 a.m., and indicated a walk-through was completed each morning, and the areas which required the most cleaning were done first. The waste management policy, reviewed on 04/20/16 at 10:00 a.m., required waste bags be closed and removed from the area when three quarters (3/4) full. During an interview with the Center Nurse Executive (CNE) on 04/19/16 at 3:30 p.m., she related the garbage should not have been allowed to overflow onto the floor and nursing staff should have emptied the garbage as needed.",2019-04-01
5388,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,272,D,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to conduct accurate comprehensive assessments for one (1) of twenty-three (23) Stage 2 sample residents. The comprehensive assessment for Resident #47 did not accurately reflect the resident's dental status. Resident identifiers: #47. Facility census: 53. Findings include: a) Resident #47 On 08/25/15 at 8:47 a.m., an observation of Resident #47 revealed most of the residents teeth were missing and the remaining teeth were carious. A review of the medical record, on 08/27/15 at 11:18 a.m., revealed Resident #47 was admitted on [DATE]. [DIAGNOSES REDACTED]. A review of the annual minimum data set (MDS) on 08/27/15 at 1:07 p.m., with an assessment review date (ARD) of 03/18/15, revealed, Section L0200 (Oral/Dental Status) (Z), had been marked as none of the above. Section L0200 (D) stated (obvious or likely cavity or broken natural teeth), which accurately reflected the oral/dental status for Resident #47. However, this selection was not marked. The concurrent review of the significant change MDS, with an ARD of 04/15/15, revealed Section L0200 (Z) marked as none of the above. This again was an inaccurate assessment of Resident #47. In an interview with the MDS coordinator and director of nursing (DON), on 08/27/15 at 1:44 p.m., revealed they were in agreement the oral/dental status, on the 03/18/15 and 04/15/15 MDSs, were incorrectly coded and would submit an immediate correction.",2019-01-01
5389,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,278,D,0,1,ZG3O11,"**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 23 residents, had an assessment completed that accurately reflected their status. Resident #18's assessment did not reflect a diganosis of [MEDICAL CONDITION] disorder. Resident identifier: #18. Facility census: 53. Findings include: a) Resident #18 On 09/01/15 at 10:21 a.m., a review, of the medical record for Resident #18, revealed this resident was readmitted from an acute psychiatric admission on 07/16/15. An new [DIAGNOSES REDACTED]. A concurrent review of the five (5) day MDS, with an ARD of 07/23/15, the fourteen (14) day MDS, with an ARD of 07/28/15 and the quarterly MDS, with an ARD of 08/01/15 did not reflect the [DIAGNOSES REDACTED]. An interview with the MDS coordinator, on 09/01/15 at 10:48 a.m., revealed she was in agreement the MDSs had not been coded to reflect the [DIAGNOSES REDACTED].",2019-01-01
5390,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,279,D,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a care plan to meet the needs for one (1) of twenty-three (23) Stage 2 residents. Resident #9, a [MEDICAL TREATMENT] patient did not have a care plan that described the services or interventions needed to attain or maintain the resident's highest practicable physical needs. Resident identifier: #9. Facility census: 53. Findings include: a) Resident #9 Review of the medical record, on 08/27/15 at 12:00 p.m., revealed this [AGE] year old resident came to the facility on [DATE]. She received [MEDICAL TREATMENT] treatments at a [MEDICAL TREATMENT] center three (3) times per week. Review of the care plan at this time found a focus on complications related to [MEDICAL TREATMENT]. One (1) intervention directed to monitor blood pressure and pulses, and report to the physician as indicated. However, the care plan did not offer directives as to when and how often to check vital signs, nor the parameter the facility desired for the vital signs. On 08/27/15 at 3:00 p.m., during an interview the director of nursing (DON) revealed it was her expectation that residents receiving [MEDICAL TREATMENT] treatments have their vital signs assessed before going out to [MEDICAL TREATMENT], and immediately upon their return to the facility following a [MEDICAL TREATMENT] treatment. She agreed that the care plan did not contain those directives, and it did not include parameters for the vital signs.",2019-01-01
5391,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,280,D,0,1,ZG3O11,"Based on observation, resident interview, medical record review and staff interview the facility failed to revise the care plan for one (1) of 23 residents. Resident #59 ' s care plan was not revised to reflect the resident's status regarding the use of a hand splint. Resident identifier: #59. Facility census: 53. Findings include: a) Resident #59 On 08/25/15 at 12:51 p.m., an observation of Resident #59 revealed he had a bed control remote in his left hand. Medical record review, on 08/25/15 at 1:00 p.m., a care plan intervention with an initiated date of 04/28/14 of Left hand splint from morning ADL's (activities of daily living) and remove by evening meal. At 1:45 p.m., on 08/26/15 during an interview, Resident #59 stated he does not wear the left hand splint during the day or night. Instead, he demonstrated how he holds the remote in the palm of his left hand, which he stated he has done for several months.",2019-01-01
5392,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,282,D,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement the care plan for one (1) of twenty-three (23) Stage 2 sampled residents. The care plan directed nursing staff to administer a medicated rectal suppository every night at bedtime, and after each bowel movement. Nursing staff failed to follow the care plan, by not administering the rectal suppository as ordered by the physician. Resident identifier: #36. Facility census: 53. Findings include: a) Resident #36 Review of the medical record, on 08/25/15 at 4:00 p.m., found [DIAGNOSES REDACTED]. A signed physician's orders [REDACTED]. The revised care plan, dated 08/11/15, read the same. The Medication Administration Record [REDACTED]. The activities of daily living (ADL) and medical record review found the resident did not receive a rectal suppository, or have a documented refusal, following twenty-five (25) bowel movements between 08/7/15 and 08/25/15. On 08/25/15 at 5:00 p.m., the director of nursing agreed that the signed physician's orders [REDACTED]. She acknowledged the care plan was not followed, as the resident received only one (1) rectal suppository and had only two (2) documented refusals between 08/07/15 and 08/24/15.",2019-01-01
5393,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,309,D,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being for two (2) of twenty-three (23) Stage 2 sampled residents. Resident #36 did not receive medicated rectal suppositories as ordered by the physician. Resident #9 did not receive vital signs assessment timely upon her return to the facility following a [MEDICAL TREATMENT] treatment. Resident identifiers: #36 and #9. Facility census: 53. Findings include: a) Resident #36 Review of the medical record, on 08/25/15 at 4:00 p.m., found [DIAGNOSES REDACTED]. A signed physician's orders [REDACTED]. Nursing staff documented family notification of this new physician's orders [REDACTED].>The Medication Administration Record [REDACTED]. Review of the medical record and the activities of daily living (ADL) record, found the resident did not receive a rectal suppository, or have a documented refusal, following any of the twenty-five (25) documented bowel movements between 08/07/15 and 08/25/15. During an interview with the director of nursing (DON) on 08/25/15 at 5:00 p.m., she acknowledged that the signed physician's orders [REDACTED]. She agreed that it appeared the resident received only one (1) rectal suppository and had only two (2) documented refusals of the rectal suppository between 08/07/15 and 08/24/15. The DON acknowledged that the order was written in a confusing manner on the MAR, which caused the resident not to receive the prescribed medication. On 08/26/15 at 8:30 a.m., the DON said she spoke with the nurse who wrote the original order for the [MEDICATION NAME] suppositories. The DON said the nurse did not mean to write it that way. The DON said nursing staff contacted the physician this morning, and received a clarification for the [MEDICATION NAME] order. The physician's orders [REDACTED]. b) Resident #9 Review of the medical record, on 08/26/15 at 12:00 p.m., revealed this [AGE] year old resident came to the facility on [DATE]. While residing at the facility, she received [MEDICAL TREATMENT] treatments at a [MEDICAL TREATMENT] center three (3) times per week. An interview, conducted with Licensed Practical Nurse #14 on 08/26/15 at 12:50 p.m., revealed this resident goes out to [MEDICAL TREATMENT] on the night shift three (3) times weekly. Upon return to the facility from [MEDICAL TREATMENT], the day shift nurse immediately assessed the resident. This assessment includes checking the fistula site for redness, drainage, bleeding or pain, checking for thrill and bruit, and obtaining vital signs. Observation, on 08/27/15 at 1:10 p.m., found Resident #9 had returned from the [MEDICAL TREATMENT] center via ambulance transport. Observation, on 08/27/15 at 1:33 p.m., found the resident eating lunch in her room. Upon inquiry, she said no one had checked her blood pressure since she returned from the [MEDICAL TREATMENT] center today. During an interview with Registered Nurse #55 on 08/27/15 at 1:35 p.m., he said the aides obtain the vital signs upon the resident's return from [MEDICAL TREATMENT], and he did not know if the aide had obtained Resident #9's vital signs yet. He said he assessed the access site after her return to the facility today. During an interview with Nursing Assistant #35 on 08/27/15 at 1:37 p.m., she spoke her belief that the nurse is supposed to check the blood pressure when the resident first returns from [MEDICAL TREATMENT]. She said she would check it now if needed. She said she usually does not work this hall. Observation on 08/27/15 at 1:43 p.m. found Nursing Assistant (NA) #30 in Resident #9's room as she obtained the resident's vital signs. Upon inquiry, she said Registered Nurse #55 directed her about a minute ago to obtain the resident's vital signs. NA#30 said she was new to day shift, and was unaware of the need to get vital signs upon the resident's return to the facility from [MEDICAL TREATMENT]. She said the aide who was permanently assigned to this hall was off today. At 2:00 p.m. on 08/27/15, Registered Nurse #55 said he should have obtained the vital signs when the resident returned to the facility from [MEDICAL TREATMENT]. He said he does not typically work day shift, and the nurse who is usually assigned to this hall is off today. During an interview with the director of nursing (DON) on 08/27/15 at 3:00 p.m., she said it was her expectation that nurses obtain vital signs prior to sending the resident out for [MEDICAL TREATMENT], and immediately upon the resident's return from [MEDICAL TREATMENT] treatments. She said it was the nurse's responsibility to take the vital signs, assess the resident, and assess the access site upon return to the facility from [MEDICAL TREATMENT].",2019-01-01
5394,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,332,D,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, medical record review, manufacturer's instructions, and policy and procedure review, the facility failed to ensure it had a medication error rate of less than five percent (5%). Resident #61 was administered two (2) different inhalers without waiting at least one (1) minute between the different inhalers. Resident #18 was administered an inhaler without waiting between puffs. Medication errors were identified for two (2) of six (6) residents observed for medication pass. There were three (3) medication errors in forty-two (42) opportunities for error, resulting in a medication error rate of 7.14% (per cent). Resident identifiers: #61 and #18. Facility census: 53. Findings include: a) Resident #61 On 08/26/15 at 8:57 a.m., during a medication observation with a Licensed Practical Nurse (LPN)#23 revealed this employee prepared [MEDICATION NAME] Diskus and [MEDICATION NAME] hand held inhaler for Resident #61. These medications were ordered for [MEDICAL CONDITION]. LPN #23 placed each inhaler on the overbed table, Resident #61 picked up the [MEDICATION NAME] inhaler and inhaled one (1) puff and proceeded to pick up the [MEDICATION NAME] Diskus and inhale one (1) puff. LPN #23 then gave Resident #61 a plastic medication cup which contained multiple medications. After exiting Resident #61's room, in a discussion with LPN #23 regarding Resident #61 administering the inhalers, she stated this is the way she always does it. When asked about the pharmacy instructions on both inhaler boxes stating, Wait at least 1 minute between different inhaled medications. Rinse mouth after each use. she stated she did not know this and had not read the instructions on the boxes, and this is the way she does this. A review of the physician orders, on 08/26/15 at 1:33 p.m., revealed orders, dated 06/18/15, for [MEDICATION NAME] Diskus Aerosol Powder Breath Activated 250-50 mcg/dose ([MEDICATION NAME]-Salmeterol ( 1 inhalation inhale orally two times a day related to [MEDICAL CONDITION] and Tiotropin [MEDICATION NAME] ([MEDICATION NAME]) 18 mcg 1 inhalation inhale orally one time a day related to [MEDICAL CONDITION]. In addition, there was a physician's order, dated 06/18/15, stating this resident may not administer own meds (medications). A review of the medical record, on 08/26/15 at 1:46 p.m., revealed Resident #61 was readmitted to the facility on [DATE] from an acute care hospital. [DIAGNOSES REDACTED]. The manufacturers instructions for the use of the [MEDICATION NAME] Diskus were reviewed on 08/26/15 at 2:03 p.m Step 3 of the instructions stated put the mouthpiece to your lips. Breathe in quickly and deeply through the Diskus. Remove the Diskus from your mouth and hold your breath for about 10 seconds, or for as long as is comfortable for you. Step 5 Rinse your mouth with water after breathing in the medicine. Spit out the water. Do not swallow it. Resident #61 was not given any of these instructions by LPN #23. A review of the facility policy and procedure titled Medication Administration: Diskus Inhaler was conducted on 08/26/15 2:26 p.m In Section 3. Administer medication stated the following: 3.6 Hold the diskus in a level, horizontal position with the mouthpiece toward the patient. 3.7 Slide the lever . 3.8 To avoid releasing . 3.9 Instruct the patient to exhale fully through the mouth. 3.10 Hold the diskus level and away from patient's mouth; 3.11 Instruct patient to breathe medication in through mouth and not exhale into the diskus; 3.12 Remove the diskus . 3.13 Instruct the patient to continue inhaling slowly and deeply, hold breath for about 10 seconds, and the exhale. 3.14 Close the diskus 3.15 Instruct patient to rinse mouth with water. A concurrent review of the facility policy and procedure titled Medication Administration: Inhaled metered dose inhaler (MDIs). In Section 3. Administer medication stated the following: 3.7 Put on gloves 3.8 Instruct patient to slowly exhale through pursed lips. 3.9 Place spacer . If not using spacer, hold MDI 1 1/2 inches away from patient's open mouth. 3.10 Instruct patient to begin inhaling slowly, while actuating the MDI. 3.11 Instruct patient to continue inhaling slowly and deeply, hold breath for 5 to 10 seconds, the exhale. 3.12 Wait for one (1) minute between puffs of the same medication and five minutes between puffs of different medications. Section 5. Instruct patient to rinse mouth. b) Resident #18. On 08/26/15 at 9:20 a.m., during a medication observation with an LPN (Employee #14), Resident #18 was administered [MEDICATION NAME] HFA two (2) puffs by E#14. There was no wait time between puffs. In a discussion with E#14, following the administration of the [MEDICATION NAME] HFA, she agreed she did not wait between puffs. A review of Resident #18's medical record, on 08/26/15 at 9:30 a.m., revealed this resident was admitted on [DATE]. [DIAGNOSES REDACTED]. A concurrent review of the physician orders, dated 07/16/15, revealed an order for [REDACTED]. The manufacture's instructions for the use of [MEDICATION NAME] HFA were reviewed, on 08/26/15 at 9:46 a.m. The instructions were as follows: 1. Take the cap off the . 2. Hold the inhaler . 3. Push the top of the canister all the way down while you breathe in deeply and slowly through your mouth. 4. Hold your breath as long as you can, up to ten (10) seconds; then breathe normally. 5. Wait about thirty (30) seconds and shake the inhaler well for five (5) seconds. Repeat steps two (2) through four (4). c) Physician interview During an additional interview with the attending physician, on 09/01/15 at 2:30 p.m., he stated he was not aware of the need to wait prior to giving a second inhaler or the need to rinse out the mouth after using inhalers. He stated he would investigate this and write more specific orders for the use of inhalers.",2019-01-01
5395,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,441,F,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy and procedure review, and infection control surveillance record review; the facility failed to provide a safe, sanitary, and comfortable environment, to help prevent the development and transmission of disease and infection. The infection- control surveillance records were not completed and maintained in their entirety. A bedpan was stored improperly in a bathroom shared by two (2) residents. Nursing staff administered medication to a resident after the medication fell on the top of an unclean medication cart. In addition, two (2) of two (2) medication carts were observed to be dirty with dust and debris. These practices had the potential to affect all residents in the facility. Resident identifiers: #93, #100, #61. Facility census: 53. Findings include: a) Infection control log surveillance records Review of the infection control surveillance records was completed on 08/31/15 at 2:00 p.m. (Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks to try to reduce morbidity and mortality and to improve resident health status.) Findings were as follows: 1. The (MONTH) (YEAR) infection control monthly line listing contained the names of twelve (12) residents with newly developed infections. None of the twelve residents with newly developed infections were documented as having had resolution of the infections. Nine (9) residents lacked an admitted . Eight (8) residents had no recorded dates of onset of the infections. Nine (9) residents had no room numbers recorded. Eleven (11) infections were not differentiated as to whether they were healthcare acquired or community acquired. Eight (8) cultures did not include the dates of the cultures. All five (5) of the urine cultures lacked the results of the organisms, which grew. In addition, the start dates for eight (8) of the antibiotics prescribed were not documented. 2. Review of the infection control monthly line listings for (MONTH) through (MONTH) found similar results. Many lacked valuable information such as room numbers, admitted s, onset dates of the infections, whether the infections were healthcare acquired or community acquired, the date of the cultures, the results of the cultures, the start dates of treatment, the precaution type, and the date the infections resolved. 3. The Multi-Drug Resistant Organism (MDRO) line listing for Methicillin Resistant Staphylococcus Aureus (MRSA), [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE), Carbapenem-Resistant [MEDICATION NAME] (CRE), Extended-Spectrum Beta Lactamase (ESBL), and Clostridium Difficile (C-Diff) all lacked the admitted fo the affected residents, dates of cultures, and the discharge date s. 4. discharged Resident #93 was listed on the (MONTH) monthly line listing as having Clostridium Difficile (C-Diff), but was not listed on the Multidrug-Resistant Organism (MDRO)[DIAGNOSES REDACTED] line listing. During interview with the infection control nurse, Registered Nurse #13, on 08/31/15 at 2:00 p.m., she said she did not know why she did not complete the infection- control surveillance records more thoroughly. She said the monthly line listing form was changed to a corporate form in (MONTH) (YEAR), and for some reason she was not completing the new form in its entirety. 08/31/15 was her last working day at the facility, and her predecessor would take over the infection control monitoring tomorrow. She agreed that the predecessor would not have enough information from the surveillance records to comprehend the tracking and trending for the most recent months. She agreed that the infection control monthly line listings lacked valuable information such as room numbers, admitted s, onset date of the infections, whether the infections were healthcare or community acquired, the dates of all the cultures, and the culture results. She said she discusses the infection control status with the administrative staff once monthly in a special meeting. She utilized a dry- erase board in these meetings to communicate the types of infection present, and where they were located in the facility. This board as the staff looked for trends or patterns of infections. After the meeting, they erased the board. An interview was completed with the director of nursing (DON) on 08/31/15 at 3:30 p.m. She said she was not present in (MONTH) for the monthly infection control meeting. She agreed that the information on the (MONTH) infection control monthly line listing, and for the MDRO line listings, lacked necessary information to be complete. She said a new infection control nurse was starting on 09/01/15, and would need all that information. She agreed that the new infection control nurse would have inadequate knowledge of the past trending and tracking information based on these surveillance records. At 4:00 p.m. on 08/31/15, the DON provided copies of the (MONTH) through (MONTH) infection control monthly line listings. She acknowledged they were similar in lacking needed information. When informed that Resident #93 was not listed on the Clostridium difficile (C-Diff) Multidrug-Resistant Organism (MDRO) line listing, the DON said she would see that Resident #93's name was added. c) Resident #61 On 08/26/15 at 8:47 a.m., during a medication observation, Licensed Practical Nurse (LPN) #23 attempted to place a tablet into a plastic cup from a blister package, the pill landed on the top of the medication cart. LPN #23 picked up the tablet with bare hands and put it into the plastic medicine cup. LPN #23 then administered the oral medication to Resident #61. During an interview with LPN #23, on 08/26/15 at 8:55 a.m., the LPN stated she did not know what to do when a resident ' s medication was dropped. A review of the facility policy and procedure General Dose Preparation and Medication Administration, on 08/26/15 at 10:27 a.m., revealed the following: 2. Dose Preparation 2.4 Do not touch the medication when opening a bottle or unit dose package. 2.5 If a medication, which is not in a protective container is dropped, discard per policy. During an interview, with the director of nursing (DON), on 08/26/15 at 10:35 a.m., she agreed the oral medication should have been discarded and facility policy and procedure had not been followed by LPN #23. d) Hall 1 & 2 Medication Cart On 08/24/15 at 1:15 p.m., an observation, of Hall 2 medication cart, with Licensed Practical Nurse (LPN) #19 revealed dust and brown debris in each drawer of the medication cart. Hall 2 medication cart, which contained liquid medication, revealed a spilled substance, which had been covered with a paper towel. LPN #19 attempted to remove the paper towel but was not successful. This employee agreed the medication cart was dirty and needed to be cleaned. A concurrent observation of the Hall 1 medication cart, with an LPN #14 revealed dust and brown debris in each drawer of the medication cart. LPN #14 stated she had no idea when the medication cart had been cleaned, and agreed the medication cart needed cleaned. e) On 08/24/15 at 3:00 p.m., an unbagged, unlabeled bed pan was found lying in the bathroom floor of Resident #100. Resident #100 stated the bedpan was for her use. Resident #100 shared the bathroom with another resident. At 3:45 p.m., the director of nursing, stated the bedpan should have been labeled and bagged, and the bedpan would be removed from the room and replaced with a new one, with proper labeling.",2019-01-01
5396,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2015-09-02,520,F,0,1,ZG3O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, policy and procedure review, infection control program review; the quality assessment and assurance (QAA) committee failed to identify and or act upon a quality deficiency within the facility's operations of which it did have or should have had knowledge. Infection Control: The QA & A committee failed to identify the need to develop and implement processes to implement an effective infection control program to prevent, recognize, and control, to the extent possible, the onset and spread of infections within the facility. This had the potentital to affect all residents in the facility. Facility census: 53. Findings include: a) Infection control log surveillance records Review of the infection control surveillance records was completed on 08/31/15 at 2:00 p.m. (Surveillance refers to the ongoing, systematic collection, analysis, interpretation, and dissemination of data to identify infections and infection risks to try to reduce morbidity and mortality and to improve resident health status.) Findings were as follows: 1. The (MONTH) (YEAR) infection control monthly line listing contained the names of twelve (12) residents with newly developed infections. None of the twelve residents with newly developed infections was documented as having had resolution of the infections. Nine (9) residents lacked an admitted . Eight (8) residents had no recorded dates of onset of the infections. Nine (9) residents had no room numbers recorded. Eleven (11) infections were not differentiated as to whether they were healthcare acquired or community acquired. Eight (8) cultures did not include the dates of the cultures. All five (5) of the urine cultures lacked the results of the organisms, which grew. In addition the start dates for eight (8) of the antibiotics prescribed were not documented. 2. Review of the infection control monthly line listings for (MONTH) through (MONTH) found similar results. Many lacked valuable information such as room numbers, admitted s, onset dates of the infections, whether the infections were healthcare acquired or community acquired, the date of the cultures, the results of the cultures, the start dates of treatment, the precaution type, and the date the infections resolved. 3. The multi-drug resistant organism (MDRO) line listing for [MEDICAL CONDITION] (MRSA), [MEDICATION NAME] resistant [MEDICATION NAME] (VRE), Carbapenem-Resistant [MEDICATION NAME] (CRE), Extended-Spectrum Beta Lactamase (ESBL), and [MEDICAL CONDITIONS] all lacked the admitted fo the affected residents, dates of cultures, and the discharge date s. 4. discharged Resident #93 was listed on the (MONTH) monthly line listing as having [MEDICAL CONDITIONS], but was not listed on the [MEDICAL CONDITION] (MDRO) [MEDICAL CONDITION] line listing. During interview with the infection control nurse, Registered Nurse #13, on 08/31/15 at 2:00 p.m., she said she did not know why she did not complete the infection- control surveillance records more thoroughly. She said the monthly line listing form was changed to a corporate form in (MONTH) (YEAR), and for some reason she was not completing the new form in its entirety. 08/31/15 was her last working day at the facility, and her predecessor would take over the infection control monitoring tomorrow. She agreed that the predecessor would not have enough information from the surveillance records to comprehend the tracking and trending for the most recent months. She agreed that the infection control monthly line listings lacked valuable information such as room numbers, admitted s, onset date of the infections, whether the infections were healthcare or community acquired, the dates of all the cultures, and the culture results. She said she discusses the infection control status with the administrative staff once monthly in a special meeting. She utilized a dry- erase board in these meetings to communicate the types of infection present, and where they were located in the facility. This board as the staff looked for trends or patterns of infections. After the meeting, they erased the board. An interview was completed with the director of nursing (DON) on 08/31/15 at 3:30 p.m. She said she was not present in (MONTH) for the monthly infection control meeting. She agreed that the information on the (MONTH) infection control monthly line listing, and for the MDRO line listings, lacked necessary information to be complete. She said a new infection control nurse was starting on 09/01/15, and would need all that information. She agreed that the new infection control nurse would have inadequate knowledge of the past trending and tracking information based on these surveillance records. At 4:00 p.m. on 08/31/15, the DON provided copies of the (MONTH) through (MONTH) infection control monthly line listings. She acknowledged they were similar in lacking needed information. When informed that Resident #93 was not listed on the [MEDICAL CONDITION] [MEDICAL CONDITIONS] (MDRO) line listing, the DON said she would see that Resident #93's name was added. b) Resident #61 On 08/26/15 at 8:47 a.m., during a medication observation, Licensed Practical Nurse (LPN) #23 attempted to place a tablet into a plastic cup from a blister package, the pill landed on the top of the medication cart. LPN #23 picked up the tablet with bare hands and put it into the plastic medicine cup. LPN #23 then administered the oral medication to Resident #61. During an interview with LPN #23, on 08/26/15 at 8:55 a.m., the LPN stated she did not know what to do when a resident ' s medication was dropped. A review of the facility policy and procedure General Dose Preparation and Medication Administration, on 08/26/15 at 10:27 a.m., revealed the following: 2. Dose Preparation 2.4 Do not touch the medication when opening a bottle or unit dose package. 2.5 If a medication, which is not in a protective container, is dropped, discard per policy. During an interview, with the director of nursing (DON), on 08/26/15 at 10:35 a.m., she agreed the oral medication should have been discarded, and facility policy and procedure had not been followed by LPN #23. c) Resident #61 On 08/26/15 at 8:47 a.m., during a medication observation, Licensed Practical Nurse (LPN) #23 attempted to place a tablet into a plastic cup from a blister package, the pill landed on the top of the medication cart. LPN #23 picked up the tablet with bare hands and put it into the plastic medicine cup. LPN #23 then administered the oral medication to Resident #61. During an interview with LPN #23, on 08/26/15 at 8:55 a.m., the LPN stated she did not know what to do when a resident's medication was dropped. A review of the facility policy and procedure General Dose Preparation and Medication Administration, on 08/26/15 at 10:27 a.m., revealed the following: 2. Dose Preparation 2.4 Do not touch the medication when opening a bottle or unit dose package. 2.5 If a medication, which is not in a protective container, is dropped, discard per policy. During an interview, with the director of nursing (DON), on 08/26/15 at 10:35 a.m., she agreed the oral medication should have been discarded, and facility policy and procedure had not been followed by LPN #23. d) Hall 1 & 2 Medication Cart On 08/24/15 at 1:15 p.m., an observation, of Hall 2 medication cart, with Licensed Practical Nurse (LPN) #19 revealed dust and brown debris in each drawer of the medication cart. Hall 2 medication cart, which contained liquid medication, revealed a spilled substance, which had been covered with a paper towel. LPN #19 attempted to remove the paper towel but was not successful. This employee agreed the medication cart was dirty and needed to be cleaned. A concurrent observation of the Hall 1 medication cart, with an LPN #14 revealed dust and brown debris in each drawer of the medication cart. LPN #14 stated she had no idea when the medication cart had been cleaned, and agreed the medication cart needed cleaned. e) On 08/24/15 at 3:00 p.m., an unbagged, unlabeled bedpan was found to be lying in the bathroom floor of Resident #100. Resident #100 stated the bedpan was for her use. Resident #100 shared the bathroom with another resident. At 3:45 p.m., the director of nursing stated the bedpan should have been labeled and bagged. The director of nursing said the bedpan would be removed from the room and replaced with a new one that was labeled properly. On 09/02/15 at 1:30 p.m., the facility administrator was interviewed concerning infection control issues found during the current QIS, including infection control surveillance, soiled medication carts, administering medication in a clean and sanitary manner, and bagging and labeling bedpans. The administrator stated the facility was in the process of completing a study on urinary tract infections but had no specific current infection control quality control interventions related to the areas of concern found during the current QIS.",2019-01-01
6530,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2014-06-04,253,E,0,1,N2BW11,"Based on observation and staff interview, it was determined the facility failed to ensure effective maintenance services. The physical environment was not in good repair. The walls had holes, the cove base was loose and hanging from the walls in resident's rooms, and a toilet seat was missing a seat bumper in a resident's bathroom. This practice affected seven (7) of twenty (20) rooms observed. This practice had the potential to affect more than an isolated number of residents. Room numbers of affected rooms: #105, #107, #109, #114, #206, #213, and #215. Facility census: 54. Findings include: a) Observations of the facility during Stage I and Stage II of the Quality Indicator Survey revealed the following rooms had environmental concerns: 1) Room #105 - The wall under the television had several holes. 2) Room #107 - The cove base was loose and hanging from the wall. 3) Room #109 - The cove base was loose and hanging from the wall. 4) Room #114 - The wall behind bed B had several holes. 5) Room #206 - The cove base was loose and hanging from the wall. 6) Room #213 - The toilet seat in the bathroom was missing a seat bumper. 7) Room #215 - The cove base was loose and hanging from the wall.",2018-02-01
6531,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2014-06-04,323,E,0,1,N2BW11,"Based on observation and staff interview, the facility failed to provide an environment that was free from accident hazards over which the facility had control. The soiled utility closet on the 100 Hall was unlocked on several occasions. The closet contained cleaning supplies, soiled linens, sharps containers, laboratory supplies, and trash. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) During the initial tour of the facility on 05/27/14 at 11:30 a.m., the soiled utility room on the 100 Hall was observed unlocked. Employee #53 (Nursing Assistant-NA) witnessed the door unlocked and stated the door should be locked at all times. The NA stated she would ensure the door was locked. The room contained cleaning supplies, soiled linens, sharps containers, laboratory supplies, and trash. An observation on 05/27/14 at 12:15 p.m. revealed the soiled utility room on the 100 Hall was again unlocked. Employee #53 (NA) witnessed the door unlocked and stated she was not sure why the door was not locking, but had informed the maintenance department to look at the door. An interview with Employee #79 (Maintenance Director), on 06/04/14 at 10:00 a.m., revealed the soiled utility room doors were to be locked at all times. The maintenance director stated the door was unlocked on 05/27/14 because someone had accidentally unlocked the door causing it not to lock when shut.",2018-02-01
6532,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2014-06-04,431,E,0,1,N2BW11,"Based on observation, staff interview, policy review, and information obtained from the Centers for Disease Control and Prevention (CDC), the facility failed to ensure the safe administration of medications. Opened vials of medications were not labeled with the dates they were opened for use. This date is essential to ensure the medications were not used beyond their safe and/or effective dates after opening. This practice had the potential to affect more than an isolated number of residents. Facility census: 54. Findings include: a) On 06/02/14 at 1:10 p.m., observation of the medication storage area behind the nursing desk was completed with Employee #33, the Director of Nursing (DON), and Employee #43, a Licensed Practical Nurse. Novolog 70/30, Lantus, and two (2) vials of Tuberculin purified protein had no dates indicating when they were opened. b) During an interview with the DON, at 11:15 a.m. on 06/04/14, she agreed medications were to be labeled and dated according to common nursing and pharmacy standards of practice. Facility policies were provided by the DON on 06/04/14 at 12:55 p.m. The facility used the consulting pharmacy recommendations which stated, All vials should be dated when opened and discarded 28 days after opening (except for Levemir (insulin detemir), Novolin R, Novolin N, and Novolin 70/30 which can be used up to 42 days after opening and Humulin which can be used up to 31 days after opening). Other multiple-dose vials for injection should be dated when opened and discarded after 28 days or in accordance with the manufacturer's recommendation. On 06/04/14 at 11:15 a.m. the DON confirmed medications were to be labeled and dated in accordance with the consulting pharmacy's recommendations. c) According to the Centers for Disease Control and Prevention(CDC), multi-dose vials of medications which have been opened or accessed should be dated and discarded within 28 days unless the manufacturer specifies a different (shorter or longer) date for that opened vial.",2018-02-01
6533,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2014-06-04,441,D,0,1,N2BW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview, the facility failed to provide a safe and sanitary environment. The shower rooms on the 100 and 200 Halls contained soiled linens, gloves on the floor, unlabeled clothing, unlabeled grooming products, soiled toilet seats, and a pool of emesis was on the floor. Resident #19's catheter bag was touching the floor, and intravenous (IV) tubing was hanging from the pump and touching the floor in a resident's room. These practices affected four (4) rooms of twenty (20) rooms observed and had the potential to affect more than an isolated number of residents. Affected room identifiers: Shower room-100 Hall, Shower room-200 Hall, #209, #211. Resident identifier: #19. Facility census: 54. Findings include: a) Observations of the facility on 06/02/14 revealed the following infection control concerns: 1) Shower room-100 Hall - The shower room was observed on 06/02/14 at 10:40 a.m. The toilet seat was covered in a brown, foul smelling, substance. There were two gloves, inside-out, on the floor. An unlabeled container of body wash was on the shower chair. 2) Shower room-200 Hall - The shower room was observed on 06/02/14 at 10:50 a.m. There was emesis with intact food (noodles) on the floor. A wet soiled washcloth was on the floor. A pair of unlabeled shoes were in a wheelchair. Employee #32 (Registered Nurse-RN) witnessed both shower rooms on 06/02/14 at 10:50 a.m. The RN stated the shower rooms should never be in their current condition and she would see they were attended to immediately. 3) room [ROOM NUMBER] - An observation of this room was completed on 06/02/14 at 10:55 a.m. Resident #19's catheter bag was touching the floor. Employee #48(Licensed Practical Nurse-LPN) verified this observation. The LPN stated the catheter bags should never be on the floor. 4) room [ROOM NUMBER] - The room was observed on 06/02/14 at 11:00 a.m. The Intravenous (IV) pump in the room had tubing touching the floor. Employee #48(LPN) verified this observation. The employee stated the tubing should never be on the floor and discarded it.",2018-02-01
6534,ANSTED CENTER,515133,PO BOX 400,ANSTED,WV,25812,2014-06-04,514,D,0,1,N2BW11,"Based on medical record review, resident interview, staff interview, and facility policy review, the facility failed to ensure the accuracy of the medical record for one (1) of one (1) resident reviewed for notification of room change. Resident identifier: #77. Facility census: 54. Findings Include: a) Resident #77 While conducting the Stage 1 interview with Resident #77, she stated she had not been informed she would have a new roommate. On 05/28/14 at 11:00 a.m., registered nurse, Employee #35 stated on 05/24/14 she had informed Resident #77 she would receive a new roommate sometime within the next twenty-four hours. Resident #77 received a new roommate on 05/25/14. Review of the medical records found no evidence Resident #77 or Resident #77's medical power of attorney (MPOA) were informed Resident #77 would receive a new roommate. After interviewing Employee #35, she stated she would create a late entry note concerning notification of a new roommate. The note was created. The facility policy and procedures concerning room transfers was received from Employee #35 at 9:50 a.m. on 06/04/14. Section 10 included, All room changes will be documented in a progress note or on the Room Transfer Form and placed in the medical records.",2018-02-01
7929,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,253,E,0,1,K06L11,"Based on observation and staff interview, the facility failed to provide a sanitary, orderly and comfortable environment in resident rooms and facility hallways. Hallways and resident rooms were in poor repair. There were scuffed floors, scraped walls with peeling paint, damaged furniture and curtains were incorrectly hung, creating an unkempt appearance. This had the potential to affect more than a minimal number of residents who resided in the facility. Facility Census: 60. Findings include: a) During the initial tour of the facility, on 12/03/12, at approximately 11:30 a.m., and with further observations during the course of the survey, it was noted the facility hallways and resident rooms were in need of numerous repairs. The following maintenance/housekeeping issues were observed: 1) The hallways on both units in resident living areas were observed to have dark marks running along the walls. 2) Numerous interior and exterior door jams, both entrance doors and bathroom doors, were observed with damage beginning at the floor and proceeding up to approximately eighteen (18) inches from the floor. This damage included multiple dark scratched areas and chipped paint. 3) Dark marks were observed on the floor covering under several resident beds. 4) Many of the walls behind resident beds had peeling drywall and chipped paint. Also, the paint on the walls in resident bathrooms had dark marks. 5) A few bathrooms had towel rack hooks (no rack attached) remaining on the wall and painted over. This left dangerously sharp protrusions from the walls. 6) Many bathroom floor coverings had separation cracks along the walls, making the area unable to be thoroughly cleaned. 7) A large portion of the baseboards in both the resident rooms and resident bathrooms were soiled. 8) Curtains in many resident rooms were not correctly fastened to the rod causing the curtain to hang in an unkempt manner. b) During observation of specific rooms the following were observed: 1) Room 100 had a wall lighting fixture hanging to one side. 2) Room 104 had two (2) resident dressers in poor repair. On each dresser, the two (2) bottom drawers were dented, chipped, and scratched until they did not have the same appearance as the top drawers. 3) Room 203 had a hole in the bottom of the bathroom door. 4) Room 210 had the baseboard missing just inside the entrance door. c) The facility administrator was interviewed on 12/11/12, at approximately 10:00 a.m. She stated the facility was aware of the maintenance/housekeeping issues and was working toward completing needed repairs. When particular areas of concern were brought to the administrator's attention, such as dry wall in need of repair, she stated the facility was in the beginning of the process of getting bids for supplies needed to make repairs.",2016-12-01
7930,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,279,E,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, resident interview, family interview, and staff interview, the facility failed to develop a comprehensive care plan for five (5) of thirty-one (31) Stage 2 sample residents. The facility failed to develop a care plan related to the use of antidepressants, prevention of contractures, care of pressure ulcers, measurement of urinary output, nausea and vomiting, [MEDICAL CONDITION] reflux disease, and insulin usage. Resident identifiers: #61, #10, #26, #19, and #62. Facility census: 60. Findings include: a) Resident #61 Review of the medical record identified Resident #61 received the antidepressant [MEDICATION NAME] for a [DIAGNOSES REDACTED]. No interventions were in place for staff to follow related to the use of this medication. Additionally, no side effects were identified for staff awareness and observation. This information was confirmed with Employee #36, the director of nursing (DON), on 12/06/12 at 9:14 a.m. b) Resident #62 Medical record review found the resident had a Foley catheter for a [DIAGNOSES REDACTED]. Further review of the physician's orders [REDACTED]. Review of the resident's current care plan, dated 03/30/12, found a problem: Resident requires indwelling Foley catheter due to: stage 3/4 pressure ulcer and quadriparesis at risk for infection. The care plan failed to address measuring urinary output on each shift. The DON was interviewed on 12/06/12 at 10:00 a.m. She acknowledged the care plan did not address the physician's orders [REDACTED]. c) Resident #10 During a stage one interview, on 12/03/12 at 2:53 p.m., the nurse stated Resident #10 had a contracture of the left hand. She related the resident did not wear a splint, and did not receive range of motion services. An observation and interview was completed with Resident #10 on 12/04/12 at 2:18 p.m. Observation of the resident revealed a contracture of her left hand. She stated services were not performed to maintain range of motion. She stated her contracture was related to a stroke. Review of the medical record, on 12/05/12, revealed the care plan did not address the contracture of the resident's left hand. The minimum data set (MDS) was reviewed on 12/11/12 at 9:00 a.m. The assessment dated [DATE] indicated the resident had an impairment of one of her upper extremities. Section S of the comprehensive assessment, dated April 2012, indicated the resident had a contracture of the left hand. Employee #57, a certified nursing assistant and family member, was interviewed on 12/11/12 at 10:10 a.m. She stated the resident did not receive therapy for the contracture of her left hand. The resident was interviewed on 12/11/12 at 10:15 a.m. She was alert, verbal and coherent. She said her hand had been this way since my stroke. She again stated the staff did not provide range of motion, nor encourage her to perform range of motion on her left hand. Employee #35, a registered nurse care plan coordinator (RN CPC), was interviewed on 12/11/12 at approximately 3:00 p.m. She acknowledged the contracture was not addressed on the care plan. Employee #31, another RN CPC, was also interviewed on 12/11/12 at approximately 3:00 p.m. She stated the MDS identified the contracture of Resident #10's left hand on the April 2012 assessment. She indicated the contracture was not addressed because it did not pull to section V for care area assessment. Employee #31 agreed the contracture of the the resident's left hand was not addressed in the care plan. d) Resident #26 Medical record review, completed on 12/10/12, indicated Resident #26 received seventeen (17) units of [MEDICATION NAME] subcutaneously daily. Additionally, the resident received [MEDICATION NAME] R solution 100 units/ml subcutaneously with sliding scale coverage four (4) times daily. The care plan was was reviewed on 12/05/12 and again on 12/11/12. It did not identify clinically significant adverse effects related to [DIAGNOSES REDACTED] or [MEDICAL CONDITION] that facility staff should be prepared to recognize. physician's orders [REDACTED]. The care plan was reviewed on 12/06/12 and again on 12/11/12. It did not address nausea, vomiting or the use of [MEDICATION NAME]. A physicians order review, completed on 12/06/12, indicated Resident #26 was started on [MEDICATION NAME] 20 mg by mouth twice daily related to [MEDICAL CONDITION] reflux disease (GERD). Review of the care plan on 12/06/12 and again 12/11/12 revealed [MEDICAL CONDITION] the use of [MEDICATION NAME] was addressed. . e) Resident #19 On 12/10/12 at 11:51 a.m., a medical record review was conducted revealing Resident #19 had a treatment order for wound vac therapy (delivery of negative pressure to promote healing) for a pressure ulcer to the coccyx area. This treatment continued until the resident was discharged to the hospital on [DATE]. On 12/10/12, the most recent care plan for this resident was reviewed. It indicated the last revision by the facility was completed on 08/08/12. This care plan made no mention of the implementation of the wound vac treatment for [REDACTED]. During an interview, on 12/11/12 at 1:21 p.m., with the DON, she confirmed the care plan did not address the wound vac therapy as treatment for [REDACTED].",2016-12-01
7931,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,280,E,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, policy review, and staff interview, the facility failed to revise the care plans for four (4) of thirty-one (31) Stage 2 sample residents. The care plans were not revised to reflect changes in lift transfer status, contact precautions, wound status, dental needs, feeding tube removal, and constipation. Resident identifiers: #26, #47, #54 and #66. Facility census: 60 Findings include: a) Resident #26 1) The current care plan was reviewed on 12/04/12 at 3:19 p.m., and again on 12/12/12 at 10:00 a.m. It indicated Resident #26 had decreased ability to self perform activities of daily living (ADLs) secondary to recent hospitalization for repair of a right [MEDICAL CONDITION]. Additionally, the care plan noted she required the assistance of a Total Lift 450/FB/Green sling to get out of bed. Review of the medical record, on 12/05/12, at approximately 4:00 p.m., revealed a physician's orders [REDACTED]. Employee #53, a nursing assistant (NA), was interviewed on 12/06/12 at 8:40 a.m. She stated the resident utilized the sit to stand lift for transfers. The care plan had not been revised to accurately reflect the resident's current needs. 2) A physician's orders [REDACTED]. Additionally, an order dated 12/01/12 was written to maintain contact precautions. The care plan did not contain this information Employee #7, a registered nurse (RN), was interviewed on 12/11/12. She stated the care plan was updated daily utilizing the pink slips from the physician's telephone orders. She reviewed the medical record and compared it to the care plan. The employee acknowledged the care plan did not accurately reflect the physician's orders [REDACTED]. 3) The residents's skin integrity report was reviewed on 12/05/1/2 at approximately 2:00 p.m. The resident had a pressure ulcer which was noted as a deep tissue injury (DTI). The information on the skin integrity reports, dated 11/23/12 and 11/30/12, noted a scab in the center of the wound. The facility's skin integrity policy was reviewed on 12/05/12. It described that a pressure ulcer in which the base was covered with eschar was an unstageable wound. Employee #36, the director of nurses (DON), evaluated the wound bed on 12/11/12. She stated the wound bed was a scab. When questioned regarding the stage of the wound, she replied, unstageable. The care plan, reviewed on 12/11/12 at approximately 4:00 p.m., noted the right heel pressure area as deep tissue injury. b) Resident #47 Review of the resident's current care plan, dated 04/07/12, found a problem, Resident exhibits or is at risk for oral health or dental care problems as evidenced by missing and carious teeth that resident and POA (power of attorney) do not wish to address at this time. At risk for pain, infection, and chewing difficulty. Resident frequently refuses to allow staff to brush his teeth and refuses to assist with brushing his own teeth. (residents MPOA (medical power of attorney) aware and also unsuccessful at getting resident to go to dentist or brush his teeth.) Resident will refuse to go to dentist for oral consult. Further review of the medical record revealed a nurse's note, dated 09/04/12, stating, Resident has a broken tooth located on the bottom side, dental appointment made. Review of the medical record found the resident went to the dentist on 09/11/12 for treatment, and had a tooth extracted. He returned to the facility with a proposed detailed treatment plan from the dentist which included seven (7) extractions and six (6) fillings. The care plan did not include this information. Employee #34, an administrative registered nurse, and Employee #79, a registered nurse, were interviewed at 9:00 a.m. on 12/06/12 regarding the failure to update the care plan with the resident's visit to the dentist and the proposed dental plan. Employee #79 agreed the facility should have updated the care plan after the dental appointment on 09/11/12. c) Resident #54 Review of the medical record found the resident had removed her own feeding tube on 11/22/12. The nurse contacted the resident's physician upon discovery of the removal of the feeding tube. The resident's physician did not want the resident to be transferred out of the facility for replacement of her feeding tube. At the time of survey, the resident did not have a feeding tube. The resident was eating well, taking medications by mouth and there were no plans for placement of a feeding tube. Review of the current plan of care, dated, 04/07/11, found a problem: Resident has an enteral feeding tube to assist with meeting nutritional needs as needed The DON was interviewed on 12/05/12 at 2:00 p.m. She agreed the care plan was not updated after removal of the feeding tube. d) Resident #66 Medical record review identified Resident #66 had a [DIAGNOSES REDACTED]. Medical record review revealed the resident was ordered iron 325 mg to be given twice a day on 09/16/12. The administration of iron further complicates constipation. No interventions were put in place to relieve the resident of constipation. The facility continued the use of the standing orders. The care plan was not updated with goals and interventions regarding the resident's problems with constipation. Review of the medical record identified the attending physician ordered, on 10/23/12, Senna S two (2) capsules to be given at bedtime. The care plan was not revised to reflect this new intervention. Although the resident had continuing constipation, the care had no revisions had for constipation since 01/19/12. On 12/06/12 at 1:30 p.m., the DON confirmed the facility failed to revise the care plan for this resident. .",2016-12-01
7932,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,282,D,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement the care plan related to behavioral flow sheets for one (1) of thirty-one (31) Stage 2 sample residents. Resident identifier: #57. Facility census: 60. Findings Include: a) Resident #57 Review of the resident's current care plan, with a review date of 10/31/12, revealed the problem, Resident at risk for complications related to the use of [MEDICAL CONDITION] drugs antianxiety and antidepressant medications, with a goal of complete behavior monitoring flow sheet. Review of physician orders [REDACTED]. On 12/06/12, at approximately 3:00 p.m., the director of nursing, Employee #36, was interviewed concerning the completion of behavioral flow sheets for Resident #57. Employee #36 stated a behavioral flow sheet was not completed when a resident is on antidepressants. A behavioral flow sheet was not implemented and/or completed as directed by the current care plan.",2016-12-01
7933,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,309,E,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, staff interview, and policy and procedure review, the facility failed to follow their protocol/policy and procedure for care of a resident receiving [MEDICAL TREATMENT]; failed to follow physician's orders to monitor the urinary output for two (2) residents with indwelling catheters; and failed to provide individualized interventions for one (1) resident with continuing constipation. This was identified for four (4) of thirty-one (31) stage 2 residents during the quality indicator survey (QIS). Resident identifiers: #45, #62, #66, and #74. Facility census: 60. Findings include: a) Resident #45 Medical record review found the resident was diagnosed with [REDACTED]. Review of the facility policy and procedure for [MEDICAL TREATMENT]: Graft and Fistula Care, dated 11/01/07, found the following: .Perform routine observation of access site daily and on return from [MEDICAL TREATMENT] center. Observe for signs of complications including, but not limited to: 2.1 Pain, swelling, redness, odor, hardness, bleeding or drainage at site: 2.2 Color, temperature of extremity; 2.3 Presence of pain or numbness in extremity; 2.4 Pulses distal to access site (fistula/graft); 2.5 Presence of bruit on auscultation with stethoscope; 2.6 Presence of thrill (vibration) by palpation The director of nursing (DON) was interviewed at 12:15 p.m. on 12/10/12. She stated the facility used a weekly [MEDICAL TREATMENT] evaluation tool to document the resident's condition before and after return from the [MEDICAL TREATMENT] center. The weekly [MEDICAL TREATMENT] evaluation tool was reviewed for the months of October and November 2012. Documentation (pre and post [MEDICAL TREATMENT]) was missing from the tool on the following days: 10/06/12 no pre-[MEDICAL TREATMENT] documentation, 10/11/12 no post-[MEDICAL TREATMENT] documentation, 10/18/12 no pre-[MEDICAL TREATMENT] documentation, 10/20/12 no documentation pre or post [MEDICAL TREATMENT], 10/23/12 no post-[MEDICAL TREATMENT] documentation, 10/25/12 no post-[MEDICAL TREATMENT] documentation, 10/27/12 no post-[MEDICAL TREATMENT] documentation 10/29/12 no pre-[MEDICAL TREATMENT] documentation 11/13/12 no post-[MEDICAL TREATMENT] documentation 11/17/12 no post-[MEDICAL TREATMENT] documentation 11/27/12 no post-[MEDICAL TREATMENT] documentation 11/29/12 no post-[MEDICAL TREATMENT] documentation Further review of the [MEDICAL TREATMENT] tool found the facility did not document the resident's pre or post [MEDICAL TREATMENT] weight on any of her [MEDICAL TREATMENT] days in October and November. The DON stated, during an interview on 12/10/12 at 12:15 p.m., the [MEDICAL TREATMENT] center was responsible for weighting the resident before and after [MEDICAL TREATMENT] and the [MEDICAL TREATMENT] center was to communicate the weights to the facility. The DON was unable to find any documentation the resident's pre and post [MEDICAL TREATMENT] weights, obtained at the [MEDICAL TREATMENT] center, were communicated to the facility. The DON also acknowledged the facility failed to complete the pre and post [MEDICAL TREATMENT] assessment of the resident on the above dates. b) Resident #62 Medical record review found the resident was re-admitted to the facility on [DATE] with an indwelling Foley catheter. There was a physician's order to measure the resident's urinary output on every shift. Further review of the facility's form for output shift totals for November 2012 found the urinary output was not completed on the following shifts for the following days: 11/01/12, 7-3 shift 11/03/12, 11-7 shift 11/04/12, 3-11 shift 11/06/12, 3-11 shift 11/09/12, 7-3 shift 11/11/12, 3-11 shift 11/13/12, 7-3 and 3-11 shifts 11/15/12, 11-7 and 3-11 shifts 11/16/12, 11-7, 7-3, and 3-11 shifts 11/17/12, 3-11 shift 11/19/12, 11-7 and 3-11 shifts 11/20/12, 11-7 and 3-11 shifts 11/21/12, 11-7 shift 11/27/12, 11-7 and 3-11 shifts 11/29/12, 11-7 and 3-11 shifts An interview with the DON, at 3:30 p.m. on 12/05/12, verified the facility failed to consistently measure the resident's urinary output as directed by the physician's order. c) Resident #66 Medical record review identified Resident #66 had a [DIAGNOSES REDACTED]. According to the medical record, the resident had frequently been given medications from the facility's standing orders for constipation. Medical record review also identified the resident was ordered iron 325 mg to be given twice a day beginning on 09/16/12. The administration of iron further complicates constipation. No other interventions were put in place to relieve the resident of constipation. The facility continued the use of the standing orders for constipation. There was no evidence the physician was notified of any issues of constipation with this resident. The following laxatives were given to the resident for constipation. This included giving an invasive suppository on a regular basis. -- 08/25/12 - Milk of Magnesia given -- 09/15/12 - [MEDICATION NAME] suppository given -- 09/26/12 - Milk of Magnesia -- 10/03/12 - Milk of Magnesia -- 10/09/12 - Milk of Magnesia -- 10/13/12 - Milk of Magnesia Review of the medical record identified an order dated 10/23/12, by the attending physician, for the resident to have Senna S two (2) capsules at bedtime. During an interview with the DON, on 12/06/12 at 1:30 p.m., it was confirmed this resident was never ordered routine medication for constipation until 10/23/12. Further review of the medical record identified the Senna was ineffective, and the facility continued to use the standing orders. No evidence was found the facility identified the Senna was not working and/or notified the physician. The facility continued to administer laxatives, including the invasive suppository, as a regular routine for constipation: -- 10/24/12 - Milk of Magnesia -- 11/06/12 - Milk of Magnesia -- 11/07/12 - [MEDICATION NAME] suppository -- 11/11/12 - Milk of magnesia -- 11/12/12 - [MEDICATION NAME] suppository -- 11/16/12 - Milk of magnesia -- 11/17/12 - [MEDICATION NAME] suppository -- 11/20/12 - Milk of magnesia -- 11/21/12 - [MEDICATION NAME] suppository -- 11/24/12 - Milk of magnesia -- 11/25/12 - [MEDICATION NAME] suppository -- 11/28/12 - Milk of Magnesia -- 11/29/12 - [MEDICATION NAME] suppository -- 12/02/12 - Milk of Magnesia -- 12/03/12 - [MEDICATION NAME] suppository -- 12/07/12 - Milk of Magnesia -- 12/08/12 - [MEDICATION NAME] suppository On 12/06/12 at 1:30 p.m., the DON confirmed the facility failed to recognize the resident was receiving multiple doses of laxatives on a regular basis from the standing orders. Further confirmation was obtained from the physician, with the DON present, during a conference call on 12/11/12 at 2:30 p.m. He confirmed there was a failure to recognize the resident was receiving multiple doses of medication for constipation. He stated the facility now had a plan in place for additional interventions for constipation for this resident. d) Resident #74 Review of the medical record for Resident #74 identified he was admitted to the facility with a Foley catheter and a gastrostomy ([DEVICE]). The physician's orders indicated this resident was to have input and output monitored related to the Foley catheter and the [DEVICE]. Intake and output records were reviewed. This revealed the facility failed to consistently monitor the intake and output of both the [DEVICE] and Foley catheter. Review of the physician's orders identified the physician ordered the facility to monitor output for twenty-four (24) hours on 07/24/12 related to the resident pulling the catheter out. Further review of the output record for 07/24/12 identified the facility failed to monitor the output for 07/24/12 according to the physician order. The intake/output two (2) week shift totals for 07/24/12 was blank for this day. On 12/11/12 at 10:45 a.m., the DON confirmed the facility did not monitor the output according to the physician's order. Further review of the intake/output two (2) week shift totals for the months of July 2012 and August 2012 identified the facility also failed to consistently monitor the intake for the [DEVICE] for the months of July 2012 and August 2012. On 12/11/12 at 10:45 a.m., the DON confirmed the facility failed to monitor the intake as ordered.",2016-12-01
7934,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,318,D,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, resident observation, staff interview, and record review, the facility failed to ensure one (1) of three (3) residents sampled for range of motion during Stage two (2) of the survey, received appropriate treatment to increase range of motion or prevent further decrease in range of motion. A resident with a contracture did not receive range of motion services. Resident identifier: #10. Facility census: 60. Findings include: a) Resident #10 A stage one staff interview, on 12/03/12 at 2:53 p.m., revealed Resident #10 had a contracture of the left hand. Additionally, it revealed the resident did not wear a splint, nor receive range of motion services. An observation and interview was completed with Resident #10 on 12/04/12 at 2:18 p.m. Observation revealed a contracture of her left hand. She stated services were not performed to maintain range of motion. The resident stated her contracture was related to a stroke. Review of the medical record, on 12/05/12, revealed a [DIAGNOSES REDACTED]. The minimum data set (MDS) was reviewed on 12/11/12 at 9:00 a.m. The assessment, dated 10/03/12, indicated the resident had an impairment of one (1) of her upper extremities. Section S of the comprehensive assessment, dated 04/02/12, indicated the resident had a contracture of the left hand. Employee #57 (a nursing assistant) was interviewed on 12/11/12 at 10:10 a.m. She stated the resident did not receive therapy or range of motion services for the contracture of her left hand. The resident was interviewed again on 12/11/12 at 10:15 a.m. She was alert, verbal and coherent. She said her hand had been this way since my stroke. She again stated the staff did not provide range of motion, nor encourage her to perform range of motion of her left hand. Employee #35, a registered nurse care plan coordinator (RN CPC) was interviewed on 12/11/12 at 3:00 p.m. She acknowledged the contracture was not addressed on the care plan and no routine preventive treatment was provided to prevent worsening of the contracture. Employee #31, another RN CPC, was also interviewed on 12/11/12 at 3:00 p.m. She stated the MDS identified the contracture of Resident #10's left hand on the April 2012 assessment. She indicated the contracture was not addressed because it did not pull to Section V for care area assessment. Employee #31 agreed the contracture of the the resident's left hand was not addressed in the care plan, nor addressed in the care area assessment. treatment of [REDACTED]. There was no evidence the resident received any services to increase range of motion and/or to prevent further decrease in range of motion.",2016-12-01
7935,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,329,D,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the facility failed to ensure two (2) of ten (10) sample residents' medication regimens were free from unnecessary medications. One (1) resident received multiple doses of laxatives, including invasive laxatives, and the antipsychotic [MEDICATION NAME] with no indication for its use. Another resident received [MEDICATION NAME] without adequate indication for its use and without an attempt at a gradual dose reduction. Resident identifiers: #66 and #11. Facility census: 60. Findings include: a) Resident #66 (Laxatives) 1) Medical record review identified Resident #66 had a diagnoses of constipation. Further review of the medical record identified this resident did not have an individualized medication regimen for the constipation. According to the medical record, the resident had frequently been given medications from the facility's standing orders for constipation. No interventions, other than frequent use of laxatives, were put in place to relieve the resident of constipation. The facility continued the use of the standing orders for constipation. There was no evidence the physician was notified of any issues of constipation with this resident. The following laxatives were given to the resident for constipation. This included giving an invasive suppository on a regular basis. -- 08/25/12 - Milk of Magnesia given -- 09/15/12 - [MEDICATION NAME] suppository given -- 09/26/12 - Milk of Magnesia -- 10/03/12 - Milk of Magnesia -- 10/09/12 - Milk of Magnesia -- 10/13/12 - Milk of Magnesia Review of the medical record identified an order dated 10/23/12, by the attending physician, for the resident to have Senna S two (2) capsules at bedtime. During an interview with the DON, on 12/06/12 at 1:30 p.m., it was confirmed this resident was never ordered routine medication for constipation until 10/23/12. Further review of the medical record identified the Senna was ineffective, and the facility continued to use the standing orders. No evidence was found the facility identified the Senna was not working and/or notified the physician. The facility continued to administer laxatives, including the invasive suppository, as a regular routine for constipation: -- 10/24/12 - Milk of Magnesia -- 11/06/12 - Milk of Magnesia -- 11/07/12 - [MEDICATION NAME] suppository -- 11/11/12 - Milk of magnesia -- 11/12/12 - [MEDICATION NAME] suppository -- 11/16/12 - Milk of magnesia -- 11/17/12 - [MEDICATION NAME] suppository -- 11/20/12 - Milk of magnesia -- 11/21/12 - [MEDICATION NAME] suppository -- 11/24/12 - Milk of magnesia -- 11/25/12 - [MEDICATION NAME] suppository -- 11/28/12 - Milk of Magnesia -- 11/29/12 - [MEDICATION NAME] suppository -- 12/02/12 - Milk of Magnesia -- 12/03/12 - [MEDICATION NAME] suppository -- 12/07/12 - Milk of Magnesia -- 12/08/12 - [MEDICATION NAME] suppository On 12/06/12 at 1:30 p.m., the DON confirmed the facility failed to recognize the resident was receiving multiple doses of laxatives on a regular basis from the standing orders. Further confirmation was obtained from the physician, with the DON present, during a conference call on 12/11/12 at 2:30 p.m. He confirmed there was a failure to recognize the resident was receiving multiple doses of medication for constipation. He stated the facility now had a plan in place for additional interventions for constipation for this resident. 2) Resident #66 ([MEDICATION NAME]) Review of the medical record identified Resident #66 was given [MEDICATION NAME], an anti-psychotic medication, for dementia with behaviors. During an interview with the DON on, 12/11/12 at 1:45 p.m., it was identified the medication was ordered related to the resident pacing, wandering, and walking with a shuffling gait. An interview was conducted with the attending physician and the DON, via a telephone conference on 12/11/12 at 2:30 p.m. The physician stated the medication was given so Resident #66 would not get up without asking for assistance, possibly resulting in a fall. The attending physician stated the [MEDICATION NAME] would keep the resident from pacing and shuffling, and he felt this out weighed the risk of her falling. Review of the medical record revealed no behaviors which warranted the use of [MEDICATION NAME]. On 12/11/12 at 1:45 p.m., the DON provided the following documentation which she referred to as behaviors: 02/09/12 -- Gait shuffled and unsteady 02/11/12 -- Resident pacing x 3 from bed 02/11/12 -- Has unsteady shuffling gait 02/19/12 -- shuffle gait 02/22/12 -- has a shuffle gait, staff reminds resident to take steps 02/22/12 -- up x 5 ambulating from room to hallway 02/22/12 -- resident has a shuffle gait 02/23/12 -- has a steady shuffle gait 02/23/12 -- less shuffling noted Medical record review found no current documentation related to the resident wandering and walking with a shuffling gait. Resident #66 used a wheelchair for ambulation and sometimes used a walker. She also required assistance of one (1) with a gait bait. On 10/03/12, Employee #35 (a registered nurse) updated the care plan for Resident #66. It stated, . resident rarely leaves room and she does not wander. This finding was confirmed with the DON on 12/11/12 at 1:10 p.m. Review of the care plan for the use of [MEDICAL CONDITION] medications found no evidence [MEDICATION NAME] was used for shuffling gait or wandering. In addition, there was no evidence of any behaviors which warranted the use of an antipsychotic medication. The care plan for [MEDICAL CONDITION] medications was last updated on 01/19/12. Further review of the care plan found no interventions had been added to the care plan since 01/19/12. Review of the social service assessments, dated 04/25/12 and 08/01/12, identified the resident had not experienced any of the following behaviors: -- hitting others -- kicking -- pushing -- scratching -- grabbing -- abusing others sexually -- threatening others -- pacing This resident was given the antipsychotic medication, [MEDICATION NAME], without adequate indications for its use. b) Resident #11 Medical record review, on 12/10/12, revealed a pharmacy consultation report dated 10/17/12. The report stated Resident #11 had a physician's orders [REDACTED]. As of 12/10/12, the order dated 09/11/12 had not been initiated. The resident was currently receiving the medication two (2) times daily. When interviewed, on 12/10/12, regarding why the ordered medication decrease had not been instituted, the DON stated the medical power of attorney for Resident #11 refused to allow suggested medication reductions. The pharmacy consultant report, dated 10/17/12, was signed by the DON. It stated, Family had been contacted regarding change & had not given consent for medication change. The report did not indicate which family member made that decision and/or if that person was the resident's medical decision maker. Additionally, there was no evidence the medical decision maker had been made aware of the pros and cons related to continuing the use of [MEDICAL CONDITION] medication for this ninety-one (91) year old resident. Further review of the medical record revealed [MEDICATION NAME] XR 150 mg twice a day was prescribed for Resident #11 for [MEDICAL CONDITION] not elsewhere classified and dementia conditions classified elsewhere (CCE) with behavioral disturbances. There was no [DIAGNOSES REDACTED]. The minimum data set (MDS) with an assessment reference date (ARD) of 11/12/12, Section E, revealed Resident #11 did not display potential indicators of [MEDICAL CONDITION] and did not display: a) physical behavioral symptoms directed toward others, b) verbal behavioral symptoms directed toward others c) other behavioral symptoms not directed toward others. In addition, behavioral flow sheets for the months of October and November 2012 revealed Resident #11 did not display any of the above behaviors. An inquiry was made regarding what behaviors the resident displayed that would necessitate this medication. Nursing note documentation, beginning in 2008, was provided by the DON. It indicated the resident once exhibited acting out behaviors, such as striking out at other residents. However, no recent behavior problems were noted. The only recent negative behavior was noted on an incident report dated 06/21/12. It stated Resident #11 hit another resident while in the dining room. Further review of a change in condition nursing note dated 06/20/12, near the time of the incident, revealed Resident #11 was positive for [MEDICATION NAME] cloacae (a urinary tract infection). Urinary tract infections can cause behavior changes in the elderly population. The resident did not display behaviors that would necessitate the continued use of the [MEDICATION NAME]. The use of this medication, without adequate indication for its use and/or without evidence attempts at a dose reduction was clinically contraindicated, resulted in this resident being provided an unnecessary medication.",2016-12-01
7936,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,428,D,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, physician interview, and staff interview, the pharmacist failed to recognize and report the excessive use of laxatives for one (1) of ten (10) sample residents. Resident #66 received frequent doses of laxatives, including invasive laxatives, for constipation. The facility was using standing orders for this resident's constipation, and did not implement an individualized plan for the resident who had frequent episodes of constipation. The pharmacist did not identify this irregularity. Additionally, the pharmacist did not identify and report the resident was prescribed an iron supplement which contributes to constipation. Resident identifier: #66. Facility census: 60. Findings include: a) Resident #66 Medical record review identified Resident #66 had a [DIAGNOSES REDACTED]. According to the medical record, the resident had frequently been given medications from the facility's standing orders for constipation. No interventions, other than frequent use of laxatives, were put in place to relieve the resident of constipation. The facility continued the use of the standing orders for constipation. There was no evidence the physician was notified of any issues of constipation with this resident. The following laxatives were given to the resident for constipation. This included giving an invasive suppository on a regular basis. -- 08/25/12 - Milk of Magnesia given -- 09/15/12 - Dulcolax suppository given -- 09/26/12 - Milk of Magnesia -- 10/03/12 - Milk of Magnesia -- 10/09/12 - Milk of Magnesia -- 10/13/12 - Milk of Magnesia Review of the medical record identified an order dated 10/23/12, by the attending physician, for the resident to have Senna S two (2) capsules at bedtime. Further review of the medical record identified the Senna was ineffective, and the facility continued to use the standing orders. No evidence was found the facility identified the Senna was not working and/or notified the physician. The facility continued to administer laxatives, including the invasive suppository, as a routine intervention for the resident's constipation: -- 10/24/12 - Milk of Magnesia -- 11/06/12 - Milk of Magnesia -- 11/07/12 - Dulcolax suppository -- 11/11/12 - Milk of magnesia -- 11/12/12 - Dulcolax suppository -- 11/16/12 - Milk of magnesia -- 11/17/12 - Dulcolax suppository -- 11/20/12 - Milk of magnesia -- 11/21/12 - Dulcolax suppository -- 11/24/12 - Milk of magnesia -- 11/25/12 - Dulcolax suppository -- 11/28/12 - Milk of Magnesia -- 11/29/12 - Dulcolax suppository -- 12/02/12 - Milk of Magnesia -- 12/03/12 - Dulcolax suppository -- 12/07/12 - Milk of Magnesia -- 12/08/12 - Dulcolax suppository On 12/06/12 at 1:30 p.m., the DON confirmed the facility failed to recognize the resident was receiving multiple doses of laxatives on a regular basis from the standing orders. Further confirmation was obtained from the physician, with the DON present, during a conference call on 12/11/12 at 2:30 p.m. He confirmed there was a failure to recognize the resident was receiving multiple doses of medication for constipation. He stated the facility now had a plan in place for additional interventions for constipation for this resident. Review of the medication regimen review conducted by the pharmacist identified the pharmacist had reviewed the medications for Resident #66 every month since January 2012. The pharmacist had not identified the excessive use of laxatives, and had not identified the use of the standing orders for constipation had not decreased after the implementation of a routine dose of Senna at bedtime. Additionally, on 09/16/12, the physician ordered iron 325 mg to be given twice a day. The administration of iron further complicates constipation. The pharmacist did not identify and report this medication had a potential to increase the resident's problems with constipation.",2016-12-01
7937,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,431,E,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of manufacturer's package inserts, review of CDC guidelines for storage of flu vaccine, and staff interview, the facility failed to maintain and/or label medications in a manner which ensured safe usage. Observation of the medication room found expired stock medications, and observation of medication Cart Two revealed open medications with no date to indicate when the medications were opened. These practices had the potential to affect more than a limited number of residents. Facility census: 60. Findings include: a) Observation of the medication storage area, on [DATE] at 11:06 a.m., found three (3) bottles of 325 mg aspirin with an expiration date of ,[DATE]. This finding was confirmed with Employee #36 (director of nursing) at the time of discovery. b) Inspection of medication Cart Two, with Employee #69, a licensed practical nurse, revealed an open vial of Lantus insulin which contained no date indicating when it was opened, to ensure the medication was still safe for use. (The manufacturer's package insert includes Open vials, whether or not refrigerated, must be used within 28 days after the first use. They must be discarded if not used within 28 days . Also, Cart Two contained an open vial of influenza vaccine. It had no date indicating when it was opened. This finding was also confirmed with Employee #36 at 11:06 a.m. (The Centers for Disease Control guidelines note multidose vials should be discarded after 28 days.)",2016-12-01
7938,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,441,E,0,1,K06L11,"**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 maintain an infection control program to help prevent the development and spread of infection. Linens were handled improperly, gloves were not changed during a dressing change, floor coverings in bathrooms were cracked, gloves were not worn in an isolation room when removing a water pitcher from the room, and a potentially contaminated water pitcher was placed on a cart with other items. This affected one (1) resident and had the potential to affect more than a limited number of residents. Resident identifier: #26. Facility census: 60 Findings Include: a) An ice pass was observed on 12/03/12 at 11:35 a.m. Employee #45, a nursing assistant (NA), touched the inside surface of the ice receptacle with her fingers. An interview with Employee #36, the director of nursing (DON), on 12/03/12, confirmed this was an infection control issue. b) During observations on 12/03/12, the floor covering was noted to be cracked in three (3) of eight (8) bathrooms observed. This impeded proper sanitation. During an interview with Employee #5 (executive director), on 12/06/12, she acknowledged the floor covering was in disrepair and would be replaced. c) Employee #45 (NA) was again observed passing ice on 12/05/12 at 1:30 p.m. She removed two (2) pitchers from the room of a resident on contact precautions related to a [DIAGNOSES REDACTED]. Additionally, she did not wear gloves when touching the water pitchers, and she did not wash her hands. Employee #76, a licensed practical nurse (LPN) was present and acknowledged the nursing assistant violated acceptable infection control practices. d) Resident #26 This resident's wound dressing change was observed on 12/05/12 at 1:45 p.m. Resident #26 was on contact precautions related to clostridium difficile. Employee #76 (LPN) removed the soiled dressing, cleansed the wound, and applied a new dressing without changing gloves and washing her hands. Additionally, a clean barrier was not placed on the over-the-bed table for the bag utilized to contain the dressing items which had been stored in the cart. The bag for soiled items was placed at the foot of the bed, which potentially contaminated the outside of the bag. The bag was not placed inside a clean bag before removing it from the room, creating another opportunity for cross contamination. An interview with the DON, on 12/05/12 at 2:15 p.m., verified the nurse did not maintain aseptic technique according to the facility's policy :14.1 dressing: Aseptic policy. e) Observation on 12/10/12 at 11:25 a.m., revealed Employee #42 making a bed. Linens for use on bed A were lying on bed B. A resident was assigned to each bed. Use of the linens lying on bed B for bed A created a potential for cross contamination of infectious organisms. This failure to follow infection control measures was confirmed with Employee #76 (licensed practical nurse), who was in the room at the time of the observation. .",2016-12-01
7939,ANSTED CENTER,515133,96 TYREE STREET,ANSTED,WV,25812,2012-12-11,514,D,0,1,K06L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure medical records were accurate for two (2) residents. Nursing staff continued to document a resident was receiving medication via her gastrostomy tube ([DEVICE]), after the tube had been removed. Another resident was ordered medications to be administered via [DEVICE], but the order read administer via mouth. Resident identifiers: #54 and #74. Facility census: 60. Finding include: a) Resident #54 Medical record review found this resident removed her [DEVICE] on 11/22/12. Nursing staff continued to document, on the Medication Administration Record [REDACTED]. A clarification order was written on 11/26/12 for the resident to receive her medications by mouth. An interview with the director of nursing, on 12/05/12 at 2:00 p.m., confirmed the facility should have clarified the route the resident's medications would be administered on 11/22/12 when the [DEVICE] was removed. b) Resident #74 Review of the medical record for Resident #74 identified this resident was admitted to the facility on [DATE]. Resident #74 had an order in place to be NPO (nothing by mouth). Review of the Medication Administration Record [REDACTED]. The nurses signed the Medication Administration Record [REDACTED]. During an interview with Employee #36 (director of nursing) on 12/11/12, at 10:45 a.m., it was verified the medications were given via the [DEVICE], but the Medication Administration Record [REDACTED]. It was confirmed the Medication Administration Record [REDACTED].",2016-12-01
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
9653,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,279,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan for the use of an antipsychotic medication for one (1) of twenty-eight (28) Stage II sample residents. Resident #56 was prescribed [MEDICATION NAME] on 10/11/10 for a [DIAGNOSES REDACTED].#56. The facility must develop a comprehensive care plan for each resident that includes measurable objectives to meet a residents medical, nursing, mental, and psychosocial needs that are identified in the comprehensive assessment. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Review of the medical record revealed no comprehensive care plan to identify the use of the [MEDICATION NAME]. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11.",2015-10-01
9654,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,281,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of Criteria for Determining Scope of Practice for Licensed Nurses and Guidelines for Determining Acts That May Be Delegated or Assigned by Licensed Nurses (Delegation Guidelines), the facility failed to provide services in accordance with accepted standards of clinical practice. Review of Resident #26's medication administration records (MARs) revealed the orders that offered the option to the licensed practical nurse (LPN) of administering by mouth or via enteral tube, with no parameters to guide the LPN's decision-making process. This practice allows an LPN to act outside his or her scope of practice as established by the WV Boards of Nursing. Resident identifier: #26. Facility census: 59. Findings include: a) Review of Resident #26's MARs found orders that offered the option to the LPNs of administering medications by mouth or through the resident's enteral feeding tube, with no parameters to guide a LPN's decision-making process. Review of the Delegation Guidelines, revised by the West Virginia Board of Examiners for Registered Professional Nurses and the West Virginia State Board of Examiners for Licensed Practical Nurses on 06/17/09, found the following information on Page 13: ACTIVITIES THAT MAY BE DELEGATED TO THE LPN Activities appropriate for delegation to the LPN should be those that, after careful evaluation by the supervising RN, are expected to contain only one option. That is, the LPN is expected to be able to proceed through the established steps or an activity without encountering an unexpected response or reaction and competence in performance of the activity has been demonstrated. ACTIVITIES THAT SHOULD NOT BE DELEGATED TO THE LPN Activities that are NOT appropriate for delegation to an LPN are those that are likely to present decision making options, requiring in depth assessment and professional judgment in determining the next step to take as the provider proceeds through the steps of the activity. During an interview with an LPN (Employee #56) on 01/27/11 at 2:34 p.m., Employee #56 stated, He can only take his medication thru his [DEVICE]. This information was related to the facility's director of nursing (DON - Employee #15) at 11:00 a.m. on 02/01/11.",2015-10-01
9655,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,329,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of twenty-eight (28) Stage II sample residents was free from unnecessary drugs. Resident #56 was ordered [MEDICATION NAME] (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. [MEDICATION NAME] is an antipsychotic used to treat [MEDICAL CONDITION], schizo-affective disorder, and mood disorders (e.g. mania, [MEDICAL CONDITION] disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of [MEDICATION NAME] to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the [MEDICATION NAME] was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, the clinical condition being treated did not meet the criteria for the use of [MEDICATION NAME]. The physician responded to the pharmacist's recommendation by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11.",2015-10-01
9656,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,425,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide medications as prescribed for one (1) of twenty-eight (28) Stage II sample residents. Resident #80 was admitted to the facility on [DATE], for rehabilitation after surgery requiring cemented left triathlon total knee arthroplasty. A dose of routine pain medication was not given as prescribed at 9:00 a.m. on 10/30/10. According to staff interview, the medication was not available for administration at that time. Resident identifier: #80. Facility census: 59. Findings include: a) Resident #80 Record review revealed Resident #80 was admitted to the facility on [DATE], for rehabilitation services related to a total knee replacement. The resident was ordered Morphine Sulfate ER 30 mg twice a day for pain related to the knee surgery. Review of the Medication Administration Record [REDACTED]. During a telephone interview with a nurse (Employee #16) confirmed the medication was not available to give to the resident that morning. She further stated she called the physician at approximately 10:30 a.m. on 10/30/10 to report the medication was not in the facility. The physician discontinued the morphine at this time. During an interview with the director of nursing (DON - Employee #15 on 02/01/11 at 12:35 p.m., she verified the medication was not available for administration to Resident #80 at that time.",2015-10-01
9657,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,428,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed, for one (1) of twenty-eight (28) Stage II sample residents, to ensure the physician acted upon reports of irregularities in a resident's medication regimen. Resident #56 was ordered Risperdal (an antipsychotic medication) on 10/11/10 for the [DIAGNOSES REDACTED].#56 had an appropriate [DIAGNOSES REDACTED]. The consulting pharmacist identified and reported to the facility and the physician that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. Resident identifier: #56. Facility census: 59. Findings include: a) Resident #56 Record review revealed Resident #56 was sent to a psychiatrist on 10/11/10 for evaluation. The psychiatrist diagnosed the resident with depression, rule out dementia, and anxiety. Risperdal is an antipsychotic used to treat schizophrenia, schizo-affective disorder, and mood disorders (e.g. mania, bipolar disorder, and depression with psychotic features). Resident #56 was prescribed 0.5 mg of Risperdal to be given at bedtime on 10/11/10. Resident #56 returned to the psychiatrist on 12/06/10, and the Risperdal was increased to 1 mg at bedtime. Further review of the medical record found the consulting pharmacist had reported to the physician and the facility, on 10/18/10, that Resident #56 did not have an appropriate [DIAGNOSES REDACTED]. In addition, he reported the clinical condition being treated did not meet the criteria for the use of Risperdal. The physician responded to the pharmacist's recommendation on 11/05/10, by stating, Still (symbol for 'with') repetitive health related complaints. GDR (gradual dose recommendation) not appropriate. However, the physician did not provide documentation of the clinical rationale for using this antipsychotic medication to treat this behavior (repetitive health complaints). This information was brought to the attention of the director of nursing (DON - Employee #15) at 1:30 p.m. on 01/31/11.",2015-10-01
9658,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2011-02-02,441,D,0,1,860Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of the facility's listing of residents with histories of Methicillin-resistant Staphylococcus aureus (MRSA), observation, and staff interview, the facility failed to assure Resident #49 was appropriately cohorted with roommates to prevent the potential spread of infection. The facility placed Resident #74 in a four-bed ward with Resident #49, when Resident #74 was receiving treatment for [REDACTED].#74 at risk of contracting a MRSA infection to her open wounds. This deficient practice affected one (1) of twenty-eight (28) residents in the Stage II sample. Resident identifiers: #74. Facility census: 59. Findings include: a) Resident #74 Review of the facility's listing of residents with a history of MRSA infection, on 01/27/11, found Resident #49 had a history of [REDACTED]. Review of Resident #74's medical record found she was receiving treatment for [REDACTED]. Observation of the facility found Resident #74 had been placed in the same room as Resident #49. When this issue was brought to the facility's attention, Resident #49 was moved to a private room. An interview with the director of nursing (DON - Employee #15), on the afternoon of 02/02/11, revealed Resident #49 was moved to a private room for infection control purposes on 01/31/11.",2015-10-01
11225,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-09-24,250,E,1,0,0T3Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, a review of the facility's policy and procedure titled ""4.1 Social Service Progress Notes"" and staff interview, the facility failed to assure the residents were assessed for unmet social service needs. The facility did not complete assessments to identify the need for social services and to promote actions by staff to enhance each resident's individuality. There was no evidence the facility assessed the current mental / psychological status, education level, prior living arrangements, and pertinent events affecting each resident's condition to assure his/her social service needs were met. This was found for four (4) of nine (9) sampled residents. Resident identifiers: #58, #38, #23, and #19. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58, a [AGE] year old female, was admitted to the facility from the hospital with chronic health problems. Prior to admission, her husband had been caring for her at home. The physician determined this resident had the capacity to understand and make her own health care decisions. It was also noted that her diabetes was very unstable and required close monitoring and frequent changes to her insulin. She experienced blood pressure elevations, and her medications were frequently changed. She received dialysis three (3) times a week. She had severe peripheral vascular disease (PVD), and her skin condition was very poor. She was admitted to the facility with extensive skin treatments. Further documentation in her record revealed she verbalized frequently that she wanted to go home. There was evidence in the progress notes that the Medicaid aged and disabled waiver program had told the facility the resident was a danger to herself due to her unsafe medical decisions. There was also evidence that the adult protective service worker (APS) had stated the husband could not care for her at home. Review of the resident's social history found no assessment to determine the social service needs of this resident either upon admission or throughout the entire time the resident was in the facility. b) Resident #38 Record review revealed this resident was admitted on [DATE]. As of 09/24/09, there was no evidence this resident was assessed to identify any unmet social service needs. In fact, there was nothing entered in the social service section of his medical record. Documentation noted the physician had determined he possessed the capacity to understand and make informed health care decision, and his care plan stated the facility's social service staff would assess the resident's response to the new situation. There was no evidence in the record to reflect this had occurred. During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. c) Resident #23 Record review revealed this [AGE] year old resident with multiple medical complications [REDACTED]. The social worker completed a mini-mental examination of the resident on 09/10/09. This was the only social service-related assessment completed for this resident. There was nothing to address his illness and his lifestyle prior to his hospitalization . During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. d) Resident #19 Record review revealed this resident was admitted to the facility on [DATE]. There was no evidence of a social service assessment completed since her admission. Her social service note simply stated, ""Resident was admitted on [DATE] from the hospital for rehab to home care."" This resident received dialysis three (3) times a week and had multiple chronic medical issues. Her care plan, established on 08/19/09, stated that social services would assess the resident's response to the new situation. There was no evidence to reflect this had occurred or that an assessment was completed to identify any unmet social service needs. During an interview on 09/24/09 at 10:45 a.m., the social worker confirmed she had not completed an assessment for this resident as required by facility policy to assess his needs. e) The corporate nurse, when asked for a copy of the facility's social service policy and procedures, produced a policy titled ""4.1 Social Services Progress Notes"" with an effective date of 06/01/01. Review of this policy revealed the facility's social service staff was to complete a progress note / check-off form which correlated with the interdisciplinary care plan (ICP) upon admission and at least quarterly. The social service staff was also to document the significant events occurring between quarterly reviews (i.e. change in health, discharge, transfer, hospitalization ) with interim notes. The policy stated the customer's progress and status was be assessed by an interview with the customer, observation, and medical record review. The concurrent note should include the following information: - 3.1 Review of the customers rights (first note, annually and as needed) - 3.2 Events leading to the admission (first note only) - 3.3 Adjustment issues (first note and ongoing) - 3.4 Functional ability and rehabilitation potential (first note and ongoing) - 3.5 Medical / cognitive / emotional status (first note and ongoing) - 3.6 Family / responsible party involvement (first note and ongoing) - 3.7 Psychotropic drug use (first note and ongoing) - 3.8 Advance directives (first note and as needed) - 3.9 Center therapeutic recreation involvement (first note and ongoing) - 3.10 Social Service intervention / involvement (first note and ongoing) - 3.11 Goals and approaches implemented by Social Service staff (first note and ongoing) - 3.12 Input from customer / responsible party (first note and ongoing) - 3.13 Discharge potential (first note and ongoing) - 3.14 Progress toward goals and effectiveness of approaches (ongoing) - 3.15 Level of peer interaction (first note and ongoing) - 3.16 Addressing of concerns / issues / interventions (first note and ongoing) - 3.17 Restraint assessment and use (first note and ongoing) - 3.18 Sensory concerns (first note and ongoing) - 3.19 Mood state and behavior problems / psychosocial adjustment (first note and ongoing) - 3.20 Personal needs / pay status (first note and ongoing) - 3.21 Referrals and use of outside resources (first note and ongoing) - 3.22 Functional abilities (first note and ongoing) - 3.23 Federal / state specific requirements - 3.24 Others as appropriate. According to the policy, whether writing in narrative format or using the check-off form, social service staff was to complete a progress note upon admission, quarterly, as needed, and at the time of the annual ICP meeting. The check-off note covered most of the above mentioned areas; however, in the comment section (on the reverse side of the form), one was able to add additional narrative information. This documentation was observed in some of the residents' records, but it was not found for these four (4) residents. .",2014-07-01
11226,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-09-24,309,D,1,0,0T3Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to assure staff routinely monitored the bowel habits of residents and monitored / recorded interventions that were initiated in accordance with the physician's standing orders when a resident was experiencing problems with constipation. According to the medical record, Resident #58 went five (5) days without a bowel movement before interventions were initiated in accordance with the standing orders. Resident #31 went four (4) days without a bowel movement, and the physician's standing orders were not initiated until Day 5, contrary to the established bowel protocol. The bowel protocol was not followed for two (2) of nine (9) sampled residents. Resident identifiers: #58 and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, the resident's bowel records indicated there was no bowel movements from 05/15/09 through 05/19/09. The facility's bowel protocol was requested for review. The director of nursing (DON) provided a ""standing orders template"" and indicated the interventions listed under the section titled ""constipation"" were what they do if there is not a bowel movement. According to these orders for constipation, if there is no bowel movement in three (3) days, staff is to give the resident one (1) dose of 30 cc Milk of Magnesia or [MEDICATION NAME] tablets. If there is still no bowel movement on Day 4, staff is to give the resident a [MEDICATION NAME] rectal suppository PRN x 1. If there is no bowel movement on Day 5, staff is to give the resident a Fleets enema. If there are no results from the enema, staff is to call the doctor for further orders. These standing orders were not followed for Resident #58. According to the resident's nurse aide flow sheet, she did not have a bowel movement on 05/15/09, 05/16/09, 05/17/09, 05/18/09, and 05/19/09. On Day 6, staff administered a [MEDICATION NAME] rectal suppository. The facility did not follow the standing physician orders [REDACTED]. The DON, when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She confirmed these bowel sheets were not part of the resident's medical record, and they did not keep these sheets for more than a couple of months, after which they threw them away. (The facility did not have bowel sheets for the time frame being reviewed for this resident.) The DON did confirm that, based on the data available in the medical record, there was no evidence the resident had a bowel movement on the days in question. The DON also confirmed the standing orders were not followed as written. b) Resident #31 Record review revealed the resident's September 2009 nurse aide flow sheet was not complete related to her bowel elimination. (See citation at F514.) A separate bowel sheet (not maintained on the resident's medical record) revealed she had gone four (4) days without a bowel movement, and the physician's standing orders were not initiated until Day 5. As of the date of this review (09/24/09), Resident #31's record indicated her last bowel movement occurred on 09/19/09. She received Milk of Magnesia on 09/22/09, which was three (3) days after her last bowel movement. She still did not have a bowel movement and on the next day (09/23/09), she was given Senakot four (4) tablets. The DON, when questioned about the bowel movements for this resident on 09/24/09 at 4:00 p.m., verified the facility's standing orders had not been properly implemented and there was no documentation to explain why these orders were not followed. According to the DON, the resident should have received a rectal suppository on Day 4 and a Fleets enema on Day 5. According to the medical record, the resident had no bowel movement for four (4) consecutive days and was on Day 5 without a bowel movement when this surveyor identified this issue. .",2014-07-01
11227,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-09-24,514,D,1,0,0T3Z11,"Based on a review of the medical record and staff interview, the facility failed to assure residents' bowel records were complete and accurate. Without accurate records of a resident's bowel movements, the facility could not assure interventions were initiated when needed to prevent complications. Residents' bowel movements were recorded on two (2) different places, and a comparison of these forms revealed the documentation did not match. The nurses kept track of each resident's bowel movements on a bowel sheet which was not part of the resident's medical record, and the information on the bowel sheets did not match the records kept by the nursing assistants which was part of the medical record. Bowel elimination records were not complete for two (2) of nine (9) sampled residents. Resident #58, and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, documentation of the resident's bowel movements on the nurse aide flow sheet indicated there were no bowel movements from 05/15/09 through 05/19/09. During this five (5) day period, the form for recording bowel movements had blanks, and it could not be determined whether the resident had a bowel movement or not. The director of nursing (DON), when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She confirmed these bowel sheets were not part of the resident's medical record, and they did not keep these sheets for more than a couple of months, after which they threw them away. The facility did not have bowel sheets for the time frame being reviewed for this resident, and the information in her medical record related to bowel elimination was incomplete. b) Resident #31 Record review revealed the resident's September 2009 nurse aide flow sheet was not complete related to her bowel elimination. There were many blank days where the bowel movements for those days were not recorded in the record. The DON, when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She also confirmed the nurse aide flow sheet did have a lot of blanks on it, and it was difficult to determined when the resident actually had a bowel movement.",2014-07-01
11228,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-11-13,323,E,1,0,0T3Z12,"Based on observation, staff interview, and record review, the facility failed to assure the resident environment remained as free of accident hazards as is possible. Staff disabled the alarming system and propped the front door open at 10:00 p.m. on the night of 11/10/09. This deficient practice placed all residents at risk should an unauthorized individual with nefarious intentions enter the facility undetected, or a confused resident not equipped with a WanderGuard device exit the facility undetected. Facility census: 54. Findings include: a) Upon arrival at the facility to conduct an unannounced follow-up survey at 10:00 p.m. on 11/10/09, observation found the front interior entrance doors were propped open with the use of the survey results notebook. When the door was pulled opened, no alarm sounded to alert staff members that someone had either entered or exited the facility. When inquiry was made of the registered nurse (RN) supervisor as to the practice of propping open the front door and turning off the alarm, the RN stated it was shift change and they did not want to have to keep getting up, unlocking the door, and turning off the alarm to let in staff members. An interview was conducted with the administrator at 12:15 a.m. on 11/11/09. He stated the doors were to be locked and the alarm turned on prior to the 9:00 p.m. medication pass. He stated the alarm that had been turned off was recently installed to provide added security, and it required a key to turn it on and off. He stated it was not acceptable for the doors to be propped open and the alarm disabled. The administrator was asked, on the afternoon of 11/11/09, to assist in a test of the front door under the conditions found upon entrance to the facility. The interior front doors were propped open with the survey results notebook, and the administrator utilized a key to disable the alarm. Observation and performance testing found the facility could be entered and exited without audible detection. A WanderGuard device was obtained and tested with the door propped open and the alarm turned off. The WanderGuard system did sound an alarm. .",2014-07-01
11229,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-11-13,492,E,1,0,0T3Z12,"Based on record review, review of West Virginia State Codes 9-6-1(2) and 9-6-11(c) and West Virginia Administrative Rule 19CSR3-14.1bb, and staff interview, the facility failed to assure allegations of abuse and/or neglect were reported to the State or Regional Ombudsman and the West Virginia State Board of Examiners for Licensed Practical Nurses (LPNs) in accordance with State law for two (2) of two (2) allegations reviewed. This deficient practice involved two (2) of five (5) sampled residents and had the potential to affect more than an isolated number of facility residents. Resident identifiers: #40 and #33. Facility census: 54. Findings include: a) Resident #40 Review of facility documents found that. on 08/11/09 at 8:30 a.m., a licensed practical nurse (LPN) was informed that Resident #40 was complaining of not feeling well and experiencing pain. A registered nurse (RN) reported to the social worker the LPN made the statement that the resident ""needs a pillow over her face"". Review of West Virginia State Code 9-6-1(2) found the definition of abuse to be the following: ""Abuse means the infliction or threat to inflict physical pain or injury on or the imprisonment of any incapacitated adult or facility resident."" Further review of West Virginia State Code 9-6-11(c) found the following language: ""If the person who is alleged to be abused or neglected is a resident of a nursing home or other residential facility, a copy of the report shall also be filed with the state or regional ombudsman and the administrator of the nursing home or facility"". Review of West Virginia Administrative Rule 19CSR3-14.1.bb found that the RN who reported the abusive statement was required to report this act of abuse to the West Virginia State Board of Examiners for Licensed Practical Nurses. The following language was found: ""14.1.bb. failed to report through proper channels a violation of any applicable state law or rule, any applicable federal law or regulation or the incompetent, unethical, illegal, or impaired practice of another person who provided health care; ..."" An interview with the director of nursing (DON), who is a registered nurse, on the afternoon of 11/11/09 revealed the LPN who made the abusive statement had not been reported to the LPN Licensing Board as required. An interview with the social worker, on 11/13/09 at 4:30 p.m., revealed this allegation of abuse was not reported to the state or regional ombudsman as required by State law. b) Resident #33 Review of facility documents found that, on the evening shift on 10/13/09, family members alleged staff left the resident incontinent of urine for one (1) hour to one-and-one-half hour (1.5) after being informed the resident was in need of care. Further review found no evidence this allegation of neglect was reported to the state or regional ombudsman as required by State law. An interview with the social worker, on 11/13/09 at 4:30 p.m., confirmed no report of this allegation of neglect was sent to the state or regional ombudsman as required. .",2014-07-01
11230,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-11-13,371,D,1,0,0T3Z12,"Based on random observation, the facility failed to assure food was distributed under sanitary conditions for residents electing to remain in their rooms for meals. Facility census: 54. Findings include: a) Random observations of the noon meal food service, on 11/13/09 at 12:10 p.m., found meal trays intended for residents to eat in their rooms were stacked on shelves on an open cart. Further observation found two (2) trays on the cart for the 200 hallway and one (1) tray on the cart for the 100 hallway were not adequately covered to prevent contamination of the residents' food. Closer inspection of the pellet system noted, in each case, the top lid had slid off the bottom portion of the pellet system, exposing a small bowl and other food items to potential contamination. .",2014-07-01
11231,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2010-11-05,225,D,1,0,OEKS11,". Based on review of facility documents, medical record review, and staff interview,the facility failed to assure one (1) of three (3) allegations of abuse / neglect was reported immediately to State officials in accordance with State law, and failed to thoroughly investigate this allegation of abuse / neglect. This deficient practice affected one (1) of three (3) sampled residents. Resident identifier: #60. Facility census: 57. Findings include: a) Resident #60 Review of facility documents found that, on 07/03/10, Resident #60 sustained lacerations to his face which required transport to an acute care facility for placement of thirty-four (34) stiches to close the wounds. Review of the medical record found a nursing note, written at 11:41 a.m. on 07/02/10, stating, ""Nursing assistant pushing resident in w/c (wheelchair) when his foot dropped onto floor, he fell forward onto floor, laceration noted above and below left eye, resident remained alert at all times, denies pain anywhere else, able to move all other extremities... pressure applied as well as ice pack, notified POA (power of attorney) and (name of physician), transferred to (name of hospital) for eval (evaluation) and treatment."" Review of facility documentation found a summary of the incident signed by the director of nursing (DON - Employee #14). Review of the summary found that, on 07/11/10, the resident's spouse spoke with the facility's physician concerning the 07/03/10 incident. The summary documented that the spouse stated, ""This is neglect and abuse and you know it."" Review of other facility documents found the facility did not report the incident until 07/21/10. Further review found that, following the delayed reporting, the facility did not complete a thorough investigation to determine if the resident's injuries were the result of abuse / neglect on the part of the staff member who was transporting the resident. The facility determined which employees were working at the time of the incident, but did not interview or collect statements from them. The facility also failed to collect a statement from the resident, who was alert and oriented and was determined to have capacity to make his own decisions. .",2014-07-01
11232,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2010-11-05,323,E,1,0,OEKS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on review of facility documents, observations, and staff interview, the facility failed to assure nursing staff followed the practice instituted by the facility for the safe transport of residents in wheelchairs, after a male resident was injured after falling forward out of his wheelchair while being transported. Additionally, the facility failed to assure licensed nursing staff secured a stocked medication cart against unauthorized access prior to leaving the cart unattended in the resident hallway. These practices affected four (4) randomly observed residents being transported in wheelchairs without leg rests, and had the potential to affect any wandering and/or confused resident with the potential to access the medications in the cart. Resident identifiers: #46, #28, #54, and #17. Facility census: 52. Findings include: a) Residents #46, #18, #54, and #17 Review of facility documents found a male resident (Resident #60) fell forward from his wheelchair while being propelled by staff on 07/03/10. The resident sustained [REDACTED]. On 07/05/10, the facility instituted a practice to ensure leg rests were placed on the wheelchairs of all residents before being transported more that three (3) feet by staff. Random observations of the evening meal on 11/05/10, between the hours of 4:15 p.m. and 4:45 p.m., found four (4) staff members transporting four (4) residents in wheelchairs without leg rests. 1. Resident #36 A nursing assistant (Employee #19) transported Resident #46 from her room to the dining room at 4:05 p.m.; the resident was seated in a wheelchair with no leg rests. 2. Resident #28 The activities director (Employee #11) transported Resident #28 from her room to the dining room at 4:22 p.m.; the resident was seated in a wheelchair with no leg rests. 3. Resident #54 A nursing assistant (Employee #7) transported Resident #54 from her room to the dining room at 4:30 p.m.; the resident was seated in a wheelchair with no leg rests. 4. Resident #17 A nursing assistant (Employee #13) transported Resident #17 from her room to the dining room at 4:45 p.m.; the resident was seated in a wheelchair with no leg rests. The director of nursing (DON - Employee #14) was informed of the observation. She agreed these residents should have had leg rests on their wheelchairs. When asked where staff would locate leg rests to place on the residents' wheelchairs, she directed this surveyor to a locked storage building in the back of the facility. -- b) Random observations of the resident environment found an unlocked medication cart sitting in the 200 hallway of the facility. Observations found no nurse was present in the vicinity of the unlocked cart. A registered nurse (RN - Employee #2) was asked to come with this surveyor to determine if the medications in the cart were accessible. Testing found the drawers of the cart containing medications were unlocked and easily opened.",2014-07-01
11233,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,241,E,0,1,Q61611,"Based on an observation and staff interview, the facility did not provide care in an environment that maintained or enhanced dignity and respect for five (5) residents of a random observation. Residents were parked in wheelchairs and a reclining chair, lined up against a wall in the hallway awaiting transportation to the dining room for a meal. Resident identifiers: #1, #2, #14, #27, and #34. Facility census: 55. Findings include: a) On the mid-morning of 07/28/09, observation revealed five (5) residents (#1, #2, #14, #27, and #34) lined up in the 100 hallway. Four (4) residents were sitting in wheelchairs, and one (1) resident was in a reclining chair. The residents were parked in a line against the right side of the hallway. Interview with the activity director, on 07/28/09 at 12:00 p.m., revealed the nursing staff brought the residents out of their rooms and placed them in the hallway to await transportation to the dining room. She could not give a reason for why they were lined up against the wall. Interview with the director of nursing, on 07/28/09 at 4:00 p.m., revealed the residents should not be placed in a line in the hallway. She confirmed the residents were waiting to go to lunch. .",2014-07-01
11234,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,309,D,1,0,Q61612,"Based on a review of the medical record and staff interview, the facility failed to assure residents' bowel records were complete and accurate. Without accurate records of a resident's bowel movements, the facility could not assure interventions were initiated when needed to prevent complications. Residents' bowel movements were recorded on two (2) different places, and a comparison of these forms revealed the documentation did not match. The nurses kept track of each resident's bowel movements on a bowel sheet which was not part of the resident's medical record, and the information on the bowel sheets did not match the records kept by the nursing assistants which was part of the medical record. Bowel elimination records were not complete for two (2) of nine (9) sampled residents. Resident #58, and #31. Facility census: 57. Findings include: a) Resident #58 Record review revealed Resident #58 had experienced problems with constipation. In May 2009, documentation of the resident's bowel movements on the nurse aide flow sheet indicated there were no bowel movements from 05/15/09 through 05/19/09. During this five (5) day period, the form for recording bowel movements had blanks, and it could not be determined whether the resident had a bowel movement or not. The director of nursing (DON), when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She confirmed these bowel sheets were not part of the resident's medical record, and they did not keep these sheets for more than a couple of months, after which they threw them away. The facility did not have bowel sheets for the time frame being reviewed for this resident, and the information in her medical record related to bowel elimination was incomplete. b) Resident #31 Record review revealed the resident's September 2009 nurse aide flow sheet was not complete related to her bowel elimination. There were many blank days where the bowel movements for those days were not recorded in the record. The DON, when interviewed on 09/22/09 at 3:00 p.m., reported the information recorded on the nurse aide flow sheet in the resident's medical record was not used to monitor the resident's bowel elimination patterns. Instead, the nurses used information recorded on a separate bowel sheet to guide the administration of the standing orders for constipation. She also confirmed the nurse aide flow sheet did have a lot of blanks on it, and it was difficult to determined when the resident actually had a bowel movement.",2014-07-01
11235,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,314,G,1,0,Q61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to monitor / assess and obtain timely medical intervention for one (1) of twelve (12) residents of the sample selection with an infected pressure sore. Resident #40 exhibited sign and symptoms of an infected pressure sore and did not receive physician intervention; the resident was taken to a [MEDICAL TREATMENT] center for treatment and was immediately transferred by the [MEDICAL TREATMENT] center to the hospital [MEDICAL CONDITION]. Facility census: 55. Findings include: a) Resident #40 A review of Resident #40's medical record revealed a skin integrity report, dated 07/02/09, which indicated the resident's Stage IV pressure ulcer had purulent drainage. There was no corresponding entry in the nursing notes to reflect the resident's physician was notified of this finding. Nursing notes, dated 07/03/09 at 7:15 p.m., recorded, ""New order noted for Tylenol 650 mg every 4 hours for elevated temp. Temperature 100.8 F."" At 10:30 p.m., the resident's temperature was 99 F. On 07/06/09 at 6:30 a.m., a nursing note indicated, ""Temperature 99.2 F and 99.4 F. ... Ambulance to take resident to [MEDICAL TREATMENT] treatment per family's request. Family wants resident to have an extra treatment."" Later on 07/06/09 (no time given), a nursing note recorded, ""[MEDICAL TREATMENT] center called to inform me resident's temp was 102 F and the resident is septic and unresponsive and was sent to the hospital."" A discharge summary from the hospital, dated 07/08/09, revealed a [DIAGNOSES REDACTED]. The resident's pressure ulcer was necrotic and was debrided at the hospital. A wound VAC was placed, and resident was given [MEDICATION NAME] (an antibiotic) after [MEDICAL TREATMENT] and received two (2) units of blood. In an interview on 07/28/09 at 2:00 p.m., the director of nursing related that the nurses had called the physician on 07/02/09, when the resident was exhibiting purulent drainage and an elevated temperature. A review of the nursing notes for 07/02/09 found no evidence to reflect the physician was notified of purulent drainage in the pressure sore. .",2014-07-01
11236,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,310,D,0,1,Q61611,"Based on an observation and staff interview, the facility did not ensure one (1) resident of a random sample received proper positioning for meals to promote self-feeding. Observation found Resident #34 in the dining area attempting to drink a cup of coffee before the lunch meal was served. The resident was seated at a table that was elevated to the level of the resident's chin. Facility census 55. Findings include: a) Resident #34 Observation, on 07/28/09 at 12:30 p.m., found Resident #34 seated at a table in the dining room. The table was elevated to the level of the resident's chin. The resident was attempting to drink a cup of coffee that was served before lunch. The resident was stating to a staff person that she wanted to be placed at another table, because the table was too high. Interview with the activity director, on 07/28/09 at 12:35 p.m., revealed the resident was able to help herself with drinking and eating, and she related that the table at that height helped her to move the cup over to her mouth. Interview with the director of nursing, on 07/28/09 at 12:37 p.m., revealed the resident needed to be placed at a table with an appropriate height; she acknowledged the table at which Resident #34 was seated was too high for her to eat and drink and the resident had requested to be moved to another table. .",2014-07-01
11237,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,371,F,0,1,Q61611,"Based on record review and staff interview, the facility failed to serve food under sanitary conditions; dietary staff failed to routinely monitor the concentration of sanitizing solution and the water temperatures of the wash and final rinse cycles in the dishwasher, to ensure they were maintained within the proper range to effectively sanitize dishware between uses. This practice has the potential to affect all residents in the facility. Facility census: 55. Findings include: a) On 07/28/09, review of the facility's July 2009 dishwasher temperature and sanitizer check log revealed places to record the concentration of sanitizing solution, wash temperature, and final rinse temperature of the dishwasher three (3) times each day, for the breakfast, lunch, and dinner meals; each of these items would have been measured and recorded eighty-one (81) times from 07/01/09 through 07/27/09. The concentration of the sanitizing solution was omitted forty-six (46) times, with no recordings during any meal time on 07/02/09, 07/12/09, 07/13/09, and 07/14/09, and no recordings during any lunch meal on any day. The wash and final rinse temperatures were omitted a total of forty-eight (48) times, with most of the omissions occurring during the dinner meal. During an interview on 07/28/09 at 11:30 a.m., the dietary manager agreed the dietary staff needed to keep up better with temperature and chemical recordings in the washing area. She noted the kitchen had a lot of temporary employees working in the kitchen lately and she would re-inservice them. Readings taken at this time, of the sanitizer concentration and the water temperatures of the wash and final rinse cycles, were found to be acceptable limits. .",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
11239,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,280,D,0,1,Q61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for two (2) of twelve (12) sampled residents when they exhibited signs and symptoms of infections. Facility census: 55. Findings include: a) Resident #17 On 07/16/09, Resident #17 tested positive for [MEDICAL CONDITIONS] Toxins A and B. Subsequently, the physician ordered an antibiotic ([MEDICATION NAME] 500 mg) every eight (8) hours for ten (10) days beginning 07/16/09. During an interview on 07/29/09 at 10:30 a.m., the director of nursing (DON) reported contact precautions were no longer employed, since Resident #17 no longer had diarrhea and had completed the ten (10) day course of antibiotics. A copy of the care plan, produced by the DON on 07/28/09 at approximately 5:00 p.m., contained no mention of the [MEDICAL CONDITION] [DIAGNOSES REDACTED]. The lack of care planning for this issue was shared with the DON during the exit conference with no additional information provided. b) Resident #40 Record review revealed a skin integrity report, dated 07/02/09, which documented a Stage IV pressure ulcer with purulent drainage. On 07/03/09, a nursing note recorded Resident #40 had an elevated temperature which was treated with Tylenol 650 mg. The interdisciplinary care team did not revise the resident's care plan when signs and symptoms of an active infection were exhibited. The resident was subsequently hospitalized for [REDACTED]. .",2014-07-01
11240,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,225,D,0,1,Q61611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to screen applicants for employment for findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Employee identifiers: #84 and #88. Facility census: 55. Findings include: a) Employees #84 and #88 On 07/28/09, review of the personnel files of a random sample of five (5) recently hired employees and five (5) employees hired greater than one (1) year ago revealed a registered nurse (Employee #84) was hired in May 2009, and a licensed practical nurse (Employee #88) was hired in June 2009. Neither employee's personnel file contained evidence to reflect the facility had screened them for adverse findings on the WV Nursing Assistant Abuse Registry. Facility staff in charge of personnel files and health records was unable to produce evidence of checks against the Abuse Registry for these two (2) employees. After surveyor inquiry, staff ran checks of these employees on the afternoon 07/28/09; no adverse results were found, and copies of these checks were placed in the employees' records for future reference. .",2014-07-01
11241,ANSTED CENTER,515133,"106 TYREE STREET OPERATIONS, LLC /P.O DRAWER 400",ANSTED,WV,25812,2009-08-05,465,C,0,1,Q61611,"Based on observations and testing conducted on 08/04/09 and 08/05/09, the facility failed to provide a safe, functional environment with respect to resident room toilets. Facility census: 58. Findings include: a) Observations and testing, conducted on 08/04/09 and 08/05/09, found the facility had installed toilet seat risers to the low type toilets in an effort to accommodate the needs of the resident in each resident rest room. The seat risers were found to move and be unstable, creating a potential fall hazard for the residents. .",2014-07-01
10082,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,502,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory tests were completed as ordered by the physician. This was true for four (4) of twenty-three (23) sampled residents' records. The facility failed to obtain laboratory test timely for Residents #45, #92, #115, and #108. Facility census: 112. Findings include: a) Resident #45 Resident #45's medical record, when reviewed on 03/02/10 at 8:45 a.m., revealed a [AGE] year old female with a history of [MEDICAL CONDITION]. Review of the current physician orders, dated 02/17/10, revealed the physician ordered a complete blood count (CBC) test monthly. Review of the laboratory test results revealed the CBC test was not done as ordered. The registered nurse (RN - Employee #25), when interviewed on 03/02/10 at 9:30 a.m., confirmed the CBC was not completed for 02/2010 as ordered. b) Resident #92 Resident #92's medical record, when reviewed on 03/02/10 at 10:00 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the current physician orders [REDACTED]. Review of the laboratory test results revealed the [MEDICAL CONDITION] level was not done as ordered. Employee #25, when interviewed on 03/2/10 at 3:30 p.m., confirmed the [MEDICAL CONDITION] test was not completed as ordered. c) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week at a [MEDICAL TREATMENT] center. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record noted there was no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2 ), when interviewed on 03/04/10 at 11:37 a.m., acknowledged the PTT test were not completed as ordered by the physician. d) Resident #108 Review of Resident #108's medical record, on 03/02/10, revealed a physician's orders [REDACTED]. Further review of the medical record revealed the most recent lab results for BUN, creatinine, and electrolytes were dated 08/31/09. There were no lab results for November 2009 or February 2010. Interview with medical records staff (Employee #12), on 03/02/10, revealed there were no lab results for the BUN, creatinine, or electrolytes found on the resident's thinned chart. These findings were reported to the DON on 03/02/10 at approximately 11:15 a.m.; subsequently, she stated she would contact the physician and request an order for [REDACTED].) .",2015-07-01
10083,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,507,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure laboratory reports were maintained on file in each resident's medical record. This was true for two (2) of twenty-three (23) sampled residents. Resident identifiers: #115 and #28. Facility census: 112. Findings include: a) Resident #115 Resident #115's closed medical record, when reviewed on 03/04/10 at 10:00 a.m., revealed a [AGE] year old resident with end-stage [MEDICAL CONDITION]. The resident received outpatient [MEDICAL TREATMENT] treatments three (3) times a week. Review of the 08/17/09 physician orders [REDACTED]. Review of the medical record found no hematological laboratory results in the medical record. The director of nurses (DON - Employee #2), when interviewed on 03/04/10 at 11:40 a.m., acknowledged the laboratory tests were not maintained in the medical record as required. b) Resident #25 Record review revealed, on 06/02/09, the physician ordered a complete blood count (CBC) each month, magnesium every three (3) months, fasting blood sugars each month, and magnesium and transferrin every three (3) months. Review of the medical record only found a lab report for a CBC dated 08/31/09; reports for fasting blood sugars dated 10/29/09, 12/17/09, 01/14/10, and 02/14/10; and reports for magnesium and transferrin for 08/31/09 only. The DON, on 03/02/10 at 4:00 p.m., reported the missing labs were pulled from the computer. .",2015-07-01
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
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
10086,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,281,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, staff interview, and record review, the facility failed to ensure two (2) of twenty (20) sampled residents received medications in accordance with physician orders. Resident identifiers: #35 and #81. Facility census: 112. Findings include: a) Resident #35 Observation of the medication pass, on 03/02/10 at 8:45 a.m., with the licensed practical nurse (LPN - Employee #204), found she administered [MEDICATION NAME] 100 mg to Resident #35. Review of the March 2010 monthly recapitulation of physician's orders [REDACTED]. During the observation and review of the medication with the nurse on 03/02/10 at 9:00 a.m., she stated, ""I owe her (Resident #35) a half tablet."" b) Resident #81 Medication pass observation, on 03/01/10 at 4:20 p.m., found Resident #81 received Calcium 500 mg from a bottle of stock medication. At 5:00 p.m., the nurse (Employee #25) passing medications stated she should have given this resident Calcium 500 mg with 200 mg Vitamin D from a bottle of stock medication, but took from the wrong bottle. During reconciliation, the physician's orders [REDACTED]. .",2015-07-01
10087,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,441,F,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on a review of the facility's hand hygiene procedure and staff interview, the facility failed to establish handwashing guidelines in accordance with current professional standards of practice as recommended by the Centers for Disease Control and Prevention (CDC). This had the potential to affect all residents. Facility census: 122. Findings include: a) Review of the facility's hand hygiene procedure found, at Step 6, ""Rub hand together vigorously for 10-15 seconds, generating fraction on all surfaces of the hands and fingers."" The policy was reviewed with the director of nursing on 03/03/10 at 12:00 p.m., at which time it was discussed that current CDC guidelines for hand washing indicate hands should be rubbed together for 15-20 seconds. --- Part II -- Based on record review, staff interview, and policy review, the facility failed to follow its own policy on [DIAGNOSES REDACTED] (TB) screening to assure all newly admitted residents were tested and found to be free of this communicable disease. This was evident for one (1) of three (3) residents' closed records. Resident identifier: #114. Facility census: 112. Findings include: a) Resident #114 Review of the facility's policy on TB screening (dated November 2008) revealed all new residents must have a 2-step Mantoux Purified Protein Derivative (PPD) on admission. The first step is to be completed within seven (7) days of admission or according State / Federal regulation, and the second step is to be completed within seven (7) to twenty-one (21) days after a negative result from the first step or according to State / Federal regulation, always following the more strict requirement. The administration and results are then to be documented on the TB Screening Record in millimeters (mm). Review of Resident #114's medical record, on 03/04/10, revealed the Step 1 PPD was administered on 09/21/09 in the left forearm to be read on 09/23/09; however, on 09/23/09, the results of the test were not read as evidenced by a blank space where the area of ""mm of induration"" was supposed to have been recorded and by a blank space where the nurse was supposed to have initialed as having read the results. Additionally, the Step 2 PPD was scheduled to be given on 10/05/09 and read on 10/07/09, but spaces were left blank regarding the manufacturer, lot number, dose, nurse's initials when the PPD was given, and ""mm of induration"" and nurse's initials when read, signifying that a second PPD was not given. Interview with a nurse (Employee #25), on 03/04/10 at approximately 10:00 a.m., revealed the PPD tests were also recorded on the medication administration record (MAR). Review of the resident's September 2009 MAR for 09/21/10 found a typed notation to ""check PPD on 09/23/09"", but the space to record the results on 09/23/09 was left blank. Employee #25 agreed there was no documentation of test results for the Step 1 PPD. Review of the October 2009 MAR revealed a PPD was initialed as having been given on 10/05/09, and there was a minus (-) sign on 10/07/09 with a nurse's initials signifying a negative PPD result. The 10/07/09 PPD test result was not recorded on the TB Screening Record, and there was no evidence of a second step having been completed seven (7) to twenty-one (21) days after the only PPD on record. .",2015-07-01
10088,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,309,G,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents in attaining or maintaining her highest practicable level of physical well-being, by failing to obtain routine laboratory testing as ordered by the physician for a resident with a [DIAGNOSES REDACTED].#108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. During this period of active physician intervention, the facility failed to document periodic nursing assessments (including vital signs) and the resident's response to treatment. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Interview with the nurse (Employee #38), on 03/04/10 at 11:45 a.m., revealed the facility uses a tickler file in a file box at each nurse's station to record the months or the weeks in a month when repeating lab work is due for specific residents. When asked, she said this is the third hall in which this resident has resided since admission to the facility last year. 6. Interview with the assistant director of nursing (ADON - Employee #4), on 03/04/10 at 2:00 p.m., revealed they were wondering about the physician's orders [REDACTED].#21 at home today and asked if she understood the order correctly (in reference to discontinuing the [MEDICATION NAME], giving IV fluids, and administering potassium chloride); Employee #21 replied in the affirmative. According to the ADON, Employee #21 said she called the physician the next morning, on 03/03/10, before giving the [MEDICATION NAME]. 7. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 8. Review of nursing notes for 03/02/10, 03/03/10, and the night shift on 03/04/10, found no assessments or vital signs documented during the time the resident was being re-hydrated and being treated for [REDACTED]. 9. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
10089,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,225,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on personnel record review and staff interview, the facility failed to screen individuals, prior to permitting them to have resident contact, for convictions of abuse, neglect, or mistreatment residents by a court of law and/or findings entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. Five (5) of five (5) contracted nursing employees reviewed did not have evidence of a statewide background check (Employees #97, #103, #108, #111, and #113), and there was no evidence of screening against the State nurse aide registry for four (4) of five (5) contracted employees and one (1) of five (5) regular employee reviewed (Employees #38, #97, #108, #111, and #113). Facility census: 112. Findings include: a) Employees #97, #103, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence of statewide background checks for contracted Employees #97, #103, #108, #111, and #113, in an effort to uncover information about any past criminal prosecutions that would indicate unfitness for service in a nursing facility caring for vulnerable adults. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed there were no statewide background checks completed for these individuals. b) Employees #38, #97, #108, #111, and #113 Review of sampled personnel files, with the payroll clerk at 4:00 p.m. on 03/03/10, failed to find evidence the State nurse aide registry was checked for Employees #38, #97, #108, #111, and #113. On 03/04/10 at 10:00 a.m., the payroll clerk confirmed the State nurse aide registry had not been checked for these individuals. .",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
10091,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,329,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the drug regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs. Resident #28 was ordered [MEDICATION NAME] 0.5 mg on 01/15/10 for Mild Mental [MEDICAL CONDITION] in the absence of adequate indications for it use. Facility census: 112. Findings include: a) Resident #28 Record review revealed Resident #28 was admitted to the facility on [DATE], and the hospital discharge summary for that date indicated the resident was receiving [MEDICATION NAME] 0.5 mg prior to admission to the facility. Copies of hospital records on the resident's medical record, when reviewed, contained no information explaining why the resident required this medication. The resident's 01/15/10 admission physician's orders [REDACTED]. Review of the physician's progress notes from 01/15/10 forward failed to find any documentation of the indications for use of the [MEDICATION NAME]. Review of the resident's 01/26/10 care plan found the resident was receiving [MEDICATION NAME] for ""MR with behaviors"" and ""Behavioral symptoms drug is intended to treat: Resists care"". This information was reviewed with the director of nursing on 03/04/10 at 4:00 p.m., and she agreed the indications for giving this resident [MEDICATION NAME] were inadequate. She reported having reviewed the medical record and finding no additional information concerning this matter. .",2015-07-01
10092,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,248,E,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on confidential resident group interview, resident interview, and staff interview, the facility failed to provide an ongoing program of activities designed to meet the interests and psychosocial well-being of each resident. This was evident by six (6) of eight (8) residents in attendance at a confidential group meeting who reported they were unable to participate in outings as a group and for one (1) of twenty (20) sampled residents (#6) who reported being unable to participate in outings as desired. Facility census: 112. Findings include: a) During a confidential resident group meeting on 03/02/10 at 10:30 a.m., six (6) of eight (8) residents in attendance reported they had never been able to attend outings as a group outside the facility as they desired. When asked, several of the residents reported they would like to visit the local Senior Center but noted transporting more than one (1) or two (2) residents in wheelchairs on the transit bus would be a problem. Group members stated the facility had no van of its own. During a confidential interview with an employee on 03/03/10 at approximately 3:00 p.m., this employee confirmed no group outings had been held for residents for at least the past two (2) years. Interview with the assistant activity director (Employee #6), on 03/04/10 at 11:15 a.m. revealed, only a few residents over the past few years have asked her about having a group outing. She stated the activities department has contacted the Marion County Transit Authority to transport individual residents for such things as shopping at Wal-Mart when requested, but the facility has not requested the Transit Authority to transport a group of residents at the same time. Interview with the activity director (Employee #10), on 03/04/10 at 2:45 p.m., revealed there have been no group outings since she has been working at the facility in July 2009. She recalled last year, in August or September, residents mentioned wanting group outings. However, she said, due to difficulties with transporting numerous residents on the Transit Authority bus, associated legalities, the need for having enough staff to accompany the residents, etc., she explained to residents the barriers to having group outing. Since that time, Employee #10 reported no one had mentioned it to her again. She acknowledged the facility had no van or bus of their own for transporting residents. She stated she would be glad to put this request for group outings ""on the table"" at the next resident council meeting to see what residents want and to see if the facility can help meet those needs. b) Resident #6 Resident #6's medical record, when reviewed on 03/03/10 at 10:00 a.m., revealed a [AGE] year old male who was admitted to the facility on [DATE]. The physician determined the resident possessed the capacity to understand and make his own medical decisions. The resident was non-ambulatory due to paralysis and utilized a motorized wheelchair for mobility. This alert and oriented resident, when interviewed on 03/03/10 at 2:30 p.m., revealed he attended some of the planned activities offered by the facility. The resident stated the facility did not provide outings and stated, ""I wish they would. It would be nice to get out once in a while."" The resident reported that, if the facility would offer facility outings, ""I would like to go."" .",2015-07-01
10093,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,327,G,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, staff interview, and physician interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. These failures resulted in actual harm to Resident #108, who was subsequently found to be dehydrated and hyperkalemic. Labs, obtained only after surveyor intervention, revealed the resident was dehydrated and hyperkalemic (elevated serum potassium level), and the physician discontinued the diuretic therapy and ordered the administration of intravenous IV fluids (to rehydrate the resident), medications to alter the resident's serum potassium level, and repeat labs. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. Review of the Medication Administration Record [REDACTED]. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. During interview with the physician on 03/04/10 at 2:15 p.m., he said his primary focus initially was to hydrate the resident. He said the nurse told him about the 6.1 potassium level 03/02/10. When asked about the order for potassium chloride, he explained he knew the potassium level would drop when she was re-hydrated. 6. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
10094,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-03-04,279,D,0,1,FFCS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, resident interview, and staff interview, the facility failed to provide necessary care and services to assist one (1) of twenty (20) sampled residents to ensure the resident maintained acceptable parameters of fluid and electrolyte balance, by failing to develop and implement a care plan to address fluid and electrolyte balance for a resident with a [DIAGNOSES REDACTED]. Resident identifier: #108. Facility census: 112. Findings include: a) Resident #108 Review of Resident #108's medical record revealed an [AGE] year old female admitted to the facility on [DATE] with the following Diagnoses: [REDACTED]. 1. Record review, on 03/02/10, revealed physician orders [REDACTED]. However, the most recent test results, dated 08/31/09, revealed the following abnormal lab values: - Potassium - high at 5.6 (normal range 3.5 - 5.2) - Chloride - high at 115 (normal range 97 - 108) - Carbon [MEDICATION NAME] - low at 17 (normal range 20 - 32) - BUN - high at 39 (normal range 5 - 26) - Creatinine - high at 3.02 (normal range 0.57 - 1.00) - Estimated Glomerular Flow Rate (eGRF - a test for monitoring kidney function) - low at 15 (normal range > 59) (Note: Abnormally high values of BUN, creatinine, and potassium are indicative of impaired kidney function; abnormally low values of eGFR are indicative of kidney damage. Abnormally high values of BUN, creatinine, and potassium are also indicative of dehydration.) Further record review revealed the addition of a diuretic, [MEDICATION NAME] 40 mg daily, which was initiated on 12/02/09. No lab results were available for November 2009 or February 2010. Observation of, and interview with, this resident, on 03/02/10 at 8:30 a.m., revealed a pleasantly confused lady who was clean in appearance and well groomed. During this conversation, she threw back the covers and spoke of her TED hose lying at the foot of her bed, saying she would need them on. Both of her legs were [MEDICAL CONDITION], more so on the left, and her finger made an imprint on her left lower thigh when she touched it. On 03/02/10, a medical records person (Employee #12) reviewed the resident's thinned record on file and was unable to find the physician-ordered laboratory tests listed above since 08/31/09. On 03/02/10 at approximately 11:15 a.m., these findings were reported to the director of nursing (DON), who stated she would notify the physician and request an order for [REDACTED]. 2. Medical record review, on 03/03/10, revealed a physician notification form dated 03/02/10 at 11:45, regarding the missing November 2009 and February 2010 labs (BUN, creatinine, and electrolytes). Labs, collected at 12:04 p.m. and reported at 2:12 p.m. on 03/02/10, yielded the following abnormal results: - Potassium - high at 6.1 (normal range 3.5 - 5.2) - Chloride - high at 111 (normal range 97 - 108) - BUN - high at 51 (normal range 5 - 26) - Creatinine - high at 3.53 (normal range 0.57 - 1.00) - eGRF - low at 12 (normal range > 59) Upon notification of these abnormal results, the physician gave orders, on 03/02/10 (with no timed entry for the telephone order), to discontinue the [MEDICATION NAME], give Potassium Chloride 30 meq (additional potassium for an individual who already had an abnormally high serum potassium level), and administer 1000 cc intravenous fluids of D5W (5% [MEDICATION NAME] and water) at a rate of 100 cc per hour with repeat labs in the morning. 3. Record review, on 03/04/10, revealed repeat labs, collected at 7:23 a.m. and reported at 12:13 p.m. on 03/03/10, yielded the following abnormal results: - BUN - high at 49 (normal range 5 - 26) - Creatinine - high at 3.29 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) Review of physician's orders [REDACTED]. Review of nursing notes found an entry, dated 03/03/10 at noon, stating, ""2nd (second) blood draw done to confirm K+ (potassium) level before administering [MEDICATION NAME]."" A subsequent entry, at 2:00 p.m. on 03/03/10, noted an elevated potassium level of 5.8 with [MEDICATION NAME] given. Another entry, also at 2:00 p.m. on 03/03/10, noted more lab work was scheduled for the morning. 4. Labs, collected at 1:21 a.m. and reported on 03/04/10 (time of report not noted), yielded the following abnormal results: - Potassium - within normal limits at 4.8 (normal range 3.5 - 5.2) - BUN - high at 45 (normal range 5 - 26) - Creatinine - high at 3.42 (normal range 0.57 - 1.00) - eGFR - low at 13 (normal range > 59) 5. Review of the resident assessment protocol (RAP) summary on the resident's comprehensive admission assessment (dated as completed on 06/06/09) found the interdisciplinary care team decided to not address dehydration / fluid maintenance on this resident's care plan, even though her admitting [DIAGNOSES REDACTED]. Review of the current care plan revealed the problem statement: ""At nutritional risk r/t (related to): Therapeutic diet r/t Stg IV CRF (Stage IV [MEDICAL CONDITION])."" There was a box to also mark ""Dehydration"", but the interdisciplinary care team chose not to mark this. The goals associated with this problem statement were: ""Resident will consume at least 75% of most meals"" and ""Weight will remain stable +/- 5 lbs adm (admission weight) 135 lb (also noted +3 [MEDICAL CONDITION] to BLE (bilateral lower extremities)"". The interventions to assist the resident in achieving these goals included: ""Monitor labs as ordered / available."" .",2015-07-01
11295,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-05-14,353,E,1,0,674B11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff, and resident interview, and a review of assignment sheets and schedules, the facility failed to deploy sufficient direct care staff across all shifts and units to meet the assessed care needs of dependent residents. This deficient practice affected more than an isolated number of residents. Facility census: 119. Findings include: a) On the evening of 05/10/09 (from 7:30 p.m. through 12:00 a.m.) continuing into the early morning of 05/11/09, observations revealed the following: - On the 3:00 p.m. to 11:00 p.m. (3-11) shift on 05/10/09, there were four (4) nurses and six (6) nursing assistants present for one hundred nineteen (119) residents. Per the planned nursing schedule, there should have been four (4) licensed nurses and eleven (11) nursing assistants in the facility. - On the 11:00 p.m. to 7:00 a.m. (11-7) shift beginning on 05/10/09 through 05/11/09, there were four (4) nurses and four (4) nursing assistants present in the facility. Per the planned nursing schedule, there should have been four (4) licensed nurses and four (4) nursing assistants in the facility. On 05/10/09, all nursing staff members who were present in the facility for the 3-11 and 11-7 shifts were confidentially interviewed. A review of the twenty-four (24) hour nursing reports for the 11-7 shift revealed: - On 05/13/09, there were only three (3) licensed nurses and four (4) nursing assistants for the entire shift. - On 05/08/09 from 11:00 p.m. through 3:00 a.m., there were only four (4) licensed nurses and three (3) nursing assistants. - On 05/07/09 from 11:00 p.m. through 3:00 a.m., there were only three (3) nurses and three (3) nursing assistants, with a fourth coming in from 3:00 a.m. to 7:00 a.m. - On 05/06/09 from 11:00 p.m. through 3:00 a.m., there were three (3) nurses and three (3) nursing assistants until 3:00 a.m., when a fourth (4) nursing assistant came in from 3:00 a.m. to 7:00 a.m. - On 05/05/09, there were four (4) nurses and three (3) nursing assistants for the entire shift. - On 05/04/09, there were two (2) nurses and three (3) nursing assistants for the entire shift. - On 05/02/09, there were three (3) nurses and two (2) nursing assistants for the entire shift. - On 04/29/09, there were four (4) nurses and three (3) nursing assistants for the entire shift. - On 04/17/09, there were four (4) nurses and three (3) nursing assistants for the entire shift. - On 04/15/09, there were three (3) nurses and three (3) nursing assistants for the entire shift. - On 04/02/09, there were four (4) nurses and three (3) nursing assistants from 3:00 a.m. through 7:00 a.m. Review of the staffing calculation worksheet found there were less than sixty (60) nursing hours for the 11-7 shift for the 2009 dates of 02/02/09, 02/13/09, 02/14/09, 02/16/09, 02/17/09, 02/20/09, 03/13/09, 03/19/09, 03/25/09 - 03/29/09, 04/04/09, 04/13/09, 04/15/09, 04/29/09, and 05/01/09 - 05/09/09. The facility's census varied from one hundred fourteen (114) to one hundred nineteen (119) residents for these days. The resident census and conditions of residents (CMS-672), dated 05/10/09, indicated there were one hundred eighteen (118) residents in the facility. Seventy (70) residents were occasionally or frequently incontinent of bladder, and seventy (70) residents were occasionally or frequently incontinent of bowel. Fifty-six (56) residents were in a chair all or most of the time. Forty-one (41) residents had documented psychiatric diagnoses, sixty-nine (69) residents had a [DIAGNOSES REDACTED]. Five (5) residents developed pressure ulcers since admission, and one-hundred eighteen (118) residents were receiving preventive skin care. Confidential interviews held with nursing staff from the 3-11 shift and the 11-7 shift found that rounds were to be made every two (2) hours on the 11-7 shift, and most agreed this was not always possible. The nursing staff agreed the licensed nurses would help by answering call lights and turning residents, but none of them made rounds with the nursing assistants. On 05/10/09, the 3-11 nursing assistants were interviewed from 9:30 p.m. through 10:30 p.m., and most agreed they had not been able to complete their assignments for the 3-11 shift at times. This happened when there was not enough staff present at the facility. Tasks not completed included final rounds (including turning / repositioning and incontinence care), denture care, emptying urinary catheter drainage bags, and charting in the kiosk. On one (1) hallway, the 8:00 p.m. snacks had not been passed. The 11-7 shift nursing assistants indicated on some nights there was only one (1) nursing assistant for half of the facility (with a total of one hundred twenty (120) beds), and they are not always able to complete their rounds. An interview with the staffing coordinator, on 05/13/09 at 11:50 a.m., found she scheduled four (4) licensed nurses for 7:00 p.m. through 7:00 a.m., with eight (8) nursing assistants for the 3-11 shift and four (4) nursing assistants for the 11-7 shift. She reported having no control over ""call-offs"", and the licenses nurses were to call out other nursing assistants if there were ""call-offs"". An interview with the director of nursing (DON) and the assistant director of nursing (ADON), on 05/13/09, found the licensed nurses were supposed to call out nursing assistants or to try to get nursing assistants to stay over or come in early in order to cover part or all of the affected shift. The nurses were supposed to let the DON or ADON know if there was not enough staff, but the nurses had not been doing so.",2014-07-01
11296,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-07-27,356,C,1,0,ONIB11,"Based on observation and staff interview, the facility failed to accurately post the actual resident census and actual numbers of licensed practical nurses (LPNs) and nursing assistants (NAs) working on the day shift on 07/26/09. Facility census: 112. Findings include: a) On 07/26/09 at 1:15 p.m., observation found a nursing staff posting form titled ""Daily Nurse Staffing Form"", dated 07/26/09, in the main dining room. The form did not specify the actual numbers of LPNs and NAs currently working in the facility on the day shift, nor did it specify the current resident census. The form reported fifteen and nine-tenths (15.9) NAs were on duty, yet observation revealed thirteen (13) NAs working on the day shift. The form also reported four and nine-tenths (4.9) LPNs were on duty, yet observation revealed four (4) LPNs working on the day shift. The day shift registered nurse supervisor (Employee #27), when interviewed on 07/26/09 at 2:00 p.m., confirmed the form was not accurate and complete. .",2014-07-01
11297,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-07-27,441,E,1,0,ONIB11,"Based on observations, medical record review, policy review, and staff interviews, the facility failed to change each resident's oxygen tubing weekly, as required. This was true for two (2) of seven (7) sampled and seven (7) randomly observed residents prescribed oxygen therapy by their physician. Residents who were using oxygen therapy did not have their oxygen supply tubing changed weekly, as ordered by the physician and in accordance with the facility's infection control policy revised on October 2008. Resident identifiers: #2, #17, #46, #66, #77, #87, #91, # 97, and #107. Facility census: 112. Finding include: a) Resident #2 On 07/27/09 at 9:15 a.m., observation found Resident #2's oxygen tubing was dated 07/11/09. Resident #2's treatment sheet for July 2009, when reviewed on 07/27/09 at 10:00 a.m., disclosed the oxygen tubing was last changed on 07/06/09. b) Resident #17 On 07/27/09 at 8:45 a.m., observation found Resident #17's oxygen tubing was dated 06/09/09. c) Resident #46 On 07/27/09 at 9:20 a.m., observation found Resident #46's oxygen tubing was dated 07/07/09. d) Resident# 66 On 07/26/09 at 12:40 p. m., observation found Resident #66's oxygen tubing was dated 07/12/09. e) Resident #77 On 07/27/09 at 8:50 a.m., observation found Resident #77 in bed receiving oxygen therapy via nasal cannula at 2 liters per minute. The oxygen tubing was dated 07/11/09. f) Resident #87 On 07/26/09 at 12:45 p.m., observation found Resident #87's oxygen tubing was dated 07/07/09. g) Resident #91 On 07/27/09 at 7:45 a.m., observation found Resident #91 in bed using his oxygen via nasal cannula. The oxygen tubing was dated 07/11/09. The nursing supervisor (Employee #27), when interviewed on 07/27/09 at 7:50 a.m., confirmed the facility's policy was to ""change the oxygen tubing weekly"". h) Resident #97 On 07/26/09 at 2:30 p.m., observation found Resident #97 in her room using her oxygen via nasal cannula. The oxygen supply tubing was dated 07/11/09. i) Resident #107 On 07/27/09 at 7:45 a.m., observation found Resident #107's oxygen tubing was dated 07/11/09. j) The director of nurses (Employee #2), on 07/27/09 at 2:30 p.m., provided a copy of the facility's policy titled ""Disposal Equipment Change Schedule"". Page 2 of the policy stated oxygen supply tubing is to be changed weekly.",2014-07-01
11298,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2010-08-12,323,G,1,0,RZPN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, confidential family interview, and review of facility incident / accident reports, the facility failed to ensure the resident environment remained as free of accident hazards as was possible, including freedom from the aggressive behaviors of Resident #119, and that each resident received adequate supervision to prevent physical abuse by Resident #119. Documentation throughout Resident #119's medical record and facility incident reports revealed numerous episodes of aggressive behavior, including entering other resident rooms and rummaging in their things, as well as striking and pinching others on at least six (6) occasions during his seventy-seven (77) day stay at the facility. The aggressive behaviors of Resident #119 resulted in at least six (6) recorded resident-to-resident physical altercations (involving Residents #23, #30, #45, #17, #7, and #25). The final aggressive episode resulted in physical injury to Resident #25, who sustained a bruised eye and skin tears to his arm. In the weeks and months leading up to Resident #25's injuries, the facility's administrative staff and interdisciplinary team failed to: - Identify the need for increased supervision in the facility (occupied by other elderly, debilitated residents) related to Resident #119's behaviors. (The resident had a prior personal history of frequent aggressive behaviors with his family members of which facility staff should have been aware.) - Evaluate and analyze the frequency, intensity, and duration of his physically abusive behaviors and identify causal / contributing factors, in order to develop appropriate interventions to reduce / eliminate these behaviors and ensure the safety of others; - Implement interventions, including providing adequate supervision, consistent with the needs, goals, and plans of care of both Resident #119 (the aggressor) and the other residents of the facility, in order to reduce the risk of resident-to-resident altercations; and/or - Monitor the effectiveness of the interventions and modify the interventions as necessary when it was apparent the interventions did not result in sustainable changes in Resident #119's aggressive behavior. One (1) family member, who was confidentially interviewed, revealed they voiced concerns about the safety of other residents (due to Resident #119's behavior) to nursing staff of the facility; however, there was no documented evidence by facility staff of this conversation. (Identifiers withheld due to request for confidentiality.) The failure of the facility to identify and eliminate or effectively mitigate the potential hazards in the environment posed by Resident #119's aggressive behaviors resulted in the physical abuse of six (6) residents (Residents #23, #30, #45, #17, #7, and #25) with resulting injury to Resident #25. It also presented the potential for more than minimal harm to all residents of the facility who were subjected to the overall hostile environment created by Resident #119. Facility census: 117. Findings include: a) Resident #119 Review of the medical record of Resident #119 revealed the resident had been admitted to an area acute care hospital from his home on 04/12/10. The history and physical examination [REDACTED]."" The resident was admitted to the nursing home from this hospitalization on [DATE]. Review of the resident's care plan revealed, on 06/09/10, a plan of care for psychotropic drug use had been implemented which listed all of the resident's mood altering medications and the behaviors which they were intended to treat. The only changes made to the plan were hand written entries at the time of medication changes. There was no mention of non-pharmacologic interventions to prevent (e.g., modification of environmental triggers, additional supervision, diversional activities, etc.) or resolve aggressive behaviors, nor were changes made to interventions to be used by staff following incidents where Resident #119 had physically attacked other residents. - b) Resident #30 A facility incident report stated that, on 06/15/10 at 1:40 p.m., Resident #119 approached Resident #30, who was sitting in the hallway, and ""hit him in the face"". There was no noted physical injury to Resident #30. The report further stated staff ""separated residents"". Review of Resident #30's most recent minimum data set (MDS), an abbreviated quarterly assessment with an assessment reference date (ARD) of 04/07/10, described this resident as weighing 134# and being totally dependent on staff for bed mobility, ambulation, etc. He could provide for none of his own needs. This resident would not have been able to independently walk or get away from Resident #119. - c) Resident #45 A facility incident report stated that, on 06/15/10 at 9:00 p.m., after hitting a different resident earlier in the day, Resident #119 was ""ambulating in the hallway, went into room (room # of Resident #45) and hit resident on L (left) arm"". The report stated there was no injury to Resident #45 and the residents were separated. The physician for Resident #119 was notified, and an order for [REDACTED]. The order was changed the next day to two (2) mg two (2) times daily. - d) Resident #17 A facility incident report stated that, on 07/11/10 at 8:10 p.m., Resident #119 entered the room of Resident #17 while the resident was lying in the bed and ""hit the resident (#17) multiple times in the head"". Again, there was no injury noted and the residents were separated. The most recent MDS for Resident #17, an abbreviated quarterly assessment with an ARD of 06/16/10, stated this resident [AGE] year old could only walk and move about in the bed with the assistance of two (2) staff; this resident would not have been able to independently walk or get away from Resident #119. - e) Resident #7 A facility incident report stated that, on 07/11/10 at 8:30 p.m., twenty (20) minutes after hitting Resident #17, Resident #119 entered the room of Resident #7 and, when asked to leave, ""struck (Resident #7) beside the R (right) side of the mouth"". The report stated Resident #7 was not injured and a stop sign was put on his door. - f) Resident #23 A facility incident report stated that, on 07/21/10 at 7:50 a.m., this resident was lying in bed and Resident #119 came into her room and started pinching her legs. This report also stated that Resident #23 was not injured and ""other resident was removed from her room"". Review of Resident #23's most recent available MDS, an abbreviated quarterly assessment with an ARD of 04/21/10, stated this [AGE] year old resident weighed 139# and was dependent on staff for any transfer. This resident would not have been able to independently walk or get away from Resident #119. - g) Resident #25 A facility incident report stated that, on 08/06/10, Resident #25 reported to facility staff that Resident #119 entered his room and walked over to his bed. When he (#25) yelled for him (#119) to leave, Resident #119 hit him (#25). Two (2) skin tears were noted on the resident's left arm and his right cheek was slightly edematous when assessed by staff immediately after the incident. The resident complained of no pain. When observed on 08/11/10 at 11:00 a.m., Resident #25 was noted to have a bruised discoloration on the outside parameter of his right eye. This resident had experienced a stroke and had minimal use of his right side. He was able to call out for help. - h) A facility registered nurse (RN - Employee #26), who was designated as in charge in the absence of the administrator and the director of nurses, was interviewed on several occasions during the two (2) day investigation. This nurse confirmed there was no evidence of attempt by facility staff to identify and eliminate causative factors of Resident #119's aggressive behaviors or to assign additional supervision for the resident and avoid aggressive behaviors. She was unaware that some of the physical altercations had been repeated in short time spans on the same days. This nurse felt there had been attempts to move the resident to a more appropriate setting without success, but no evidence of these attempts could be provided. This nurse did also confirm that Resident #119 was not confined to the unit of the facility on which he resided, but he did wonder throughout the facility. This nurse stated that staff was aware of the behaviors of Resident #119 since his admission, but they did not expect it to escalate to the point it did when he hit Resident #25. - i) Social service progress notes found on the medical record of Resident #119 disclosed no evidence of attempts to transfer / move the resident to another setting to assure the safety of other facility residents prior to his transfer on 08/09/10. A facility social worker (Employee #5), when interviewed on 08/11/10 at approximately 4:00 p.m., confirmed these notes as accurate and complete.",2014-07-01
11479,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,278,B,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of minimum data set (MDS) assessments, and staff interview, the facility failed to accurately document assessment data on the MDS relative to pressure ulcers, infections, and toileting plans for four (4) of twenty (20) sampled residents. Resident identifiers: #65, #3, #4, and #81. Facility census: 113. Findings include: a) Resident #65 Record review (on 01/06/09) revealed the resident had a Stage II pressure ulcer to the coccyx which was recorded as being healed on 12/02/08. This information was noted on the December 2008 treatment administration record and a nurse's note dated 12/02/08. A skin assessment, dated 12/20/08, recorded no pressure ulcer(s) present at that time. Review of the resident's MDS, with an assessment reference date (ARD) of 12/24/08, found the assessor recorded in Section M1 the resident had one (1) Stage II ulcer. The MDS nurse (Employee #23) was interviewed on 01/07/09 about the information coded in Section M1 of the MDS. After reviewing the issue, she verified the MDS was coded incorrectly. On 01/08/09 at 11:05 a.m., the MDS nurse provided a copy of a corrected MDS, with an ARD of 12/24/08. In Section M1, the assessor documented no pressure ulcer(s). b) Resident #31 Review (on 01/07/09) of the admission MDS, completed on 12/24/08, revealed the assessor indicated, in Section I2, the resident had an antibiotic-resistant infection. Interview with the director of nursing (DON - Employee #2), at about 6:00 p.m. on 01/07/09, and review of the laboratory reports confirmed that, when the resident was admitted on [DATE], the resident had a [DIAGNOSES REDACTED]. c) Resident #40 Review (on 01/06/09) of the quarterly MDS, completed on 11/12/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at 1:05 p.m., confirmed the resident was not on a toileting plan but was checked regularly for bladder incontinence. d) Resident #81 Review (on 01/06/09) of the quarterly MDS, completed on 11/23/08, revealed the assessor indicated the resident was non-ambulatory and incontinent of bladder. In addition, the assessor marked Item H3a to indicate the resident was on a scheduled toileting plan. Interview with a nursing assistant (Employee #63), on 01/06/09 at about 1:00 p.m., confirmed the resident was not on a toileting plan. .",2014-02-01
11480,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,279,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, the facility failed to develop individualized comprehensive care plans for each resident to include services / treatments to be provided and appropriate interventions to assist with achievement of established goals. Care plans were not developed and individualized to reflect the actual care and services to be provided for six (6) of twenty (20) sampled residents. Resident identifiers: #36, #10, #97, #28, #62, and #81. Facility census: 113. Findings include: a) Resident #36 Review of the interdisciplinary care plan for Resident #36, found a sixty-four (64) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan was hard to follow, and it did not always accurately reflect what problems the resident was experiencing for which specific interventions were being applied. 1. This resident had a history of [REDACTED]. devices. There was a different care plan for each device. The problem statements and goals were the same for each device, and each began with the statement: ""Refer to the physical restraint / enabler assessment."" 2. The physical restraint / enabler care plan was reviewed. This care plan was dated 12/05/08. The plan did not have a problem statement, goal, or interventions to achieve the goal. The care plan simply said, ""Refer to the physical restraint / enabler assessment."" The goal associated with this problem was ""(Resident) will be free of negative effects with the use of an enabler."" This goal did not address what the resident would achieve through the use of the device, i.e., improve functioning, increased independence, etc.) Review of the interventions associated with this goal found no measures to assist the resident in achieving the stated goal. The interventions simply said to apply the enabler (a lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which, when reviewed, did not refer to the lap buddy in any way); refer to the falls assessment prevention and management plan of care (which did not include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy): prevention and management plan of care; maintain resident bowel and bladder routine; educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was incomplete). The care plan for this resident's lap buddy use did not specify the problem necessitating the application of the device. Additionally, record review revealed the resident became agitated and had sustained injuries when the device was applied, and this response was not addressed in the resident's care plan. b) Resident #10 Review of the interdisciplinary care plan for Resident #10, found a fifty (50) paged document consisting of pre-printed problems, goals, and interventions with blanks to be filled in to make the care plan individualized. The care plan stated, ""Recent or chronic history of incontinence. Contributing factors included laxative use PRN and cognitive / perceptual impairment, loss of sphincter control, and decreased physical activity."" One (1) goal for problem statement was: ""Will ingest adequate fluids evidenced by resident's skin turgor."" Other goals were: ""Will have bowel movement every three days"" and ""Will be cooperative with assisted toileting."" The interventions to assist with achievement of these goals included, ""See nutritional care plan"" and ""See skin integrity prevention and management plan of care."" The stated interventions did not address the identified problem and would not lead to achievement of the established goals. c) Resident #97 1. Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized to address Resident #97's pain. 2. The resident's care plan also contained the following problem statement: ""Refer to the physical restraint / enabler assessment."" The goal stated: ""Will be free of negative effects with the use of an enabler."" (There was no mention about how the enabling device was intended to improve the resident's functionality.) One (1) intervention simply stated what device was to be used (1/2 top side rail) to aid in turning and reposition. The only other intervention was ""Refer to the mood and behavior symptom plan of care."" Review of the mood and behavior plan of care found no interventions related to the use of an enabler. There were no interventions written to assist in achieving the goal established. 3. The director of nursing (DON - Employee #2) was made aware of the inconsistencies in Resident #97's care plan at 10:00 a.m. on 01/08/09. She stated she was aware there were a lot of pages in the care plan, but this was the way their corporation required them to do the care plans. She was made aware that the resident's true problems often could not be identified and the treatment they were to receiving often did not match the care plans. d) Resident #28 Medical record review, on 01/06/09 at 1:32 p.m., revealed Resident #28 was on several medications for moods / behaviors, including [MEDICATION NAME] 12.5 mg via g tube BID (two-times-a-day), [MEDICATION NAME] 0.5 mg via g tube TID (three-times-a-day), and [MEDICATION NAME] 10 mg via g tube QD (every day). Review of the resident's most current care plan, dated 11/26/08, found the facility identified the resident was at risk for depression as evidence by ""unhappy behavior symptoms"" and persistent anger with self or others. The goal included reduction / elimination of unhappy behavior symptoms. Interventions to achieve the goal included: ""offer time to express feelings and concerns; separate from stressful situations; 1:1 (one on one) conversation to maintain trust of staff; offer reassurance; and depression scale q3 (every three) months."" Another problem was behavioral symptoms that may be harmful to self or others or interfere with function or care as evidence by yells out loud and grabs, combative with staff. The goal included no injury to self or others. Interventions included: ""administer medications, see nsg (nursing) mar (medication administration record), redirect to activity of 1:1 diversion, offer time to express feelings and concerns, separate from stressful situations, redirect to act. or 1:1 act (activity or one-on-one activity) offer to call son."" Review of the resident's minimum data set assessment (MDS), dated [DATE], revealed Resident #28 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited repetitive verbalizations, repetitive anxious complaints, sad pained worried facial expressions crying and tearfulness (of which all were easily altered). Review of the behavior tracking report, from 06/01/08 through 11/30/08, found the following: - 06/17/08 - crying and ""mood persistence"" (each one time). - 07/27/08 - crying - 08/08/08 - crying and ""mood persistence"" - 08/21/08 and 08/30/08 - crying - 09/02/08 and 09/03/08 - physical abuse (a behavior which was not described) - 10/03/08 - crying - 10/04/08 - crying and ""mood persistence"" - 10/06/08 - sad / pained / worried facial expression and ""mood persistence"" - 10/07/08 - crying two (2) times and ""mood persistence"" - 10/26/08 - crying and repetitive verbal, unrealistic fears, repetitive anxious, sad / pained / worried facial expression, and ""mood persistence"" - 10/27/08 - crying and ""mood persistence"" - 11/15/08, 11/21/08, and 11/25/08 - crying and ""mood persistence"" The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. e) Resident #62 Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several medications for moods / behaviors. Her physician's orders [REDACTED]. - On 10/31/07 - [MEDICATION NAME] tablets 20 mg PO (by mouth) Q AM (every morning) and [MEDICATION NAME] 50 mg po BID; - On 02/20/08 - [MEDICATION NAME] 200 mg PO QD and [MEDICATION NAME] 100 mg PO QD; - On 05/15/08 - [MEDICATION NAME] 5 mg po BID; - On 11/12/08 - [MEDICATION NAME] 0.25 mg PO Q AM, [MEDICATION NAME] 0.5 mg PO Q HS (every night), and [MEDICATION NAME] ER 250 mg PO QD. Review of resident's current care plan, last updated on 10/15/08, revealed the interdisciplinary care team identified Resident #62 exhibited behavioral symptoms that may be harmful to self and/or others or that interfered with function or care, as evidenced by ""cognitive deficit Alzheimer's, doesn't understand the need to be here."" The goals associated with this problem statement were no injury to self or others and to reduce the frequency of behavioral symptoms. Interventions included: ""1:1 conservation to calm, reminisce, see act poc (see activity plan of care), offer to call family."" Another problem statement addressed: ""Socially inappropriate - yells out loud for nurses to help her. Yells that she's sick or has to go to the bathroom; anxious / repetitive questions, statements."" The goal associated with this problem statement was: ""Will exhibit socially appropriate behaviors."" Intervention included: ""offer reassurance, encourage rest encourage activities, separate from stressful situations, offer to call son, take for a walk."" Review of the resident's most recent MDS, dated [DATE], revealed Resident #62 had short and long term memory problems and moderately impaired cognitive skills for daily decision making, and she exhibited negative statements, repetitive questions, repetitive verbalizations, unrealistic fears, recurrent statements that something terrible was about to happen, repetitive anxious complaints, [MEDICAL CONDITION], sad / pained / worried facial expressions, crying / tearfulness, and repetitive movements (all of which were not easily altered). Additionally, the assessor identified that the resident exhibited wandering, verbally abusive, physical abusive, and socially inappropriate behaviors and resists care (all of which were not easily altered). Review of the behavior tracking report, from 09/11/08 through 10/10/08, revealed she exhibited behaviors on only four (4) days during the two-month period (09/30/08, 10/06/08, 10/07/08, and 10/10/08). The behaviors being tracked were: negative statements, repetitive questions, repetitive verbal, persistent anger, self deprecation, unrealistic fears, terrible things to happen, repetitive health, unpleasant mood, [MEDICAL CONDITION], sad / pained / worried facial expression, crying, repetitive physical, mood persistence, wandering, wandering altercation, verbal abuse, verbal altercation, physical abuse, physical altercation, socially inappropriate, social altercations, and resists care. Specific examples of these behaviors (such as what constituted ""mood persistence"") were not identified in either the resident's assessments, care plan, or behavior tracking report. The facility failed to develop an individualized care plan to address specifically identified behaviors exhibited by the resident based on a comprehensive assessment of factors causing or contributing to these behaviors, and failed to develop individualized, realistic interventions in recognition of this resident's limited cognitive ability and identified triggers. f) Resident # 81 Medical record review (on 01/06/09) of the physical restraint / enabler plan of care, dated 09/24/08, revealed the following problem statement: ""Refer to the physical restraint / enabler assessment."" The associated goal was: ""Will be free of negative effects with the use of the enabler"". The plan did not identify the reason for use of the enabler and did not establish a goal based on the assessment and the use of the enabler. .",2014-02-01
11481,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,309,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide care in accordance with each resident's plan of care for three (3) of twenty (20) sampled residents. Resident #97 indicated she was in pain, and this expressed pain was not further assessed or treated. Resident #10 was receiving intravenous (IV) fluids on an ""as needed"" (PRN) basis for her poor fluid intake, and her fluid intake and output were not being accurately monitored; this same resident was observed to have severely contracted hands, and she did not have rolled wash cloths or any type of devices in her hands for positioning to prevent further contractures. The facility also failed to staff applied double geri-gloves and elevated the heels of Resident #40 as ordered by the physician. Resident identifiers: #97, #10, and #40. Facility census: 113. Findings include: a) Resident #97 Record review found a nursing note recording the resident requested pain medication at 10:50 a.m. on 12/18/08. The nurse noted having instructed the resident that her ""pain medications are scheduled"". There was no evidence that the nurse assessed the pain or offered her one (1) of her prescribed PRN medications for breakthrough pain. Another nursing note, dated 12/30/08 at 1:30 p.m., stated, ""Resident belligerent with staff today about her pain medicine ([MEDICATION NAME]). Resident is on pain medication around the clock, offered Tylenol in between doses, resident refused meds (Tylenol). "" Another note, dated 01/01/09 at 4:35 a.m., stated, ""Resident requested this nurse to give pain pill early, when this nurse refused resident became upset mumbled statements under her breath, and accepted her set schedule resting at this time."" A nursing note, dated 01/01/09 at 1:35 p.m., stated, ""Resident upset pain meds are on a scheduled basis instead of PRN. Attempted redirection but resident became more agitated. Continue to monitor."" There was no evidence of further monitoring in the nursing notes, and this was the last nursing note written as of 01/06/09, which was the date of this medical record review. A review of the physician orders [REDACTED]. The resident also had a PRN order for [MEDICATION NAME]. There was no evidence in Resident #97 that staff offered the [MEDICATION NAME] for breakthrough pain between the scheduled doses of [MEDICATION NAME]. During an interview with Resident #97 on 01/06/09 at 10:00 a.m., she identified that her scheduled pain medication was not always effective. She stated that, sometimes, the pain in her back and shoulder was severe. A review of the resident's care plan, dated 11/25/08, revealed this resident had persistent (chronic) pain with ""an alteration in comfort related to pain secondary to L (left) shoulder pain."" Pre-printed goals were checked for this problem statement as follows: ""Decrease persistent pain to a tolerated level so resident can function in daily life""; ""Resident will report pain relief within 30 - 60 minutes receiving pain medication or treatment as ordered; and ""Will have not signs and symptoms of unrelieved pain no complaints of pain when questioned, no vocalization related to pain, no non-verbal signs, verbalization of pain, no decline in activity."" Also included were the following functional goals: ""Participate in ADL's""; ""Participate in therapies""; ""Will not experience decline in functioning related to pain""; and ""Non-pharmacological measures will be used as alternatives to medication when appropriate."" The interventions for achieving the goals written above were as follows: ""Administer pain medication as ordered, Tylenol 650 mg po (by mouth), monitor and record effectiveness, side effects of medication PRN (as needed) observe and notify provider for s/s (signs / symptoms) of constipation, administer bowel care per protocol, assess for verbal and non-verbal signs and symptoms of distress or pain unrelieved by ordered treatments / medications, observe during rest and during movement for pain, [MEDICATION NAME] 50 mg po (by mouth) q4h (every four hours) PRN, [MEDICATION NAME] 5/500 ([MEDICATION NAME]) q4h PRN, position changes, encourage mobility, physical activity as tolerated to prevent stiffness / contractures, Physical therapy and Occupational therapy to evaluate and treat as ordered to improve functional states, refer to pain management clinic PRN, discuss progress toward or maintenance goals for medication therapy, review medication regimen with the provider and the pharmacist PRN."" This care plan was not individualized, and the stated interventions were not initiated when the resident expressed that her routine pain medication was not effective. The nurse did not offer her the PRN [MEDICATION NAME] for breakthrough pain, and there was no evidence that, when the resident expressed continued pain between the routine doses of [MEDICATION NAME], the nurse assessed the pain (type, location, severity, etc.) and provided alternate interventions. The director of nursing (DON - Employee #2) was notified, on 01/07/09 at 6:30 p.m., of the episodes of pain which were not thoroughly assessed and treated by the nurse. The DON agreed the nurse did not intervene according to the standards of practice when the resident expressed the need for additional pain medication. b) Resident #10 1. The physician' s orders, dated 01/01/09, contained an entry for: ""0.45% NS (normal saline) infuse at 75cc/hr PRN if not eating / drinking."" Medical record review revealed the resident was not eating, and she was receiving comfort care. The family did not desire a feeding tube, but they did want the IV fluids for hydration. This resident was observed on 01/05/09 at 2:30 p.m. with IV fluids infusing into her right hand. Another observation, at 6:00 p.m. on 01/06/09, found two (2) different nursing assistants attempting to feed this resident. She would not eat, spitting the food out and turning her head. She also was not drinking. The IV fluids were infusing at 75cc/hour at that time. Review of the medical record revealed staff was not accurately recording the amounts of fluid received by the resident on a daily basis. This IV fluid was ordered ""as needed"" and not continuously, and there was no record of accurate intake of these fluids per shift. There was no intake and output (I&O) record in the medical record on 01/01/09 or 01/05/09. It could not be determined, from the medical record, how much fluid intake this resident. Additionally, the resident's fluid output was not recorded on the I&O worksheets. This resident had an indwelling Foley urinary catheter, which would facilitate the measurement of the resident's urinary output. However, the urinary output was not recorded, and there was no evidence that anyone had compared the resident's output to the intake to check for a fluid balance. The Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. According to the MAR, there was no documentation to reflect IV fluids were administered on 01/06/09, and there was no intake records found for that day; however, this surveyor observed IV fluids being administered on 01/06/09 at a rate of 75cc/hour. During an interview with the minimum data set assessment (MDS) nurse (Employee #23) at 10:45 a.m. on 01/07/09, on she was asked if fluid I&Os were recorded elsewhere. She was unable to locate any further records of fluid I&O, and she verified there was no evidence the resident's fluid balance was being adequately monitored. 2. Resident #10 also had contractures to both hands. The resident's most current plan, updated on 11/25/08, specified as an intervention: ""Rolled up washcloths in left hand at all times."" The care plan also stated, ""Place resting splint on right hand from 9:00 a.m. to 3:30 p.m.""; staff was to place a rolled up washcloth in her right hand after the splint was removed. On multiple occasions on 01/05/09, 01/06/09, 01/07/09, and 01/08/09, observation found nothing in this resident's hands to prevent further contractures. On two (2) different occasions, the resident was wearing socks over her hands, but there were no devices in place to address the resident's contractures. During an interview with the MDS nurse at 10:45 a.m. on 01/07/09, she stated this resident should have had something for positioning in her hands due to the contractures. c) Resident #40 1. Medical record review, observation, and staff interview (on 01/06/09 and 01/07/09) revealed Resident #40 did not have on the ""double Geri gloves at all times"" as ordered by her physician. Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found the geri gloves were above her wrist and were not the double gloves. 2. The resident also had a physician's orders [REDACTED].@ all times"". Observation of the resident, with the MDS nurse on 01/06/08 at about 11:00 a.m., found both heels were resting directly on the beds. .",2014-02-01
11482,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,371,F,,,UFEY11,"Based on observations and staff interview, the facility failed to assure foods were served under conditions which assured the prevention of contamination, and failed to reduce practices which have the potential to result in food contamination and compromised food safety. This practice has the potential to affect all residents who receive nourishment from the dietary department. Facility census: 113. Findings include: a) At 2:30 p.m. on 01/05/09, observations, during the initial tour of the dietary department, revealed two (2) trays of cups and five (5) trays of cereal bowls; the cups and bowls were inverted on a synthetic shelving mat on flat trays prior to air drying. The cups and bowls were observed with trapped moisture, creating a medium for bacterial growth. The assistant dietary manager (Employee #45) was present and confirmed the identified problem. b) Observation with the dietary manager (Employee #42), on the afternoon on 01/07/09, again revealed inverted cups on a flat tray with a shelving mat which prevented the cups from proper air drying. The tray was observed under the area where the residents' food trays were served in the dining room. .",2014-02-01
11483,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,441,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on record review, staff interview, resident interview, and review of the infection incidence rate reports, the facility did not maintain an effective infection control program whereby infectious organisms leading to urinary tract infections (UTIs) were identified. Subsequently, the facility had no data by which analyze infection control data for trends and clusters. Organisms were not identified on the infection incidence log, nor were they tracked for infection control purposes. There was no evidence that clusters were identified. This was evident for four (4) of twenty (20) sampled residents. Resident identifiers: #11, #65, #75, and #35. Also, Resident #97 reported improper perineal care that could potentially cause a UTI from fecal contamination. Facility census: 113. Findings include: a) Residents #11 and #85 Resident #11 experienced repeated UTIs colonized with Escherichia coli (E. coli), bacteria found in feces. Record review revealed positive urine cultures for E. coli on the following dates: 05/18/08, 06/21/08, 08/28/08, 10/20/08, 12/07/08. Other organisms cultured included Alpha Streptococcus and [MEDICATION NAME] species on 07/25/08. Resident #11's roommate, Resident #85, also experienced UTIs as evidenced by positive urine cultures of E. coli with colony counts greater than 100,000 for the following dates: 09/23/08 and 11/03/08. Resident #85 also had a UTI identified in the emergency roiagnom on [DATE] (which was treated with Cipro), but the facility was unable to produce that culture report. Review of the facility's most recent quarter's infection incidence rate report (October, November, and December 2008) found Resident #11's E. Coli infections were not recorded for either October or December. With permission, perineal care was observed for Resident #85 on 01/07/09 at 1:45 p.m., after an episode of urinary incontinence. The nursing assistant used a [MEDICATION NAME] Care body wash / shampoo product for cleansing. After the incontinence brief was removed and the resident was cleansed, the nursing assistant used her contaminated gloved hands to pull up the resident's covers and pull back the privacy curtain between the two (2) beds. During interview with the director of nursing (DON - Employee #2) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). b) Resident #65 During record review on 01/06/09, the record revealed Resident #65 had a urinalysis laboratory report showing a UTI, reported on 11/06/08. This urinalysis / urine culture report identified E. coli as the infecting organism. The record contained another urinalysis laboratory report showing a UTI, reported on 10/25/08. This urinalysis / urine culture report identified Citrobacter freundii as the infecting organism. On 01/07/09, review of the infection control report / log for November 2008 did not show this resident's name, the presence of a UTI, or the cultures infectious. Review of the October 2008 infection control report / log, on 01/07/09, revealed this resident's name and ""UTI""; however, the infecting organism was not noted. On 01/07/09 at 6:30 p.m., the DON (who was also the infection control nurse) was made aware of these findings. No additional documentation was provided. c) Resident #75 Record review, on 01/07/09, revealed Resident #75 was seen at the emergency department at a local hospital on [DATE] - 12/19/08. The ""Hospital to Extended Care Facility Transfer Information"" form (dated 12/19/08) recorded a [DIAGNOSES REDACTED]. The facility subsequently obtained the laboratory report and provided copy to the surveyor on 01/08/09. This urine culture laboratory report identified Proteus mirabilis as the infecting organism. On 01/08/09, review of the infection control report / log for December 2008 revealed this resident's name with ""URI"" (upper respiratory infection) listed. The log did not show the resident's UTI or the infecting organism. d) Resident #35 Record review for Resident #35 revealed a urinalysis (UA) done on 12/19/08. The laboratory results indicated this resident had a UTI with E. coli present. This resident's UTI was treated, but there was no evidence the facility had monitored the infection and investigated the reason for this infection. This type of infection is often caused by inadequate perineal care. There was no evidence that the facility placed this resident on the facility's infection tracking form for tracking or trending. e) Resident #97 During an interview on 01/06/09, this resident stated, ""I have urinary tract infections a lot, and I am careful how I wash."" The resident then explained that she does not like the facility staff to give her a bath or wash her, because ""they do not know how to do it right to keep you from getting an infection."" She said, ""When I came in here, one of the nursing assistants gave me a shower and washed me back to front, and I will not let them wash me anymore."" The resident stated she ""reported this to the desk"" and now they let her take a bath herself. --- Part II -- Based on random observations, the facility failed to ensure staff distributed ice water in a manner to prevent the potential development and transmission of disease and infection. This was evident for all the residents on the 300 Hall and 400 Hall who were allowed to have water pitchers at the bedside. Facility census: 113. a) First observation 01/05/09 at 3:00 p.m., and shortly thereafter on the 300 Hall, a nursing assistant was observed during ice pass holding water pitchers directly over the open ice chest while dipping ice into the residents' used water pitchers, a practice which could potentially transmit microorganisms from the exterior surface of the dirty pitcher to the clean ice which was served to the residents on that hall. The nursing assistant was observed filling two (2) pitchers from room [ROOM NUMBER], one (1) pitcher from room [ROOM NUMBER], and two (2) pitchers from room [ROOM NUMBER] in this manner. At 3:15 p.m., the above observations were reported to the nurse (Employee #27), who immediately spoke with the nursing assistant about the matter. On the 400 Hall, three (3) nursing assistants were observed during ice pass dipping ice into residents' used water pitchers directly over the open ice chest below. At 3:20 p.m., 3:21 p.m., and 3:22 p.m., three (3) nursing assistants were each observed filling two (2) pitchers at a time in this manner, and one (1) single pitcher filled at 3:25 p.m. At 3:26 p.m., this practice was relayed to the corporate nurse (Employee #100), as she also observed one (1) of the three (3) nursing assistants dipping ice into two (2) pitchers directly over the ice chest, and she immediately addressed the situation with that nursing assistant. The corporate nurse then relayed information regarding this practice of dispensing ice to the administrator (Employee #1). b) Second ice pass observation During an observation of medication administration on 01/06/09 at 9:10 a.m., a nursing assistant (Employee #58) was observed passing ice to the residents on the 400 hall. Employee #58 was observed to enter room [ROOM NUMBER] and remove two (2) ice pitchers. The nursing assistant held the ice pitchers over the ice chest and filled them with ice. Following the previous day's observations and management interventions, staff continued to pass ice in a manner which could lead to the spread of microorganisms. .",2014-02-01
11484,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,328,E,,,UFEY11,"Based on random observation, staff interview, and policy review, the facility failed to ensure that residents received proper care for the special service of respiratory care as per facility policy. This was evident for four (4) of six (6) residents on the 300 Hall (Residents #2, #21, #26, and #108) and three (3) residents on the 400 Hall (Residents #48, #62, and #105), whose oxygen delivery supplies were not being changed weekly in accordance with facility policy. Facility census: 113. Findings include: a) Residents #2, #21, #26, and #108 During initial tour of the 300 Hall on 01/05/09 at approximately 2:30 p.m., observation found four (4) of the six (6) residents on that hall had oxygen (02) concentrators with oxygen delivery tubing dated 12/20/08. This was true for Residents #2, #21, #26, and #108. Resident #108 also had a nebulizer tubing and mask dated 12/20/08. (A fifth resident was receiving oxygen but refused the surveyor admittance into her room.) These findings were reported to the nurse (Employee #27) at approximately 2:55 p.m. 01/05/09, who reported that oxygen tubing was to be changed weekly. After checking the above referenced residents, she said she would see they were taken care of and would notify the nurse covering the 300 Hall. b) Residents #48, #62, and #105 On the morning of 01/07/09, observation found two (2) residents on the 400 Hall (Residents #48 and #62) with had no dates on their oxygen tubings. Also on 400 Hall, Resident #105 had a nebulizer tubing dated 12/02/08. These findings were reported, and the tubings were shown to the nurse (Employee #35). When asked who typically changed the oxygen tubing, she replied they were changed weekly, and that Employee #16 usually changed them. c) On 01/06/09 at approximately 2:00 p.m., the facility's Oxygen Administration policy was reviewed. In the revised January 2006 Respiratory Practice Manual, under Section 6.2.1. Oxygen Administration, the policy stated: ""Label nasal cannula (also humidifier) with resident name, date, and liter flow."" Review of Section 2.2.1. General Requirements found, under the procedure for the subject of Disposable Equipment Change Schedule subset 1.n.: ""02 (Oxygen) delivery devices - for example Venturi masks, nasal cannulas, oxygen supply tubings - every 5 days and PRN (as needed)."" When asked on 01/06/09 approximately 2:30 p.m., the director of nursing (DON - Employee #2) said the facility's policy was to change nasal cannulas and tubings weekly. On 01/07/09 at approximately 6:30 p.m., the above findings were reported to the DON. .",2014-02-01
11485,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,164,E,,,UFEY11,"Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to maintain resident privacy during showers. This was evident for three (3) of twenty (20) sampled residents and one (1) anonymous resident at the confidential resident group meeting. Resident identifiers: #51, #11, and #85. Facility census: 113. Findings include: a) Resident #51 During an interview on 01/06/09 at approximately 3:00 p.m., Resident #51 reported a lack of privacy in the shower room. She stated she was able to see the buttocks and breasts of other female residents, and that she, too, was exposed to another person in the adjoining shower. There was a big curtain separating the doorway from the shower stalls, but she stated you could see around the curtain where it was not fully block the view. b) Resident #11 On 01/07/09 at 9:25 a.m., Resident #11 was observed during a shower with her permission. She was in the left shower stall being bathed by a nursing assistant, while another resident was in the right shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. c) Resident #85 On 01/07/09 at 9:25 a.m., Resident #85 was observed during a shower with permission. She was in the right shower stall being bathed by a nursing assistant, while another resident was in the left shower stall being bathed by a different nursing assistant. A divider shower curtain between the two (2) stalls was present but not being used. Rather, the shower curtain was against the wall behind a Hoyer lift. d) Confidential resident group meeting interview On 01/06/09 at 10:30 a.m., a resident who attended the confidential group meeting reported the shower was not private. She also reported she was not always fully dressed properly when brought out of the shower. When asked for clarification in a separate interview on 01/07/09 at 2:00 p.m. regarding how the shower experience lacked privacy, she said she can see the breasts of residents in the adjoining shower while she is being showered. When asked about the blocks that extended part of the way up the shower stalls on each side facing the other stall, she replied she could see the residents' breasts over the blocks, as they were not high enough to block the view. When asked about the shower curtain between the stalls, she replied she had not ever noticed if there was a shower curtain between the stalls. She clarified she also saw the ""bottoms"" of other residents when they were brought out of the shower stall naked. When asked if there was a curtain between the showers and the main door, she replied in the affirmative but stated, for example, when she was brought in for a shower and was waiting her turn to get in, she could see the bodies of other residents around the curtains, as the curtains were not pulled fully closed and/or gapped open. e) The above findings were reported to the director of nursing (DON - Employee #2) at approximately 6:30 p.m. on 01/07/09. She stated she was not aware of these findings in the facility. .",2014-02-01
11486,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,221,E,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, a review of the incident / accident reports, and staff interview, the facility failed to assure that devices, applied and/or attached to a resident to restrict voluntary movement and/or normal access to one's body, were ordered by a physician to treat a medical symptom after the completion of a comprehensive assessment, to include the development and implementation of plans to systematically and gradually reduce the use of these physical restraints. Staff applied socks to Resident #10's hands, which restricted movement, without a physicians' order. Documentation in the medical records of Residents #36, #5, #28, and #85 inconsistently addressed the purpose of lap buddies applied to prevent rising and subsequent falls; throughout their charts, staff referred to these devices as ""enablers"" instead of physical restraints. Resident #36 consistently resisted the use of her lap buddy, injuring herself when her device was being applied; a plan to address this, as well as a plan for the systematic / gradual reduction of the use of this device, was not initiated. Devices were not adequately addressed for five (5) of twenty (20) sampled residents. Resident identifiers: #10, #36, #35, #28, and #85. Facility census: 113. Findings include: a) Resident #10 During an observation on 01/05/09 at 2:30 p.m., Resident #10 was laying in the bed with a sock applied to her right hand. This sock covered the resident's entire hand and was pulled up to the resident's elbow. Another observation, on 01/06/09 at 10:00 a.m., found socks present on both of the resident's hands, pulled up to her elbows. Review of the resident's medical record, including the monthly recapitulation of physician's orders (dated 01/01/09 through 01/31/09) revealed no active physician's order for any type of physical restraint, including the application of socks on this resident's hands. Review of Resident #10's current care plan, dated 11/25/08, found a plan directing staff to apply ""socks to hands at all times"". The medical symptom for the use of this physical restraint was ""prevent scratching face, removal of O2 (oxygen)"". This care plan then said, ""D/C (discontinue) 12/19/2008."" During an interview with the minimum data set assessment (MDS) nurse (Employee #23) on 01/07/08 at 10:45 a.m., the MDS nurse verified that the intervention to put socks on Resident #10's hands was discontinued on 12/19/08, and restraints should not have been in use on the days this surveyor observed the socks on this resident's hands on 01/05/09 and 01/06/09. b) Resident #36 Review of Resident #36's medical record found a physician's order, dated 12/05/08, stating, ""Resident may have standard size lap buddy to be used to protect resident from injury to herself or others as a therapeutic enabler to maintain the resident's highest physical & mental well being. Will re-evaluate prn (as needed), not to exceed 90 days. Will monitor use of this enabler @ least q (every) 30 minutes & release, assess & provide needs q2hr / prn (every two hours as needed). Resident may be enabler free during meal time while supervised. Use of this enabler is secondary to unsteady gait secondary to dementia."" Further review of the medical record revealed that, on 12/05/08, a ""Physical Restraint / Enabler Assessment"" was completed. Documentation on this assessment stated the conditions and circumstances necessitating the use of the restraint were ""danger of harming self or others"", as well as ""to improve self functioning"" through promoting ""proper positioning"". Instructions on the section titled ""Restraining Device"" stated ""complete if device is a restraint to be used to enhance functioning""; this section was left blank, even though the section above stated the device was being used ""to improve self function"". The next section on the assessment was titled ""Enabler Device"", which was to be completed if the device were an enabler to enhance functionality. The assessor recorded ""poor safety awareness with frequent falls"" as the medical symptom to be treated by the use of the device. The assessor also recorded that the device was to be used when the resident was in the wheelchair. Another form in the medical record titled ""Physical Restraint / Enabler Information"" was reviewed. There was a separate form for various devices used for this resident. These forms described if the device was a physical restraint or an enabler and the potential benefits and risks. (A separate form was completed for the perimeter mattress, the mobility alarm to the bed, the mobility alarm to the wheelchair, the low bed, and the lap buddy.) The form completed for the lap buddy identified was the device as an enabler of which this resident was cognitively aware. Among the benefits for using this device, the assessor recorded reduce risk of falls and maintenance of proper body positioning. The form contained a section titled ""Potential risks of a physical restraint / enabler use may include:""; this section was left blank. Further review of the nursing notes and incident / accident reports revealed this resident did not want the lap buddy attached to her chair, and it caused increased agitation. An incident / accident report, dated 12/05/08 at 7:00 a.m., stated, ""Resident continually tries to get out of chair to bed or from bed to chair. Resident placed in chair, belt alarm on and checked, resident taken to area beside nurses station. Lap Buddy put on and seat belt alarm removed."" An incident / accident report, dated 12/06/08 at 7:00 a.m., stated, ""Res (resident) was pushing at lap buddy while CNA (certified nursing assistant) was trying to put it on her wheelchair and residents wrist band slid and cut her arm."" Further documentation on this report recorded the resident ""stated that she was mad over lap buddy and was trying to keep the CNA from putting it on the WC (wheelchair)"". Another incident / accident report, dated 12/11/08 at 11:30 a.m., stated, ""Res (resident) did not want lap buddy put back on after going to the restroom. She pushed on lap buddy, fighting against the CNA and she got a skin tear on R (right) forearm."" Documentation on this incident / accident report indicated the resident was not compliant with the use of the prescribed assistive device and she tried to remove the lap buddy. An incident / accident report, dated 12/21/08 at 10:00 a.m., stated Resident #36 ""reopened a ST (skin tear) to the L (left) arm. Resident was fighting against CNA who was putting lap buddy on WC. She was flailing her arms around and hit arm on wheelchair."" A nursing note, dated 12/21/08 at 4:30 p.m., recorded, ""Resident continues to kick and hit during the application of lap buddy. Will monitor use of new lap buddy."" A nursing note, dated 12/25/08 at 1:00 p.m., recorded, ""Resident loud and verbal this a.m. (morning) Has made several attempts at removing lap buddy from chair, becomes physically aggressive with staff during care. Continue to monitor."" A nursing note, dated 01/03/08 at 6:30 p.m., recorded, ""Res observed throwing water pitcher full of water onto floor of room. She had also pushed over the bedside table. Resident stated that she wanted her lap buddy removed. Will continue to monitor for adverse behavior."" An interdisciplinary progress note, dated 12/15/08, recorded a new medication was being used and stated, ""She is also not always compliant with wearing double geri-gloves. She will take the off and not let the staff place them."" There was nothing mentioned about the noncompliance with the lap buddy or the fact that this resident was resistant to its use and was injuring herself with this device, which was ordered for safety to prevent injury. The resident's physical restraint / enabler care plan, dated 12/05/08, did not contain a problem, goal, or interventions with respect to the use of the lap buddy to promote increased functioning; the care plan simply said, in the first section, ""Refer to the physical restraint / enabler assessment""; the associated goal was: ""Will be free of negative effects with the use of an enabler."" The interventions listed did not assist in achievement of the stated goal. The interventions were: apply the enabler (lap buddy) when in the wheelchair for poor safety awareness with frequent falls; review the enabler information sheet every ninety (90) days; refer to the Mood and Behavior Symptom Assessment plan of care (which was reviewed and did not refer to the lap buddy in any way or resisting its use); refer to the falls assessment prevention and management plan of care (which did include the lap buddy use); refer to the skin integrity assessment (which did not contain information about the lap buddy) prevention and management plan of care; maintain resident bowel and bladder routine; and educate resident / family about physical restraints / enabler using the physical restraint / enabler information form (which was not complete). The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning, nor did it address the fact that the resident became agitated / resisted using this device and sustained injuries when the device was applied. During a dinner observation at 6:00 p.m. on 01/06/09 and a lunch observation at 12:30 p.m. on 01/07/09, this resident was observed sitting in her room eating independently with the lap buddy still attached to her wheelchair. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she stated this device was not a physical restraint; it was an enabler. When questioned about the difference between a physical restraint and an enabler, she indicated that, if a resident could not get up own his/her own, it was not a restraint. She was made aware of the inconsistent documentation and the inadequate assessment of this device for Resident #36. c) Resident #35 Record review revealed the following physician's order dated 12/19/08: ""Lap buddy may be used to protect resident to maintain residents highest physical / mental well being. Will reevaluate prn (as needed) not to exceed 90 days. Will monitor use of this restraint at least 30 minutes and release q 2 hours prn to assess and provide needs as needed. May be restraint free during meal time while supervised. Use secondary to dementia."" Further record review revealed a form titled ""Physical Restraint / Enabler Information"", dated 12/19/08, on which was written ""Lap Buddy"". Documentation on the form indicated the lap buddy was an enabler and the resident could remove it at will. The record contained another form titled ""Physical Restraint / Enabler Assessment. Documentation on this assessment form stated that the conditions for restraint consideration for this resident included ""danger of harming self or others"". Documentation at the bottom of the form indicated the device was an enabler to enhance functionality. According to this information, the enabler device was being used to treat the following medical symptom: ""Unable to ambulate independently secondary to [MEDICAL CONDITION]"". Review of the resident's current care plan, dated 12/05/08, found the statement: ""Refer to the physical restraint / enabler assessment."" The goal associated with this statement was: ""Will be free of negative effects with the use of an enabler."" The interventions were not pertinent to assist with the achievement of this goal. The interventions simply stated: ""Apply enabler, lap buddy, to wheelchair. Medical symptom: poor safety awareness secondary to dementia and [MEDICAL CONDITION]. Review the physical restraint / enabler sheet every 90 days."" The care plan did not identify how the lap buddy was being used to increase the resident's level of functioning. The DON, when interviewed about the use of this lap buddy, verified that the use / purpose of this device was inconsistently documented, and she acknowledged it was ordered by the physician as a physical restraint but was treated by the facility as an enabler. d) Resident #28 Medical record review, conducted on 01/06/09 at 1:32 p.m., revealed Resident #28 had physician's orders for a pommel cushion and a lap buddy. Further review revealed both devices were identified as ""enablers"" to protect her from injury due to decreased safety awareness. Review of the facility document titled ""Physical Restraint / Enabler Information"" found the following difference between a physical restraint and an enabler: - ""A physical restraint is any manual or physical or mechanical device, material or equipment attached or adjacent to the resident body that cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body."" - ""An enabler is a device, material or a piece of equipment attached or adjacent to the residents' body that the resident can easily remove and is cognitively aware of."" The Centers for Medicare & Medicaid Services (CMS) state, ""Physical Restraints are defined as any manual method or physical or mechanical device, material, or equipment attached or adjacent to the resident's body that the individual cannot remove easily which restricts freedom of movement or normal access to one's body."" On 01/06/09 at 5:30 p.m., the licensed practical nurse (LPN - Employee #36) identified that Resident #28 was not able to remove her lap buddy. Review of the resident's quarterly minimum data set assessment (MDS), dated [DATE], identified the resident's cognitive skills for daily decision making were moderately impaired. The use of the lap buddy with pommel cushion with Resident #28, therefore, did not meet the facility's own definition of an ""enabler"". Review of the facility policy titled ""5.2.1 Physical Restraint / Enabler Program"" revision date April 2006 identifies on page, in section 3-C: ""Select appropriate physical restraint alternative / enabler based on assessment. - Complete Restraining Device Section, if the device is a restraint used to enhance functionality. - Complete Enabler Device Section, if the device is an enabler used to enhance functionality."" Review of the document titled ""Physical Restraint / Enabler Assessment"" for the lap buddy (initially completed on 11/28/07 updated on 02/03/08, 05/14/08, and 11/19/08) found the assessor never identified the lap buddy as a physical restraint. Review of the resident's current care plan, dated 11/26/08, found staff identified the lap buddy as an enabler, although the device met the facility's definition of a physical restraint (not an enabler). The care plan did not contain a systematic and gradual plan towards reducing the use of the restraint (e.g., gradually increasing the time for ambulation and muscle strengthening activities), nor did the care plan identify what care and services would be provided during the periods of time when the restraint would be released or what meaningful activities would be provided. e) Resident #85 Record review revealed Resident #85 used a lap buddy daily, but there was no systematic plan for restraint reduction, release, and meaningful activities to be provided. There was also a discrepancy within the facility's documentation as to whether her lap buddy was a physical restraint or enabler. Documentation on the physical restraint information sheet, dated 4/15/08, noted the application of a lap buddy to her wheelchair and defined a physical restraint as a device that ""cannot be easily removed by the resident and restricts freedom of movement or normal access to one's own body"". The assessor consistently documented in Section P4 of the resident's MDS assessments, dated 06/26/08, 09/25/08, and 12/2508, that a ""trunk restraint"" was in use. During an interview on 01/08/09 at 11:15 a.m., Employee #18 said the MDS assessments were coded incorrectly, and the lap buddy should have been coded as a chair preventing rising, and agreed they should have one (1) care plan per device. Review of Resident #85's current care plan found the use of a physical restraint was initially developed on 04/15/08. The care plan did not specify interventions of a systematic plan for restraint reduction nor for planned releases of the lap buddy. The care plan also did not specify meaningful activities, rather it stated to ""See Activity Pursuit POC"" (plan of care). Review of the activity pursuit plan of care found interventions of large music groups, socials, parties, and visits with family, but there were no plans to offer diversional activities as a part of a restraint reduction plan to keep the resident engaged, so that a physical restraint may not be necessary. Interview with the activities director (Employee #11), on 01/08/09 at 2:00 p.m., revealed her belief that Resident #85 had declined a lot the past few months and no longer took part in many activities; she estimated the resident's attention span to be ten (10) minutes at the most. She said she did provide for Resident #85 one-on-one activities two (2) or three (3) times per week. She cited the resident's illness in September as the beginning of her decline and produced an activity record for August that evidenced much more participation in activities. Random observation on 01/07/09, between 11:15 a.m. and 11:30 a.m., found her up in the wheelchair with the lap buddy in place. During this time, she entered four (4) residents' rooms. Housekeeping staff brought her out once, a nursing assistant brought her out once, and she left on her own accord twice. Another random observation on 01/07/09, between 11:33 a.m. and 11:41 a.m., revealed she was up in the wheelchair with the lap buddy in place. Her daughter came in for a visit to feed her and to walk around the building with her, and she continued to have the lap buddy in place throughout the family visit until the daughter left at 1:30 p.m. She was returned to bed at 1:45 p.m. after being in the wheelchair with the lap buddy for at least two and one-half (2-1/2) hours. On 01/07/09 at 6:15 p.m., the DON stated a ""restraint is anything that restricts you from standing up"", citing if a resident could not stand up voluntarily anyway, then the device was an enabler (not a physical restraint). She stated that, if a resident were leaning or scooting out of a chair, then the lap buddy would also be an enabler; she replied in the affirmative when asked if a tied restraint would also be an enabler in that same situation. She said she believed an enabler was coded as a trunk restraint on the MDS. .",2014-02-01
11487,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,285,D,,,UFEY11,"Based on record review and staff interview, the facility failed to assure that a Level II evaluation was completed, when indicated, prior to the admission of one (1) of twenty (20) sampled residents. Resident identifier: #108. Facility census: 113. Findings include: a) Resident #108 Record review, on 01/07/09, revealed Resident #108 was admitted to the facility in 2008. The Pre-Admission Screening and Resident Review (PASRR) Determination, dated eleven (11) days prior to the current admission, stated that a Level II evaluation was required for this individual. However, the Level II evaluation itself was not completed prior to this admission to this facility. These findings were reported to Employee #8 on the morning of 01/08/09. She, in turn, referred the matter to the admissions / social worker to see if more information was on record in the social worker's office. On 01/08/09 at approximately 11:55 a.m., Employee #8 produced a Level II assessment signed by a supervised psychologist that was dated six (6) days after Resident #108's current admission. Employee #8 stated they thought the PASRR had been completed by the transferring facility. The finding of the delinquent pre-admission Level II evaluation was reported to the director of nursing at approximately 6:30 p.m. on 01/07/09. .",2014-02-01
11488,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,329,D,,,UFEY11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility did not ensure the medication regimen of one (1) of twenty (20) sampled residents was free from unnecessary drugs without adequate indications for use. Resident #62 was under the care of a psychiatrist for her mood / behavior, having been evaluated on 05/09/08; in addition to medication changes, the psychiatrist recommended a follow-up appointment within nine (9) weeks or as necessary. Additional psychoactive medications ([MEDICATION NAME] and [MEDICATION NAME] ER) were added to the resident's medication regimen without first assessing for [MEDICATION NAME] / extrinsic factors that may have caused or contributed to changes in the resident's behavior and/or without contacting the psychiatrist. Resident identifiers: #62. Facility census: 113. Findings include: a) Resident #62 1. Medical record review, on 01/06/09 at 4:15 p.m., revealed Resident #62 received several psychoactive medications for mood / behavior, including [MEDICATION NAME], and [MEDICATION NAME]. Further review revealed a psychiatric evaluation was completed on 05/09/08, after which the psychiatrist recommended increasing her [MEDICATION NAME] and instructed the facility to watch her for serotoni[DIAGNOSES REDACTED], since she was already receiving [MEDICATION NAME] and [MEDICATION NAME]. The psychiatrist also recommended a follow-up appointment in nine (9) weeks, or sooner if needed. Subsequent to the psychiatric consult, the resident's attending physician increased the [MEDICATION NAME] to 0.5 BID on 05/10/08 and decreased her [MEDICATION NAME] to 5 mg BID on 05/15/08. 2. At the beginning of June, Resident #62 began to exhibit increased anxiety, and in July, she had a panic attack. The facility did not contact the psychiatrist regarding these events. 3. On 09/30/08, she exhibited increased behaviors and was given [MEDICATION NAME] 1 mg intramuscularly (IM). Nursing progress notes did not contain any documentation to reflect an assessment for [MEDICATION NAME] or extrinsic factors that may have caused or contributed to the increase in behaviors. On 10/01/08, she again exhibited increased behaviors, and she was given [MEDICATION NAME] 1 mg IM. The facility did not contact the psychiatrist regarding these events. A urinalysis later revealed Resident #62 had a urinary tract infection [MEDICAL CONDITION]. The facility failed to rule out [MEDICATION NAME] or extrinsic causes of the increased behaviors prior medicating her with [MEDICATION NAME] IM. 4. On 11/12/08, the attending physician added [MEDICATION NAME] ER to the resident's medication regimen. There was no evidence to reflect the facility contacted the psychiatrist regarding changes in the resident's behaviors / condition for which the attending physician added the [MEDICATION NAME] ER. 5. On 01/07/09 at 4:15 p.m., the director of nursing (DON - Employee #2) was questioned if psychiatric services was consulted upon increase in behaviors. On 01/08/09, the DON was unable to provide any information to show that the facility had contacted the resident's psychiatrist after any of the episodes which resulted in changes in her psychoactive medications. .",2014-02-01
11489,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,520,E,,,UFEY11,"Based on medical record review, review of the facility's infection control tracking log, and staff interview, the facility failed to maintain a quality assessment and assurance (QAA) committee that identifies quality deficiencies (of which it should have been aware) and develops / implements plans of action to correct these deficiencies. The facility had a high number of residents with urinary tract infections (UTIs). The QAA committee failed to identify deficits in the infection control program (with respect to tracking infectious organisms, identifying trends through analysis of the facility's infection control data, and investigating the UTIs to identify any underlying causal or contributing factors) and failed develop / implement measures to address these deficits. Facility census: 113. Findings include: a) Record review, during the facility's annual certification resurvey conducted from 01/05/09 through 01/08/09, revealed multiple residents with UTIs, several of whom had the same infectious organism and resided in the same location (same room and/or hall within the facility). On the afternoon of 01/06/09, the director of nursing (DON - Employee #2) was identified as the individual designated as responsible for infection control tracking. At this time, a copy of the November and December 2008 infection control tracking logs was requested and received. A review of the infection control tracking logs revealed the DON / infection control nurse failed to log the organisms identified through cultures as being responsible for each infection. In an interview with the DON and administrator (Employee #1) on 01/07/09 at 4:30 p.m., the DON acknowledged that she did not record infectious organisms on the tracking logs. During interview with the director of nursing (DON) on 01/07/09 at approximately 6:30 p.m., she produced the facility's most recent quarter (October through December 2008) of monthly incidence rates of infections. This form was to contain the names and room numbers of each resident with infection as well as the types of infection (i.e., respiratory, urinary, skin), the onset date, antibiotic prescribed, and the type of precautions utilized. All of the precautions for all of the infections (regardless if UTI, respiratory, or skin) were listed as ""standard"" precautions for those three (3) months. The accompanying infection surveillance worksheets listed the onset of symptoms, whether it was urinary or respiratory, the name of the antibiotic prescribed, and the start / stop dates of the antibiotic. Neither the organisms isolated, nor the antibiotics the organisms were resistant to, nor the date and site of the culture were listed on any of the infection surveillance worksheets, although there were designated places on the form for recording each these items. A breakdown of numbers of residents with infections were recorded during the most recent quarter as follows: - October - twenty-two (22) residents with sixteen (16) infection surveillance worksheets; - November - twenty-four (24) residents with nine (9) infection surveillance worksheets; - December - eighteen (18) residents with seven (7) infection surveillance worksheets. The DON stated she did not track the infectious organisms anywhere and was not aware of any method they used to assess for clusters of organisms (e.g., to determine whether staff may be communicating infectious organisms between residents on the same unit, etc.). There was no evidence that the facility's QAA committee had been monitoring the effectiveness of the facility's infection control program. (See also citation at F441.) Quality deficiencies would have been evident had the QAA committee members reviewed the facility's infection incidence rate reports and/or infection surveillance worksheets, which were incomplete. .",2014-02-01
11490,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,225,D,,,UFEY11,"Based on a review of the facility's complaint files, observation, and staff interview, the facility failed to immediately report and/or thoroughly investigate injuries of unknown origin and allegations of abuse to the appropriate State agencies. For Resident #96, an allegation of abuse was reported to the facility and investigated, but the facility did not report the allegation to State agencies. Resident #75 had bruising of unknown origin to her leg and lower back area, and this was not reported or investigated. This was true for one (1) of six (6) randomly reviewed complaints (#96), and one (1) of twenty (20) sampled residents (#75). Facility census: 113. Findings include: a) Resident #96 Review of the facility's complaint files found a concern report, dated 12/02/08, documenting that this resident's daughter called and said her mother said her legs were hurting and, when the resident was given a shower, ""the aids (sic) hurt her legs and were rough with her"". The facility conducted an internal investigation and took statements from the aides, but the allegation of abuse / mistreatment was not immediately reported to State agencies as required, nor were the results of the facility's investigation forwarded to the State within five (5) working days of the incident. During an interview with the director of nursing (DON - Employee #2) on 01/07/09 at 6:30 p.m., she verified this incident was investigated but was not reported as abuse, stating it was already resolved by the time the concern was filed by the family. b) Resident #75 A record entry on a Physician Notification form, dated 01/07/09, noted bruises of unknown origin to the right inner thigh (measuring 18 cm x 0.25 cm) and the left inner thigh (measuring 1 cm x 8 cm) and a buttock abrasion (measuring 2.3 cm x 2 cm). The entry noted the physician was notified of these injuries at 8:40 a.m. on 01/07/09. During a review of the facility's incident / accident reports for that day, there was no evidence that an accident / incident report had been completed. There was also no evidence that this bruising of unknown origin was investigated or reported to the appropriate state agency. During an interview at 12 noon on 01/08/09, the DON stated she did not report the injuries. During an interview at 12:10 p.m. on 01/08/09, the administrator stated she would check into these injuries. She subsequently confirmed there was no accident / incident report and the injuries were not been reported to the State agencies. There was no formal investigation initiated to find the cause of the injuries. A ""late entry"" accident / incident report was shown to the surveyor at 1:30 p.m. on 01/08/09. .",2014-02-01
11491,ARBORS AT FAIRMONT,515189,130 KAUFMAN DRIVE,FAIRMONT,WV,26554,2009-01-08,313,D,,,UFEY11,"Based on observation, record review, and resident interview, the facility failed to assist residents with the use of assistive devices needed to maintain hearing or vision. Residents were observed without their assistive devices in place, which could affect their abilities to interact with their environment. This occurred for two (2) of twenty (20) sampled residents. Resident identifiers: #65 and #36. Facility census: 113. Findings include: a) Resident #65 On 01/07/09 at 10:00 a.m., Resident #65, when observed in physical therapy (PT), was not wearing eyeglasses. During resident interview, Resident #65 stated she needed her glasses both to read and to ""see all the time"". Staff members were present at the time this surveyor was questioning the resident, and one (1) staff member went to get the resident's glasses and returned to PT. She then placed the eyeglasses on the resident's face. b) Resident #36 During initial tour of the facility on 01/05/09 at 2:30 p.m., this surveyor spoke to Resident #36. The resident did not answer questions and looked at the surveyor with a puzzled look. The surveyor introduced herself and asked what her name was. She did not answer or give any sign that she understood what was being asked of her. During another visit on the morning of 01/06/09, Resident #36 was observed sitting up in her wheelchair; she had just finished eating her breakfast. This surveyor spoke to the resident, and again she looked puzzled as if she did not understand what was being said. The surveyor the leaned down and spoke louder and directly into the resident's left ear, asking how her breakfast was. The resident immediately started discussing her breakfast and responded appropriately to each question subsequently asked of her when it was spoken directly into her ear. The resident stated, ""I don't hear well."" After this, all communication was understood by this resident. In a nursing note entry, dated 01/07/09 at 10:00 p.m., the nurse recorded, ""Resident noted to refuse to interact with staff members for brief period, ignored this nurse when asked to take medications. VS (vital signs) were WNL (within normal limits)."" The nurse then indicated that, when the nursing assistant addressed the resident, the resident responded cooperatively. During medical record review, the resident's hearing was reviewed. The admission assessment, dated 04/08/08, indicated the resident had hearing aids. The minimum data set (MDS) assessment indicated the resident did not have problems understanding others when a a hearing device was used. The care plan identified the resident was hard of hearing and contained an intervention - ""hearing aid clean"" . The care plan did not direct the caregiver to be sure the resident wore the hearing aids when she was up and/or to be sure that the hearing aids were working properly. A nursing assistant (Employee #63) was observed providing care for this resident at 12:30 p.m. on 01/08/09. She was asked if she had provided care to this resident in the past, and she said she had been here a while and had worked with this resident many times. When asked if she was aware the resident had hearing aids, she stated she was not aware of this and she had not seen them. At that time, Resident #36's roommate, from behind the privacy curtain, said, ""She has them in her drawer at her bedside."" The nursing assistant looked in the drawer and found two (2) hearing aids in a small case. The nursing assistant tried them and said that they must need batteries, because they were not working. The facility did not assure this resident's assistive hearing devices were clean, working properly, and placed in her ears so that she could communicate with and understand others. .",2014-02-01
3510,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2019-04-17,584,E,0,1,280911,"Based on observation and staff interview, the facility failed to provide a comfortable and homelike environment during meals in the dining room. The dining room environment did not offer stimulation such as television, music, or any activities, while the residents waited for their meals. This practice affected more than a limited number of residents. Facility census: 19. Findings included: a) Observations An observation of the dining room, on 04/15/19 at 11:40 AM, revealed residents were brought in for the lunch dining service. There were approximately fourteen (14) residents. There was no stimulation in the dining room. The room was quiet. Five (5) residents were observed sleeping in their chairs. The lunch trays were not served until 12:05 PM. An observation of the dining room, on 04/16/19 at 11:45 AM, revealed residents were brought in for the lunch dining service. There were approximately thirteen (13) residents. There was no stimulation in the dining room, The room was quiet. Six (6) residents were observed to be asleep in their chairs. A female resident asked the staff what am I supposed to be doing right now? b) Interviews An interview with Nurse Aide (NA) #25, on 04/16/19 at 12:15 PM, revealed they never play music or do activities with the residents before meals in the dining room. An interview with the Administrator, on 04/16/19 at 1:45 PM, revealed they used to play music in the dining room but stopped a few years ago due to complaints. The Administrator stated they had not tried to reintroduce the music or any dining room stimulation since the complaints were voiced.",2020-09-01
3511,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2019-04-17,641,D,0,1,280911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, record review and staff interview the facility failed to accurately complete an assessment, reflective of Resident #3 status at the time of the assessment. The facility failed to check depression on the MDS section I Active Diagnosis. The failed practice affected one (1) of ten (10) residents. Resident identifier: #3. Facility census: 19. Findings included: a) Resident #3 An observation of Resident #3, on 04/15/19 at 11:00 AM, revealed Resident #3 was socially withdrawn from facility activities. An interview with Resident #3, on 04/15/19 at 11:00 AM, stated he felt tired all the time. Resident #3 stated that he participated in rehab but rehab wore him out so he doesn't participate in facility activities. A record review, on 04/16/19 at 09:40 AM revealed a current [DIAGNOSES REDACTED]. The minimum data set (MDS) dated for 02/27/19 revealed that depression was not marked as an active [DIAGNOSES REDACTED]. An interview with MDS Coordinator, on 04/16/19 at 10:00 AM, confirmed depression should have been marked on the MDS. MDS Coordinator stated I do not have depression marked, I missed it.",2020-09-01
3512,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2019-04-17,684,D,0,1,280911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have written physician orders for residents receiving [MEDICAL TREATMENT] and hospice. This practice affected two (2) of ten (10) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #6 and #11. Facility census: 19. Findings included: a) Resident #6 An interview with Licensed Practical Nurse (LPN) #30, on 04/16/19 at 9:00 AM, revealed the Resident was in hospice. A review of the Resident's physician orders, on 04/16/19 at 9:15 AM, revealed there was not an order in the record for hospice services. An interview with the Director of Nursing (DON), on 04/17/19 at 8:30 AM, revealed the resident was admitted to the unit on 12/10/18 with continuing hospice services. The DON stated the facility failed to obtain the written order from the physician when the resident was admitted on [DATE]. The DON obtained the order from the physician on 04/16/19 when it was requested during the LTCSP. b) Resident #11 A record review, on 04/16/19 at 2:31 PM, revealed a care plan that stated Resident #11 required [MEDICAL TREATMENT] 3 days a week on Tues, Thurs and Sat at 11:20AM @Fresenius [MEDICAL TREATMENT] Center in Dunbar, WV. Further record review of physician orders, on 04/16/19, revealed no physician order for [REDACTED].>An interview with the DoN, on 04/17/19 at 8:36 AM, confirmed there was no written physician order for [REDACTED].",2020-09-01
3513,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2019-04-17,812,E,0,1,280911,"Based on observation, staff interview and policy review the facility failed to store, distribute and serve food in accordance with professional standards for food service safety. Butter was found in the dining room condiment station not refrigerated and an employee in the kitchen did not wear a beard restraint in the food production area. The failed practice had the potential to affect more than a limited number of residents. Facility census: 19. Findings included: a) Butter An observation in the dining room, on 04/15/19 at 12:12 PM, revealed individually wrapped butter stored in the condiments station. The wrapper stated contains cream and milk. Butter was warm to touch and not refrigerated. An interview with Dietary Manager, on 04/15/19 at 12:16 PM, revealed that butter is real and that it should have been refrigerated. b)[NAME]Restraint During the initial tour of the kitchen, on 04/15/19 at 10:10 AM, observed a male kitchen staff (KS) #1 was not wearing a beard restraint over his goatee. An immediate interview with Dietary Manager (DM), on 04/15/19 at 10:10 AM, revealed that he does not normally wear one, as it is is usually not that long. A review of the facility's policy titled Food Safety and Hygiene Policy was conducted on 04/16/19 at 9:05 AM. The policy stated, Keep beard and mustaches neat and trimmed.[NAME]restraints are required in any food production area.",2020-09-01
3514,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2019-04-17,842,D,0,1,280911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to have complete and accurate medical records. There were no written physician orders for residents receiving [MEDICAL TREATMENT] and hospice in their medical records. This practice affected two (2) of ten (10) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #6 and #11. Facility census: 19. Findings included: a) Resident #6 An interview with Licensed Practical Nurse (LPN) #30, on 04/16/19 at 9:00 AM, revealed the Resident was in hospice. A review of the Resident's physician orders, on 04/16/19 at 9:15 AM, revealed there was not an order in the record for hospice services. An interview with the Director of Nursing (DON), on 04/17/19 at 8:30 AM, revealed the resident was admitted to the unit on 12/10/18 with continuing hospice services. The DON stated the facility failed to obtain the written order from the physician when the resident was admitted on [DATE]. The DON obtained the order from the physician on 04/16/19 when it was requested during the LTCSP. b) Resident #11 A record review, on 04/16/19 at 2:31 PM, revealed a care plan that stated Resident #11 required [MEDICAL TREATMENT] 3 days a week on Tues, Thurs and Sat at 11:20AM @Fresenius [MEDICAL TREATMENT] Center in Dunbar, WV. Further record review of physician orders, on 04/16/19, revealed no physician order for [REDACTED].>An interview with the DoN, on 04/17/19 at 8:36 AM, confirmed there was no written physician order for [REDACTED].",2020-09-01
3515,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,656,D,0,1,TL6L11,"Based on observation, record review and staff interview, the facility failed to ensure staff implement care plan interventions for incontinence care and failed to fully develop another care plan for a resident receiving Hospice services. This was true for two (2) of eleven (11) care plans reviewed during the annual Long Term Care Survey Process. Resident identifier: #2, and #17. Facility census: 20. Findings included: a) Resident #2 Review of an annual minimum data set (MDS) with an assessment reference date (ARD) of 03/10/18 revealed a resident with dementia, bladder and bowel incontinence, totally dependent for toileting, transferring, and bathing; as well as needing extensive assistance for all other activities of daily living (ADL). Observations of Nurse Aide (NA) #51 and NA #18 providing perineal incontinence care to Resident #2, on 06/19/18 at 02:28 PM, revealed the NA's did not apply skin cream to the resident's skin after providing peri-care. Perineal care is usually called peri care. Peri-care refers to washing the perineal area, the genitals and anal area. Peri-care helps prevents skin breakdown of the perineal area in those incontinent of bladder and bowel. On 06/19/18 at 03:59 PM, review of Resident #2's care plan, revealed incontinence care was addressed. One of the interventions included apply skin cream after each incontinent episode. During an interview, on 06/19/18 at 04:03 PM, NA #51 reported being aware skin cream was to be applied after each incontinent episode. When inquired if skin cream was applied after providing incontinence care to Resident #2, NA#51 said, I'll be honest with you I didn't apply the skin cream. I forgot . b) Resident #17 Review of a significant change minimum data set (MDS) with an assessment reference date (ARD) of 05/23/18 revealed a resident with dementia, dependent with bathing and needing extensive assistance for all other activities of daily living (ADL). The resident's Brief Interview for Mental Status (BIMS) score is five (5) out of 15 indicating the resident is severely cognitively impaired. Resident receiving hospice services. Review of records, on 06/20/18 at 01:16 PM, revealed Resident #17 was referred to hospice on 05/16/18. Review of the resident's care plan revealed no interventions indicating how Hospice and the facility communicated with each other or any contact information for the facility to be able to contact hospice twenty-four (24) hours a day. On 06/20/18 at 01:52 PM, an interview with the Director of Nursing (DON), Assistant Director of Nursing (ADON), and Minimum Data Set Registered Nurse (MDS RN) RN#61 occurred. Interview revealed hospice contact information had not been placed in the resident's care plan but would be added.",2020-09-01
3516,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,657,D,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure they revised two (2) of twelve (12) care plans when a resident's health status and needs changed. Resident #120's care plan was not revised to include a nutritional intervention and Resident #13's care plan was not revised to reflect a change in the time of transport for [MEDICAL TREATMENT]. Resident identifiers: #13 and #120. Facility census: 20. Findings included: a) Resident #120 The medical record review for Resident #120 revealed a physician's orders [REDACTED]. The resident had a care plan developed for risk of weight loss due to being new to the facility. This plan was started on 05/31/18. The care plan for nutrition was not revised to reflect the addition of Ensure Plus as an intervention for weight loss. On 06/21/18 at 9:45 AM Registered Nurse #61 was asked if the Ensure Plus was included under the interventions for the care plan area of nutritional risk of weight loss. She said it had not been included yet. b) Resident #13 An interview with the Assistant Director of Nursing (ADON), on 06/18/18 at 11:48 AM, revealed Resident #13 received [MEDICAL TREATMENT] services from a [MEDICAL TREATMENT] center. When asked how the facility communicates with the [MEDICAL TREATMENT] center, the ADON said a [MEDICAL TREATMENT] communications notebook was kept. The [MEDICAL TREATMENT] communications notebook had vital signs, POST (Physician order [REDACTED]. The ADON said an ambulance service provided transportation for the resident to and from [MEDICAL TREATMENT]. On 06/20/18 at 03:53 PM, interview with Licensed Practical Nurse (LPN#35), revealed what the nurse did when Resident #13 returns to the facility from [MEDICAL TREATMENT]. LPN#35 said she assesses the resident, checks for pain, and sees if the dressing on his catheter port site is clean. LPN#35 stated she checks the communication sheets, that are returned with the resident from [MEDICAL TREATMENT], to see if there are any new orders. LPN#35 said she then places the communication sheets in the [MEDICAL TREATMENT] communication book. Review of a quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/25/18, on 06/19/18 at 06/21/18 at 08:05 AM, revealed the resident's Brief Interview for Mental Status (BIMS) score is fourteen (14) indicating the resident is cognitively intact. The resident needs extensive assistance for activities of daily living (ADL). Pertinent [DIAGNOSES REDACTED]. Resident #13 is receiving [MEDICAL TREATMENT] services. On 06/21/18 at 09:04 AM a review of the care plan revealed a focus concerning [MEDICAL TREATMENT] with appropriate interventions. One of the interventions stated the resident goes to [MEDICAL TREATMENT] at 9:00 AM on [MEDICAL TREATMENT] scheduled days. Observations on 06/21/18 at 09:28 AM, a scheduled [MEDICAL TREATMENT] day, revealed the resident was still in his room lying in his bed. Upon inquiry The Minimum Data Set Registered Nurse (MDS RN) RN#61 stated, Resident#13 was scheduled to leave for [MEDICAL TREATMENT] at 9:00 AM. When asked why the resident was still in his room, RN#61 said she was not sure, but would find the nurse on duty and find out. Nurse Aide (NA#52) was observed in the hallway outside the resident's room and was asked when the resident is transported to [MEDICAL TREATMENT]. NA #52 said it used to be at 9:00 AM now the ambulance picks up the resident later, she thought around 10:00 AM. When asked how she knew what time the resident was to be ready for transport, she said a nurse had told her the other day the time had been changed. During an interview on 06/21/18 at 09:35 AM, Resident #13 explained, he goes to [MEDICAL TREATMENT] around 10:00 AM. Further stated, he has been going at 10:00 AM, for about ten (10) days. After reviewing the [MEDICAL TREATMENT] communication book on 06/21/18 at 10:10 AM, the ADON reported, could not find the changed current time the resident went for [MEDICAL TREATMENT]. The ADON said, would expect to see it communicated in the book or in a progress note. Review of records revealed no note concerning the change in time. The ADON said she was aware of the change from 9:00 AM to 10:00 AM for ambulance pick up and was surprised she did not make a note. When asked how NA's would know about the change, the ADON said it would be on the NA's assignment schedule and nurses would know from the care plan. Review of the assignment sheet for NA#52 assigned to Resident #13, dated 06/21/18 for 7 AM to 3 PM shift, specified [MEDICAL TREATMENT] Tues (Tuesday), Thurs (Thursday), Sat (Saturday) p/u (pick up) 9:00 AM. Review of care plan showed it was not revised, and still indicating 9:00 AM. as the time of transport to [MEDICAL TREATMENT]. The ADON reported on 06/21/18 at 11:21 AM, the facility was notified of the change of time on 06/05/18. She said it should have been placed in Resident #13's record, so his care plan could have been updated.",2020-09-01
3517,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,689,D,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident's environment, over which it had control, was as free from accident hazards as possible. A Nurse Aide (NA) left a resident, with a history of falls, unattended in their bed in a high position. This was true for one (1) of twelve (12) residents reviewed during the annual Long Term Care Survey Process. Resident identifier: #13. Facility census: 20. Findings included: a) Resident #13 Review of Resident #13's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 04/25/18 revealed the resident's Brief Interview for Mental Status (BIMS) score is fourteen (14) out of fifteen (15) indicating the resident is cognitively intact. The resident needs extensive assistance for activities of daily living (ADL). Pertinent [DIAGNOSES REDACTED]. Resident #13 is receiving [MEDICAL TREATMENT] services from a [MEDICAL TREATMENT] center. Observations on 06/21/18 at 09:28 AM, revealed NA #52 assisting Resident #13 with personal hygiene and ADL's. While NA #52 was providing the care the resident's bed was observed in the high position. On 06/21/18 at 09:35 AM, the resident was observed alone in his room lying in his bed, with the bed still in the high position. During an interview Resident #13 was lying in his bed, which positioned him well above this surveyor's waist. The resident was asked some questions about [MEDICAL TREATMENT], and then asked if his bed is usually left in the high position. Resident#13 replied No, it never is. While waiting outside Resident #13's room for NA #52 to return, on 06/21/18 at 09:43 AM, observed NA #51 walking in the hallway carrying soiled linen. NA #51 was asked to come to Resident #13's room doorway and inquired the resident's bed was to be left that high with no one in the room. NA#51 replied, No Ma'am it is not. NA #51 continued down the hall to dispose of the soiled linen. At 09:45 AM, NA #51 returned and entered Resident#13's room and lowered the bed. On 06/21/18 at 09:49 AM, NA #52 when returning to the hall was asked, by this surveyor, if any resident was to be left alone with their bed in a high position. NA #52 replied, No. NA #52 said she forgot that it was left in the high position, and agreed it was a fall hazard.",2020-09-01
3518,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,711,D,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to identify a discrepancy in an order regarding the route of administration of insulin via an insulin pen for a diabetic resident. This was true for one (1) of five (5) residents reviewed during the annual Long Term Care Survey Process for unnecessary medications. Resident identifier: #3. Facility census: 20. Findings included: Review of Resident #3's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/20/18, on 06/21/18 at 08:00 AM, revealed the resident's Brief Interview for Mental Status (BIMS) score is six (6) indicating resident is cognitively severely impaired. The resident needs extensive assistance for activities of daily living (ADL), except resident needs supervision with eating. Pertinent [DIAGNOSES REDACTED]. Review of orders for Resident #3 revealed an order for [REDACTED]. The order read Basaglar KwickPen 100ml (milliliters) three (3) ml SQ (subcutaneous) (35 U (units) IM (intramuscular) Q (every) D (day) DM (for Diabetes Mellitus)). Review of the manufacturer's (Eli Lilly) instructions, revised on 04/20/17, approved by the U.S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneously) of your stomach area, buttocks, upper legs or upper arms. On 06/21/18 at 12:21 PM, interview with Licensed Practical Nurse (LPN#47), revealed the resident receives Basaglar at 4:00 PM every day. LPN#47 said she works days shift and is not at the facility when the resident receives Basaglar at 4:00 PM. This surveyor requested LPN#47 to review the order. LPN#47 said after the order was reviewed said, Thats wrong, you would not give it IM. Review of records, on 06/21/18 at 12:23 PM, revealed medication regimen reviews, were completed by the Pharmacy on dates 06/07/18, 05/03/18, 03/30/18, and 03/01/18. On 06/21/18 at 12:40 PM Director of Nursing (DON), agreed Basaglar insulin is not given IM, but only SQ. Review of the Medication Administration Record (MAR) for the month of (MONTH) revealed the MAR stated Basaglar KwickPen 100ml 3ml SQ (35 U IM Q D DM). A nurse signed each day in (MONTH) that the insulin was given. The DON said the nurses have been trained that when they sign the MAR they are stating they gave the insulin IM. The DON agreed the order should have been clarified by the nurses, the Physician and the Pharmacy should have caught the discrepancy on the route of administration of the insulin. The Physician when he signed the order and/or reviewed the physician monthly summary of orders. The Pharmacy when the monthly medication regimen reviews were completed.",2020-09-01
3519,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,726,E,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure the competency of licensed nursing staff who were responsible for administering medications to residents. The nursing staff failed to identify and clarify an order regarding a discrepancy in the route of administrating insulin to a diabetic resident. Nursing staff documented giving insulin multiple times using an intramuscular (IM) route instead of the appropriate recommended route of subcutaneous (sq). This was true for one (1) of five (5) residents reviewed during the annual Long Term Care Survey Process for unnecessary medications. Resident identifier: #3. Facility census: 20. Findings included: a) Resident #3 Review of Resident #3's orders, on 06/21/18 at 12:04 PM, revealed an order for [REDACTED]. The order read Basaglar KwickPen 100 ml (milliliters) three (3) ml SQ (subcutaneous) (35 U (units) IM (intramuscular) Q (every) D (day) DM (for Diabetes Mellitus)). Review of the manufacturer's (Eli Lilly) instructions, revised on 04/20/17, approved by the U.S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneous) of your stomach area, buttocks, upper legs or upper arms. According to the American Diabetes Association (ADA), insulin cannot be taken as a pill because it would be broken down during digestion just like the protein in food. Insulin Basics, according to the ADA, includes insulin must be injected into the fat under your skin (subcutaneous) for it to get into your blood. On 06/21/18 at 12:21 PM, interview with Licensed Practical Nurse (LPN#47), revealed the resident receives Basaglar at 4:00 PM every day. LPN#47 said she works days shift and is not at the facility when the resident receives Basaglar at 4:00 PM. This surveyor requested LPN#47 to review the order. After reviewing the insulin order for Resident #3 LPN #47 said, That's wrong, you would not give it IM. LPN #47 agreed the route for insulin injects is SQ (subcutaneous). On 06/21/18 at 12:40 PM Director of Nursing (DON), agreed Basaglar insulin is not to be given IM, but only SQ. Review of the Medication Administration Record (MAR) for the month of (MONTH) revealed the MAR stated Basaglar KwickPen 100 ml 3 ml SQ (35 U IM Q D DM). A nurse signed each day in (MONTH) and May, the insulin was given according to the order on the MAR. After reviewing the MAR, the DON said, the nurses have been trained when they sign the MAR they are stating they gave the insulin IM. The DON agreed the order should have been clarified by the nurses, the Physician and the Pharmacy should have caught the discrepancy on the route of administration of the insulin. The Physician when he signed the order and/or reviewed the physician monthly summary of orders should have caught it, and the Pharmacist when the monthly medication regimen reviews were completed.",2020-09-01
3520,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,756,D,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the pharmacist failed to identify or report irregularities during the monthly medication review for one (1) of five (5) residents reviewed for unnecessary medications, during the annual Long Term Care Survey Process. The pharmacist failed to identify irregularities on the Medication Administration Record [REDACTED]. Resident identifier: #3. Facility census: 20. Findings included: a) Resident #3 Review of Resident #3's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 03/20/18, on 06/21/18 at 08:00 AM, revealed the resident's Brief Interview for Mental Status (BIMS) score is six (6) indicating resident is cognitively severely impaired. The resident needs extensive assistance for activities of daily living (ADL), except with eating, the resident needs only supervision. Pertinent [DIAGNOSES REDACTED]. Review of Resident #3's orders, on 06/21/18 at 12:04 PM, revealed an order for [REDACTED].S. Food and Drug Administration, revealed the following instructions. Step #10 of the instructions read, BASAGLAR is injected under the skin (subcutaneous) of your stomach area, buttocks, upper legs or upper arms. According to the American Diabetes Association (ADA), insulin cannot be taken as a pill because it would be broken down during digestion just like the protein in food. Insulin Basics, according to the ADA, includes insulin must be injected into the fat under your skin (subcutaneous) for it to get into your blood. Review of records, on 06/21/18 at 12:23 PM, revealed medication regimen reviews, were completed by the Pharmacy on dates 06/07/18, 05/03/18, 03/30/18, and 03/01/18. On 06/21/18 at 12:40 PM Director of Nursing (DON), agreed Basaglar insulin is not to be given IM, but only SQ. Review of the Medication Administration Record [REDACTED]. A nurse signed each day in (MONTH) and May, the insulin was given according to the order on the MAR. The DON agreed the order should have been clarified by the nurses, and the Pharmacy should have caught the discrepancy on the route of administration of the insulin, when they did the monthly medication regimen reviews.",2020-09-01
3521,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,842,D,0,1,TL6L11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to ensure they maintained an accurate and complete medical record for two (2) of twelve (12) residents whose medical records did not contain complete and accurate information. Resident identifiers: #15 and #120. Facility census: 20. Findings included: a) Resident #15 A medical record review for Resident #15 revealed this resident had two (2) diet orders listed in their medical record. The resident had an order dated 03/15/17 for a regular diet and an order dated 05/21/18 for a mechanical soft diet. A physician's orders [REDACTED]. Resident #15 also had a physician's orders [REDACTED]. On 06/19/18 at 1:40 PM during an interview with Dietary Manager (DM) #41 the DM said the resident only received the mechanical soft diet for a brief period after having had teeth extracted. On 06/20/18 at 10:00 AM the assistant director of nursing (ADON) provided a copy of an interdisciplinary note dated 06/19/18 at 1:47 PM which stated, Clarification Order: Mech (mechanical) soft diet ordered 5/31/18 was for one week only related to tooth extraction, regular diet since 6/8/2018. Confirmed by dietary manager. b) Resident #120 A medical record review for Resident #120 revealed the resident had a physician's orders [REDACTED]. The resident's medical record contained the following weights: 05/31/18 150.80 lbs., 06/01/18 150.30 lbs. and 06/15/18 147.20 lbs. There was no weight recorded in the medical record for 06/07/18 or 06/08/18. On 06/20/18 at 10:09 AM the Director of Nursing and Registered Nurse (RN) #61 located a book that contained weights for residents. Resident #120's weight was record was 150.2 on 06/07/18. This weight had not been recorded in the medical record.",2020-09-01
3522,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2018-06-21,880,D,0,1,TL6L11,"Based on observation and staff interview, the facility failed to maintain an effective infection control program to provide a safe and sanitary environment to help prevent the development and transmission communicable diseases and infections. A random observation discovered an improperly stored bedpan in a resident bathroom. This practice had the potential to affect a limited number of residents. Resident identifiers: #15. Facility census: 20. Findings included: a) Resident #15 A random observation on 06/19/18 at 10:05 AM, revealed a bedpan in Resident#15's bathroom was not properly stored in a plastic bag. The bedpan was lying upside down on top of and against the commode lid of a bed side commode stored in the resident's bathroom. Registered Nurse (RN#50) was asked to look in to the resident's bathroom and see if there were any issues. RN #50 immediately identified the unbagged bed pan as an issue. RN#50 said the bed pan should be bagged and agreed it was an infection control issue. On 06/19/18 at 02:50 PM, an interview with the Assistant Director of Nursing (ADON), revealed the ADON is responsible for infection control program. The ADON agreed the bed pan found in Resident#15's bathroom breeched infection control principals by not being stored properly in a plastic bag.",2020-09-01
3523,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,278,D,0,1,7U2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure a complete and accurate quarterly minimum data set (MDS) for one (1) of five (5) residents reviewed for the care area of unnecessary medications. Resident identifier: #12. Facility census: 20. Findings include: a) Resident #12 Review of the residents Medication Administration Record [REDACTED] --[MEDICATION NAME] 25 - 100 milligrams (mg), take 2 tablets three times a day (TID) for [MEDICAL CONDITION]. --Comtan 200 mg, 1 tablet, TID for [MEDICAL CONDITION]. --Requip 2 mg, 1 tablet, TID for [MEDICAL CONDITION]. --[MEDICATION NAME] 25 mg, 1 tablet at nighttime (qhs) for dementia with behaviors The resident refused medications on the following occasions: --06/07/17 the 2:00 p.m. dosage of [MEDICATION NAME] 25 - 100 mg --06/08/17 the 9:00 p.m. dosage of [MEDICATION NAME] 25-100 mg --06/07/17 the 2:00 p.m. dosage [MEDICATION NAME] mg --06/08/17 the 9:00 p.m. dosage [MEDICATION NAME] mg --06/07/17 the 2:00 p.m. dosage of Requip 2 mg --06/08/17 the 9:00 p.m. dosage of Requip 2 mg --6/08/17 the 9:00 p.m. dosage of [MEDICATION NAME] 25 mg Review of the last MDS, a quarterly, with an assessment reference date (ARD) of 06/10/17, found the facility failed to code the refusal of medications in Section E, entitled Behavior, on the MDS. The question on Section [NAME] of the MDS reads, Did the resident reject evaluation or care (e.g. blood work, taking medications, ADL assistance) that is necessary to achieve the residents goals for health and well being? During the 7 day look back period (06/04/17 to 06/10/17) required for completion of the 06/10/17 MDS, the resident had refused medications on two (2) separate days. The correct coding for the 06/10/17 MDS should be, behavior of this type occurred 1 to 3 days. The facility coded the MDS as behavior not exhibited. At 1:18 p.m. on 08/09/17, the assistant director of nursing (ADON) had no comments regarding the competition of the MDS. The director of nursing and the social worker (SW) reviewed the MDS At 3:22 p.m. on 08/09/17. The SW said she completed the behavior section of the MDS. She said she thought the resident could refuse to take his medications. The SW was asked if taking the medications used to treat the residents behaviors and [MEDICAL CONDITION] were necessary to achieve the residents goals for health and well being? The SW said she guessed she didn't understand the question when she completed the resident's MDS.",2020-09-01
3524,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,279,D,0,1,7U2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop care plans to accurately reflect the assistance required for transfers for two (2) of ten (10) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #6 and #18. Facility census: 20. Findings include: a) Resident #6 Review of the resident's current care plan, dated 11/18/16, for ADL (activities of daily living) function / rehabilitation potential, identified a problem: (name of resident) has impaired mobility related to generalized weakness/fatigue, history of fracture right femur and right elbow, [DIAGNOSES REDACTED]. Interventions on the care plan included: (name of resident) transfers with one/two person assist for all transfers via stand and pivot. Further review of the residents Care Guide for the nursing assistants, noted, Transfers and ambulation / mobility: 2 person assist for transfers. Geri chair for mobility when out of bed. At 2:05 p.m. on 08/08/17, the director of nursing (DON) verified the care plan needed to be corrected. The DON verified the resident requires two (2) staff members at all times to assist with transfers. b) Resident #18 A review of Resident #18's medical record at 3:40 p.m. on 08/08/17, found a care plan intervention which read, Resident is a one to two person assist with transfers. When asked, How a residents care needs are relayed to the Nurse Aides, the staff indicated they have a Resident ADL/Daily Care List in the computer, and each Nurse Aide can see this list and know what care to provide the residents. A review of Resident #18's daily care list found the following, Transfers and ambulation mobility: 1 assist with transfers and wheelchair. An interview with the Director of Nursing at 9:00 a.m. on 08/10/17 confirmed Resident #18's care plan did not match the residents transfer status. She indicated the resident was to only be transferred with the assistance of one (1) staff member, however the care plan has always reflected the resident needed the assistance of one to two staff members.",2020-09-01
3525,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,280,D,0,1,7U2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure Resident #4's care plan was revised when his preferences changed as to when he would like to take his medications. 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 (QIS). Resident Identifier: #4. Facility Census: 20. Findings include: a) Resident #4 A review of Resident #4's medical record at 9:00 a.m. on 08/09/17, found the following care plan intervention related to his status as a [MEDICAL TREATMENT] patient, Please give following medications after 4:00 p.m. when (Name of resident) returns form HD ([MEDICAL TREATMENT]), Provella, Vit D3, vitamin B - 12, [MEDICATION NAME], [MEDICATION NAME], and nepro shake. Review of the residents Medication Administration Record [REDACTED]. An interview with the Director of Nursing at 1:26 p.m. on 08/09/17 found the residents care plan needed to be revised. She stated at one point Resident #4 wanted these medications given after [MEDICAL TREATMENT] because he felt they would dialyze out and he would refuse to take them. She stated since his most recent readmission the resident has changed his preference and does not care to take the medication prior to [MEDICAL TREATMENT]. She stated the care plan was not revised when Resident #4's preferences changed. .",2020-09-01
3526,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,282,E,0,1,7U2711,"Based on record review and staff interview the facility failed to ensure that Resident #9's care plan was implemented in regards to her transfer status. This was true for one (1) of four (4) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident Identifier: #9. Facility Census: 20 Findings Include: a) Resident #9 A review of Resident #9's medical record, at 9:51 a.m. on 08/08/17, found a lift assessment completed on 11/13/16. This lift assessment indicated the safest way to transfer Resident #9 was with a total mechanical lift. A review of Resident #9's care plan found the following intervention, (First name of Resident) transfers with a full body lift two person assist for all transfers. A review of Resident #9's nurse aide daily flow sheets from 01/01/17 through 08/08/17, found the following occasions when Resident #9 was transferred inappropriately: On the following occasions Resident #9 was transferred with extensive assist with a one person physical assist. (Please note extensive assist means the resident was not transferred via a mechanical lift.) -- 01/02/17 at 7:54 p.m. -- 01/04/17 at 4:41 a.m. -- 01/05/17 at 11:30 a.m. -- 01/10/17 at 9:25 p.m. -- 01/15/17 at 3:23 a.m. -- 01/20/17 at 9:33 p.m. -- 01/21/17 at 2:07 a.m. -- 01/27/16 at 1:52 a.m. -- 01/29/17 at 10:29 p.m. -- 02/03/17 at 3:56 p.m. -- 02/06/17 at 9:02 p.m. -- 02/13/17 at 12:49 a.m. and 6:46 a.m. -- 02/16/17 at 10:52 p.m. -- 02/17/17 at 4:46 p.m. -- 02/21/16 at 2:39 p.m. -- 03/01/17 at 1:23 p.m. -- 03/02/17 at 10:23 p.m. -- 03/04/17 at 3:26 a.m. and 4:28 a.m. -- 03/06/17 at 9:22 p.m. -- 03/13/17 at 9:11 p.m. -- 03/14/17 at 11:29 a.m. and 8:06 p.m. -- 03/15/17 at 1:37 p.m. -- 03/17/17 at 8:35 p.m. -- 03/19/17 at 11:17 a.m. -- 03/21/17 at 8:10 p.m. -- 03/23/17 at 2:03 p.m. -- 03/28/17 at 11:35 a.m. -- 03/30/17 at 11:58 a.m. -- 03/31/17 at 3:21 a.m. -- 04/04/17 at 8:07 a.m. -- 04/06/17 at 9:13 a.m. -- 04/09/17 at 3:33 a.m. -- 04/12/17 at 2:41 a.m. -- 04/16/17 at 4:29 a.m. -- 04/21/17 at 2:00 p.m. -- 04/23/17 at 1:31 p.m. -- 04/26/17 at 3:47 a.m. -- 04/28/17 at 7:38 a.m. -- 05/05/17 at 1:22 p.m. -- 05/12/17 at 10:36 a.m. -- 05/13/17 at 10:35 p.m. -- 05/17/17 at 9:59 p.m. -- 05/18/17 at 3:41 p.m. -- 05/19/17 at 3:03 p.m. -- 05/21/17 at 9:41 a.m. and 10:11 p.m. -- 05/26/17 at 9:13 p.m. -- 05/28/17 at 8:55 p.m. -- 06/01/17 at 5:29 a.m. and 2:10 p.m. -- 06/07/17 at 2:46 a.m. -- 06/20/17 at 7:51 p.m. -- 07/16/17 at 2:30 p.m. -- 07/25/17 at 12:26 a.m. On the following occasions Resident #9 was transferred with extensive assist with the physical assistance of two (2) staff members. (Extensive Assist means the resident was not transferred with the total lift.) -- 01/05/17 at 10:42 a.m. -- 01/15/17 at 12:53 p.m. -- 01/17/17 at 10:03 p.m. -- 01/24/17 at 8:57 p.m. -- 02/02/17 at 2:57 p.m. -- 02/22/17 at 3:00 p.m. -- 03/18/17 at 2:19 p.m. -- 03/21/17 at 2:40 p.m. -- 04/01/17 at 2:06 p.m. -- 04/22/17 at 1:51 p.m. -- 05/03/17 at 2:55 a.m. -- 05/09/17 at 10:14 a.m. -- 05/27/17 at 8:46 p.m. -- 06/25/17 10:48 a.m. -- 07/18/17 at 2:35 p.m. and 4:44 p.m. -- 07/23/17 at 10:42 p.m. On the following occasions Resident #9 was transferred with a total mechanical lift, but only with the assistance of one (1) staff member instead of the required two (2) staff members. -- 02/01/17 at 2:47 p.m. and 7:57 p.m. -- 02/09/17 at 9:10 p.m. -- 02/26/17 at 11:22 a.m. -- 03/26/17 at 2:03 p.m. -- 04/12/17 at 3:42 p.m. -- 06/09/17 at 2:43 p.m. and 3:39 p.m. -- 07/10/17 at 10:23 a.m., 2:51 p.m., and 11:35 p.m. -- 07/19/17 at 9:03 p.m. -- 07/22/17 at 1:25 p.m. -- 07/23/17 at 2:47 p.m. -- 07/24/17 at 1:35 p.m. -- 07/27/17 at 2:26 p.m. -- 07/29/17 at 10:03 a.m. -- 08/04/17 at 9:43 a.m. -- 08/08/17 at 1:57 p.m. An interview with the Director of Nursing (DON) at 1:06 p.m. on 08/09/16, confirmed on the above mentioned dates the nurse aides documented they improperly transferred Resident #9. She confirmed Resident #9's care plan in regards to transfers was not implemented.",2020-09-01
3527,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,323,E,0,1,7U2711,"Based on record review and staff interview the facility failed to ensure that Resident #9's environment over which the facility had control was as free from accident hazards as possible. Facility staff failed to transfer Resident #9 in a manner which was deemed safe for her transfers. This was true for one (1) of four (4) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey. Resident Identifier: #9. Facility Census: 20 Findings Include: a) Resident #9 A review of Resident #9's medical record, at 9:51 a.m. on 08/08/17, found a lift assessment completed on 11/13/16. This lift assessment indicated the safest way to transfer Resident #9 was with a total mechanical lift. A review of Resident #9's care plan found the following intervention, (First name of Resident) transfers with a full body lift two person assist for all transfers. A review of Resident #9's nurse aide daily flow sheets from 01/01/17 through 08/08/17, found the following occasions when Resident #9 was transferred inappropriately: On the following occasions Resident #9 was transferred with extensive assist with a one person physical assist. (Please note extensive assist means the resident was not transferred via a mechanical lift.) -- 01/02/17 at 7:54 p.m. -- 01/04/17 at 4:41 a.m. -- 01/05/17 at 11:30 a.m. -- 01/10/17 at 9:25 p.m. -- 01/15/17 at 3:23 a.m. -- 01/20/17 at 9:33 p.m. -- 01/21/17 at 2:07 a.m. -- 01/27/16 at 1:52 a.m. -- 01/29/17 at 10:29 p.m. -- 02/03/17 at 3:56 p.m. -- 02/06/17 at 9:02 p.m. -- 02/13/17 at 12:49 a.m. and 6:46 a.m. -- 02/16/17 at 10:52 p.m. -- 02/17/17 at 4:46 p.m. -- 02/21/16 at 2:39 p.m. -- 03/01/17 at 1:23 p.m. -- 03/02/17 at 10:23 p.m. -- 03/04/17 at 3:26 a.m. and 4:28 a.m. -- 03/06/17 at 9:22 p.m. -- 03/13/17 at 9:11 p.m. -- 03/14/17 at 11:29 a.m. and 8:06 p.m. -- 03/15/17 at 1:37 p.m. -- 03/17/17 at 8:35 p.m. -- 03/19/17 at 11:17 a.m. -- 03/21/17 at 8:10 p.m. -- 03/23/17 at 2:03 p.m. -- 03/28/17 at 11:35 a.m. -- 03/30/17 at 11:58 a.m. -- 03/31/17 at 3:21 a.m. -- 04/04/17 at 8:07 a.m. -- 04/06/17 at 9:13 a.m. -- 04/09/17 at 3:33 a.m. -- 04/12/17 at 2:41 a.m. -- 04/16/17 at 4:29 a.m. -- 04/21/17 at 2:00 p.m. -- 04/23/17 at 1:31 p.m. -- 04/26/17 at 3:47 a.m. -- 04/28/17 at 7:38 a.m. -- 05/05/17 at 1:22 p.m. -- 05/12/17 at 10:36 a.m. -- 05/13/17 at 10:35 p.m. -- 05/17/17 at 9:59 p.m. -- 05/18/17 at 3:41 p.m. -- 05/19/17 at 3:03 p.m. -- 05/21/17 at 9:41 a.m. and 10:11 p.m. -- 05/26/17 at 9:13 p.m. -- 05/28/17 at 8:55 p.m. -- 06/01/17 at 5:29 a.m. and 2:10 p.m. -- 06/07/17 at 2:46 a.m. -- 06/20/17 at 7:51 p.m. -- 07/16/17 at 2:30 p.m. -- 07/25/17 at 12:26 a.m. On the following occasions Resident #9 was transferred with extensive assist with the physical assistance of two (2) staff members. (Extensive Assist means the resident was not transferred with the total lift.) -- 01/05/17 at 10:42 a.m. -- 01/15/17 at 12:53 p.m. -- 01/17/17 at 10:03 p.m. -- 01/24/17 at 8:57 p.m. -- 02/02/17 at 2:57 p.m. -- 02/22/17 at 3:00 p.m. -- 03/18/17 at 2:19 p.m. -- 03/21/17 at 2:40 p.m. -- 04/01/17 at 2:06 p.m. -- 04/22/17 at 1:51 p.m. -- 05/03/17 at 2:55 a.m. -- 05/09/17 at 10:14 a.m. -- 05/27/17 at 8:46 p.m. -- 06/25/17 10:48 a.m. -- 07/18/17 at 2:35 p.m. and 4:44 p.m. -- 07/23/17 at 10:42 p.m. On the following occasions Resident #9 was transferred with a total mechanical lift, but only with the assistance of one (1) staff member instead of the required two (2) staff members. -- 02/01/17 at 2:47 p.m. and 7:57 p.m. -- 02/09/17 at 9:10 p.m. -- 02/26/17 at 11:22 a.m. -- 03/26/17 at 2:03 p.m. -- 04/12/17 at 3:42 p.m. -- 06/09/17 at 2:43 p.m. and 3:39 p.m. -- 07/10/17 at 10:23 a.m., 2:51 p.m., and 11:35 p.m. -- 07/19/17 at 9:03 p.m. -- 07/22/17 at 1:25 p.m. -- 07/23/17 at 2:47 p.m. -- 07/24/17 at 1:35 p.m. -- 07/27/17 at 2:26 p.m. -- 07/29/17 at 10:03 a.m. -- 08/04/17 at 9:43 a.m. -- 08/08/17 at 1:57 p.m. An interview with the Director of Nursing (DON) at 1:06 p.m. on 08/09/16, confirmed on the above mentioned dates the nurse aides documented they improperly transferred Resident #9. She confirmed the resident was to be transferred with a total mechanical lift with two (2) staff person assist.",2020-09-01
3528,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,371,F,0,1,7U2711,"Based on observation and staff interview, the facility failed to ensure foods were stored in a safe and sanitary manner to prevent the outbreak of foodborne illness. Foods were not dated to indicate when they were opened. In addition, foods items were expired and needed to be discarded, yet they remained available for use. This had the potential to effect all residents residing at the facility. Facility census: 20. Findings include: a) Initial tour of the kitchen During the initial tour of the kitchen with Employee #54, the dietary manager (DM) at 9:30 a.m. on 08/07/17, the following food items were found to be expired or were not dated with a date the item was opened or the date to discard: b) Walk in refrigerator: Sour Cream, stamped with a manufactures expiration date of 07/31/17, A Ziploc bag of sliced cheese with no dates to indicate when the cheese was opened and no date of expiration, A jar of Pesto, stamped with a manufactures expiration date of 07/17/17, A jar of Horseradish with no date to indicate when the item was opened or when the item expired. c) Kitchen area A bottle of Classic Cesar dressing was found on a serving tray beside the steam table, stored among other sauces not requiring refrigeration. The instructions on the bottle directed refrigeration after opening. The bottle was room temperature to touch. DM #54 said she would discard the above items immediately. d) Residents pantry refrigerator Observation of the residents refrigerator, with the director of nursing (DON) at 9:45 a.m. on 08/07/17, found the following expired items: A bottle of prune juice belonging to resident #23, with an expiration date of 07/09/17. A package of cheese sticks belonging to a discharged Resident, with an expiration date of 07/13/17.",2020-09-01
3529,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2017-08-10,504,D,0,1,7U2711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to ensure laboratory tests were obtained on the date ordered by the physician. Resident #4 had two (2) [MEDICATION NAME] time/ international normalized ratio (PT/INR) tests ordered for one (1) week from the previous test, however the test was obtained in four (4) days instead of one (1) week as ordered by the physician. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident #4. Facility Census: 20. Findings include: a) Resident #4 A review of Resident #4's medical record at 9:00 a.m. on 08/09/17 found, two PT/INR test results dated 07/20/17 and 07/31/17. On both lab tests the physician wrote, Repeat in one week. Further review of the record found the lab test ordered to be repeated in one week from 07/20/17 was obtained on 07/24/17, and the lab test ordered to be repeated in one week from 07/31/17 was obtained on 08/03/17. Both were obtained in only four (4) days instead of one (1) week as ordered by the physician. An interview with the Director of Nursing (DON) at 10:59 a.m. on 08/09/17, confirmed both pt/inrs were not obtained as ordered. She confirmed both labs were obtained three (3) days prior to the order date.",2020-09-01
4870,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2016-07-18,272,D,0,1,S2TR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and a dental consultant report, the facility failed to conduct an accurate comprehensive minimum data set (MDS) assessments for one (1) of three (3) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The comprehensive assessments for Resident #16 did not accurately identify the resident's dental status. Resident identifiers: #16. Facility census: 18. Findings include: a) Resident #16 Observations of Resident #16's oral cavity on 07/13/16 at 9:00 a.m., revealed the resident had broken and missing teeth. A review of Resident #16's annual MDS with an assessment reference date (ARD) of 05/09/16 was reviewed on 07/13/16 10:04 a.m. The MDS did not reflect the residents as having been missing or broken teeth. The nursing assessment with the date of 12/16/13 found the resident had been missing teeth. Observation of Resident #16's oral cavity on 07/13/16 at 10:22 a.m. with the assistant director of nursing (ADON) #48, found the resident had broken and missing teeth. The ADON confirmed the MDS was inaccurate due to the resident having these broken and missing teeth for some time. On 07/13/16 at 12:00 p.m., Registered Nurse/Minimum Data Set Coordinator (RN-MDSC) confirmed the resident nursing assessment form dated 12/16/13 finds the resident has some missing teeth. The RN-MDSSC stated, The monthly summary dated 04/19/16 does not identify missing or broken teeth. She stated, I went to do an oral examine, but I could not get the resident to open up his mouth, so I could not really identify whether there was missing or broken teeth. The resident was seen by the dentist on 04/12/16. The note revealed the resident had broken teeth. The teeth was [MEDICATION NAME] to prevent further chipping, and cutting the resident's lip or cheek. The dental exam revealed the area where he has been missing teeth.",2019-07-01
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
5786,"ARTHUR B HODGES CENTER, THE",515193,300 BAKER LANE,CHARLESTON,WV,25302,2015-07-10,279,D,0,1,0TIA11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a care plan with measurable goals for the treatment of [REDACTED]. Resident identifier: #11. Facility census: 19. Findings include: a) Resident #11 Review of medical records, on 07/08/15 at 12:33 p.m., revealed Resident #11 was admitted to the facility on [DATE], after a [MEDICAL CONDITION]. Upon admission to the facility, the physician ordered [MEDICATION NAME] 7.5 milligrams (mg)/[MEDICATION NAME] 325 mg every four (4) hours as needed related to pain. Review of the resident's medication administration records (MAR) revealed Resident #11 received [MEDICATION NAME] 7.5mg/[MEDICATION NAME] 325mng for pain twenty-three (23) times during the month of (MONTH) (YEAR) and nine (9) times during the month of (MONTH) (YEAR). Review of the initial care plan, with a start date of 05/21/15, did not reveal a problem, goal, or interventions related to pain. Continued review of the care plan revealed a care plan problem, with a start date of 06/25/15, related to pain due to a recent [MEDICAL CONDITION] with surgical repair. On 07/08/15 at 1:50 p.m., Registered Nurse #6, stated she neglected to include the problem of pain in Resident #11's care plan from 05/21/15 until 06/25/15.",2018-08-01
11217,BARBOUR COUNTY GOOD SAM. CTR.,515116,"ROUTE 3, BOX 15C",BELINGTON,WV,26250,2011-03-30,225,D,1,0,SIMK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the immediate reporting to the administrator of the facility, and to other officials in accordance with State law through established procedures, all alleged violations involving mistreatment, neglect, or abuse. This was evident for one (1) of five (5) sampled residents. Resident identifier: #52. Facility census: 49 Findings include: a) Resident #52 I. Record review of an incident report dated [DATE] revealed that Resident #52 was being transferred from a seat on the activity bus to a wheelchair by nursing assistant #43, when the resident experienced a ""popping sound that appeared to come from R (right) side of {sic}rib cage"" and she ""felt something move (rib) when (sic) sound was heard"". Further review of the incident report revealed that the family and physician was notified on [DATE], the administrator notified on [DATE], and it was coded as not requiring notification to a State/Agency. Pertinent [DIAGNOSES REDACTED]. Review of Interdisciplinary Progress Notes dated [DATE], revealed the resident complained of tenderness to the touch in the right rib area, and a new order was received for an x-ray of the right ribs, which was completed at the facility on [DATE]. Review of Interdisciplinary Progress Notes, dated [DATE], revealed x-ray results of anterior rib fractures, sixth through eighth ribs; the physician was notified, and he ordered a Hoyer lift for future transfers. Review of physician orders [REDACTED]. every one (1) hour prn (as needed) was increased to Roxinal 10 (ten) mgs. every one (1) hour prn on [DATE]. Additionally, on [DATE], the physician gave a new order for Roxinal 10 (ten) mgs. sublingually scheduled three (3) times daily prior to transferring at 7:00 a.m., 11:00 a.m., and 4:00 p.m. due to the fractured ribs. These pain medications were in addition to the twice daily [MEDICATION NAME] ER (Extended Release) 30 mgs. tablets prescribed on [DATE], and the [MEDICATION NAME] ,[DATE] tablet every eight (8) hours prn she had ordered for breakthrough pain. Review of the immediate reporting of that [DATE] incident to the Nurse Aide Registry, revealed the initial and immediate reporting of this incident did not occur until [DATE]. However, according the the Office of Health Facility Licensure and Certification (OHFLAC) Reporting Memorandum ,[DATE], a facility must immediately (within twenty-four (24) hours of discovery by the facility) report all allegations of mistreatment, neglect, or abuse made by a resident, to officials in accordance with State law through established procedures. During interview with the Licensed Social Worker (LSW) on [DATE] at 3:15 p.m., she said the facility initially did not report the [DATE] incident to the Nurse Aide Program because they knew what happened and it wasn't intentional; however, after their corporate office reviewed the incident report, corporate instructed the facility to complete a fax reporting of allegations to the state agency (Nurse Aide Program). The LSW stated they now know that even if no harm was intended and the injury was not of unknown origin, they must immediately report. During interview with nurse #17 on [DATE] at 4:30 p.m., she stated that since the nature of the injury was known, staff felt it wasn't reportable; however, they now know better. During interview with the administrator on [DATE] at approximately 9:00 a.m., he stated that staff opinions on whether this was a reportable incident were fairly evenly divided at the time of the incident; the decision was made that it was not a reportable incident to the state. However, after their corporate office reviewed the facility's incident reports, corporate directed them in mid [DATE] to report the [DATE] incident, and they did. II. Record review of a ""suggestion or concern"" report dated [DATE] revealed the daughter of Resident #52 alleged the resident did not receive her pain medication over the weekend. Investigation by the facility found MS ([MEDICATION NAME])[MEDICATION NAME] not given to the resident for three (3) consecutive days, and cited the medication was ordered on Friday, but the pharmacy needed a prescription before it could be dispensed; therefore, the resident was given another pain medication she had ordered prn (as needed) more frequently to try to compensate for the omitted [MEDICATION NAME]. The resolution to this problem included the Director of Nursing (DoN) speaking with nurses related to ordering and obtaining prescriptions, and weekly checks by the DoN and ward clerk for narcotics that need ordered. Review of an incident reported dated [DATE] revealed the resident did not receive [MEDICATION NAME] daily as prescribed on [DATE], [DATE], and [DATE] because the prescription was not obtained and sent to the pharmacy. This amounted to six (6) consecutive missed doses of MS Contin. Further review of the incident report revealed that the family and physician was notified on [DATE], the administrator notified on [DATE], and it was coded as not requiring ""notification to a State/Agency"". Review of the immediate reporting of this [DATE] incident to the Nursing Home Program, revealed the reporting of this incident occurred on [DATE]. However, according to the Office of Health Facility Licensure and Certification (OHFLAC) Reporting Memorandum ,[DATE], a facility must immediately (within twenty-four (24) hours of discovery by the facility) report all allegations of mistreatment, neglect, or abuse made by a resident or family to officials in accordance with State law through established procedures. During interview with the LSW on [DATE] at 3:15 p.m., she stated that when the corporate office reviewed the incident report, they instructed the facility to complete a report to the state agency. The LSW said the resident was given alternate pain medications during those times she was without the [MEDICATION NAME] ER 30 mg. twice daily. During interview with nurse #17 on [DATE] at 4:30 p.m., she also stated that the resident received other pain medications in the absence of the [MEDICATION NAME] ER, and wasn't in distress when she was without the [MEDICATION NAME]. She said there have been no further problems with not acquiring medications in a timely manner since that incident. During interview with the administrator [DATE] at 9:00 a.m., he said the Director of Nursing (DoN) put a system in place related to getting medications in a timely manner and is monitoring; there have been no further problems with getting medications from pharmacy since the September incident. He stated that in the interim when Resident #52 was out of [MEDICATION NAME], nurses gave other pain medications she had ordered for prn (as needed) in its place, and she was in no discomfort; she also had other scheduled medications for comfort that she received. No interview is available for Resident #52, because she is now deceased .",2014-07-01
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
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
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
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
8299,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,225,E,0,1,TTVD11,"Based on record review, policy review, and staff interview, the facility failed to make reasonable efforts to uncover information about any past criminal prosecutions of potential employees by not including a West Virginia (WV) statewide investigation for two (2) of the five (5) sampled employees hired in 2012. This practice had the potential to affect more than an isolated number of residents. Employee identifiers: #41 and #67. Facility census 52. Findings include: a) Employee #41 A review of the personnel files, at 1:00 p.m. on 07/17/12, revealed no evidence that a statewide criminal background check had been completed on Employee #41, who was employed as a nursing assistant on 07/09/12. This person was involved in direct resident care. b) Employee #67 A review of the personnel files, at 1:00 p.m. on 07/17/12, revealed no evidence that a statewide criminal background check had been completed on Employee #6, who was employed as a nursing assistant on 07/11/12. This person was involved in direct resident care. c) An interview was conducted with Employee #22, the office manager, at 11:55 a.m. on 07/18/12. She stated, after searching the files and consulting Employee #44 (the director of nursing), that there was no record of a criminal background check on these employees. At the time of exit on 07/24/12, no further information had been produced regarding criminal background checks for these employees.",2016-07-01
8300,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,272,D,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility's interdisciplinary team failed to conduct comprehensive assessments that accurately reflected each resident's health status/condition for two (2) of forty-five (45) sampled residents. Resident identifiers: #42 and #32. Facility Census: 52. Findings include: a) Resident #42 On 07/23/12 at 1:15 p.m., review of the hospital discharge summary, dated 06/16/11, revealed this resident had been admitted with a [MEDICAL CONDITION], a history of multiple falls with fractures, and a pressure ulcer. Review, on 07/23/12 at 2:00 p.m., of admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/29/11, found Section H did not indicate the resident had an ostomy, Section J indicated the resident had not had any falls or fractures in the last six (6) months, and Section M had been left blank, which indicated the resident had no pressure ulcers. An interview conducted with Employee #33, the registered nurse MDS coordinator, on 07/24/12 at 9:40 a.m., verified that sections H, J, and M of the admission MDS assessment had been inaccurately completed. b) Resident #32 Chart review revealed that resident's most recent minimum data set (MDS), with an assessment reference date (ARD) of 04/08/12, did not identify the resident's recurrent urinary tract infections. Section I, Item I2300, did not identify she had had a urinary tract infection [MEDICAL CONDITION] in the last 30 days. The resident had urinary tract infections identified on 03/10/12 and 03/29/12. Both of these UTIs were identified within 30 days of the ARD and should have been reflected on the assessment.",2016-07-01
8301,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,279,E,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs and to describe the services needed for residents to maintain a safe environment, to prevent further decline, and to prevent complications in their conditions. The care plans were not complete and/or did not contain measurable interventions to provide care in areas of pressure ulcers, intravenous fluids, [MEDICAL TREATMENT], hydration, discharge changes, and accident/falls. This was evident for five (5) of forty-five (45) Stage II sample residents. Resident identifiers: #33, #63, #10, #42, and #20. Facility census: 52. Findings include: a) Resident #33 Review of a history and physical from the hospital, dated 04/16/12, revealed this resident was admitted with [DIAGNOSES REDACTED]. Record review found she had a low potassium level ([DIAGNOSES REDACTED]) upon admission to the hospital, and an elevated BUN (blood urea nitrogen) and creatinine, the latter two of which are indicative of dehydration. Upon discharge from the hospital, on 04/19/12, she was prescribed intravenous fluids (IV) with potassium supplement of twenty milliquivalents (20 MeQ) to infuse at 75 cc an hour. Medical record revealed there was no care plan related to intravenous fluid administration with potassium supplement for this resident, or for her recent hospitalization with fluid volume depletion, urinary tract infection [MEDICAL CONDITION], and electrolyte imbalance. Review of the history and physical from the hospital, dated 04/23/12, found an admitting impression of acute [MEDICAL CONDITION], as well as volume in her lungs with bilateral pleural effusions and crackles, the latter of which was indicative of fluid excess in her lungs. Review of the discharge summary from the hospital, dated 04/26/12 revealed she had [MEDICAL CONDITION] (elevated potassium level) upon admission on 04/23/12. During an interview with the Employee #44, the director of nursing, on 07/23/12, at approximately 11:00 a.m., she agreed the intravenous fluid therapy should have been care planned, but was not. b) Resident #63 On 07/17/12 at 3:30 p.m., a review of the medical record for Resident #63 revealed this resident experienced a fall on 07/10/12. The care plan, dated 06/27/12, contained a problem statement of, Risk for falls d/t (due to) impaired thought processes and muscle weakness. Long/short term goals: Will sustain no falls through next review. Interventions included, Encourage resident to use call light; keep call light within reach at all times. While in room; monitor resident frequently for restlessness and assist with repositioning; encourage resident to participate in group exercise class to maintain current strength and mobility levels. The frequent monitoring did not provide staff members a specific directive regarding how often the resident was to be monitored. On 07/24/12 at 10:00 a.m., an interview was conducted with Employee #33, the minimum data set (MDS) coordinator. When asked about how frequent monitoring was assessed, she stated when anyone goes past (the resident's room). In addition, she stated sensor pads could be used to assist staff in monitoring the resident for falls. No further information was provided regarding a fall protocol by the end of the survey. c) Resident #10 1) Medical record review revealed Resident #10 had a significant weight loss of 24% which was not addressed in the care plan. On 01/08/12, the resident weighed 225 pounds. The 07/02/12 weight for this resident was 170 pounds. Review of the care plan revealed there had been no care plan or interventions established relative to this significant weight loss. 2) Additionally, medical record review revealed this resident had experienced repeated falls in her room. There was no evidence the facility recognized and established goals and interventions which reflected the resident's repeated falls in her room. d) Resident #42 Medical record review, on 07/23/12, revealed this resident had experienced falls, was on a fluid restriction, received [MEDICAL TREATMENT], and used [MEDICATION NAME], a psychoactive medication, on an as needed basis. Review of the resident's current care plan revealed none of these issues, which impacted the resident's care needs, were a part of the care plan. On 7/24/12 at 9:40 a.m., an interview was conducted with Employee #33 (MDS coordinator). She verified these identified resident care needs had an impact on the resident's care, but had not been addressed in the resident's current care plan. e) Resident #20 A review of the medical record revealed that Resident #20 was a [AGE] year old woman with history of an acute renal injury secondary to [MEDICATION NAME] and ischemic acute tubular necrosis (ATN). Her other [DIAGNOSES REDACTED]. She had been receiving [MEDICAL CONDITION] of packed red blood cells on a weekly and/or biweekly basis as an outpatient at the hospital. She was being monitored for fluid overload due to her [MEDICAL CONDITIONS]. She had an infus-a-port in place for the [MEDICAL CONDITION]. During an interview with Employee #31 (licensed practical nurse), at 8:30 a.m. on 07/18/12, she stated Resident #20 had to be monitored closely for signs and symptoms of bleeding and for signs and symptoms of fluid overload after her [MEDICAL CONDITION]. Review of the nurses' notes revealed the resident was on daily weights and had orders for diuretics to be given prior to blood [MEDICAL CONDITION] and when the resident failed to lose less than one (1) pound within two (2) hours of the first medicine being administered. She also had a physician's orders [REDACTED]. The current care plan did not address the care required due to the blood [MEDICAL CONDITION] and/or the care of the port. No measurable goals for these needs had been formulated, and no nursing interventions were planned to ensure the resident maintained her maximum health status. These concerns were reviewed with the director of nurses and Employee #33 (MDS nurse) at 9:50 a.m. on 07/24/12. They reviewed the record and agreed these needs were overlooked and were not reflected on the current care plan.",2016-07-01
8302,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,280,E,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise the comprehensive care plan to include changes in health status, for one (1) of forty-five (45) Stage II sample residents. Resident identifiers: #33. Facility census: 52 Findings include: a) Resident #33 1) Review of physician orders, for this resident's re-admission to the facility on [DATE], revealed an order for [REDACTED]. These physician orders [REDACTED]. Review of the care plan found it only stated the knee braces were to be applied to both knees for six (6) hours while in bed for the night. This was not as ordered by the physician. During an interview with Employee #44 (the director of nursing), on 07/23/12, at approximately 11:00 a.m., she said the care plan was incorrect related to the braces. Employee #44 stated the resident's family member asked to have the leg braces applied only in the day time while the resident was up in the chair, and not at night while in bed, because the braces were interfering with the resident's sleep. Employee #44 confirmed this care plan should have been revised. 2) Review of the medical record found a physician's orders [REDACTED].#33. The care plan contained an intervention for restorative nursing to ambulate the resident five (5) times weekly PRN (as needed or desired) with a gait belt and staff assistance of two (2) when the resident was able to be ambulated. When interviewed on 07/23/12, at approximately 11:00 a.m., Employee #44 also confirmed this care plan should have been revised, but was not.",2016-07-01
8303,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,282,E,0,1,TTVD11,"Based on medical record review, policy and procedure review, and staff interview, the facility failed to ensure a qualified professional assessed pressure ulcers and/or wounds for three (3) of forty-five (45) Stage II sample residents. The assessments were conducted by staff members who were not qualified to complete assessments of residents without oversight. In addition, the assessments were not completed by qualified personnel as directed in the facility's wound care policies and procedures. Resident identifiers: #63, #48, and #53. Facility census: 52. a) Resident #63 On 07/23/12 at 9:00 a.m., this resident's 05/30/12 care plan was reviewed. It contained a handwritten note, dated 07/04/12, which described an unstageable wound on the left heel which measured 3 cm long by 3 cm wide. The note also described a Stage 2 wound to the right heel which was 4.5 cm long by 5 cm wide. The note was signed by a licensed practical nurse (LPN), Employee #45. The care plan, dated 06/27/12, contained no mention of a pressure ulcer; although other medical record review revealed the areas remained on the resident's heels. Review of the wound flow sheets revealed Employee #45 (LPN) completed wound measurements and characteristics of the left and right heels on 06/21/12, 07/04/12, and 07/16/12. The flow sheet contained no evidence a registered nurse (RN) completed any part of the wound assessment. The sections requiring an RN signature on the wound assessments did not contain a signature. The facility's policy and procedure, Wound Flow Sheet, was reviewed. The section entitled Use, required at least a weekly assessment when skin integrity was impaired or there was an open area, such as a pressure ulcer or surgical wound. An LPN was to complete the wound measurements and describe the characteristics of the wound. An RN was to complete the assessment of the wound, including a determination of the type of wound. The Instructions section directed the RN to, Check the box for pressure ulcer or wound type. This section also sated the RN was supposed to sign and date the assessment. Page 4 of the policy and procedure contained an area, within the assessment, for the RN to indicate whether the care plan had been updated, and to sign and date this section. This section directed an RN to assess/evaluate and document the status of the wound at least weekly. In an interview with the director of nursing (DON), and in the presence of the administrator, on 07/23/12 at 3:15 p.m., the DON agreed an RN had not completed the assessment/evaluation of the pressure ulcers for Resident #63. b) Resident # 48 Review of the wound care flow sheets for Resident #48 revealed the wound care flow sheets contained no evidence an RN had assessed this resident's wounds from 04/03/12, up to and including 07/17/12. This resident had wounds to the left outer foot, right hip, left hip, and left upper hip.",2016-07-01
8304,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,309,G,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on record review and staff interview, the facility failed to ensure consistent assessment, monitoring, and evaluation of a resident receiving intravenous fluids. Additionally, the facility failed to ensure timely medical intervention when a resident experienced deterioration in health status. The facility ' s failure to provide the necessary care and services for this resident resulted in harm. This practice affected one (1) of 45 Stage II sample residents. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 Medical record review revealed Resident #33 began receiving intravenous (IV) fluids with 20 MeQ (milliquivalents) of potassium at 75 cc per hour shortly after midnight on 04/20/12. Factors which placed her at higher risk for potential adverse reactions from receiving IV fluid therapy included a [DIAGNOSES REDACTED]. Despite the increased risk of adverse reactions, record review revealed that nursing staff were not consistently assessing lung sounds or early signs of fluid overload. Review of a hospice note, written by a registered nurse from hospice, found notation that the resident's lung sounds were clear when assessed on 04/20/12. Further medical record review found no evidence of lung sound assessments by facility staff on any of the three (3) shifts on 04/20/12, 04/21/12, or 04/22/12. The 04/23/12 nurse's notes for 3:00 a.m. noted the resident's respiratory rate had been 32 breaths per minute at 10:00 p.m., and lung sounds were diminished bilaterally in the lower lobes. Later, at 8:45 a.m. on 04/23/12, the hospice aide notified the nurse that the resident was coughing. The nurse assessed the resident ' s moist lung sounds and noted rhonchi present bilaterally. The nurse ' s note indicated the hospice nurse was called to come in and evaluate the resident. Upon her arrival to the facility at 10:30 a.m., the hospice nurse assessed the resident with slight expiratory wheezing. Neither the physician nor the responsible party was notified of the changes in the resident ' s respiratory status/lung sounds. 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 transported to the hospital, on 04/23/12 at 12:40 p.m., where she was admitted . Review of the hospital ' s admission history and physical, dated 04/23/12, revealed the documented admitting impression was the resident .seems to have volume in her lungs with bilateral pleural effusions and crackles. The physician noted she also had acute [MEDICAL CONDITION] and [MEDICAL CONDITION] that appeared to be systolic Comparatively, the facility ' s medical record review found a chest x-ray which had been completed on 04/16/12. This x-ray revealed no acute infiltrates or effusions were seen, and no acute cardiopulmonary process was noted at that time. Review of the hospital discharge summary, dated 04/26/12, found discharge [DIAGNOSES REDACTED]. During an interview with the director of nursing (DON), 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. The DON said she would have expected the nurses to have notified the physician regarding the lung sound assessment changes on 4/23/12. She said the facility had no policy about assessing lung sounds on residents who were receiving IV fluids. II. Based on medical record review and resident interview, the facility failed to ensure residents received services and care necessary to promote their highest level of well-being. The facility failed to ensure services were provided to promote comfort and relieve pain. Resident identifiers: #42 and #48. Facility census: 52 Findings include: a) Resident # 42 Medical record review of nurses' notes, dated 06/25/12 at 6:00 p.m., written by Employee #14, found, Resident was sitting in solarium with husband. She is asking and hollering to be layed down. She was told that as soon as dinner is over she will be layed down due to pain in back and legs. She tells her husband 'just push me out of the chair and maybe then I will get layed down.' The next entry was written on 06/26/12 at 3:25 a.m., by Employee #28, which described, . complains of leg and back pain and scheduled pain medication given per order with short term pain relief and Tylenol prn given for breakthrough pain as well as repositioning, massage and relaxation techniques. Each produced short term results with one (1) to two (2) hours of relief. There was no evidence the physician was notified of the increase in the resident's back and leg pain or that only short term relief was obtained from the prescribed medications. An entry in the nurse's notes, on 06/26/12 at 3:50 p.m., by Employee #14, noted a new order for [MEDICATION NAME] due to back and leg pain. The record contained nothing regarding the efficacy of this new medication and there was no evidence of continued assessment to determine whether the current medication regimen relieved the resident's pain. During an interview with the resident regarding her pain, in the afternoon of 07/25/12, the resident stated the facility gave her pain medications, but it only sometimes helped relieve her pain. b) Resident #48 Review of the facility's policy for medication response revealed that ongoing pain and the use of as needed (PRN) pain medication was to be documented upon giving the medication, and completed again within a reasonable time. The Pain Policy also stated that PRN medications were to be followed up with a pain level assessment. The Medication Administration Record [REDACTED]. During this time period, PRN pain medication was given ten (10) times.",2016-07-01
8305,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,315,G,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations and staff interview, the facility failed to provide care and services to prevent infections related to catheter usage, failed to assess for and implement interventions to restore bladder continence to the extent possible, and/or failed to ensure there were valid medical justifications for the use of catheters for two (2) of 45 Stage II residents. Additionally, there was no evidence of ongoing assessment and/or implementation of individualized interventions in an effort to discontinue the catheter and/or to provide services to restore normal bladder function for these residents. There was no evidence the facility assessed the residents for causal factors for the incontinence, as urinary incontinence is a symptom of a condition which may be reversible. Additionally, there was no evidence the facility managed the Foley catheters in a manner which reduced complications, such as urinary tract infections (UTIs), which are a known complication related to catheter usage. Resident identifiers: #32 and #70. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed a bladder assessment dated [DATE]. At that time restorative retraining was not recommended due to urge incontinence. There was no evidence that possible causal factors for the urge incontinence had been explored. According to the medical record, the resident had a Foley catheter inserted on 12/31/10, at the request of Hospice, for [MEDICAL CONDITION]. There was no evidence of [MEDICAL CONDITION] at the time of insertion of the catheter, and there was no evidence of a urology consultation before or since the Foley catheter was inserted. Additionally, there was no evidence of any attempts to remove the Foley catheter and initiate interventions in an effort to restore normal bladder functioning. An interview was conducted with a licensed practical nurse (LPN), Employee #45, at 10:20 a.m. on 07/18/12. She stated bladder training was tried and failed, during one of the times the resident was receiving hospice. The LPN stated the resident had been on and off hospice a few times. The director of nursing was asked to provide evidence of attempts to discontinue the Foley catheter, but was unable to provide that evidence. The resident was also diagnosed with [REDACTED]. Coli, proteus, and pseudomonas were identified. She had a UTI five (5) of six (6) months in 2012. At the time of the survey, the resident was receiving [MEDICATION NAME] 100 mg twice daily for the prevention of UTIs. The current care plan contained no goals, interventions, or any plan in an attempt to prevent the recurrent UTIs. Medical record review revealed the resident's average daily fluid intake was 857cc. An inadequate fluid intake is known to contribute to the development of UTIs. There was no evidence the resident's fluid intake was evaluated in relationship to the UTIs. An interview was conducted with Employee #54, a nursing assistant (NA), who was familiar with the resident. She stated the resident was assisted in toileting. The NA said when the resident had a bowel movement (BM), the BM got all over the Foley catheter. She also stated the resident's Foley catheter often had BM on it. This interview also revealed the resident often had stool leakage. Employee #54 stated BM got on the Foley catheter at those times. b) Resident # 70 Interview with Employee #62, a registered nurse, on 07/16/12 at 9:29 a.m., revealed this resident had a Foley catheter. Employee #62 stated the Foley catheter was in place due to [MEDICAL CONDITION]. Medical record review revealed no evidence of [MEDICAL CONDITION], or any other medical condition which necessitated the use of a Foley catheter. Additionally, there was no evidence of any trials without a catheter. During an observation, on 07/18/12 at 10:40 a.m., the resident's Foley catheter was lying on the floor, creating a potential for the introduction of bacteria and other infectious organisms into the catheter. On 07/18/12 at 2:05 p.m., catheter care was observed being performed by Employee #51, a nursing assistant. At that time, the catheter drainage bag was observed lying on the floor beside of the bed. This was verified with Employee #51. At 2:30 p.m. on 7/18/12, the resident was observed lying on his right side. The Foley catheter was lying on the floor on the left side of the bed.",2016-07-01
8306,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,323,F,0,1,TTVD11,"Part I Based on observation, staff interview, staff-assisted checks of facility water temperatures, review of the Guidance to Surveyors found in the State Operations Manual (SOM) published by the Centers for Medicare & Medicaid Services, and the West Virginia Nursing Home Licensure Rule, the facility failed to provide a resident environment as free of accident hazard as possible. Water temperatures were measured by the maintenance director, using the facility's thermometer, to be as high as 120 degrees Fahrenheit (F) at the hand sinks in various residents' rooms and a shower room sink. This had the potential to affect more than an isolated number of residents due to the potential for scalding/burn injuries, especially for independently mobile residents with cognitive impairment and/or decreased sensitivity to pain and extreme temperatures. Facility census: 52. Findings include: a) On 07/23/12 at 10:40 a.m., a surveyor informed the maintenance supervisor the hot water in resident sinks felt too hot to touch and requested the hot water temperatures be checked using a facility thermometer. A check of the hand sinks, on 07/23/12 between 10:50 a.m. and 11:10 a.m., located in the following resident rooms, found the excessively hot water temperatures registered as follows: Room #100 - 120 degrees F Room #105 - 120 degrees F Room #202 - 120 degrees F Room #211 - 120 degrees F Room #302 - 120 degrees F Room #313 - 120 degrees F Shower room on 200 Hall - 120 degrees F The maintenance supervisor stated he had been told by his predecessor the water temperatures were to be maintained between 115 and 120 degrees (F). He further stated he visually checked the water temperatures each day but had no written evidence of the temperatures. Information in the Guidance to Surveyors for this requirement, found in Appendix PP of the CMS State Operations Manual, revealed the following: Water Temp - Time Required for a 3rd Degree Burn to Occur 155 degrees F - 1 sec 148 degrees F - 2 sec 133 degrees F - 15 sec 127 degrees F - 1 min 124 degrees F - 3 min 120 degrees F - 5 min 100 degrees F - Safe Temperature for Bathing (See Note) Note: Burns can occur even at water temperatures below those identified in the table, depending on an individual's condition and the length of exposure. Review of the West Virginia Nursing Home Licensure Rule N525 indicates, .the temperatures shall be appropriate for comfortable use but shall not exceed 110 degrees F. ==== Part II Based on observations, staff interview, resident interview, and record review, the facility failed to provide adequate supervision to prevent falls for two (2) of 45 Stage II sample residents, three (3) additional residents identified during random observations, and residents who were capable of independent ambulation within the facility. Water was left on the floor in the dining room, the laundry was unlocked, and residents had unsupervised access to a machine which was capable of causing a burn. Supervision/Adequate Supervision, as defined in the State Operations Manual (SOM), refers to an intervention and means of mitigating the risk of an accident. Facilities are obligated to provide adequate supervision to prevent accidents. Adequate supervision is defined by the type and frequency of supervision, based on the individual resident's assessed needs and identified hazards in the resident environment. Adequate supervision may vary from resident to resident and from time to time for the same resident. Resident identifiers: #63, #35, #6, #36, and #31. Facility census: 52. a) Resident #63 On 07/11/12 at 2:30 p.m., Resident #63 was observed with his feet hanging off of the bed. When asked if he was okay, the resident grunted. An interview with a nurse who was familiar with the resident, during Stage I of the survey, revealed the resident had a fall within the last 30 days. Medical record review revealed the resident was identified as being at risk for falls. The interdisciplinary care plan review, dated 06/27/12, noted the resident was at risk for falls due to impaired thought processes and muscle weakness. His goal was to .sustain no falls through next review. The interventions included, Encourage resident to use call light; keep call light within reach at all times while in room; monitor resident frequently for restlessness, and assist with repositioning . Due to the resident's impaired thought processes, it was unlikely he could use the call light to summon assistance. The Hospice care plan, dated 06/21/12, also noted the resident was a safety/fall risk due to weakness. This resident was identified at risk for falls. The care plan identified this potential problem and developed goals and interventions related to falls; however, some of the interventions were not appropriate due to the resident's cognitive status. Additionally, the intervention for monitoring and assistance with repositioning were either not implemented, not implemented frequently enough, or were inappropriate for this resident's current status. b) During the initial tour, on 07/15/12, the door to the laundry was observed unlocked. This area contained potentially hazardous chemicals, as well as equipment. No staff members were present in the area. There was a potential for a resident to wander into this area undetected. c) Resident #35 During the initial dining room observation, on 07/15/12 at 4:40 p.m., a wet floor sign was observed over spilled water on the floor. At 5:20 p.m., Employee #42 removed the wet floor sign; however, two (2) surveyors observing the dining room noted there was still a puddle of water on the floor. At 5:25 p.m., Resident #35 entered the dining room, ambulating with a walker. The resident walked through the puddle of water on the floor. At that time, Employee #7 was informed the floor was wet, and that Employee #42 had removed the wet floor sign, even though there was water on the floor. The water was cleaned up at 5:27 p.m. d) Residents #6, #36, and #31 On 07/15/12 at 4:30 p.m., a machine was noted sitting on the counter beside the refrigerator in the dining room. The machine was labeled as a hot cab sterilizer for towels. The door to the machine was opened and the interior felt hot. Between 4:40 p.m. and 5:00 p.m., Residents #6, #36 and #31 were observed opening the door of this machine and getting out towels. During this observation, no staff members were present for supervision. At 6:00 p.m., a kitchen thermometer was used to measure the temperature inside the machine. It was 138 degrees F. The temperature was measured with facility staff present.",2016-07-01
8307,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,325,D,0,1,TTVD12,"Based on medical record review, resident interview, and staff interview, the facility failed to provide nutritional care and services to prevent unplanned weight loss for one (1) of twenty sample residents. The facility failed to recognize, evaluate, and address the individual nutritional needs of this resident to ensure she maintained an acceptable nutritional status. Resident identifier: #10. Facility census: 49 Findings include: a) Resident #10 An interview was conducted with the resident on 10/03/12 at 9:00 a.m. When asked about her meals, the resident stated she did not like the food. She stated the food did not taste good to her. When she was asked about an alternate meal, she stated there were no alternates. Medical record review, on 10/04/12, revealed Resident #10 had a severe unplanned weight loss of 6.3% in a thirty-seven (37) day period which was not addressed by the facility. On 08/01/12, the recorded weight was 175 pounds. On 09/07/12, the weight recorded was 164 pounds. This was an eleven (11) pound weight loss. The dietitian noted the weight loss on 09/11/12, and ordered weekly weights for four (4) weeks. The dietitian's notes described the resident as obese and above her ideal body weight recommendation, which was 102 to 112 pounds. The nursing assistants' meal tracking showed the resident frequently refused breakfast, and the overall meal consumption was frequently less than fifty (50) percent. Review of the medical record revealed the resident's care plan was not updated to address the weight loss or poor meal consumption. The care plan did not include any interventions to encourage the resident to eat. There were no interventions to offer alternatives when she refused to eat, or ate less than a certain percentage of her meals. An interview was conducted on 10/04/12, with the director of nursing (DON), regarding the weekly weights. The DON was unable to locate the weekly weights. The DON contacted the certified manager (CDM), who was also unable to produce weekly weights for the resident. There was no evidence weekly weights were being done. On 10/04/12, an interview was conducted with the CDM. She stated the resident had capacity, and if she did not want to eat, she could not be made to eat. When asked if the resident was offered alternatives or given other food choices, the CDM stated, Yes, as far as I know. She also stated that the facility had attempted supplements, such as 2-Cal and Magic Shakes; however, the resident refused them. There was no evidence the facility explored what the resident would like to eat. Additionally, there was no evidence the facility made an attempt to determine why the resident's meal consumption was frequently less than 50%.",2016-07-01
8308,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,327,G,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide one (1) one of 45 Stage II sample residents with sufficient fluid intake to maintain proper hydration and health. The resident's care plan did not contain interventions to ensure the resident was provided and accepted sufficient fluids daily. Additionally, there was no ongoing monitoring of the resident's fluid intake to determine if her intake was adequate and/or if there was a need for interventions to ensure adequate fluid intake. The resident was hospitalized with dehydration. Resident identifier: #33. Facility census: 52. Findings include: a) Resident #33 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 care plan, dated 01/25/12, found an intervention to offer fluids frequently while awake. This intervention did not provide a distinct action plan for offering fluids, or improving fluid intake. Review of the former care plan, dated 10/26/11, found another generic intervention to Encourage adequate fluid intake q. (every) shift. Review of the consultant registered dietitian (RD) notes, dated 02/16/12, revealed a description that the most recent lab results indicate pos (possible)/slight dehydration. The RD recommended staff to encourage fluid intake and monitor for changes. Record review revealed the most recent BMP (basic metabolic profile) the dietitian referred to was completed on 01/28/12. The BUN (blood urea nitrogen) 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 values can be indicative of dehydration. Record review found no further dietitian notes prior to discharge from the facility on 04/23/12. Review of a discharge summary from the hospital, dated 04/19/12, revealed Resident #33 was admitted to the hospital on [DATE] with the [DIAGNOSES REDACTED]. The admitting laboratory work, completed at the hospital on [DATE], included an elevated BUN of 70, with the normal reference range between 6-19. The urea/creatinine ration was also elevated at 65, with the normal reference range between 12-20. During an interview with Employee #44 (DON), on 07/23/12, at approximately 11:00 a.m., the estimated daily fluid needs 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 where she consumed 1500 cc 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. Review of the dietary manager's note, dated 02/15/12, revealed the resident's average fluid intake at that time was 554 cc. Daily supplements of 300 cc would bring that total to 854 cc, if she accepted them. When asked if this resident's fluid or food intake had been discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE], Employee #44 checked with the Employee #46 (director of dietary services). Employee #44 then reported Resident #33's fluid and/or food intake was not discussed in daily or monthly meetings in March 2012, or prior to hospitalization on [DATE]. She stated the resident was offered food and fluid frequently, but would often refuse. During an interview with Employee #46 on 04/23/12, at approximately 2:00 p.m., she said residents who triggered for weight loss received follow-ups. Since Resident #33 did not trigger for weight loss in March 2012 and April 2012, there was no follow-up by dietary in those two (2) months. This resulted in a failure to to monitor the resident's fluid intake to identify potential risks for dehydration. Review of dietary notes found the last entry for this resident, prior to her final discharge to the hospital on [DATE], was dated 02/28/12. There was nothing in the notes related to the assessment and/or monitoring of the resident's fluid intake.",2016-07-01
8309,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,328,D,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure proper care for special resident needs for one (1) of forty-five (45) Stage II sample residents. A hand-held nebulizer [MEDICATION NAME] treatment was not effectively administered. Resident identifier: #29. Facility census: 52. Findings include: a) Resident #29 Observation on 07/16/12, from 2:00 p.m. through 2:34 p.m., found Resident #29 lying in bed on his back with his head lying on the pillow leaning slightly toward the right. A medicated aerosol nebulizer treatment was being administered via a mouthpiece that was lying on a towel placed across his chest. Supplemental oxygen was being administered by a nasal cannula. During this observation, the mouthpiece was noted beneath the resident's right arm, while the nebulizer machine was still running. No staff were in attendance. A licensed nurse, Employee #45, entered the resident's room at 2:34 p.m. to perform a decubitus ulcer treatment. When asked if the resident was supposed to be getting a nebulizer treatment, she stated, He's supposed to, but obviously not, as she removed the mouthpiece from beneath his right arm. The medicine cup still had some of the medication present when the nurse lifted the mouthpiece and tubing back to the nebulizer machine. Employee #45 said the nebulizer treatment was prn (as needed), rather than scheduled. When asked if the resident had been wheezing or short of breath, Employee #45 said she would have to ask his nurse, Employee #14. The resident's medical record was reviewed, on 07/17/12. The resident had [DIAGNOSES REDACTED]. Review of the Medication Administration Record [REDACTED]. The space provided on the back of the MAR for the result, or progress of the treatment was left blank. During a meeting with Employee #44 (Director of Nursing) and Employee #37 (Administrator) on 07/18/12 at 4:00 p.m., the report of this finding was discussed. No further information was provided prior to exit.",2016-07-01
8310,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,329,D,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of consultant pharmacist reports, and of the current recommendations for the maximum dose of Tylenol ([MEDICATION NAME]), the medication regimens for three (3) of forty-five (45) Stage 2 sample residents were not free from unnecessary medications. The facility failed to ensure there were adequate indications for the use, reasons for not implementing a gradual dose reduction of a psychoactive medication, and failed to ensure residents were not provided excessive doses of medications. Resident identifiers: #67, #32, and #10. Facility census: 52. Findings Include: a) Resident #67 This resident was admitted to the facility from the hospital on [DATE], with an order for [REDACTED]. Review of the consultant pharmacist report, dated 06/08/12, revealed the suggestion, Please consider reducing the dose of [MEDICATION NAME] to 0.5 mg hs (hour of sleep), with the eventual goal of discontinuation, if possible. There was no evidence the facility made an effort to determine why the resident was ordered this medication, and no evidence the facility reevaluated the use of the [MEDICATION NAME], in an effort to reduce or discontinue the medication. b) Resident #32: Medical record review revealed this resident's orders for Tylenol and [MEDICATION NAME] had no dosing parameters in place. This created a potential for the resident to receive 4550 mg of [MEDICATION NAME] in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. This would be 3900 mg, if the resident received the allowed six (6) doses of 650 mg of [MEDICATION NAME]. The resident also had an order for [REDACTED]. Two (2) of these daily would be 650 mg of [MEDICATION NAME]. The two (2) of these together are equivalent to 4550 mg of [MEDICATION NAME]. c) Resident #10 Medical record review revealed this resident's orders for Tylenol and [MEDICATION NAME] had no dosing parameters in place. This created a potential for the resident to receive 4550 mg of [MEDICATION NAME] in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. The two (2) of these together are equivalent to 4550 mg of [MEDICATION NAME]. d) McNeil, the manufacturer of Tylenol ([MEDICATION NAME]), has posted on their website : As the first step in a series of changes we are making to help ensure the appropriate use of [MEDICATION NAME], we are: ? Reducing the maximum daily dose from 8 pills (4,000 mg) per day to 6 pills (3,000 mg) per day ? Changing the dosing interval from every 4-6 hours to every 6 hours. This dose reduction information has also been posted in Consumer Reports, July 28, 2011; WebMD, July 28, 2011; Medical News Today, July 28, 2011, and others.",2016-07-01
8311,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,371,F,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of policies and procedures, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Opened and undated foods were observed in the kitchen refrigerator and freezer. Food carts were left open and unattended in the dining room and on the units. Spices were found open without indication of when they were opened. Effective hair restraints were not worn while in the food preparation/serving area. Tube feeding formulas and nutritional supplements were stored in an unsecured building which had extreme temperature fluctuations. Soiled food service items were in contact with clean items. Hands were not washed as necessary. Foods were handled with bare hands. These practices had the potential to affect all residents who resided at the facility. Facility census: 52. Findings include: a) During the initial observation of the kitchen, on July 15, 2012 at 4:30 p.m., the following sanitation infractions were observed: -The walk-in freezer contained opened and undated packages of meat and broccoli. -The walk-in refrigerator had opened and undated packages of cottage cheese and strawberry yogurt on the shelf. This information was discussed with the dietary manager (DM), Employee #46, on 07/16/12. At that time, the DM verified the opened and undated items in the freezer. b) During the first dining observation, on 07/15/12, the food cart on the 300 hall was left open and unattended while trays were being served. c) During additional dining observations, on 07/16/12 and 07/18/12, staff members were observed entering the kitchen into the area with the steam table without effective hair restraints. d) During the initial dining room observation, on 07/15/12 at 4:28 p.m., the following sanitation issues were observed: - Two (2) dirty coffee cups were observed sitting on a tray with clean coffee cups. - Kitchen doors were open and numerous employees entered without wearing effective hair restraints. - The waste receptacle underneath the counter below the coffee machine was full and overflowing. - An empty soda can was sitting on top of the juice machine. - Employee #64, a nursing assistant, was observed handling residents' foods with his bare hands. - Employee #11, a nursing assistant, was observed coughing repeatedly into her hand without washing her hands or using a hand sanitizer after coughing. e) Observations, on 07/17/12 at 11:35 a.m., revealed Employee #43, the director of health information management, and Employee #29, a nursing assistant, as well as other staff members and a resident entered the kitchen without wearing hair restraints. When a person stepped through the kitchen door, the steam table, from which meals were served, was approximately two (2) steps from the door. According to the dietary manager (DM), the staff members entered the kitchen to get their own lunch trays, and the resident entered the kitchen to get another fish sandwich. The DM confirmed the employees also assisted the cook in preparing their meal trays. The DM stated she had instructed these persons to not come into the kitchen without hairnets, but they did it anyway. f) On 07/17/12 at 12:00 p.m., a meal tray was prepared for the dining room. A nursing assistant took the tray to the table and then brought it back to kitchen when it was realized the resident was not in the dining room. A dietary staff member returned the plate of food to the warmer. This was verified by Employee #3, a dietary assistant. g) On 07/19/12 at 10:00 a.m., observation of an outside storage building found tube feeding formulas and nutritional supplements stored in this building. The storage building had an open garage door and entrance door. Supplies stored in the unattended building included: Glucerna, [MEDICATION NAME], and [MEDICATION NAME]. These products are used for residents with feeding tubes and as nutritional supplements. A request was made, on 07/24/12 at 9:30 a.m., for the manufacturer's information regarding the storage temperature requirements for the tube feeding and nutrition supplements. The manufacturer information was provided. The Temperature Guidelines included the following statement: Our general recommended storage temperatures are between 32 and 95 degrees F (Fahrenheit). The most desirable temperature range for storage is between 55 degrees and 75 degrees F. Prolonged exposure to temperatures below 32 degrees or to direct heat above 95 degrees could affect the physical consistency of the product. While the product within the sealed container is commercially sterile and of sound nutritional quality, a change in the consistency of the product could temporarily affect appearance, flavor, and other sensory attributes. We therefore do not recommend use of product exposed to adverse temperatures. A review of the ambient temperatures for the month of June 2012, found the temperatures ranged from a low of 40 degrees F to a high of 96 degrees F. From July 1, 2012 to July 24, 2012, temperatures ranged from a low of 56 degrees to a high of 96 degrees F. The administrator was informed of the manufacturer's recommendations for storage and he stated the products would be discarded. h) Observation of the resident snack room refrigerator, on 07/23/12 at 3:30 p.m., found sliced meat and cheese, stored in separate containers with dates of 07/15/12 and 07/19/12 respectively. Furthermore, two (2) bowls of cereal stored in the cabinet were not dated. There was an open box of plastic ware stored under the sink. There was a plunger stored on the opposite side of the cabinet under the sink. A nursing assistant (NA), Employee #9, was in the snack room and agreed the meat and cheese were outdated. When asked if the dates were the expiration date or the date the items were placed in the refrigerator, the NA stated she was not sure. The NA stated she thought the items were good for six (6) days. Going with the NA to the kitchen, the cooks (Employees #5 and #46) stated the items were good for seven (7) days, but would consult with the dietary manager. On 07/23/12 at 5:00 p.m., the administrator (NHA), provided a copy of a policy and procedure entitled Food Storage. The NHA stated the dietary manager said the meat and cheese were to be discarded after three (3) days. Review of this policy found, under the procedure section of the Food Storage, that Expiration dates will be checked on a regular basis and foods/fluids which have expired will be discarded. Potentially hazardous foods will be discarded after three (3) days in refrigerator.",2016-07-01
8312,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,425,E,0,1,TTVD11,"Based on observation and staff interview, the facility failed to ensure the safe provision of pharmaceutical services. The disposition of expired medications was not timely, resulting in a potential to administer expired medications. The medication cart had an expired bottle of ear drops for one (1) resident, and expired influenza virus vaccine was found in the medication room. This practice had the potential to affect more than a limited number of residents. Resident identifier: #26. Facility census: 52. Findings include: a) Resident #26 During a visual check of the medication cart, on the 200 hall at 5:00 p.m. on 07/15/12, an opened bottle of Carbamoxide ear drops, labeled for this resident, was observed. Its label noted the date the ear drops were opened, which was more than 18 months ago, on 01/01/11. Employee #42 (registered nurse) was present at the time of the observation. She acknowledged the medication was opened over a year ago, and should have been discarded. b) On 07/15/12 at 4:15 p.m., observation of the medication room revealed seven (7) vials of influenza virus vaccine in a plastic bag labeled expired 5/31/12. An interview was conducted with a registered nurse (RN), Employee #42, on 07/15/12 at 4:25 p.m. Employee #42 stated expired medications were supposed to be sent back to the pharmacy. This employee stated the pharmacy came to the facility every night.",2016-07-01
8313,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,428,D,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the consultant pharmacist failed to report medication irregularities for two (2) of forty-five (45) Stage II sample residents. These residents had physician's orders [REDACTED]. Resident identifiers: #32 and #10. Facility census: 52 Findings include: a) Resident #32 Medical record review revealed this resident's orders for Tylenol and Percocet had no dosing parameters in place. This created a potential for the resident to receive as much as 4550 mg of acetaminophen in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. This would be 3900 mg, if the resident received the allowed six (6) doses of 650 mg of acetaminophen. The resident also had an order for [REDACTED]. Two (2) of these daily would be 650 mg of acetaminophen. The two (2) of these together are equivalent to 4550 mg of acetaminophen. Review of the resident's medication review revealed the pharmacist failed to identify and report there were no dosing limitations on the medications containing acetaminophen. Interview with Employee #44, the director of nursing (DON), confirmed these irregularities were not identified by the consultant pharmacist. The DON also stated the pharmacist was responsible for identifying the potential for overdoses, and for placing dosing alerts on the medical record. b) Resident #10 Medical record review revealed this resident's orders for Tylenol and Percocet had no dosing parameters in place. This created a potential for the resident to receive 4550 mg of acetaminophen in a 24 hour period, which exceeds the maximum recommended safe amount over a 24 hour period. The resident had physician's orders [REDACTED]. The two (2) of these together are equivalent to 4550 mg of acetaminophen. Review of the resident's medication review revealed the pharmacist failed to identify and report there were no dosing limitations on the medications containing acetaminophen. Interview with Employee #44, the DON, confirmed these irregularities were not identified by the consultant pharmacist. The DON also stated the pharmacist was responsible for identifying the potential for overdoses, and for placing dosing alerts on the medical record.",2016-07-01
8314,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,431,E,0,1,TTVD11,"Based on observation, policy review, review of the guidelines in Appendix PP of the State Operations Manual, and staff interview, the facility failed to ensure the consultant pharmacist maintained a formal system for safe and secure use and storage of medications. 1) Multi-dose medication vials were not labeled with the date they were first opened; 2) There was no permanently affixed storage container in the refrigerator for the secure storage of controlled medications; and 3) The biohazard storage refrigerator in the medication preparation room was not clearly identifiable as such with a visible label. These practices affected Residents #32 and #69, and had the potential to affect more than an isolated number of residents. Facility census: 52. Findings include: a) Resident #32 During a visual check of the medication cart on the 200 Hall, at 5:00 p.m. on 07/15/12, a previously opened bottle of Brimonidine eye drops with a label indicating that they were for Resident #32 was observed. There was no date written on the bottle to indicate when they had been opened. b) Resident #69 During a visual check of the medication cart on the 200 Hall, at 5:00 p.m. on 07/15/12, a previously opened bottle of Carbamoxide ear drops with a label indicating that they were for Resident #69 was observed. There was no date written on the bottle to indicate when they had been opened. c) Employee #42 (registered nurse) was present at the time of the observations regarding Residents #32 and #69. She acknowledged the medications should have been labeled with the date of opening, and stated it was the policy of the facility, in order to set the expiration date. d) Observation, on 07/15/12 at 4:15 p.m., revealed the medication refrigerator contained two (2) clear plastic boxes. One (1) box contained six (6) vials of Lorazepam which had a blue numbered break away lock. The other box was empty. Both boxes were freely moveable in the refrigerator. Another observation, on 7/24/12 at 10:15 a.m., revealed the medication refrigerator had four (4) single dose vials and 1 multi-dose vial of Lorazepam in one box. The second box contained one (1) multi-dose vial of Lorazepam. e) The State Operations Manual (SOM), Appendix PP includes The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. f) The facility procedure entitled Acquisition, Receiving, Dispensing and Storage of Medications revealed under section 8, Controlled drugs (Schedule II) and other drugs subject to possible abuse will be stored in separate, locked, permanently fixed compartments, except when a single unit package drug distribution is used. If the medication requires a refrigerator these need to be locked in a separate container. In an interview conducted with the director of nursing (Employee #44) and the administrator (Employee #37), on 07/23/12 at 3:15 p.m., they agreed the boxes were not permanently affixed in the refrigerator. g) On 07/15/12 at 4:15 p.m., two (2) refrigerators were noted in the medication room. The first refrigerator was not marked and contained Programing cassettes. No other items were found in the refrigerator. On 07/16/12 at 9:30 a.m., this same refrigerator contained two (2) vials of yellow liquid in a plastic bag labeled biohazard. The infection preventionist was asked to verify the use of this refrigerator. The infection preventionist verified the refrigerator was used to store blood, urine, and other potentially infectious material. She further agreed the refrigerator did not have a biohazard label and could not be locked. She also stated the Programing cassettes were not to be stored in this refrigerator and placed them in the medication refrigerator. On 07/23/12 at 10:15 a.m., a random observation revealed a sign stating lab only was taped to the outside of the refrigerator. According to the Occupational Safety & Health Administration (OSHA) in section 1910.1030(g)(1)(i)(A) Warning labels shall be affixed to containers of regulated waste, refrigerators and freezers containing blood or other potentially infectious material; and other containers used to store, transport or ship blood or other potentially infectious materials . In an interview with the administrator, on 07/23/12 at 3:15 p.m., he stated biohazard labels had been ordered for the refrigerator.",2016-07-01
8315,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,441,E,0,1,TTVD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interviews, medical record reviews, and review of manufacturer's instructions, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper disinfectant was used on the shower cart after showering a resident with Clostridium difficile (C. diff); failed to ensure proper hand sanitation during food service; failed to conduct medication pass in a sanitary manner; and failed to ensure nebulizer equipment was cleaned and stored in a manner to prevent the spread of infectious organisms. These practices affected five (5) five of forty-five (45) Stage II sample residents, and had the potential to affect all residents who received showers on Hallway 2, all residents who received nebulizer treatments, all residents who received medication, and all residents who received meals in the dining room. Resident identifiers: #48, #20, #29, #30, and #17. Facility census: 52. Findings include: a) Resident #48 Medical record review revealed this resident was positive for Clostridium difficile (C. diff). During an interview, on 07/18/12 at 2:45 p.m., Employee #21, a nursing assistant, stated after showering Resident #48, the shower cart was cleaned with a disinfectant spray. She stated housekeeping placed the container of disinfectant on the wall, and this was what they used. On 07/18/12, at approximately 2:30 p.m., the director of maintenance (Employee #58) was interviewed. He stated the disinfectant placed in the shower room container was a product called Cen-Kleen IV. He also reported the isolation rooms were cleaned with a product called Virasept. On 07/24/12 at 1:45 p.m., Employee #29, a nursing assistant, stated after showering Resident #48, the shower cart was cleaned with the disinfectant in the container on the shower wall and then rinsed with warm water. Review of the labels for these products revealed Cen-Kleen IV was not an effective cleanser for[DIAGNOSES REDACTED]. This was the cleanser the nursing assistants stated they used in the shower room, after showering Resident #48, who had [DIAGNOSES REDACTED]. The label on the Virasept noted it was effective for[DIAGNOSES REDACTED]; however, this was not the product used by the nursing assistants. b) Resident #20 During observations, on 07/17/12 at 1:45 p.m. and 3:05 p.m., Resident #20's nebulizer machine and disposable nebulizer kit were observed on the resident's bed. The nebulizer equipment looked as though it had not been cleaned since the last use. On 07/17/12 at 3:10 p.m., the licensed nurse, Employee #62, confirmed the nebulizer equipment had been used at 12:00 p.m. and was not cleaned after use. Review of the manufacturer's cleaning recommendations revealed instructions to disassemble the nebulizer cup, tee, and mouthpiece completely after each use, wash all parts in warm soapy water, and rinse thoroughly, and allow the parts to air dry. The cleaning recommendations contained this warning: Warning - To prevent possible risk of infection from contaminated medication, cleaning of the nebulizer is recommended after each treatment. c) Residents #29, #30, and #17 Observations, on 07/23/12 and 07/24/12, found nebulizer machines sitting on the bedside table by each of these resident's beds. The disposable nebulizer mouthpieces and tubing were lying uncovered beside the nebulizer machine, creating a potential for contamination from the table or from airborne dust and particles. The director of nursing was shown the uncovered nebulizer mouthpieces and tubing on 07/24/12, at approximately noon. She said the facility had no policy regarding covering the nebulizer mouthpiece and tubing when not in use. d) Employee #62 During a random observation of a medication pass, on 07/17/12 at 12:45 p.m., a registered nurse (Employee #62) was observed placing medications in her hand before putting the medication into a cup. This included pushing the medication from the blister pack into her hand and then placing the medication into a plastic medicine cup. Further, medications from floor stock were poured into the cap and Employee #62 used her fingers to retrieve a pill and place the pill in a plastic medicine cup. The pills remaining in the cap were placed back in the bottle. An interview with the director of nursing was conducted on 07/18/12 at 10:00 a.m. She agreed medications were not to be dispensed by any nurse by utilizing their hands or fingers to place the medication into a medicine cup during a medication pass.",2016-07-01
8316,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,465,F,0,1,TTVD12,"Based on observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the refrigerator of the resident snack room. When opening the door to the refrigerator, a smell of spoiled milk was noted. White debris was found on the shelf where milk cartons were stored. This practice had the potential to affect all residents in the facility. Facility census: 49 Findings include: a) On 10/03/12 at 9:00 a.m., observation of the resident snack room found the refrigerator smelled of spoiled milk. White debris was found on the shelf where milk cartons were being stored. The dietary manager (DM) was interviewed, on 10/03/12 at 9:30 a.m., in the resident snack room. When the DM opened the refrigerator door, she stated, This smells, and needs to be cleaned. She agreed the refrigerator smelled of spoiled milk.",2016-07-01
8317,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,490,F,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility was not administered in a manner in which its resources were used effectively and efficiently to ensure optimum quality of care for each resident. The facility failed to provide individualized services to assist each resident in attaining or maintaining the highest practicable physical, mental, and/or psychosocial well-being. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34, the Quality Assurance (QA) committee contact person, at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been presented to the facility's QA committee. The facility's administrative personnel were part of the QA committee. The facility's administrative personnel did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update and revise the care plan for two (2) of three (3) sample residents, residents #10 and #42, when their health status deteriorated. d) Medical record review and staff interviews revealed the facility failed to provide care as established in the care plan and as ordered by the physician for one (1) of four (4) sample residents, Resident #42. The facility failed to ensure pre and post care of a resident receiving dialyses. e) Observations and staff interviews revealed the facility failed to ensure food was stored, prepared and served under sanitary conditions. Effective hair restraints were not worn while in the food preparation area. Gloves were not worn while serving food. The walk in refrigerator had a personal lunch bag in it. The kitchenette refrigerator and cabinets had out dated food items in them. These practices had the potential to affect all resident who received nourishment from the dietary department. f) Observation and staff interview revealed the facility was unable to provide evidence that medications were stored under proper temperature controls. This had the potential to affect all residents who received medications that required refrigeration. g) Facility policy review and staff interview revealed the facility failed to develop and put into effect a written plan and procedure addressing missing residents. This had the potential to effect all residents.",2016-07-01
8318,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,514,D,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR. An order was present for the application of [MEDICATION NAME] twice daily to the resident's right [MEDICAL CONDITION] stump. According to the TAR, this treatment was discontinued on 09/19/12. Interview with the treatment nurse, Employee #48, at 10:15 a.m. on 10/03/12, confirmed this treatment was discontinued on the date indicated on the TAR. The medical record contained a physician's orders [REDACTED]. Observation on 10/04/12 at 3:00 p.m., with Employee #48, revealed the mattress on the resident's bed was not an air mattress, but was instead a pressure relieving mattress. Employee #48 stated there would be a pump mechanism at the foot of the bed were this an actual air mattress.",2016-07-01
8319,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,517,F,0,1,TTVD11,". Based on facility policy review and staff interview, the facility failed to maintain an up to date, complete, and easily accessible written plan and procedure manual to meet potential emergencies. This had the potential to affect all residents. Facility census: 52. Findings include: a) A review of the Emergency Manual was done at 8:00 a.m. on 07/24/12. The manual was presented to the surveyors by Employee #58 (director of maintenance), who stated he was responsible for overseeing the employee training of emergency procedures and providing staff drills to ensure resident safety. A front sheet entitled Annual Review and Update of The Disaster Plan contained annual signatures of the Administrator starting with 09/06/05 and ending with 04/05/11. There was no index, tabs, or other method for easy and quick access to the various procedures contained in the manual. During an interview with Employee #58, at 8:45 a.m. on 07/24/12, he stated he had gotten the manual from the nurses' station and that, as far as he knew, it was the only one available in the facility. He stated he was not sure who was in charge of the policies it contained. During an interview with Employee #62 (registered nurse), at 9:15 a.m. on 07/24/12, she verified there was only one (1) emergency manual and it was kept on a shelf at the nurses' station. There was no evidence the manual was periodically reviewed or revised as evidenced by the following: 1) There was no order to the policies. 2) There were multiple policies in various locations in the manual, such as: a) A Fire Plan (Number VII.2a) issued July 1998 with an effective date of April 2001 b) An undated Fire Plan (it contained a policy entitled Heat Emergency Plan with an effective date of 10/10/1983), which was different than a and it had an addendum dated 1990. c) There was a third Fire Plan, dated 2001. 3) The manual contained two (2) different, undated, Disaster Evacuation Plans. 4) The manual contained four (4) different plans for the procurement of fresh water in an emergency. One (1) of these, with a local fire department, was unsigned and dated 01/10/2002. The plans were in various locations in the manual and contained no instructions which indicated the order of use. 5) There was a policy entitled Employee Incidents with an effective date of 01/01/1996, which was not the same policy which was provided upon entrance to the facility. 6) There was a policy entitled Heat Emergency Plan effective 10/10/1983, in one (1) of the fire plans. It was also found alone in two (2) other locations. Upon inquiry, neither Employee #58 or #62 could remember it ever being used. 7) The manual contained a Three Day Emergency Menu. It was undated and was not the same Emergency Menu provided by the Director of Dietary Services, Employee #46, when requested upon entrance. 8) There was no Missing Persons Policy in the manual. Employee #62 was asked to produce the policy at 9:15 a.m. on 07/24/12. After 15 minutes, she located a policy entitled Elopement with a revision date of 7/08 and stated she had located it in the nursing policy manual provided by The Good Samaritan Society. It should also be noted that none of the plans and/or policies and procedures included the name of the facility. In addition, none of them were individually signed to indicate actual reviews and revisions. During an interview with the administrator, at 9:40 a.m. on 07/24/12, he acknowledged there was Probably only one manual. He had no comments regarding the specific findings related to the facility's Emergency Manual.",2016-07-01
8320,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,518,C,0,1,TTVD11,"Based on facility policy review, personnel records review, and staff interview, the facility failed to adequately train employees in emergency procedures by failing to use the current Fire Plan as the basis for the training. This had the potential to affect all residents. Facility census: 52. Findings include: a) After a review of the personnel records, at 2:00 p.m. on 07/17/12, a meeting was held with Employee #52 (Registered Nurse and Staff Development Coordinator). She explained all of the required in-services for both orientation purposes and annual in-services were completed by using a computerized video training program which was provided by the corporate office. The exception to this was the emergency, fire, and disaster training, which Employee #52 stated was provided by the Maintenance Director. A review of the Emergency Manual was done at 8:00 a.m. on 07/24/12. The manual was presented to the surveyors by Employee #58 (Director of Maintenance), who stated he was responsible for overseeing the employee training of emergency procedures and providing staff drills to ensure resident safety. There was no evidence the manual was periodically reviewed or revised as evidenced by the multiple Fire Plans it contained. 1) A Fire Plan (Number VII.2a) issued July 1998 and effective April 2001 2) An undated Fire Plan (it contained a policy entitled Heat Emergency Plan with an effective date of 10/10/1983), which was different than 1 and an it had an addendum dated 1990. 3) A third Fire Plan was provided, and it was also dated 2001. Employee #52, the staff development coordinator, was asked for the teaching aids used for the emergency procedures training. She provided a Fire Plan at 10:35 a.m. on 07/24/12. The fire plan Employee #52 stated was used in the training was not the current Fire Plan. The plan being used for training was the undated plan described in 2 above. During an interview with the Administrator, at 9:40 a.m. on 07/24/12, he had no comments about the concerns above, and expressed his thanks that the information had been brought to his attention.",2016-07-01
8321,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,520,F,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34 (QA Committee Contact Person), at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). The plan of correction referred to submitting results to the QA committee as part of their correction. The QA committee did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update and revise the care plan for two (2) of three (3) sample residents, residents #10 and #42, when their health status deteriorated. d) Medical record review and staff interviews revealed the facility failed to provide care as established in the care plan and as ordered by the physician for one (1) of four (4) sample residents, Resident #42. The facility failed to ensure pre and post care of a resident receiving dialyses. e) Observations and staff interviews revealed the facility failed to ensure food was stored, prepared and served under sanitary conditions. Effective hair restraints were not worn while in the food preparation area. Gloves were not worn while serving food. The walk in refrigerator had a personal lunch bag in it. The kitchenette refrigerator and cabinets had out dated food items in them. These practices had the potential to affect all resident who received nourishment from the dietary department. f) Observation and staff interview revealed the facility was unable to provide evidence that medications were stored under proper temperature controls. This had the potential to affect all residents who received medications that required refrigeration. g) Facility policy review and staff interview revealed the facility failed to develop and put into effect a written plan and procedure addressing missing residents. This had the potential to effect all residents.",2016-07-01
8322,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2013-08-01,253,E,1,0,7GX311,"Based on observation, staff interview, and record review, the facility failed to ensure housekeeping services were provided to maintain a clean shower room. The shower room on the 200 hall had dried white debris going down from the shower panel and a black moist mold-like substance against the molding on the bottom of the wall and floor. A clear colored substance had leaked out from underneath the shower panel. This had the potential to affect more than a limited number of residents as any resident could shower in the 200 hall shower room. Facility census: 50. Findings include:a) Observation of the 200 hall shower room, on 07/29/13 1:00 p.m., revealed a shower panel on the left side of the wall with dried white debris going down from the shower panel to the floor. The white debris covered an area which measured three (3) feet in length by two (2) feet in width. A black moist mold-like substance was on the tile floor below the shower panel measuring one (1) foot by one (1) foot. This substance was also on the molding against the bottom of the wall and measured two (2) feet in length by one (1) foot in width. There was clear leakage coming from underneath the shower panel. On 07/30/13 at 2:30 p.m. and 07/31/13 at 09:45 a.m., observations found the condition of the shower unchanged.Observations of the shower room on the 200 hall, were made on 07/31/13 at 09:48 a.m., with Employee #62, a registered nurse (RN). When asked what was on the wall and the floor, she stated it was a dried white chemical from the shower panel that was leaking, and there was some kind of black mold-like substance on the molding against the bottom of the wall and on the floor. A tour of the 200 hall shower room was conducted on 07/31/13 at 09:50 a.m., with Employee #15, the environment assistant (EA). She agreed it looked like a mold-like substance on the floor, and stated the white substance on the wall looked like the chemical cleaner they used on the shower panel.During a tour of the 200 hall shower room with Employee #2, the housekeeping assistant (HA), on 07/31/13 at 10:00 a.m., she was asked what the substance on the wall and floor underneath the shower panel was. She stated the black area on the floor and around the molding against the bottom of the wall looked like mold, and the white substance on the wall looked like it was related to the chemical cleaner that had been leaking out underneath the shower panel. An interview was conducted on 07/31/13 at 10:10 a.m., in the 200 hall shower room with nursing assistants (NA), Employee #42 and Employee #55. When asked what was on the wall and floor underneath the shower pane, both stated they thought the black substance on the floor and the molding against the bottom of the wall was mold and the white substance on the wall was from the cleaner in the shower panel. Employee #55 reported there was one side of the shower panel to clean the residents, and the other side, which was leaking, was used to clean the shower. During an interview and tour of the 200 hall shower room with Employee #48, the director of nursing (DON), on 07/31/13 at 10:15 a.m., she stated the shower panel had been there for a long time and recently had not been working properly. The maintenance supervisor had been trying to fix it. She acknowledged the presence of the white debris on the shower wall and the black appearance at the bottom of the wall and the shower floor. When asked about the residents who used this shower, she reported any resident in the facility could use either of the two (2) facility showers. Observation of the shower room on the 200 hall, on 07/31/13 at 12:20 p.m., revealed the wall had less white dried debris and the black mold-like substance was no longer visible on the molding against the wall and floor.",2016-07-01
9919,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,241,E,1,0,943L11,". Based on observation and staff interview, the facility failed to provide an environment which maintained or enhanced each resident's dignity. The privacy curtains were too short to provide privacy for all residents. This had the potential to affect all residents in B beds. Facility census: 53 Findings include: a) B beds Observation during the initial tour, on 07/11/12 at 2:30 p.m., found the privacy curtains in the residents' rooms were pulled. Observation revealed they were too short to provide privacy for residents in the B beds (Beds in semi-private rooms are often referred to as A and B). The maintenance director stated in an interview, on 07/11/12 at 3:30 p.m., that all of the curtains in all of the rooms were the same and fit around every B bed the same way. The maintenance director said it had been that way for 8 years. The findings were verified with Employee #44 (DON) at 3:00 p.m. on 07/11/12. .",2015-08-01
9920,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-07-24,463,E,1,0,943L11,". Based on observation and staff interview, the facility failed to provide a functioning call system for residents residing on the 100 Hall and residents utilizing the resident bathroom on the 100 Hall. This had the potential to affect more than an isolated number of residents. Facility census: 52. Findings include: a) On 07/11/12 at 1:50 p.m., the resident bathroom call light, on the 100 Hallway, was observed blinking red and no staff were visible in the hallway. This was observed for five (5) minutes. A resident in the room was heard asking, "" someone out there? "" At that time the ward clerk (Employee #17) was told a resident needed assistant in the bathroom. When asked how the call system worked, Employee #17 went to the wall telephone, directly across from the nurses station, and stated the system was working because the call light was noted on the LED screen. When asked if the call system had an audible alarm, she confirmed it should be sounding, but was not. Employee #58 (maintenance director) was paged to the desk and stated, ""There was a problem with the call cord in room 103 earlier, and maybe it was not the right cord and caused the audible alarm malfunction."" He took the unit off the wall, turned it over, and stated he thought it might be the battery. He said he did not want to shut down the system because it was so busy. Employee #58 verified the system for the 100 Hall was not working in regard to the audible alarm. He informed staff at the nurses station the audible alarm was not working on the 100 Hallway. At approximately 3:30 p.m., the maintenance director stated the call lights on the 100 hallway were working and thought it might be from interference with some electrical cord close to the call system phone, He stated he would take care of this in the morning by drilling a hole and relocating the wire. When checking the call bell system in room 103, with Employee #58, he pulled the call light cord out of the panel and no light came on. He explained when a call light cord is removed from the panel, a red light goes on, the main panel at the nurses station will display a visual, as well as, an audible alarm. He stated the call system in room 103 was not working properly. .",2015-08-01
9921,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-10-05,325,D,0,1,TTVD12,". Based on medical record review, resident interview, and staff interview, the facility failed to provide nutritional care and services to prevent unplanned weight loss for one (1) of twenty sample residents. The facility failed to recognize, evaluate, and address the individual nutritional needs of this resident to ensure she maintained an acceptable nutritional status. Resident identifier: #10. Facility census: 49 Findings include: a) Resident #10 An interview was conducted with the resident on 10/03/12 at 9:00 a.m. When asked about her meals, the resident stated she did not like the food. She stated the food did not taste good to her. When she was asked about an alternate meal, she stated there were no alternates. Medical record review, on 10/04/12, revealed Resident #10 had a severe unplanned weight loss of 6.3% in a thirty-seven (37) day period which was not addressed by the facility. On 08/01/12, the recorded weight was 175 pounds. On 09/07/12, the weight recorded was 164 pounds. This was an eleven (11) pound weight loss. The dietitian noted the weight loss on 09/11/12, and ordered weekly weights for four (4) weeks. The dietitian's notes described the resident as obese and above her ideal body weight recommendation, which was 102 to 112 pounds. The nursing assistants' meal tracking showed the resident frequently refused breakfast, and the overall meal consumption was frequently less than fifty (50) percent. Review of the medical record revealed the resident's care plan was not updated to address the weight loss or poor meal consumption. The care plan did not include any interventions to encourage the resident to eat. There were no interventions to offer alternatives when she refused to eat, or ate less than a certain percentage of her meals. An interview was conducted on 10/04/12, with the director of nursing (DON), regarding the weekly weights. The DON was unable to locate the weekly weights. The DON contacted the certified manager (CDM), who was also unable to produce weekly weights for the resident. There was no evidence weekly weights were being done. On 10/04/12, an interview was conducted with the CDM. She stated the resident had capacity, and if she did not want to eat, she could not be made to eat. When asked if the resident was offered alternatives or given other food choices, the CDM stated, ""Yes, as far as I know."" She also stated that the facility had attempted supplements, such as 2-Cal and Magic Shakes; however, the resident refused them. There was no evidence the facility explored what the resident would like to eat. Additionally, there was no evidence the facility made an attempt to determine why the resident's meal consumption was frequently less than 50%. .",2015-08-01
9922,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-10-05,465,F,0,1,TTVD12,". Based on observation and staff interview, the facility failed to ensure sanitary conditions were maintained in the refrigerator of the resident snack room. When opening the door to the refrigerator, a smell of spoiled milk was noted. White debris was found on the shelf where milk cartons were stored. This practice had the potential to affect all residents in the facility. Facility census: 49 Findings include: a) On 10/03/12 at 9:00 a.m., observation of the resident snack room found the refrigerator smelled of spoiled milk. White debris was found on the shelf where milk cartons were being stored. The dietary manager (DM) was interviewed, on 10/03/12 at 9:30 a.m., in the resident snack room. When the DM opened the refrigerator door, she stated, ""This smells, and needs to be cleaned."" She agreed the refrigerator smelled of spoiled milk. .",2015-08-01
9923,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-10-05,514,D,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure an accurate medical record for two (2) of twenty (20) residents in the sample. The monthly recapitulation orders did not contain revisions and changes made from one month to the next. Resident identifiers: #53 and# 42. Facility census 49. Findings include: a) Resident #53 A review of the medical record revealed the physician's orders [REDACTED]. During an interview with the director of nurses (DON), at 8:50 a.m. on 10/4/12, she stated the resident no longer had pressure ulcers. She said they were healed in August and treatment was discontinued. She located evidence of this in the record. Upon review of the record, she agreed the orders for treatment had not been deleted from the record. . b) Resident #42 Review of the resident's medical record, at 10:00 a.m. on 10/03/12, revealed the October 2012 recapitulation orders contained five (5) orders that had been discontinued. The orders on the recapitulation were indicated accurate by the director of nursing services (DON), Employee #20, on 09/28/12. Additionally, the physician approved the orders, by signature, on 10/01/12. An order was present for monitoring an incision site on the resident's back for signs and symptoms of infection due to status [REDACTED]. Review of the treatment administration record (TAR) revealed this treatment was discontinued on 09/28/12. Interview with the treatment nurse (Employee #48) at 10:15 a.m. on 10//03/12 confirmed this area was healed on the date indicated on the TAR. There was an order for [REDACTED].#20, on 10/04/12 at 12:00 p.m., she clarified the resident went to [MEDICAL TREATMENT] on Monday, Wednesday, and Friday. The resident's physician's orders [REDACTED]. According to the TAR, the stage II pressure ulcer was healed on 08/23/12. During the interview with Employee #48, at 10:15 a.m. on 10/03/12, she confirmed the pressure ulcer was healed on the date indicated on the TAR. An order was present for the application of [MEDICATION NAME] twice daily to the resident's right [MEDICAL CONDITION] stump. According to the TAR, this treatment was discontinued on 09/19/12. Interview with the treatment nurse, Employee #48, at 10:15 a.m. on 10/03/12, confirmed this treatment was discontinued on the date indicated on the TAR. The medical record contained a physician's orders [REDACTED]. Observation on 10/04/12 at 3:00 p.m., with Employee #48, revealed the mattress on the resident's bed was not an air mattress, but was instead a pressure relieving mattress. Employee #48 stated there would be a pump mechanism at the foot of the bed were this an actual air mattress. .",2015-08-01
9924,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-10-05,520,F,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interviews, and policy review, the facility's quality assurance program failed to develop and implement appropriate plans of action to correct identified quality deficiencies. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34 (QA Committee Contact Person), at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). The plan of correction referred to submitting results to the QA committee as part of their correction. The QA committee did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update and revise the care plan for two (2) of three (3) sample residents, residents #10 and #42, when their health status deteriorated. d) Medical record review and staff interviews revealed the facility failed to provide care as established in the care plan and as ordered by the physician for one (1) of four (4) sample residents, Resident #42. The facility failed to ensure pre and post care of a resident receiving dialyses. e) Observations and staff interviews revealed the facility failed to ensure food was stored, prepared and served under sanitary conditions. Effective hair restraints were not worn while in the food preparation area. Gloves were not worn while serving food. The walk in refrigerator had a personal lunch bag in it. The kitchenette refrigerator and cabinets had out dated food items in them. These practices had the potential to affect all resident who received nourishment from the dietary department. f) Observation and staff interview revealed the facility was unable to provide evidence that medications were stored under proper temperature controls. This had the potential to affect all residents who received medications that required refrigeration. g) Facility policy review and staff interview revealed the facility failed to develop and put into effect a written plan and procedure addressing ""missing residents."" This had the potential to effect all residents. .",2015-08-01
9925,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-10-05,490,F,0,1,TTVD12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observations, staff interviews, and policy review, the facility was not administered in a manner in which its resources were used effectively and efficiently to ensure optimum quality of care for each resident. The facility failed to provide individualized services to assist each resident in attaining or maintaining the highest practicable physical, mental, and/or psychosocial well-being. Six (6) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 07/24/12 were still out of compliance during the re-visit survey which ended 10/05/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F279, F280, F309, F371, F431, and F517. This had the potential to affect all residents in the facility. Facility Census 49. Findings Include: a) Staff interview with Employee #34, the Quality Assurance (QA) committee contact person, at 2:00 p.m. on 10/04/12, revealed the issues identified from the previous QIS survey had been presented to the facility's QA committee. The facility's administrative personnel were part of the QA committee. The facility's administrative personnel did not ensure the deficient practices cited during the survey which ended 07/24/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F279, F280, F309, F371, F425, and F517. They remained out of compliance when evaluated for compliance during the re-visit survey which ended 10/05/12. b) Staff interview and medical record review revealed the facility failed to provide interventions necessary to ensure the highest possible level of well-being for one (1) of three (3) residents sampled for quality of care, a resident who received [MEDICAL TREATMENT] services. The facility did not provide the pre and post [MEDICAL TREATMENT] care as instructed on the care plan and according to the facility's policy. c) Medical record review and staff interview revealed the facility failed to update and revise the care plan for two (2) of three (3) sample residents, residents #10 and #42, when their health status deteriorated. d) Medical record review and staff interviews revealed the facility failed to provide care as established in the care plan and as ordered by the physician for one (1) of four (4) sample residents, Resident #42. The facility failed to ensure pre and post care of a resident receiving dialyses. e) Observations and staff interviews revealed the facility failed to ensure food was stored, prepared and served under sanitary conditions. Effective hair restraints were not worn while in the food preparation area. Gloves were not worn while serving food. The walk in refrigerator had a personal lunch bag in it. The kitchenette refrigerator and cabinets had out dated food items in them. These practices had the potential to affect all resident who received nourishment from the dietary department. f) Observation and staff interview revealed the facility was unable to provide evidence that medications were stored under proper temperature controls. This had the potential to affect all residents who received medications that required refrigeration. g) Facility policy review and staff interview revealed the facility failed to develop and put into effect a written plan and procedure addressing ""missing residents."" This had the potential to effect all residents. .",2015-08-01
10021,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,225,D,0,1,4T1611,". Based on a review of personnel files and staff interview, the facility failed to thoroughly screen one (1) of ten (10) sampled employees for findings of abuse or neglect, by failing to make an inquiry to the WV Nurse Aide Registry as required before the new employee was permitted to begin work at the facility. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 A review of the personnel file for Employee #75, on the morning of 02/09/10, revealed that she was hired as a nursing assistant on 10/05/09. However, there was no evidence to reflect this individual was screened through the WV Nurse Aide Registry for findings of resident abuse / neglect. When interviewed on 02/09/10 at 3:00 p.m., the director of nursing (Employee #7) confirmed there was no evidence the required registry check was made prior to the employment of Employee #75. .",2015-07-01
10022,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,496,D,0,1,4T1611,". Based on review of sampled personnel records and staff interview, the facility failed to receive registry verification that individuals met competency evaluation requirements before allowing them to serve as nurse aides. This was found for one (1) of ten (10) records reviewed. Employee identifier: #75. Facility census: 50. Findings include: a) Employee #75 Review of the personnel records of Employee #75 (a nursing assistant), on the morning of 02/09/10, revealed she started working on 10/05/09. The facility had no evidence this nursing assistant was registered with the WV Nurse Aide Registry as having completed the State-required minimum training and competency evaluation. During an interview on 02/09/10 at 3:00 p.m., the director of nursing (DON - Employee #7) confirmed that Employee #75 had been performing direct patient care while the facility had no verification she had successfully completed the training and competency evaluation as required by the State. .",2015-07-01
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
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
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
10026,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,371,F,0,1,4T1611,". Based on observation and staff interview, the facility failed to ensure the proper sanitation of the kitchen area to prevent potential contamination of food products by inadequate cleaning of the equipment. This had the potential to affect all residents. Facility census: 50. Findings include: a) During the general tour of the kitchen and dry storage room at 12:50 p.m. on 02/08/10, observation found the inner aspect of the steam table to be dirty, with dried food debris and stains visible. The backsplash of the stove was also covered with baked and dried food stains. During service of the noon meal at 11:15 a.m. on 02/09/10, observation found the steam table to be cleaner, but the stove was still very stained. The dietary manager was present during both observations and stated there was a schedule for cleaning the steam table, but it had been overlooked. She agreed the backsplash needed to be cleaned. .",2015-07-01
10027,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,387,D,0,1,4T1611,". Based on record review and staff interview, the facility failed to assure one (1) of twelve (12) sampled residents was seen by a physician at least once in every sixty (60) days. Resident identifier: #1. Facility census: 50. Findings include: a) Resident #1 A review of the clinical record, completed on 02/09/10, revealed the last entry by a physician was dated 10/02/09. A review of the nurses' notes failed to reveal any other visits. During an interview with the director of nurses (DON) and the administrator at 11:10 a.m. on 02/11/10, the DON stated she had reviewed the record and questioned the nurses, but she could not show evidence to reflect the physician had seen the resident since 10/02/09. The administrator stated he would notify the physician and the quality assurance committee of this problem. .",2015-07-01
10028,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2010-02-11,278,D,0,1,4T1611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments by failing to accurately encode the resident's skin condition and/or [MEDICAL TREATMENT] treatments on two (2) different assessments for one (1) of twelve (12) sampled residents. Resident identifier: #13. Facility census: 50. Findings include: a) Resident #13 1. A review of the clinical record revealed, in Section M4 of the 08/14/09 admission MDS, no entry for ""Surgical wounds"", although the admission nursing assessment dated [DATE] stated the resident was admitted with [DIAGNOSES REDACTED]. 2. A review of the clinical record also revealed, in Item P1b of the 11/13/09 quarterly MDS, no entry to indicate the resident received [MEDICAL TREATMENT], although the resident had orders for and received [MEDICAL TREATMENT] three (3) times weekly on a continuing basis. 3. In an interview with the director of nurses at 1:20 p.m. on 02/10/10, she reviewed the assessments and stated these were oversights and they would be corrected. .",2015-07-01
10029,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-03-21,225,E,1,0,YLY611,". Based on record review, review of concern forms, and staff interview, the facility failed to ensure all allegations involving mistreatment, neglect, abuse, and misappropriation of resident property, were reported immediately to officials in accordance with State law through established procedures. Allegations found in four (4) concern forms, from residents and/or families, included failure to provide mouth care and wound care, verbal abuse, stolen personal property, and failure to provide care for dentures. These allegations were not reported as required. Resident identifiers: #37, #70, #53, and #54. Facility census: 52. Findings include: a) Resident #37 Review of concern forms revealed the family of Resident #37 reported a concern on 10/12/11. The family expressed Resident #37's tooth brushing and oral care were not adequate. The family member alleged while brushing the resident's teeth, just prior to the evening meal, the resident had some type of green material still in her mouth. The family member also reported the previous weekend, when Resident #37 was at the emergency room , emergency room staff had to suction food out of the resident's mouth. This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the social worker (SW), confirmed this allegation of neglect should have been reported. b) Resident #70 1) Review of concern forms revealed Resident #70 complained to staff, on 12/28/11, that her daily dressing change to a wound was omitted on 12/23/11. The report noted she ""...had to 'fuss' at staff on 12/24/11 to get it changed because it leaked all over her slacks."" This allegation of neglect was not reported to state agencies. On 03/21/11, at approximately 3:00 p.m., the SW confirmed this allegation of neglect should have been reported. 2) According to concern forms, Resident #70 complained to staff, on 12/28/11, that former nursing assistant, Employee #68, was rude to her when she was asked to change the resident. This allegation of verbal abuse was not reported to state agencies. During an interview with the SW, on 03/21/11, at approximately 3:00 p.m., she stated the director of nursing informed her this allegation of abuse should have been reported to the nurse aide registry when the allegation occurred. c) Resident #53 Review of concern forms revealed an e-mail complaint from a family member of Resident #53 on 01/06/12. The family member stated someone had stolen a bottle of perfume out of the resident's nightstand drawer. The resident was so upset she was crying. Record review found no evidence this allegation of theft was reported to state agencies. During an interview with the SW, on 03/21/11, at approximately 3:00 p.m., she stated an investigation was done. She said there was no evidence Resident #53 ever had a bottle of White Diamonds perfume. The SW said the resident had spoken to her, on 01/05/12, about a missing bottle of White Diamonds perfume. The SW said in the future, whenever there is a ""gray"" area of uncertainty related to reporting, they will proceed with reporting to err on the side of caution. d) Resident #54 Review of concern forms revealed Resident #54's family member filed a complaint on 11/28/11. The family member reported when this resident was on leave for Thanksgiving, his dentures ""were so dirty that I am surprised they did not give his intestines an infection."" The family member even took pictures of the dentures. Record review found no evidence this allegation of neglect was reported to state agencies. Interview with the SW, on 03/21/11, at approximately 3:00 p.m., confirmed this allegation of neglect had not been reported. .",2015-07-01
10030,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-03-21,226,D,1,0,YLY611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure their policies and procedures for identification and reporting of abuse were implemented. The facility required immediate reporting of abuse to the supervisor. A nursing assistant (NA) failed to immediately report two (2) witnessed incidents of abuse to the supervisor for more than two (2) months after witnessing the incidents. The alleged abuse was committed by the same NA, involving two (2) different residents. Resident identifiers: #24 and #36. Facility census: 52. Findings include: a) Resident #24 Record review revealed nursing assistant, Employee #27, reported to facility staff, on 02/24/12, during an investigation, she had witnessed a former nursing assistant, Employee #69, slap a resident. Employee #27 stated Employee #69 walked up behind Resident #24, who was being changed from soiled clothing, and ""opened handedly slapped the resident on her bare behind."" In response, the resident at first screamed aloud, then cursed at Employee #69. Employee #27 then allegedly verbally rebuked Employee #69. Record review revealed this incident allegedly occurred sometime between 11/30/11 and 02/10/12, but the allegation was not reported to facility staff until 02/24/11. Interviews with the social worker and the administrator, on 03/21/12, revealed the facility's expectation was for any allegation of abuse witnessed by staff be immediately reported to the supervisor. b) Resident #36 Record review revealed nursing assistant, Employee #27, reported on 02/24/12 during an investigation, she had witnessed former nursing assistant, Employee #69, [MEDICATION NAME] ""in a sexual nature at a resident (Resident #36) embarrassing her,"" while personal hygiene care was being given by Employee #27. Employee #27 reported she told Employee #69 ""to leave the room and stated to him that his actions was both inappropriate and unacceptable."" Record review revealed this incident allegedly occurred sometime between 11/30/11 and 02/10/12, but the allegation was not reported to facility staff until 02/24/12. . Interviews with the social worker and the administrator, on 03/21/12, confirmed their expectation that any allegation of abuse witnessed by staff should immediately be reported to the supervisor. .",2015-07-01
10161,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2012-02-23,318,E,1,0,X35X11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure four (4) of nine (9) sample residents received treatment and services to increase range of motion and/to prevent further decrease in range of motion. Three (3) residents were not ambulated as ordered and one (1) resident did not have knee braces applied as ordered. Resident identifiers: #56, #53, #24, and #02. Facility census: 55. Findings include: a) Resident #56 This resident had physician's orders [REDACTED]. This restorative service was ordered every day, and as needed, for strength and endurance. Review of the restorative nursing documentation, for the month of January 2012 to 02/23/12, revealed no evidence this service was done daily as ordered by the physician. b) Resident # 53 This resident had a physician's orders [REDACTED]. Review of documentation revealed no evidence the knee braces were applied as ordered every night. This resident also had an order, dated 01/24/12, for passive range of motion to each leg three (3) to five (5) times every week. During a review of the restorative nursing assistant documentation, on 02/22/12, it was discovered there was evidence of only two (2) days this service was provided between 01/24/12 and 02/22/12. The dates of service were 01/26/12 and 02/09/12. c) Resident # 24 This resident had physician orders [REDACTED]. During a review of the restorative documentation, from 01/01/12 through 02/22/12, it was discovered there was no evidence this service was done daily as ordered. Restorative documentation indicated the resident was walked only three (3) times between 01/01/12 through 02/22/12. d) Resident #2 This resident had a physician's orders [REDACTED]. The order noted the resident was to ambulate with a front wheeled walker. Staff members were to use a gait belt and to follow the resident with a wheelchair. Review of restorative documentation, from 01/01/12 through 02/22/12, revealed no evidence this service was done every day as ordered. e) During an interview conducted with the director of nursing (Employee #6), on 02/23/12 at 10:45 a.m., it was confirmed there was no evidence the services for these residents were done according to physician's orders [REDACTED]. .",2015-06-01
10397,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2011-12-07,309,E,1,0,OLNF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide treatment and services to attain the highest practicable physical well being for five (5) of forty-eight (48) sampled residents, by following physician's orders [REDACTED]. Residents affected: Residents #10, #17, #32, #37, and #47. Facility census: 48 Findings include: a) On 12/6/11 at 10:55 a.m., facility documentation regarding bowel movements was reviewed. The facility has transitioned to the exclusive use of an electronic medical record for the nursing assistants to document their provision of care, including bowel movements. There were fields in which to enter the date, the shift, continent/amount/type, incontinent/amount/type, No or independent/unknown, and the nursing assistant's name. The director of nursing confirmed on 12/6/11 at 10:50 a.m. that there was no other documentation available except for "" Hands On "" reports generated by the nursing assistants. The ""hands on"" report was reviewed for all residents for regular bowel movements for the time period of 11/1/11 through 12/5/11. Five (5) residents were found that did not have any documented bowel movements for days as follows: --Resident #10 had no recorded bowel movement for 11/7, 11/8, 11/9, 11/10, 11/11, and 11/12, a six (6) day period. --Resident #17 had no recorded bowel movement for 11/23, 11/24, 11/25, 11/26, 11/27, 11/28, and 11/29, a seven (7) day period. --Resident #32 had no recorded bowel movement for 11/29, 11/30, 12/1, 12/2, 12/3, and 12/4, a six (6) day period. --Resident #37 had no recorded bowel movement for 11/26, 11/27, 11/28, 11/29, 11/30, and 12/1, a six (6) day period. --Resident #47 had no recorded bowel movement for 11/7, 11/8, 11/9, 11/10, 11/11, and 11/12, a six (6) day period. All of these residents were assessed on the current Minimum Data Set Assessment (MDS 3.0) as requiring limited to extensive assistance of two (2) staff for toileting. ------------ Current physician's orders [REDACTED].#10, 17, 32, 37, and 47 on 12/6/11 at 11:27 a.m.. each resident's physician's orders [REDACTED]. "" ------------ Medication administration records (MAR) for the appropriate time period were reviewed for residents #10, 17, 32, 37, and 47 on 12/6/11 at 11:38 a.m. There was no documentation of any intervention by the nurse for any of these residents due to no bowel movements for November 2011 or December 1st through December 5th, 2011. ------------ The facility director of nursing, employee #7, was interviewed on 12/6/11 at 11:45 a.m. She confirmed that all five (5) residents have an active physician's orders [REDACTED]. She agreed that there was no evidence of any intervention by nurses as ordered. She expressed that she felt there was some problem with the handheld units used by the nursing assistants to document bowel movements, but acknowledged that she cannot say with certainty that those residents had any bowel movements during the time periods specified. ------------ A follow up review was conducted to ensure that no resident was harmed by this practice. All the residents were found to have had bowel movements documented since the reviewed time period, and there was no evidence found to suggest any harm may have occurred.",2015-04-01
10398,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2011-12-07,312,E,1,0,OLNF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility did not provide showers and/or baths per stated facility protocol to maintain personal hygiene for residents who could not bathe independently. This was found for thirteen (13) of forty-eight (48) current residents. Resident identifiers: REsidents #2, #7, #8, #11, #17, #20, #24, #25, #26, #32, #34, #35, #44. Facility census: 48 Findings include: a) Resident #13 was interviewed on 12/5/11 at 2:00 p.m. Resident #13 is a sixty-six (66) year old woman who was admitted to the facility on [DATE]. She has been determined to possess the capacity to make informed medical decisions, and was assessed as cognitively intact with a score of 15 on the brief interview for mental status (BIMS) conducted on 11/16/11. Her [DIAGNOSES REDACTED]. She was asked if she received a shower or bath at least two (2) times a week. She replied that she did, because she was able to speak up for herself and insist that she receive them. She said that she feels strongly that those residents who cannot speak for themselves do not always get their showers or baths as they should. ------------ On 12/5/11 at 12:00 p.m., facility documentation regarding shower/baths was reviewed. The facility has transitioned to the exclusive use of an electronic medical record for the nursing assistants to document their provision of care, including baths/showers. There are fields in which to enter the date, the shift, the type of bath given, not available or refused, and the nursing assistant's name. The director of nursing confirmed on 12/5/11 at 3:45 p.m. that there was no other documentation available except for the "" hands on "" reports generated by the nursing assistants. ------------ All residents were reviewed for the provision of showers/baths for the time period of 11/22/11 through 12/5/11, approximately a two (2) week period. Fifteen residents did not have documented showers/baths two (2) times each week as follows: --Resident #2 had one (1) documented shower on 11/22/11. --Resident #7 had one (1) documented shower on 11/22/11. --Resident #8 had no documented showers/baths for the period. --Resident #11 had one documented shower on 11/29 and one (1) documented bed bath on 12/3. --Resident #17 had two (2) documented bed baths on 11/22 and 11/29. --Resident #20 had two (2) documented showers on 11/26 and 11/29. --Resident #24 had one (1) documented shower on 11/26. --Resident #25 had one (1) documented shower on 11/29. --Resident #26 had two (2) documented showers on 11/27 and 11/30. --Resident #32 had one (1) documented shower on 11/26. --Resident #34 had one (1) documented sponge bath on 11/30. --Resident #35 had one (1) documented shower on 11/25. --Resident #44 had two (2) documented showers on 11/26 and 12/5. --Resident #46 had two (2) documented bed baths on 11/22 and 11/29. --Resident #47 had two (2) documented showers on 11/22 and 11/29. ------------ All of these residents were assessed on the current Minimum Data Set Assessment (MDS 3.0) as requiring physical assistance to total dependence upon staff for showers/bathing. Further review found that resident #2 and resident #5 are hospice residents. Hospice staff was providing showers/baths for these residents with appropriate documentation found in the record. ------------ An interview was conducted with a facility licensed practical nurse, employee #34 on 12/5/11 at 2:15 p.m. She was asked about the expectation for resident baths/showers. She replied that residents are to be bathed two (2) times a week and as needed. An interview was conducted with a facility nursing assistant, employee #43, on 12/5/11 at 2:30 p.m. When asked how often residents are to receive baths or showers, she stated two (2) times a week and as needed. An interview was conducted with the facility director of nursing, employee #7, on 12/5/11 at 3:45 p.m. She confirmed that the facility expectation is that residents receive showers or baths two (2) times a week and as needed. She further agreed that available documentation indicated that thirteen (13) residents had not been given baths or showers two (2) times a week for the period of 11/22/11 through 12/5/11. She said she felt that there may be a problem with the handheld units used by the nursing assistants to document the care, but acknowledged that she cannot say with certainties that those residents received showers/baths as they should have, per facility expectation and resident/family understanding.",2015-04-01
10399,BARBOUR COUNTY GOOD SAMARITAN SOCIETY,515116,216 SAMARITAN CIRCLE,BELINGTON,WV,26250,2011-12-07,364,E,1,0,OLNF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, review of West Virginia State Licensure regulation, and record review, the facility did not provide hot food served at a palatable temperature. This was found for one (1) resident at the evening meal on 12/4/11, and has the potential to affect all residents who eat their evening meal in the dining room. Facility census: 48. Findings include: a) The initial dining observation began on 12/4/11 at 5:15 p.m. Residents who were capable of independent dining began eating at approximately 5:15 p.m. Staff stated that residents who needed assistance or feeding came in later. Trays were seen in open tall carts in the kitchen adjacent to the open door to the dining room. The trays were being set up, were uncovered, and stored in the open racks until they were served to the residents. As a result, residents who came later to the dining room were served food that had been sitting in the racks for a longer period of time. As the observation continued, resident #36, immediately after being served her tray at 5:42 p.m., was heard to tell staff that her food was cold and it was decided to have it reheated. Her tray was taken to the kitchen, and dietary aide, employee #67, was immediately asked to take the temperature of the food. The corn was found to be at 132 degrees Fahrenheit, while the entree, turkey a la king, was found to be at 119 degrees Fahrenheit. These temperatures do not meet the 135 degree holding temperature requirements, and the food was not palatable to resident #36 when it was served to her. Although preferred temperatures for hot food may vary from person to person, West Virginia State Licensure regulations specify that food is not to be served to residents at less than 120 degrees Fahrenheit, and resident #36 obviously felt her food was served cold. Following this determination, with the remaining meal trays, it was observed that dietary staff began waiting until residents arrived for service before they took the food from the steam table and plated it. ------------ Resident #2 was interviewed on 12/5/11 at 12:45 p.m. Resident # 2 is a fifty-six (56) year old man who was admitted to the facility on [DATE]. He has been determined to possess the capacity to make informed medical decisions, and was assessed as cognitively intact with a score of 15 on the brief interview for mental status (BIMS) conducted on 11/22/11. His [DIAGNOSES REDACTED]. He was asked if he usually ate in the dining room, or preferred to eat in his room. He replied that he eats all his meals in the dining room. He was asked if the food was generally served at the proper temperatures during the evening meal. He stated that the food was served cold at times in the evenings. He confirmed that he was currently president of resident council, and said that cold food at supper had been discussed on multiple occasions in council meetings. ------------ Resident #3 was interviewed on 12/5/11 at 1:05 p.m. Resident #3 is a seventy-three (73) year old woman who was admitted to the facility on [DATE]. She has been determined to possess the capacity to make informed medical decisions, and was assessed as cognitively intact with a score of 13 on the brief interview for mental status (BIMS) conducted on 10/6/11. Her [DIAGNOSES REDACTED]. She was asked if she usually ate in the dining room or preferred to eat in her room. She said that she eats most meals in the dining room. She was asked about the temperatures of the food when it is served. She replied that the food is often cold when served during the evening meal. ------------ Resident #13 was interviewed on 12/5/11 at 2:00 p.m. Resident #13 is a sixty-six (66) year old woman who was admitted to the facility on [DATE]. She has been determined to possess the capacity to make informed medical decisions, and was assessed as cognitively intact with a score of 15 on the brief interview for mental status (BIMS) conducted on 11/16/11. Her [DIAGNOSES REDACTED]. She was asked if she usually ate in the dining room or preferred to eat in her room. She said that she eats most meals in her room. She was asked about the temperatures of the food when it is served. She replied that the food is often cold when served during the evening meal. ------------ Another observation was conducted the next evening on 12/5/11 at 5:45 p.m., beginning ? hour later than 5:15 p.m. in an effort to determine if there were uncovered trays sitting on the racks for longer periods of time. Upon entering the dining room, certified dietary manager, employee #60 was observed standing in the dining room observing meal service. Staff were observed plating food as it was being served to each resident. The dietary manager stated that her expectation for meal service was that food was not supposed to be plated in advance for multiple residents and held on the carts until residents entered the dining room. The food temperatures sampled on the previous evening were discussed. The dietary manager was aware of the temperatures and acknowledged that the temperature of the turkey a la king served to resident #36 was only 119 degrees, and that the resident had stated that it was cold. ------------ A follow-up interview was conducted with resident #13 on 12/5/11 at 6:00 p.m. She was asked about the temperature of the evening meal this evening. She replied that it was ""served hot for once."" ------------ When resident council meeting minutes were reviewed on 12/5/11 at 4:00 p.m., the following entry was noted under new business during the council meeting of 10/25/11 (typed as written): ""Residents discussed concerns they believe meal time trays are always delivered in same order which makes the middle section of dining room get meals about ? hour after meal time to start and it's cold. One resident stated he planned on coming down ? hour later due to the pattern. Dietary manager to discuss the issue with staff and try to alternate tray delivery if possible. Discussed regulations mandate how tables have to be served as they are all at the assigned table, so if a table mate is late, then the food will be served when they all arrive for that table.""",2015-04-01
2233,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2018-03-21,758,D,0,1,IUL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility failed to ensure adequate indicators of use for an anti-depressant for Resident #60, one of 6 residents reviewed for unnecessary medications. Resident identifier: #60. Facility census: 78. Findings included: a) Resident #60 According to the 02/17/18 Minimum Data Set (MDS) assessment, Resident #60 had [DIAGNOSES REDACTED]. According to this assessment, Resident #60 exhibited no signs of mood or behavior issues and denied any issues with mood. Similarly, on the 06/02/17, 07/05/17, 07/11/17, 07/26/17, 09/2/17 and 12/01/17 MDS assessments, the resident denied any issues with mood and displayed no behavioral symptoms. Record review revealed the resident had received the anti-depressant [MEDICATION NAME] since at least 04/21/15. A Pharmacy Consultation, dated 03/06/17, identified the resident had been on [MEDICATION NAME] 10 milligrams (mg) since last decrease 10/12/16. The pharmacist recommended the physician consider a discontinuation of the medication. The physician accepted the recommendation and the [MEDICATION NAME] was discontinued on 3/16/17. The facility monitored the resident for adverse effects of the discontinuation of the medication however none were noted. Resident #60 was sent to the emergency roiagnom on [DATE] for a change in his health condition. He was admitted to the hospital and re-admitted to the facility on [DATE]. Records from the hospital, including the Hospital Urology Consultation, dated 06/21/17, and the Hospital Infectious Disease Consult Note, dated 06/26/17, identified Current Facility - Administered Medications as including [MEDICATION NAME] 10 mg. The hospital Discharge Summary, dated 06/28/17, included an order for [REDACTED]. The facility administered the anti-depressant to Resident #60 daily, with no indication for use. Staff monitored for signs and symptoms of depression, but noted none. More than eight months later, based on a Pharmacy Consultation, dated 03/05/18, the dose was decreased to 5 mg daily on 03/12/18 due to no signs or symptoms of depression. In an interview on 03/20/18 at 4:20 PM, Resident #60 was pleasant, responsive and appeared in good spirits. He stated he took the medications that were given to him. He knew he was on an anti-depressant, but stated he felt fine and did not know why it was ordered. He denied any depressed mood, sadness, or other indicators of depression. In an interview on 03/20/18 at 5:04 PM, Social Worker #88 stated the resident exhibited no behaviors or signs of depression. She stated she has no concerns about his mental health and could not explain why the anti-depressant had been restarted. In an interview on 03/21/18 at 1:15 PM, the Director of Nursing (#61) stated she thought it was an error at the hospital, that the [MEDICATION NAME] was restarted, and the facility did not question the medication when the resident readmitted to the facility. She stated the physician approved it, but was unable to show consideration had been given to the reasons it was restarted or that the medication's use had been questioned. She stated the facility would implement procedures to identify these types of discrepancies in the future.",2020-09-01
2234,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2018-03-21,805,E,0,1,IUL911,"Based on observation, record review and staff interviews, the facility failed to follow recipes for pureed food items to ensure the pureed texture was prepared properly for eighteen out of 18 residents the facility identified as receiving pureed foods. Facility census: 78. Findings included: Observation on 03/20/18 at 9:40 AM revealed Cook #15 training Dietary Aide #104 on how to puree food items. Cook #15 had a recipe for pureed spaghetti noodles. The recipe was written for 25 servings. Cook #15 stated verbally there were only 19 residents who required a puree diet, so she would make the recipe for 19 residents. She scooped 19 servings of noodles, counting out loud, and then followed the rest of the recipe's instructions using the ingredients for 25 servings. The recipe called for 1/3 cup and 1 and 1/3 Tablespoons of butter. Cook #15 retrieved a liquid measuring cup and cut off a section of a solid block of butter. Dietary Aide #104 asked if the butter was supposed to be melted first. Cook #15 stated the recipe did not clearly indicate one way or the other, so she put the solid butter in the liquid measuring cup and began to cut more. She added more butter to the measuring cup, then looked at the surveyor who was taking notes and said, Maybe we should ask (Assistant Dietary Manager #7). Assistant Dietary Manager #7 was requested and she stated Cook #15 should melt the butter and then measure it out. Cook #15 melted and measured the amount of butter intended for 25 servings, then measured and added 1.5 cups and 1 Tablespoon of water, as called for by the recipe if making 25 servings. She blended it together well, looked at the recipe, then said to Dietary Aide #104, I have it all. It's done. She poured the pureed noodles into a pan, covered it with aluminum foil and placed it in the warmer. Cook #15 was then asked by the surveyor if she added the thickener, as called for in the recipe. She stated she forgot to do so, even after reviewing the recipe. She then added 1/2 cup and 2 Tablespoons of powdered thickener, as called for by the recipe if making 25 servings. After Cook #15 placed the noodles back in the oven, Regional Chef #119 was informed of the concern with the recipe not being followed. He understood and directed Cook #15 on how to correct the mistake. He stated the recipe for 25 servings should have been fully followed, even if only 19 servings were required and that all ingredients must be added, including the thickener. In addition, he stated the recipe should clearly identify instructions such as whether the butter should be melted. He stated he expected staff to bring those issues to his attention but that had not been done in this instance.",2020-09-01
2235,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2018-03-21,880,D,0,1,IUL911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, and review of the Infection Control Policy the facility failed to maintain a sanitary environment to prevent the potential for transmission and spread of disease and infection. Staff failed to administer medications in a sanitary manner and did not use good infection control technique. This affected one of one residents who received medications via gastrostomy tube. Resident identifier: #50. Facility census: 78. Findings included: a) Resident #50 On 03/20/18 at 4:15 PM, observations were made of Licensed Practical Nurse (LPN) #110 administer medications to Resident #50 in her room via gastrostomy tube. LPN #110 removed [MEDICATION NAME] Chloride 5 milligrams (medication used for [MEDICAL CONDITION]) from the medication cart, crushed the tablet and placed it in a clear, plastic medication cup that was sitting on top of the medication cart. LPN #110 then removed a bottle of [MEDICATION NAME] Solution (medication for unspecified convulsions) and poured 7.5 milliliters of the liquid into a clear, plastic medication cup that was sitting on top of the medication cart. Both medications were observed in separate clear medication cups on top of the medication cart prior to administration. LPN #110 stacked the medication cups by placing the medication cup containing the liquid on top of the crushed medication in the clear plastic cup, carried them into the resident's room and placed them on the over bed table. The medication cups were unstacked and placed on top of the resident's over bed table. The medications were administered separately via the resident's gastrostomy tube. LPN #110 was interviewed after the medication administration at 4:25 pm. LPN #110 verified stacking and unstacking the medications on top of the medication cart and the resident's over bed table was not sanitary and could be an infection control issue. The Director of Nursing (DON) #61 was interviewed on 03/21/18 at 11:40 am. DON #61 stated stacking medication cups with medication in them prior to administration was not addressed in the facility's Infection Control policy. DON #61 stated the medication administration policy for gastrostomy tubes did not address this practice either. DON #61 stated the facility ordered trays for the medication carts, but could not explain why LPN #110 did not use one during the administration of the medications. DON #61 verified LPN #110 did not use good infection control technique to maintain a sanitary environment when medications were stacked after being on top of the medication cart and unstacked on the resident's over bed table and were then administered to Resident #50. The Infection Control policy was reviewed at 11:45 AM. It indicated: It is the policy of this Center to establish and maintain an infection prevention and control program designed to proved a safe, sanitary, and comfortable environment and to help prevent the development and transmission of communicable diseases and infection.",2020-09-01
2236,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,550,D,0,1,MO6K11,"Based on random observation and staff interview, the facility failed treat a resident with dignity while assisting the resident to eat. This is true for one (1) of one (1) residents observed. Resident identifier: #23. Facility census: 91. Findings include: a) Resident #23 On 06/10/19 at 3:08 PM nursing assistant (NA) #92 stood beside of seated Resident #23 while assisting the resident to eat a midday snack of egg salad. At this same time NA #92 agreed she should have been sitting while feeding the resident and obtained a chair to sit down and finished feeding Resident #23.",2020-09-01
2237,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,554,D,0,1,MO6K11,"Based on observation and staff interview, the facility failed to ensure residents had been assessed to self-administer medications prior to having medication remain at the bedside. This was evident for two of 21 sampled residents. Resident identifiers: #64 and #54. Facility census: 91. Findings included: a) Resident #64 During the initial tour, on 06/10/19 at 12:00 PM, R# 64 was observed with a tube of Muscle Rub laying on the resident's bedside table in plain view. A review of the medical record, conducted 06/10/19 at 12:15 PM, noted no current order for a tube of Muscle Rub and no assessment for self-administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON #43 stated there was no order for the Muscle Rub found at the bedside and was unaware the medication was being kept in the room. b) Resident #54 During the initial tour on, 06/10/19 at 12:15 PM, R# 54 was observed with a bottle of Calcium Antacid laying on the resident's bedside table in plain view. A review of the medical record for R#54, conducted 06/10/19 at 12:20 PM, noted no current order for Calcium Antacid and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON#43 stated there was no order for the Calcium Antacid found at the bedside and was unaware the medication was being kept in the room.",2020-09-01
2238,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,576,E,0,1,MO6K11,"Based on Resident Council members interview, and staff interview, the facility failed to deliver mail to residents on Saturday. This has a potential to effect more than a limited number. Facility census: 91. Findings include: a) On 06/11/19 at 10:00 AM during a Resident Council meeting, Resident #26, #73, #31, #8, and #48 stated the facility does not pass mail out on Saturdays, and they would like to have their mail the day it is delivered. At 1:25 PM on 06/11/19 the activity director explained the mail delivery to the facility is between 4:00 PM and 8:00 PM on Saturdays. Due to the late delivery the mail is held and passed out on Sundays. She explained arrangements will be made for the mail to be given to the residents on the day it is delivered.",2020-09-01
2239,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,583,D,0,1,MO6K11,"Based on staff interview and observation, the facility failed to ensure medication packets with pharmacy labels were not left on top of the medication cart when not in use. These medication packets contained personal identifiers including the resident's name, medication, physician, and diagnoses. This practice affected one (1) of five (5) residents observed during medication administration. Resident identifier: #44. Facility census: 91. Findings included: a) Resident #44 An observation of medication administration, on 06/11/19 at 7:45 AM, revealed two (2) medication packets, with pharmacy labels, were left on top of the medication cart while unattended. The medication packets were visible for anyone walking past to see. The medication packets contained the following information concerning the Resident: -Resident's name -Medication -Physician -Diagnoses An interview with Licensed Practical Nurse (LPN) #16, on 06/11/19 at 8:05 AM, revealed the medication packets should have been put back into the medication cart while she was giving out medications. The LPN stated I know better.",2020-09-01
2240,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,657,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise Care Plans for residents receiving pain medication and oxygen saturation levels. This practice affected two (2) of twenty-one (21) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifier: #19 and #82. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's Care Plan, on 06/11/19 at 9:25 AM, revealed the problem Potential for pain with the interventions Administer as needed pain medications as needed and utilize the PAINAD Pain Scale for pain assessment. The Care Plan did not include what level of pain is considered moderate pain for the as needed pain medication. An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the staff should use the Wong-Baker Faces Pain Rating Scale to determine if Resident #19 was having moderate pain which warranted as needed pain medication. The ADON confirmed the Wong-Baker Faces Pain Rating Scale was not addressed on the Resident's Care Plan and should have been. b) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The physician's orders [REDACTED]. An interview with Nurse Aide (NA) #60, on 06/11/19 at 11:00 AM, revealed the NA was not sure when to monitor the Resident's oxygen saturation level. An interview with the Director of Nursing (DON), on 06/11/19 at 11:30 AM, revealed the order and care plan should have included how often to monitor the Resident's oxygen saturation levels.",2020-09-01
2241,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,684,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and policy review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice. Physician orders [REDACTED]. This practice affected three (3) of twenty-one (21) residents reviewed during the Long Term Care Survey Process (LTCSP). Resident identifiers: #19, #82, and #64. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the [MEDICATION NAME] should not have been given for a pain levels of 0 and 2 which was considered mild pain. b) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. Further review of the medical record, on 06/11/19, revealed the Resident's oxygen saturation level was being monitored on the following dates: --05/22/19 --05/23/19 --05/24/19 --05/25/19 --05/29/19 --05/31/19 --06/01/19 --06/02/19 --06/06/19 --06/08/19 --06/09/19 --06/11/19 A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The physician order [REDACTED]. An interview with Nurse Aide (NA) #60, on 06/11/19 at 11:00 AM, revealed the NA was not sure when to monitor the Resident's oxygen saturation level. An interview with the Director of Nursing (DON), on 06/11/19 at 11:30 AM, revealed the order and care plan should have included how often to monitor the Resident's oxygen saturation levels. c) Resident #64 An observation on 06/10/19, at 12:00 PM, revealed R#64 receiving oxygen (O2) per nasal cannula at 6 liters per minute (L/min). An observation on 06/11/19 at 08:12 AM, revealed R#64 receiving O2 per nasal cannula at 6L/min. A review of the physician's orders [REDACTED]. On 06/11/19 at 08:12 AM, an interview with ADON#43, verified R#64's O2 was being administered at 6L/min and was not being administered in accordance with the physician's orders [REDACTED]. A review of the policy and procedure, Oxygen Administration, revision date: 4/1/14, noted under step 10, Set the oxygen according to physician's orders [REDACTED].>",2020-09-01
2242,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,689,E,0,1,MO6K11,"Based on observation, record review and staff interview, the facility failed to provide an environment free from accident hazards over which it had control. The facility failed to ensure that medications were not kept at the bedside unless it was determined to be safe for a resident to self-administer and if so, kept in a secure place. The facility failed to ensure two bathrooms, accessible to residents, were equipped with an emergency call mechanism. These practices had the potential to affect more than a limited number of residents. Resident identifier: Resident #64 and Resident #54. Facility census: 91. Findings included: a) Resident #64 During the initial tour, on 06/10/19 at 12:00 PM, R# 64 was observed with a tube of Muscle Rub laying on the resident's bedside table, unsecured, in plain view. A review of the medical record, conducted 06/10/19 at 12:15 PM, noted no current order for the Muscle Rub and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON #43 stated there was no order for the Muscle Rub found at the bedside and was unaware the medication was being kept in the room. b) Resident #54 During the initial tour on, 06/10/19 at 12:15 PM, R# 54 was observed with a bottle of Calcium Antacid laying on the resident's bedside table unsecured, in plain view. A review of the medical record for R#54, conducted 06/10/19 at 12:20 PM, noted no current order for Calcium Antacid and no assessment for self- administration of the medication located in the medical record. An interview, on 06/10/19 at 12:35 PM, with LPN#21, verified there was no order for the medication found at the bedside and further stated the medication should not have been there. An interview on 06/10/19 at 12:40 PM, with the Assistant Director of Nursing (ADON #43), revealed there had been no self-administration assessment completed to determine if the resident could self-administer the medication observed at the bedside. Additionally, ADON#43 stated there was no order for the Calcium Antacid found at the bedside and was unaware the medication was being kept in the room. c) Bathroom Locks Observation found two bathrooms near the entrance of the facility without a way to lock them on the outside. This is an area mobile residents walk by. Neither of the bathroom had a safety cord for a resident to use in the need of assistance. On 06/12/19 at 10:00 AM the facility administrator expressed he would secure the doors immediately to prevent accident hazards.",2020-09-01
2243,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,695,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, and policy review, the facility failed to deliver respiratory care services consistent with professional standards of practice. Physician orders [REDACTED]. This practice affected two (2) of five (5) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifiers: #82 and #64. Facility census: 91. Findings included: a) Resident #82 A review of the Resident's physician orders, on 06/11/19 at 10:35 AM, revealed the order Oxygen Saturation above 90% is acceptable with an order date of 05/30/19. Further review of the medical record, on 06/11/19, revealed the Resident's oxygen saturation level was being monitored on the following dates: --05/22/19 --05/23/19 --05/24/19 --05/25/19 --05/29/19 --05/31/19 --06/01/19 --06/02/19 --06/06/19 --06/08/19 --06/09/19 --06/11/19 A review of the Resident's Care Plan, on 06/11/19 at 10:45 AM, revealed the problem Palliative Care due to [MEDICAL CONDITION] with the intervention Oxygen Saturation above 90% is acceptable. The physician order [REDACTED]. An interview with Nurse Aide (NA) #60, on 06/11/19 at 11:00 AM, revealed the NA was not sure when to monitor the Resident's oxygen saturation level. An interview with the Director of Nursing (DON), on 06/11/19 at 11:30 AM, revealed the order and care plan should have included how often to monitor the Resident's oxygen saturation levels. b) Resident #64 An observation on 06/10/19, at 12:00 PM, revealed R#64 receiving oxygen (O2) per nasal cannula at 6 liters per minute (L/min). An observation on 06/11/19 at 08:12 AM, revealed R#64 receiving O2 per nasal cannula at 6L/min. A review of the physician's orders [REDACTED]. On 06/11/19 at 08:12 AM, an interview with ADON#43, verified R#64's O2 was being administered at 6L/min and was not being administered in accordance with the physician's orders [REDACTED]. A review of the policy and procedure, Oxygen Administration, revision date: 4/1/14, noted under step 10, Set the oxygen according to physician's orders [REDACTED].>",2020-09-01
2244,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,697,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure pain management was provided to a Resident consistent with professional standards of practice and the person centered care plan. A resident's care plan for pain gave no direction for assessing the varying levels of pain associated with ordered medications. The resident was also given unnecessary pain medication in accordance with their pain level. This practice affected one (1) of two (2) residents reviewed for pain management during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 A review of the Resident's Care Plan, on 06/11/19 at 9:25 AM, revealed the problem Potential for pain with the interventions Administer as needed pain medications as needed and utilize the PAINAD Pain Scale for pain assessment. The PAINAD Pain Scale does not specify what is considered moderate pain. The Care Plan did not include what specific level of pain is considered moderate pain for the as needed pain medication. An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the directive to use the Wong-Baker Pain Scale should have been included on the Care Plan. The ADON stated the [MEDICATION NAME] should not have been given for a pain levels of 0 and 2 which was considered mild pain.",2020-09-01
2245,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,730,E,0,1,MO6K11,"Based on employee record review and staff interview, the facility failed to provide employees with required regular in-service education based on the outcome of these reviews. This was found true for four (4) of five (5) employees. Employee identifers: #36, #52, #20 and #23. Facility census: 91. Findings included: a) Nurse Aide (NA) regular in-service education. A review of the facility's employee regular in-service education found NA's #36 and #52 did not have twelve hours of in-service education per year. NA's #20 and #23 did not receive the abuse training. An interview with the Director of Nursing (DoN) on 06/12/19 at 11:00 AM, verified the above facility's NA's did not receive their regular in-service education.",2020-09-01
2246,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,757,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a resident's drug regimen was free from unnecessary drugs. A resident was given pain medication for moderate pain when they were assessed to be having mild pain. This practice affected one (1) of six (6) residents reviewed for unnecessary medications during the Long Term Care Survey Process (LTCSP). Resident identifier: #19. Facility census: 91. Findings included: a) Resident #19 A review of the Resident's physician orders, on 06/11/19 at 9:15 AM, revealed the order [MEDICATION NAME] HCL Tablet 50 milligrams every 12 hours as needed for moderate pain with an order date of 3/05/19. A review of the Resident's (MONTH) 2019 Medication Administration Record [REDACTED] -06/18/19 for a pain level of 0 -06/11/19 for a pain level of 2 An interview with Assistant Director of Nursing (ADON) #43, on 06/11/19 at 3:15 PM, revealed the facility uses the Wong-Baker Faces Pain Rating Scale to assess the difference between mild, moderate, and severe pain. The ADON stated the pain scales are accessible at each of the nurses station. The ADON stated moderate pain is considered a pain level of 4 to 7 on the Wong-Baker scale. The ADON stated the [MEDICATION NAME] should not have been given for a pain levels of 0 and 2 which was considered mild pain.",2020-09-01
2247,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,761,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure drugs and biological's used in the facility were stored and labeled in accordance with currently accepted professional principles. A medication stored in a medication cart was unlabeled and undated as to when it was first used. This practice affected one (1) of five (5) residents reviewed during medication administration. Resident identifier: #44. Facility census: 91. Findings included: a) Observation An observation of Resident #44's medication during medication administration, on 06/11/19 at 7:35 AM, revealed the following: -One (1) opened, undated, and unlabeled [MEDICATION NAME] Pen. b) Interview An interview with Licensed Practical Nurse (LPN) #16, on 06/11/19 at 7:40 AM, revealed the medication should have been labeled with a name and an open date as soon as it was opened by the staff. The LPN then proceeded to label the medication with the current date. An interview with the Director of Nursing (DON), on 06/12/19 at 8:00 AM, revealed the medication should have been dated and labeled with initials when it was first opened by the staff. The DON stated LPN #16 should not have dated it with the current date upon discovering it was not appropriately labeled and dated.",2020-09-01
2248,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,801,E,0,1,MO6K11,"Based on review of documentation and staff interview, the facility failed to ensure the person serving as Dietary Manager, enrolled in an approved program to become a certified dietary manager within 60 days of accepting responsibility for the position. This practice had the potential to effect more than a limited number of residents. Facility census: 91. Findings included: A review of documentation on 06/11/19 at 08:50 AM, showed a hire date for the Food Service Director as 09/13/2018. Through interview on 06/11/19, at 08:50 AM, the Food Service Director stated he had not enrolled in a program until (MONTH) 2019 and had no other food or nutrition related credentials. The Food Service Director stated further, his work responsibility made it hard to find time to complete the modules required. An interview with the Administrator, on 06/12/19 at 7:30 AM, verified the person serving as the Dietary Manager had not enrolled in an approved program in a timely manner",2020-09-01
2249,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,812,E,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to store food in accordance with professional standards for food service safety. The facility contained several areas with undated, expired, and opened resident food items. These practices had the potential to affect more than a limited number of residents. Room identifiers: 100 Hall Nourishment Room, 300 Hall Nourishment Room, and 200 Hall Dining/Activity Room. Facility census: 91. Findings include: a) Observation An observation of the 200 Hall Dining/Activity Room, [DATE] at 8:10 AM, revealed the following items in the unlocked drawers: --Two (2) packs of undated French dressing. --One (1) pack of undated Italian dressing. --One (1) opened and undated pack of Thick and Easy Food Thickener. --Two (2) packs of undated Saltine Crackers. --Three (3) packs of undated jelly. --Four (4) packs of undated coffee creamer. --One (1) pack of undated whipped spread with the label Refrigerate for best quality. --One (1) container of opened and undated Iced Tea Mix. --Two (2) packs of undated Malt Vinegar. Further observations of the 100 and 300 Hall Nutrition Rooms, on [DATE], revealed: --Three (3) opened and undated loaves of bread. b) Interview An interview with the Dietary Manager (DM), on [DATE] at 9:00 AM, revealed all the food items in the activity room and nourishment rooms should not have been there. The DM stated all food items should have dates on them.",2020-09-01
2250,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,868,F,0,1,MO6K11,"Based on the review of Quality Assessment and Assurance (QAA) Meeting Attendance Records and staff interview, the facility failed to ensure the Facility's Medical Director attended quarterly (QAA) meetings. The Medical Director failed to attend all but one QAA meetings held at the facility in the last calendar year. This practice had the potential to affect all residents. Facility census: 91. Findings included: a) Quality Assessment and Assurance (QAA) Meeting Attendance Records review A review of the attendance records for the last calendar year of QAA meetings was conducted on 06/12/19. The attendance record for the Medical Director was: -06/20/18-The Medical Director was not in attendance. -08/29/18-The Medical Director was not in attendance. -10/24/18-The Medical Director was not in attendance. -11/16/18-The Medical Director was not in attendance. -12/19/18-The Medical Director was not in attendance. -01/16/19-The Medical Director was not in attendance. -02/20/19-The Medical Director was in attendance. -03/21/19-The Medical Director was not in attendance. -04/24/19-The Medical Director was not in attendance. -05/15/19-The Medical Director was not in attendance. b) Interview An interview with the Director of Nursing (DON), on 06/12/19 at 9:30 AM, revealed the Medical Director is required to attend the quarterly QAA meetings. The DON stated the Medical Director is aware of this requirement and is invited to all meetings.",2020-09-01
2251,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2019-06-12,883,D,0,1,MO6K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, facility's policy, and the State Operation Manual Appendix P, the facility failed to ensure the Pneumococcal [MEDICATION NAME] vaccine (PPSV) history was obtained for two (2) of five (5) resident reviewed to determine the correct vaccine (Prevnar 13 or 23) to administer. Resident identifiers: #7 and #12. Facility Census: 91. Findings included: a) Resident #7 Resident #7 had a informed consent for his PPSV dated 04/12/18. The informed consent revealed the resident's representative had refused with the reason being the resident had received both injections. Resident #7's date of birth is 05/14/36. Resident # 7 is [AGE] years old. A review of Resident #7's immunization record finds the resident had received PPSV 23 from the facility. The facility had no information on Prevnar 13. b) Resident #12 Resident #12 had a informed consent for her PPSV dated 04/27/18. The informed consent revealed the resident's representative had refused with the reason being the resident had received both injections. Resident #12's date of birth is 01/17/37. Resident #12 is [AGE] years old. A review of Resident #12's immunization record finds the resident received Prevnar 23. There were no evidence Resident #12 had received the Prevnar 13. When the Assistant Director of Nursing (ADoN) on 06/11/19 at 2:50 PM, was asked for evidence Resident #7 and #12 had received both Prevnar 13 and 23. The ADoN said that he did not have all of the updated history related to their PPSV vaccination. The ADoN stated that he had updated Resident #7's PPSV history relate to him receiving the Prevnar 13 on 06/28/17 from a hospital according to what the Health Department Nurse had told the ADoN on 06/11/19. The Health Department Nurse in (county's name) informed the ADoN on 06/11/19, that Resident #12 had not received the Prevnar 13, but had received the PPSV 23. The ADoN verified that he did not know the date or where Resident #12 had received PPSV 23 until he had called the Health Department. The ADoN stated that he had updated the date and where Resident #12 had received the PPSV 23 after surveyor had inquired about whether the resident had received both Prevnar 13 and 23. The ADoN also confirmed that he had updated Resident #7 record to reflect when he had received the Prevnar 13. The facility's policy states each resident will be assessed for pneumococcal immunization upon admission. Self-report of immunization shall be accepted. Any additional efforts to obtain information shall be documented, including efforts to determine date of immunizion or type of vaccine received.",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
2253,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,253,E,0,1,DU6R11,"Based on observation and staff interview, the facility failed to provide housekeeping/maintenance services necessary to maintain a sanitary, orderly, and comfortable interior. This affected six (6) of twenty-nine (29) rooms observed in Stage I of the Quality Indicator Survey. Cosmetic imperfections, or items in need of repair and/or cleaning in resident rooms, included resident bathrooms with persistent stale and/or urine odors, chipped paint on the walls and/or door frames, and/or chair rails, lack of caulking around the base of commodes, brown colored stain on the bathroom flooring alongside the commode, and a specialty chair with a torn arm rest. Room identifiers: #207, #208, #209, #303, #308, #311. Facility census: 81. Findings include: a) During Stage I of the Quality Indicator Survey on 06/12/17 and on 06/13/17, twenty-nine (29) resident rooms were observed. Of that number, six (6) rooms were found with concerns related to maintenance and/or housekeeping issues, or cosmetic imperfections. A tour of those rooms was conducted with housekeeping manager Employee #91 on 06/14/17 between 9:30 a.m. and 10:00 a.m. Identified concerns were as follows: --Room 207: The paint was chipped above the baseboard in the bathroom along the wall on the right side facing the commode. The paint was chipped from the bedroom door along the border near the door handle. The bathroom had an odor of urine during Stage I of the survey, and at the time of this observation this bathroom continued to have a persistent, lingering urine odor. Employee #91 said they previously had an issue with urine odors in this bathroom when they had a riser over the commode. She said urine somehow got onto the floor. They now use a raised over-the-toilet seat in this bathroom. --Room 208: There was no caulking around the base of the commode. There was a brown stain on the flooring alongside the base of the commode. --Room 209: There was no caulking around the base of the commode. Paint was chipped on the door frame upon entry to the bathroom. --[RM #]3: The white paint was scuffed off on the outside of the bathroom door, showing a dark green color beneath it. There were scrapes on the wall to the right side of the bathroom door, and on the chair rail, and on the door frame. --[RM #]8: There were four (4) circular areas on the wall between Resident #25's bed and her roommate's bed, where the green paint chipped off and showed a white color beneath it. There were three (3) paint scuffs on the wall by the sink. Also, the left arm rest of Resident #25's specialty chair was torn, and the foam beneath it was visible. Employee #91 said the arm of the chair would be replaced today. --Room 311: The bathroom had an odor of urine during Stage I of the survey, and at the time of this observation this bathroom continued to have a persistent, lingering urine odor. Employee #91 agreed this bathroom had a urine odor. Employee #91 verified these observations and stated they would be taken care of immediately.",2020-09-01
2254,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,256,D,0,1,DU6R11,"Based on resident interview and staff interview, the facility failed to provide adequate lighting levels to meet the resident's needs. One (1) of thirty-five (35) Stage I sampled residents did not have the lighting she desired in her room. Resident identifier: #92. Facility census: 81. Findings include: a) Resident #92 During Stage I of the Quality Indicator Survey, on 06/13/17 at 9:37 a.m.,Resident #92 was asked if she had any problems with the lighting in her room which affected her comfort. She replied in the affirmative. She said it was hard to read at night due to the low lighting level in her room. She said she thought she might need more electrical outlets in her room in order to achieve her goal of having better reading light. On 06/14/17 at 9:30 a.m., a tour of the room was completed, while accompanied by housekeeping supervisor Employee #91. Resident #92 said she enjoys reading, but can only do so during daylight hours when bright sunlight comes through her window. She said she depends on natural sunlight, because the overbed lights in her room do not provide enough reading light for her needs. A view of her room found she had multiple electronic devices which used all of her wall outlets except for an outlet beneath her sink. Resident #92 explained that they are not allowed to have extension cords in their rooms. During an interview with Employee #91 at this time, she said housekeeping and maintenance tried in the past to figure out a way in which to accommodate all of her electronic needs, and were aware of her desire for a reading lamp. She said that her outlets are all in use. During further interview with Resident #92, she said she believed some re-arranging of items in her room might allow her to plug in the recliner the facility provided for her, as she might enjoy reclining a bit while she reads. At present, her recliner is unplugged. She said she does not need the recliner to watch television, rather, just to sit and read. She said that a battery operated reading light of some type might suffice if they could not give her more electrical outlets. She said the closet area across the room was also rather dark in the evenings, and she would appreciate if a battery operated light could be obtained for her closet as well. These findings were shared with the director of nursing prior to exit on 06/14/17 at 3:00 p.m., with no further information provided prior to exit.",2020-09-01
2255,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,278,D,0,1,DU6R11,"Based on record review and staff interview, the facility failed to complete an accurate assessment regarding a resident's self performance for locomotion on the unit. This failed practice affected one (1) of seventeen (17) sample residents. Resident identifier: 54. Facility census: 81. Findings include: a) Resident #54 During a medical record review conducted 06/13/17 at 3:46 p.m., the 14 day minimum data set (MDS) assessment with an assessment reference date (ARD) of 04/26/17 was inspected. Specifically, Section G for Functional Status, item G0110 for Activities of Daily Living (ADL) Assistance of the MDS was reviewed. Question [NAME] pertains to Locomotion on unit - how resident moves between locations in his/her room and adjacent corridor on same floor. The facility response for this question identified Resident #54 as having required extensive assistance with one person physical assist. The point of care TASK log completed during the required look back period from 04/20/17 through 04/26/17 identified Resident #54 as having been totally dependent with full staff performance required for locomotion on the unit for every occurrence. This was discussed with MDS nurse #951 on 06/13/17 at 4:05 p.m. She agreed the assessment was incorrect and completed a modification of the 14 day MDS assessment prior to the end of the survey.",2020-09-01
2256,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,309,D,0,1,DU6R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the highest practicable well-being for one (1) of one (1) residents observed for fingerstick blood sugar during medication administration. The nurse failed to follow a physician's orders [REDACTED]. Resident identifier: Resident #16. Facility census: 81. Findings include: a) Resident #16 During a medication administration observation, on 06/13/17 at 5:01 p.m., Licensed Practical Nurse (LPN) #581, using a glucometer, obtained a finger stick blood sugar for Resident #16. The digital reading was 406 mg/dl. The LPN verbalized the facility protocol was to give eight (8) units if above 400 mg/dl and call the physician for orders. The nurse placed a call to notify the physician, and administered eight (8) units of [MEDICATION NAME] insulin. Licensed Practical Nurse (LPN) #621 interviewed on 06/14/17 at 9:48 a.m., reviewed the Medication Administration Record [REDACTED]. The nurse verbalized the physician would give a specific order for when to repeat the fingerstick blood sugar. With further inquiry, the nurse said she would not repeat the test prior to notifying the physician and would obtain a physician's orders [REDACTED]. During an interview with the director of nursing (DON) and Regional Clinical Consultant (RCC) #1231 on 06/14/17 at 2:48 p.m., the director voiced the blood sugar test should have been repeated immediately for verification of an accurate result, which was the facility policy and good clinical practice. The DON said it would be completed prior to calling the physician for orders. When the order was reviewed, the director acknowledged the order on the MAR indicated [REDACTED]. Additionally, staff members were not knowledgeable of the facility policy. [DIAGNOSES REDACTED]/[MEDICAL CONDITION] management policy, reviewed on 06/14/17 at 2:59 p.m., noted to Perform a fingerstick blood glucose test. If the results are abnormal, repeat the test to verify reading. Obtain vital signs notify Registered Nurse (RN) supervisor, assess condition, notify physician, and initiate treatment as directed. Each order was written as a separate order. physician's orders [REDACTED]. 1) Fingerstick before breakfast, before lunch and before supper. Before meals. Call physician, if fingerstick below 60 or above 400. Obtain repeat blood sugary test if less than 60 or greater than 400. 2) If Fingerstick is above 400 mg/dl give 8 units of [MEDICATION NAME] and call physician for further instructions. The DON requested a follow-up interview for herself with LPN #581 and Regional Consultant #123 present. The director said the LPN had contacted the physician and received orders to complete a follow-up blood sugar in one (1) hour, but that he had not written the order and was writing it at this time. It was again discussed the LPN #581 failed to follow a physician's orders [REDACTED].",2020-09-01
2257,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,441,E,0,1,DU6R11,"Based on observation, staff interview and policy review, the facility failed to prevent the transmission and spread of disease and infection to the extent possible. Staff failed to utilize proper hand hygiene, and failed to handle medical supplies in a sanitary manner. This practice affected two (2) residents but had the potential to affect more than a limited number. Resident identifiers: Resident #16 and Resident #34. Facility census: 81. Findings include: a) Resident #16, #34, and #42 During a medication observation on 06/13/17 at 5:01 p.m., Licensed Practical Nurse (LPN) #581 obtained a container of blood sugar monitoring strips from the medication cart, walked down the corridor to the room of Resident #16. The nurse placed the container of strips of the over-the-bed table without utilizing a barrier. Upon completion of the fingerstick blood sugar, the LPN picked up the container and placed it on the sink while he removed his gloves. LPN #581 then picked up the container and returned it to the medication cart without sanitizing the bottle. LPN #581 later returned to Resident #16's room and without utilizing gloves, administered the insulin. The LPN exited the room and utilized hand sanitizer from a wall unit as he walked down the hallway to the medication cart. The Director of Nursing (DON), interviewed in the presence of Regional Clinical Consultant #123, verbalized gloves should be worn when administering the insulin injections. b) Resident #34 On 06/14/17 at 7:08 a.m., Licensed Practical Nurse (LPN) #621 entered the room of Resident #34. The nurse turned on the faucet to obtain warm water desired by the resident. The nurse did not utilize gloves. After obtaining the water, the nurse handed the cup to the resident. Resident #34 was not satisfied and LPN #621 again turned on the faucet without utilizing gloves then handed the cup of water to the resident. A third time, the nurse turned on the faucet without utilizing gloves, then handed the cup to the resident. Upon completion of the medication administration, the nurse returned to the cart and utilized hand sanitizer located in the bottom drawer of the medication cart. c) Resident #42 On 06/14/17 at 7:15 a.m., LPN #1101 poured medications then entered the room of Resident #42. The nurse assisted the resident into a seated position at the bedside and administered medications. Upon completion, the LPN washed her hands, turned off the faucet with bare hands, then obtained paper towels and dried her hands. d) The DON, interviewed on 06/14/17 at 2:00 p.m., said the facility practice required staff place a barrier beneath items placed on the over-the-bed table and sanitize the item prior to placing back in the medication cart. The nurse also confirmed staff utilized improper hand hygiene protocol. e) The hand hygiene policy, reviewed on 06/14/17 at 3:04 p.m., required hand hygiene utilized before and after direct patient contact, before inserting invasive devices, after removing gloves, and after contact with objects and equipment in the patient's immediate vicinity. The policy noted hand hygiene was always the final step after removing personal protective equipment (PPE) and did not replace hand hygiene. The hand washing technique noted after washing and rinsing hands to dry hands thoroughly and then obtain a clean dry paper towel to turn off the faucet.",2020-09-01
2258,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2017-06-14,469,D,0,1,DU6R11,"Based on observation, family interview and staff interview, the facility failed to ensure the environment was free of pests. One (1) out of twenty-nine (29) rooms observed in Stage I of the Quality Indicator Survey was found to have ants, and directly affected one (1) resident. Resident identifier: #68. Facility census: 81. Findings include: a) Resident #68 On 06/13/17 at 8:24 a.m., several dozen small ants were observed on the windowseal, on the wall beneath the windowseal, and on the top ledge of the vent which was located on the floor and extending about a foot vertically on the wall beneath the windowseal. A family interview was conducted with the resident's responsible party on 06/13/17 at 9:50 a.m. She said they have had trouble with ants in this resident's room, and she does not know the reason why. She said she has spoken with facility staff about the ants, but the ants just keep coming back. A tour of the facility was conducted, on 06/14/17 between 9:30 a.m. and 10:00 a.m., with housekeeping supervisor Employee #91. Ants again were observed on the wall and heater ledge beneath the window, but a lesser number than previously observed on 06/13/17. Upon inquiry, Employee #91 said she has never seen ants in this resident's room. Two (2) nursing assistants in that room who had just finished care for this resident said that Resident #68 liked to sit in her wheelchair and look out the window. They said staff at times provided her snacks to eat and drink while she sat by the window. An interview was conducted with the director of nursing on 06/14/17 at 3:00 p.m She said they have had ant issues in the past in other rooms, specifically in rooms where residents keep a lot of snack foods. She said she was unaware of ants in this resident's room.",2020-09-01
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
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
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
4700,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,226,F,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, review of facility documents, staff interview, personnel file review, and review of facility policies and procedures, the facility failed to implement and operationalize its policies regarding abuse/neglect, including injuries of unknown origin. The facility failed to investigate and report occurrences of possible neglect and/or injuries of unknown origin for four (4) of thirty (30) Stage 2 residents. Resident identifiers: #48, #105, #75, and #37. This deficient practice had the potential to affect all residents. Facility census: 92. Findings include: a) Resident #48 This [AGE] year-old resident, initially, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. and acute pain due to trauma. 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 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 4cm (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 (wheelchair) 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 (Situation, Background, Assessment, and Recommendation) 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. [DATE] at 00:50 (12:50 a.m.) Nurse's Note: Received call from (hospital) ER they have done a Ct (computerized tomography) scan and everything appears to be in proper alignment no acute fractures found. [DATE] at 15:34 (3:34 p.m.) Nurse's Note: Call placed to (hospital) resident has a non displaced right [MEDICAL CONDITION] and a pelvic fracture. She will be returning in a couple days. 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 eventually 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 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. 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. e) Review of the facility's policies and procedures for abuse prohibition on [DATE] at 1:20 p.m., found they included: -- efforts to prevent abuse and/or neglect through employee screening and training, -- taking appropriate action when abuse or neglect was suspected, -- thorough investigation of suspected or possible abuse/neglect, including injuries of unknown origin, by review of incident reports and interviews with any possible persons who might have been aware of any pertinent information, all of which was to be put in writing, -- and immediate reporting of any allegations or possible abuse/neglect, including injuries of unknown origin by anyone in the facility who becomes aware. For injuries of unknown origin, the policy and procedure required the completion of an incident report, and compiling a list of all personnel, including consultants, contract employees, visitors, family members, etc., who had had contact with the resident during the past 48 hours to be interviewed. Review of the personnel files of ten (10) employees on [DATE] beginning at 1:30 p.m., found evidence all ten (10) had been oriented and/or trained in the abuse/neglect policies and procedures. f) Based upon the findings for Residents #48, #105, #75, and #37 during the survey, the facility failed to operationalize its policies and procedures to ensure staff reported and documented possible instances of neglect and injuries of unknow origin, and failed to investigate to ensure abuse/neglect were not involved. The facility also failed to report these occurrences to the appropriate State agencies. 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.",2019-08-01
4701,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,253,E,0,1,TULX11,"Based on observation and staff interview, the facility failed to provide effective housekeeping and maintenance services necessary to ensure the environment was sanitary, orderly and comfortable for residents as evidenced by numerous cosmetic imperfections. Concerns included stained discolored tile and caulking around toilet bases and door frames, rusted sink drains, and stained sink basins. In addition, the baseboard heaters on either side of the 200 hall had large scratches and dents with missing paint. This had the potential to affect more than an limited number of residents. Room numbers: #202, #203, and #207. Facility census: 92. Findings include: a) On 04/04/16 at 1:45 p.m. until 2:00 p.m., accompanied by Maintenance Supervisor #6 and Housekeeping/Laundry Supervisor #55, a tour of the facility was conducted. At the conclusion of the tour, both agreed the environmental issues observed during the tour required cleaning, repair and/or replacement. 1. Room 202: The tile around the base of the toilet in the bathroom was stained and discolored. The sink basin in the resident's room was stained and discolored. The sink drain was rusted. 2. Room 203: The tile around the base of the toilet in the bathroom was stained and discolored. 3. Room 207: The tile around the base of the toilet in the bathroom was stained and discolored. The floor tile around the interior bathroom door frames was stained and discolored with a buildup of grime. 4. The baseboard heaters on either side of the 200 hall had large scratches, dents, and rust, and had missing paint.",2019-08-01
4702,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,278,D,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the Resident Assessment Instrument (RAI) Version 3.0 Manual, and staff interview, the individual assessing and certifying the accuracy of Sections J and O of Resident #16's quarterly Minimum Data Set (MDS), failed to ensure the assessment was accurate regarding prognosis and Hospice services. This was found for one (1) of one (1) Hospice residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #16. Facility census: 92. Findings include: a) Resident #16 On 03/28/16 at 2:00 p.m., a medical record review revealed Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Resident #16 was prescribed Hospice services on 11/04/15 for the [DIAGNOSES REDACTED]. Review of the resident's quarterly minimum data set (MDS) with an assessment reference date (ARD) of 02/16/16, found item J1400 Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months, was coded as, No. Item O0100K - Hospice care was also coded as, No According to the Resident Assessment instrument (RAI) 3.0 user's manual, Item J 1400 is to be coded, Yes, if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After reviewing the quarterly MDS for Resident #16 on 03/28/16 at 3:20 p.m., Registered Nurse (RN) #65 agreed and stated, Will correct it immediately.",2019-08-01
4703,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,279,D,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan based on a resident's current health condition/status that included measurable objectives and timetables to meet a resident's needs. Three (3) of twenty-seven (27) Stage 2 sample residents whose care plans were reviewed during the Quality Indicator Survey (QIS) were affected. Resident #75's care plan was silent regarding a transfer to the 500 hall (downstairs of the building which had the potential to affect her emotional/mental status). Resident #32's care plan did not have an adequate individualized measurable goal related to restorative therapy. Resident #79's care plan was silent regarding her isolation status. Resident identifiers: #75, #32, and #79. Facility census: 92. Findings include: a) Resident #75 On 04/05/16 at 7:15 a.m., review of Resident #75's medical record revealed she was admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was transferred downstairs to the 500 hall on 02/23/16. A progress note dated 02/23/16 revealed, Resident was very anxious with new room change A review of the care plan revealed it was silent for the resident being anxious related to the room/floor transfer. On 04/05/16 at 8:55 a.m., after reviewing the care plan for Resident #75, the Director of Nursing (DON) stated, I do not see the room change/unit change addressed, and it should have been due to being her being anxious with the transfer. b) Resident #32 On 03/29/16 at 1:20 p.m., medical record review revealed Resident #32 was admitted on [DATE]. Her [DIAGNOSES REDACTED]. The resident received restorative nursing therapy for dining and PROM (passive range of motion) to the left upper extremity 3 times a week and application of a splint 7 hours a day. On 03/30/16 at 9:20 a.m., review of the resident's care plan revealed a F[NAME]US: Resident receives Restorative Services to promote mobility and joint movement initiated on 05/06/15. GOAL: Resident will participate with Restorative through review date. The goal did not include parameters to render it measurable. During an interview with Nurse Consultant #134, after reviewing the care plan, she stated that is not really considered a goal for restorative therapy. After reviewing the care plan on 03/30/16 at 10:35 a.m., the DON stated, that is not really a goal for this resident. It should include measurable goals for PROM and her splint. Also her meal consumption and also her restorative dining such as cueing, etc. c) Resident #79 A review of the medical record for Resident #79 on 04/05/16 at 10:00 a.m., revealed this [AGE] year old female was admitted on [DATE]. She was placed in contact precautions for extended spectrum beta lactamase (ESBL) in her urine and prescribed antibiotics in (MONTH) (YEAR). Review of Resident #79's care plan found no mention of isolation/contact precautions for ESBL of urine. After reviewing the care plan for Resident #79 on 04/05/16 at 11:50 a.m., Registered Nurse (RN)/Infection Control Nurse #97 stated, No, it is not there and, yes it should be care planned if a resident is on isolation. I will get the MDS (minimum data set) nurse to fix it because this is her resident. On 04/05/16 at 12:05 p.m., during an interview with RN/MDS Coordinator #100, she stated, I already looked and no it is not care planned for isolation, her roommates' isolation is, but don't know how I missed her. It will be on there now.",2019-08-01
4704,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,280,D,0,1,TULX11,"Based on record review and staff interview, the facility failed to review and revise the care plan for one (1) of twenty-seven (27) Stage 2 sample residents. The care plan was not revised after she was ordered nothing by mouth (NPO) and intravenous fluids (IV). Resident identifier: #105. Facility census: 92. Findings include: a) Resident #105 A medical record review on 04/06/16 at 10:15 a.m., found a physician's verbal order on 12/08/15 stating, Start IV (intravenous), give NS (normal saline) at 125 ml (milliliters) (give 1000 ml). A previous order, written on 12/08/15, directed, . 24 hour hold on all po (by mouth) intake until next ST (speech therapy) evaluation. The care plan with a revision of 12/10/15, was silent for prescribed NPO status and IV fluids. After reviewing the care plan for Resident #105 on 04/06/16 at 10:45 a.m., the Director of Nursing (DON) stated, it (NPO and IV fluids) is no where in the care plan and it should be there.",2019-08-01
4705,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,282,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 provide services in accordance with the resident's written plan of care for activities of daily living (ADL) which includes brushing teeth and oral hygiene for one (1) of twenty-seven (27) Stage 2 sample residents. Resident identifier: #105. Facility census: 92. Findings include: a) Resident #105 During an interview with Speech/Language Pathologist (SLP) #38 on 04/06/16 at 7:45 a.m., she provided copies of Speech/Language Pathology Daily Notes. A review of the notes revealed a daily treatment on 12/08/15 with the following documentation; 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 (flexible part of the mouth toward the back of the roof of the mouth/the membrane-lined cavity behind the nose and mouth, connecting them to the esophagus) revealed thick brown build up on and around the patient's uvula (fleshy extension at the back of the soft palate that hangs above the throat). Following oral care one swallow was triggered by the patient with slight movement in the sound of her breathing. A further review of the notes revealed a daily treatment on 12/09/15, Therapy services provided in pt 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 12/08/15 and 12/09/15 and was seen prior to that on 12/04/15. 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 and there were four (4) days between 12/04/15 and 12/08/15. We talked with the nurses about this. The resident had declined in health, but there were four days from 12/04 to 12/08 that we did not see her and she had significant residue in her mouth that prevented her swallowing. The care plan for Resident #105 dated 09/03/15. included: -- Focus: The resident has an ADL self care Performance Deficit r/t (related to)[MEDICAL CONDITION], muscle weakness, [MEDICAL CONDITION] and [MEDICAL CONDITION]. -- Interventions: Assist resident with daily ADL care The medical record was silent for oral care being provided by staff other than the SLP. After repeated requests, no evidence was provided regarding daily ADL care which would have included oral care being provided for Resident #105 by staff other than the referenced SLP notes.",2019-08-01
4706,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,309,G,0,1,TULX11,"**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 was provided with the assistance she required as identified in her comprehensive plan of care. Resident #37 experienced pain and anxiety after falling out of bed when a staff member failed to provide care in accordance with the resident's assessed needs. This avoidable incident resulted in the actual harm to the resident. One (1) of twenty-seven (27) Stage 2 residents was affected. Resident identifier: #37. Facility census: 92. Findings include: a) Resident #37 Review of Resident #37's medical record on 03/28/16 at 1:20 p.m., found a nursing progress written by Licensed Practical Nurse (LPN) #130 on 03/04/16 stating, 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 (nostril). The resident was urgently transferred to the hospital for evaluation. The nursing progress note dated 03/05/16 at 11:54 a.m. stated (typed as written), . Resident terrified whenever staff does personal care, and when repositioned. Resident reassured by having several staff members present when doing care. Given PRN (as needed) [MEDICATION NAME] for general pain . Requested to stay in bed due to being sore. Niece in to visit. After speaking with her and resident, call placed to MD (Medical Doctor) about increasing pain medication until she feels better from . Message left According to the minimum data set (MDS) assessment, with an assessment reference date (ARD) of 12/03/15, the resident required the extensive assistance of two (2) person for bed mobility and was totally dependent on two (2) people for transfers. The care plan, updated on 03/14/16, included a Focus of Resident requires extensive assist to remain clean, neat and free of body odors due to: history of falls, muscle weakness, depression, [MEDICAL CONDITIONS] and generalized pain. The interventions were, Plan of care per Kardex. The nursing Kardex stated under Transferring . 2 staff for bed mobility, 2 staff for repositioning and incontinence care. Review of incident reports on 03/29/16 at 9:00 a.m., revealed Resident #37 had rolled out of bed onto the floor on 03/04/16. 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. In an interview on 03/31/16 at 9:00 a.m., Nurse Aide (NA) #49 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 (a system to communicate the care needs of the individual resident to direct care staff). Resident #37 had been a two (2) person reposition and lift since this NA started working in (MONTH) (YEAR). Licensed Practical Nurse (LPN) #130 reported during an interview on 04/05/16 at 1:30 p.m., Resident #37, . is now scared to death of falling. The facility provided the resident with a wider bed to assist with her anxiety related to falling out of bed during care. This avoidable incident resulted in actual harm to the resident as she experienced pain, had to be sent to a hospital, and had persisting anxiety about falling out of bed.",2019-08-01
4707,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,312,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 provide the necessary care and services to maintain good oral hygiene for Resident #105. The resident was found on two (2) consecutive days to have a build up of secretions in her mouth. This was found for one (1) of twenty-seven (27) sample residents in Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: 105. Facility census: 92. Findings include: a) Resident #105 On 04/05/16 at 4:40 p.m., review of the resident's closed medical record revealed this [AGE] year-old female, admitted on [DATE], had [DIAGNOSES REDACTED]. Review of the minimum data set (MDS), with an assessment reference date (ARD) of 11/09/15, identified Resident #105 as being an extensive assist for personal hygiene (including brushing teeth). According to nursing progress notes on: -- 12/08/15, weight loss of 7 lbs. since 08/14/15 -- 12/08/15 at 12:38 (12:38 p.m.), Resident has been having difficulty swallowing today During an interview with Speech/Language Pathologist (SLP) #38 on 04/06/16 at 7:45 a.m., she provided copies of Speech/Language Pathology Daily Notes. A review of the notes revealed a daily treatment on 12/08/15 stating, 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. A further review of the notes revealed a daily treatment on 12/09/15 with the following documentation; Therapy services provided in pt 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 12/08/15 and 12/09/15 and was seen prior to that on 12/04/15. 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 12/04 to 12/08 that we did not see her and she had significant residue in her mouth that prevented her swallowing. With this type of residue, she could not have received any hydration or nutrition during this time due to being unable to swallow. The medical record was silent for oral care being provided by staff other than the SLP and silent regarding the resident's oral fluid and meal intake. Numerous requests were made for the ADL (activities of daily living) sheets documenting the provision of oral care and showing the resident's fluid and meal intakes, but none of these were provided during the survey.",2019-08-01
4708,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,323,K,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to ensure the resident environment remained as free of accident hazards as possible and that each resident received adequate supervision to prevent accidents. Seven (7) residents resided on the 500 hall/Memory Care Unit (MCU), a separate unit isolated from other parts of the building. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. Three (3) (Residents #61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 1:45 p.m. the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. Two tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:09 p.m., Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of the incident for Resident #93's, the administrator prepared a second plan of abatement which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility ' s plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. Resident identifiers: #61, #93, #76, #94, #75, #39, and #54. Facility census: 92. Findings include: a) Memory care unit/500 hall During the initial tour of the Memory Care Unit (MCU)/500 hall with the Director of Nursing (DON) on 03/23/16 at 8:45 a.m., the DON said they closed the assisted living unit and plans were in place to renovate this wing in anticipation of licensure for an Alzheimer's unit. To gain entrance to the unit from the main part of the building required exiting the main building to the outdoors, walking down a paved hill and entering through the front door. The DON reported there was no internal access to this unit. The seven (7) residents resided in rooms 501 through 508, in the main hall between the front door of the unit and the television lounge. A follow up observation of the MCU/500 hall on 03/29/16 at 12:00 p.m. found the following: 1. Main hall -- Several unsecured and unused resident rooms located beyond the unlocked and unalarmed fire doors past the television lounge and room 508. -- An alarmed egress was located at the end of this hall between rooms 515 and 516, which was not visible from the nurses' desk because of the closed fire doors, -- Outside of this door was a small-unsecured cement patio. A three (3) foot high fence with two (2) unlocked gates surrounded the patio. -- Immediately in front of the patio was a water treatment pond surrounded by a six (6) foot high locked fence. -- The left unlocked gate in the fence around the patio led to a grassy area between other sections of the building and the right unlocked gait had four (4) steps that led to a gravel road and construction zone. -- In the construction zone, there was a ladder to the roof of the building, a dump truck, and a dumpster containing old roofing material. -- Beyond the gravel road was an unpopulated wooded area. 2. Second hall -- A second unsecured hall, located between the nurses' station and the television lounge, across from room 506, had two (2) yellow and black cones with a detachable barrier strip between them blocking the hall. -- This hall contained the laundry services, the food dumbwaiter, a beauty shop, a lounge, a storage area, and five (5) unsecured resident rooms. -- There was a secured exit door, not visible from the nurses' station, located at the end of this hall. The door exited to a grassy area between other sections of the main building. On 03/30/16 at 11:45 a.m., review of the nursing schedules for (MONTH) and (MONTH) (YEAR) verified the unit was staffed every shift with two (2) staff members, a nurse and a nurse aide. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. The door had a doorknob and a metal latch at the top. The door had a sign that said there was no push bar, but one was ordered. A faint alarm sounded, but no staff approached in response. Then at 10:05 a.m., Therapy Staff #35 came to the front door from outside and was able to get it to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. At 10:08 a.m., Therapy Staff #37 approached the door. She was told to push the red button. She did, but the door would not open. At 10:13 a.m., she was told to go around the back way. Observations during this time, found no staff except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came through the hall that had barriers up saying Caution with two black and yellow cones and barrier tape stretched between them. Therapy Staff #37 said he/she came in through the door at the end of that hall. Then Maintenance Director #6 entered the unit by that door. Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. A second observation from 11:00 a.m. until 12:01 p.m., found the main entrance door would open, but the alarm system was not functioning. Registered Nurse #92, during an interview at 11:00 a.m., acknowledged there was a risk of elopement, but said there had never been any elopements. When advised Resident #61 had eloped on 03/26/16 and found outside by a nurse, she said she was unaware of any elopements and acknowledged that staffing of two (2) persons for the unit was not sufficient to permit adequate monitoring of all residents. While conducting additional interviews and observations at 11:29 a.m., Housekeeper #28 said, the door hasn't been broken long, only a week or two. Observations at that time found the doorknob to go out had been removed and the door opened with a push. The alarms were turned off. Some residents were at lunch, and some were sitting in their rooms. No staff were monitoring the exit. Unit Director RN #100, in an interview on 03/29/15 at 1:15 p.m., acknowledged the front door had been an issue since the residents were moved to the unit. Staff could not hear the alarm and they had been asking for it to be repaired. c) Immediate Jeopardy After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 12:26 p.m., the findings were relayed to the Office of Health Facility Licensure and Certification (OHFLAC) for review and the decision was made to identify this as an Immediate Jeopardy (IJ). On 03/29/16 at 1:45 p.m., the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. There corrective actions were for an employee to monitor the front door for a 24 hour watch until the door was fixed, and an additional nurse aide or staff member would be added to each shift for all three shifts. Two (2) tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:08 p.m., found Dietary Supervisor #81 sitting at the front of the building with a resident monitoring the front door, Licensed Practical Nurse (LPN) #30 sitting in the nurses' station charting on the computer. Nurse Aide (NA) #27 sitting in the TV lounge with a few of the residents. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurse's station and informed LPN#30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN#30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumb waiter accompanied by Dietary Aide #101, opened the door to room #524 and found Resident #93 standing next to the wall. LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of this, the administrator prepared a second plan of abatement, which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility's plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. b) Wandering residents residing on the 500/Memory Care Unit These three (3) resident were not provided with supervision to prevent accidents. 1. Resident #61 Review of the resident's medical record on 03/29/16 at 10:19 a.m., revealed Resident #61 transferred to the memory care unit/500 hall on 02/23/16. The resident's [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/16, and the annual MDS with an ARD of 10/19/15, identified the resident wandered one (1) - three (3) days during the 7 day look back period in E0900. The resident's care plan, with a revision date of 01/27/16, identified Resident #61's exit seeking behaviors were related to her [DIAGNOSES REDACTED]. The interventions include wearing three (3) Wanderguard bracelets and monitoring the resident when close to the door; avoid over stimulation, and removing the resident from the situation when agitated. Two separate incidents were found regarding Resident #61's wandering. An incident report, dated 02/27/16 documented the resident went out the back door. On 03/2616, which was a Saturday, there was a progress note in the computer stating she had gotten out the front door. The incident report with a revision date of 02/28/16, stated Resident #61 exited through the back door onto the unlocked patio on 02/27/16 with the alarm sounding. A staff member from another department found the resident and notified the unit nurse, Licensed Practical Nurse (LPN) #74. The nursing progress note dated 03/26/16 stated LPN #74 observed the resident exit out the alarming front door onto the sidewalk. LPN #74 documented the resident returned to the unit after much encouragement and a third Wanderguard bracelet was applied to the resident. During an interview on 03/29/16 at 12:50 p.m., Nurse Aide (NA) #64 reported Resident #61 had three (3) Wanderguard bracelets on because they do not alarm if covered up, She likes to pull her socks up over them. 2. Resident #93 Review of the resident's medical record on 03/30/16 at 8:00 a.m., revealed Resident #93 moved to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The annual MDS, with an ARD of 02/02/16, noted the resident wandered daily and had a Brief Interview for Mental Status (BIMS) of three (3), indicating severe cognitive impairment. The care plan, with a revision date of 03/29/16, noted Resident #93's [DIAGNOSES REDACTED]. The interventions include a Wanderguard bracelet, redirect the resident when wandering towards the outside doors, and, Observe frequently and place in supervised area when out of bed. Observations during a second tour of the unit on 03/29/16 at 3:08 p.m. noted Resident #93 left her walker next to the yellow and black caution cones and detachable barrier and walked down the unsecured and unused short hall of the department; unobserved by either staff member working on the unit at that time. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room #524 (a closed room). LPN #30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumbwaiter accompanied by Dietary Aide #101, opened the door to room #524 and found Resident #93 standing next to the wall. During an interview immediately after this observation, LPN #30 admitted she would not have known where the resident was if the Dietary Aide had not notified her. 3. Resident #75 Review of the medical record on 04/06/16 at 12:00 p.m. revealed Resident #75, a [AGE] year-old woman, transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The significant change MDS, with an ARD of 01/17/16, noted the resident's BIMS score was one (1), indicating severe cognitive impairment with inattention and disorganized thinking and rejection of care at times. The current care plan, with a revision date of 03/24/16, identified the use of a Wanderguard bracelet, and that the resident had short and long-term memory problems with decision-making impairment related to Alzheimer's disease and dementia. Registered Nurse (RN) #92, during an on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she took her breaks on the unit, but some staff left for smoke breaks and that left one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents.",2019-08-01
4709,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,353,K,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, and review of staffing schedules, the facility failed to provide sufficient nursing staff to provide needed care and supervision to all residents residing on the 500 hall/memory care unit. Deployed staffing was not adequate for monitoring the resident population which included residents with dementia, and residents that wandered and were at risk of eloping. Seven (7) residents with dementia-related [DIAGNOSES REDACTED]. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. In addition to the [DIAGNOSES REDACTED].#61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on 03/29/16 at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On 03/29/16 at 1:45 p.m. the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on 03/29/16. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. Two tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on 03/29/16 at 3:09 p.m., Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room [ROOM NUMBER] (a closed room). LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on 03/29/16 at 3:13 p.m. The surveyor team met with the Administrator on 03/29/16 at 3:44 p.m. When advised of the incident for Resident #93's, the administrator prepared a second plan of abatement which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on 03/29/16 at 3:44 p.m. As of 4:17 p.m. on 03/29/16, all the residents were back in the main building. An abatement plan of correction was prepared and sent to the State Survey Agency Director. The State agency reviewed and accepted the facility's plan of correction. After all residents moved back to the main building, the immediate jeopardy was removed with no deficient practices remained. Resident identifiers: #61, #93, #94, #76, #54, #75, and #39. Facility census: 92. Findings include: a) During the initial tour of the memory care unit/500 hall with the Director of Nursing (DON) on 03/23/16 at 8:45 a.m., the DON reported the residents residing on the unit were considered appropriate for the future memory care unit. Surveyors were informed plans were in place to renovate this wing in anticipation of licensure for an Alzheimer's unit. Entrance to the unit was made by exiting the main building to the outdoors, walking down a paved sloping roadway and entering through the front door. The DON reported there was no internal access to this unit. The seven (7) residents were residing in rooms 501 through 508, in the main hall between the front door of the unit and the television lounge. A follow up observation of the memory care unit/500 hall on 03/29/16 at 12:00 p.m. found several unsecured and vacant resident rooms located beyond the unlocked and unalarmed fire doors past the television lounge and room [ROOM NUMBER]. An alarmed egress was located at the end of this hall between rooms [ROOM NUMBERS] and was found to not be visible from the nurses' desk because of the closed fire doors. Outside of this door was a small unsecured cement patio. The patio was surrounded by a three (3) foot fence with two (2) unlocked gates. Immediately in front of the patio was a water treatment pond surrounded by a six (6) foot locked fence. The left gate led to a grassy area between other sections of the building and the right unlocked gait had four (4) steps which led to a gravel road and construction zone. There was a ladder to the roof of the building, a dump truck, and a dumpster containing old roofing material. Beyond the gravel road was an unpopulated wooded area. A second unsecured hall was located between the nurses' station and the television lounge, across from room [ROOM NUMBER]. This hall was blocked with two (2) yellow and black cones with a detachable barrier strip between them and contained the laundry services, the food dumbwaiter, a beauty shop, a lounge, a storage area, and five (5) unsecured resident rooms. A secured exit door, not visible from the nurses' station was located at the end of this hall and exited into a grassy area between other sections of the main building. b) Residents residing on the 500 hall/memory care unit: 1) Resident #61 Review of the medical record on 03/29/16 at 10:19 a.m. revealed Resident #61 was transferred to the memory care unit/500 hall on 02/23/16. Her [DIAGNOSES REDACTED]. The quarterly minimum data set (MDS) with an assessment reference date (ARD) of 01/19/16, and the annual MDS with an ARD of 10/19/15, identified the resident wandered one (1) - three (3) days during the 7 day look back period for Item E0900. The care plan, with a revision date of 01/27/16, identified Resident #61's exit seeking behaviors related to her [DIAGNOSES REDACTED]. The interventions include wearing a Wanderguard bracelet and monitoring the resident when close to the door; avoid over stimulation, and removing the resident from the situation when agitated. An incident and accident report with a revision date of 02/28/16, stated Resident #61 exited through the back door onto the unlocked patio on 02/27/16 with the alarm sounding. A staff member from another department found the resident and notified the unit nurse, Licensed Practical Nurse (LPN) #74. The nursing progress notes, dated 03/26/16, stated LPN #74 observed the resident exit out the alarming front door onto the sidewalk. LPN #74 documented the resident returned to the unit after much encouragement and a third Wanderguard bracelet was applied to the resident. During an interview on 03/29/16 at 12:50 p.m. Nurse Aide (NA) #64 reported Resident #61 had three (3) Wanderguard bracelets on because they do not alarm if covered up, She likes to pull her socks up over them. These were two (2) separate incidents. Review of incident reports found the resident went out the back door on 02/27/16. On 03/2616, which was a Saturday, there was a progress note in the computer stating she had gotten out the front door, but no written incident report was filed. 2) Resident #93 Review of the medical record on 03/30/16 at 8:00 a.m. revealed Resident #93 was moved to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The annual MDS with an ARD of 02/02/16, noted the resident wandered daily and had a Brief Interview for Mental Status (BIMS) of three (3) - indicating severe cognitive impairment. The care plan, with a revision date of 03/29/16, noted Resident #93's [DIAGNOSES REDACTED]. The interventions included a Wanderguard bracelet, redirect the resident when wandering towards the outside doors, and observe frequently and place in supervised area when out of bed. Observations during a second tour of the unit on 03/29/16 at 3:08 p.m. noted Resident #93 left her walker next to the yellow and black caution cones and detachable barrier and walked down the unsecured and unused short hall of the department; unobserved by either staff member working on the unit at that time. At 3:09 p.m. on 03/29/16, Dietary Aide #101 walked up to the nurse's station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room [ROOM NUMBER] (a closed room). LPN #30 found a walker sitting next to the caution cones and detachable barrier strap; she walked down the closed hall past the dumbwaiter accompanied by Dietary Aide #101 opened the door to room [ROOM NUMBER] and found Resident #93 standing next to the wall. During an interview immediately after this observation, LPN #30 admitted she would not have known where the resident was if the Dietary Aide had not notified her. Registered Nurse (RN) #92, during an interview on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she takes her break on the unit, but some staff leave for smoke breaks and that leaves one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents. 3) Resident #94 Resident #94's medical record, reviewed on 03/30/16 at 11:30 a.m., found this [AGE] year-old transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The quarterly MDS with an ARD of 03/11/13 noted the resident had inattention and disorganized thinking continuously present. The care plan, updated 01/14/16, addressed the resident's cognitive loss and risk for decline in activities of daily living related to dementia and [MEDICAL CONDITION]. Plans of action included consistent routines/caregivers, allow adequate time to respond, do not rush the resident, and check every two (2) hours for comfort, positioning, pain, and needs. 4) Resident #76 Review of the resident's medical record on 03/30/16 at 11:00 a.m., revealed this [AGE] year-old man transferred to the 500 hall/memory care unit on 02/23/16. His [DIAGNOSES REDACTED]. His care plan with a revision date of 03/29/16, identified his dementia with cognitive loss. He required verbal cues for names, room location, and activity reminders. 5) Resident #54 Review of the resident's medical record on 03/30/16 at 8:35 a.m., revealed this [AGE] year-old woman transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The MDS with an ARD of 02/09/16, assessed the Brief Interview for Mental Status (BIMS) as 99 (unable to determine mental status), with moderately impaired cognition, inattention and disorganized thinking. Her care plan, revised on 04/04/16, identified the resident was dependent on others for environmental stimuli. She needed encouragement to remain active and required hands on assistance to complete tasks. Resident #54 had hallucinations and could present with anger. She required assistance with activities of daily living (ADLS) because of muscle weakness, [MEDICAL CONDITION], and dementia. 6) Resident #75 The resident's medical record, reviewed on 04/06/16 at 12:00 p.m., revealed this [AGE] year-old woman transferred to the 500 hall/memory care unit on 02/23/16. Her [DIAGNOSES REDACTED]. The significant change MDS with an ARD of 01/17/16, identified the resident's BIMS score as one (1) - indicating severe cognitive impairment with inattention and disorganized thinking and rejection of care at times. The current care plan, with a revision date of 03/24/16, identified the use of a Wanderguard bracelet, short and long-term memory problems with decision-making impairment related to [MEDICAL CONDITION] and dementia. 7) Resident #39 Review of the resident's medical record on 04/06/16 at 12:30 p.m., revealed this [AGE] year-old woman's [DIAGNOSES REDACTED]. She was transferred to the memory care unit/500 hall on 02/23/16. Her quarterly MDS, with an ARD of 02/09/16, identified the resident required supervision to minimal assistance with ADLS. Her care plan, updated 03/29/16, identified her history of a [MEDICAL CONDITION], mildly impaired cognition, and TIAs. She required some assistance with ADLS related to TIAs, muscle weakness, and walking difficulties. c) Staffing schedules On 03/30/16 at 11:45 a.m., review of the nursing schedules for (MONTH) and (MONTH) (YEAR) verified the unit was staffed every shift with two (2) people, a nurse and a nurse aide. d) Staff interviews During an interview on 03/23/16 at 12:00 p.m. Licensed Practical Nurse (LPN) #124 reported the 500 hall was currently staffed with two (2) people every shift and in an emergency the unit would have to call upstairs for assistance. There were no plans put into place. No certain number to call to guarantee someone would answer and provide assistance. The future unit director, RN #100, the current MDS nurse, was working on these plans. Registered Nurse (RN) #92, during an interview on 03/29/16 at 11:00 a.m., acknowledged that with dementia residents there was always a risk for elopement and two (2) staff members per shift was not enough. She said she took her break on the unit, but some staff left for smoke breaks and that left one (1) person on the unit with seven (7) residents. On 03/23/16 at 3:20 p.m., Nurse Aide (NA) #27 reported she planned care around the residents' activities. It was easier to shower a resident when the other residents were napping and the nurse could help monitor the other residents. During an interview on 03/29/16 at 1:15 p.m., the unit director, RN #100, reported the facility had a staffing plan in place when the residents were moved to the 500 hall/memory care unit. The plan did not work and the 500 hall staff was maintained with two (2) people per shift. She stated the corporation deemed two (2) staff members per shift was adequate for the unit. RN #100 remained silent when asked if she thought this was adequate staffing for the seven (7) residents currently residing on the 500 hall/memory care unit.",2019-08-01
4710,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,356,C,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to post nurse staffing data in a prominent place readily accessible to residents and visitors and in a clear and readable format. This had the potential to affect all residents and visitors. Facility census: 92. Findings include: a) During the initial tour at 8:30 a.m. on 03/24/16, an observation of the daily staff posting of the direct care staff found the posting form located outside of room [ROOM NUMBER]. This was across from the 100 hall nurses' station, approximately five (5) feet from the floor. The information occupied an 8.5 by 11 inch sheet of paper and was a typed form filled in with handwritten figures. A follow up observation with the Director of Nursing (DON) on 03/24/16 at 10:15 a.m., found the staffing sheets bent over the plastic holder and unreadable by anyone. The DON confirmed the staff posting was not easily accessible for residents and visitors to read.",2019-08-01
4711,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,371,F,0,1,TULX11,"Based on observation and staff interview, the facility failed to prepare and serve food under sanitary conditions. The tiles of the floor in the kitchen were stained and cracked, there was loose and torn cove molding, and loose cracked baseboard tile that was not adhered to the wall in the dish room. Additionally, during a dining observation, staff handled glasses and cups by their rims and a staff member repeatedly touched her face and hair without performing hand hygiene before continuing with the meal service. This had the potential to affect all residents who received nourishment from this central area. Facility census: 92. Findings include: a) Kitchen Observations during a tour of the kitchen on 03/24/16 at 9:45 a.m., accompanied by the Dietary Manager (DM) found: -- stained and darkened discolored tile throughout the kitchen and dishwashing area, -- cracked floor tile with grime and debris between the stove and steamer and under the prep sink, -- loose and torn cove molding behind the stove and on the wall next to the convection ovens, -- uneven cracked and broken floor tile with dirt, grime and debris between the prep area and dishwashing room, and -- loose cracked baseboard tile that was not adhered to the wall in the dish room. The DM stated, Yes, the uneven floor and tiles need to be repaired or replaced and the molding needs to be replaced. The floor is scrubbed and cleaned daily by the dietary staff, but it has not been stripped and waxed for three (3) years, I am not going to lie to you. b) On 03/23/16 at 11:40 a.m., observations of the memory care unit/500 hall lunch service found Nurse Aide (NA) #64 and Licensed Practical Nurse (LPN) #124 picking up coffee cups and juice glasses by the upper rim when serving drinks to the residents. In addition, LPN #124 repeatedly scratched her head and face while serving the meals without washing / disinfecting her hands. During an interview on 03/23/16 at 12:00 p.m., LPN #124 confirmed both staff members had picked the cups up by the rim when serving the residents. In addition she agreed she had scratched her hair and touched her face during meal service and stated: You just don't realize you're doing it.",2019-08-01
4712,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,431,F,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 store medications in a clean, safe and secure manner and/or failed to maintain records of receipt and disposition of controlled substances. Medication carts were unkempt and contained loose unlabeled pills. Controlled substance records were incomplete and/or lacked information to show complete reconciliation by on-coming and off-going nurses. This practice had the potential to affect all residents. Facility census: 92. Findings include: a) Medication carts On 03/29/16 at 7:52 a.m., an observation of the 400 hall medication cart with Licensed Practical Nurse (LPN) #8 found two (2) loose white pills, along with tiny pieces of debris (paper, dust, and crumbs) in the top drawer of the medication cart among other medication bottles. LPN #8 discarded the unlabeled loose pills and acknowledged the cart needed cleaned. The 500 hall medication cart was reviewed with LPN #30 on 03/29/16 at 3:12 p.m. An unlabeled loose green tablet was found in the second drawer along with multiple specks of debris (paper and crumbs). LPN #30 discarded the loose pill and agreed the medication cart needed cleaned. On 03/29/16 at 3:55 p.m., inspection of the 100 hall medication cart with Registered Nurse (RN) #118 found four (4) loose white pills among the residents' pill punch cards. RN #118 stated: There's lots of loose pills in here, as she discarded the loose medication. She agreed the medication cart needed cleaned and stated she was unaware of who should do this. b) Resident #102 Review of the resident's medical record on 03/30/16 at 11:30 a.m. revealed Resident #102 was a [AGE] year old woman with dementia admitted to the facility after falling and fracturing her hip. On 02/17/16 the physician prescribed a Duragesic-25 micrograms per hour patch applied every seventy-two (72) hours. The Medication Administration Record [REDACTED]. The second patch was applied seventy-two (72) hours later as prescribed on 02/21/16. The third patch was placed forty-eight (48) hours later on 02/23/16. The forth patch was placed on the resident on 02/25/16, again forty-eight (48) hours after the facility was unable to locate the third pain patch. The nurse's progress notes dated 02/26/16 8:54 p.m., stated (typed as written), Late entry for 2/24/16.5pm (02/24/16 at 5:00 p.m.) unable to locate duragesic 25mcg (microgram) patch which was place by (initials) and (RN#92) on 02/23/16 evenings & secured with paper tape, (spoke with (nurse's name) personally this same evening) Grand-daughter (Name) said she examined her grandmother & there was no pain patch to be found. Notified (Name of RN#65) on call & updated on all the above & was instructed to apply another patch & correct MAR for next due date. The medical record was silent in regards to any documentation by the nursing staff verifying the location of the Duragesic-25 patch on each shift. The Director of Nursing reviewed the narcotic records and the MAR indicated [REDACTED]. c) On 04/04/16 at 2:30 p.m. after observing a shift to shift narcotic count with Licensed Practical Nurse (LPN) #30 and LPN #3, they both explained the procedure for counting the narcotics. LPN #30 stated, At the end of a shift and beginning of a shift, the on coming nurse and off going nurse count all of the narcotics in the cart. LPN #3 stated, This is done at each change of shift and the two (2) nurses initial the narcotic sheets. Even though it says a signature, we just initial that it is done and correct. Review of the shift change controlled substance inventory logs, dated (MONTH) (YEAR) through (MONTH) (YEAR), on 04/04/16 at 2:45 p.m., found there were 148 blank signature/initial spaces for reconciliation of the controlled medication counts at the change of shifts identified. The Director of Nursing (DON) reviewed the controlled substance logs during an interview on 04/04/16 at 3:05 p.m. He stated, There should not be be any blanks for initials on the narcotic sheets. We do not sign our signatures, just our initials, even though it says signature on the sheet. I am sure my nurses counted at each shift change, but I can't swear to it. This could pose a problem as far as accuracy of the narcotic count. A review of the Pharmacy Services Procedure and Policy on 04/04/16 at 3:45 p.m. revealed on page 255 titled Shift Verification of Controlled Substances: --Two licensed nurses shall reconcile all doses of controlled substances stored in the assigned medication cart at the change of shift. --Each nurse performing the reconciliation shall place his/her signature on the appropriate line for the date and shift. The monthly consultant pharmacy reports for January, February, and (MONTH) (YEAR) stated the controlled substance logs were not reconciled according to facility procedures and there were concerns with inaccurate and incomplete controlled substance documentation. On 04/04/16 at 4:20 p.m., during a follow-up interview the DON stated, Yes I am told about the reviews monthly by the Pharmacist and she talks about it in QA (Quality Assurance), but nothing is in place to correct this or to prevent it from happening. I understand it is narcotics, but I don't think we have a problem. He did not reply when asked if no checks or balances were in place, how could he tell that he did not have a problem.",2019-08-01
4713,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,441,D,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain an effective infection control program to prevent and control to the extent possible, the onset and spread of infection within the facility. A urinal and urine container were stored improperly in a resident bathroom. This was found for one (1) of the rooms of thirty-five (35) Census Sample residents during Stage 1 of the survey. Staff failed to obtain a physician order [REDACTED]. Room identifier: #203. Resident identifier: #79. Facility census: 92. Findings include: a) room [ROOM NUMBER] A room observation on 03/23/16 at 2:20 p.m., revealed a urinal and a urine collection container sitting on the back of the commode in the bathroom. The urinal and urine collection container were uncovered and were not labeled with the name of the resident to whom it belonged. This bathroom was shared by the two (2) residents who resided in room [ROOM NUMBER]. During an interview with of the Director of Nursing (DON) on 03/23/16 at 2:25 p.m., he viewed the uncovered and unlabeled urinal and urine collection container in the bathroom of room [ROOM NUMBER]. He stated, I will toss them and get new ones because I don't know who they belong to. They should be bagged and labeled because of infection control. b) Resident #79 On 03/24/16 at 8:15 a.m., an isolation cart and signage were observed outside of Resident #79's room. Licensed Practical Nurse (LPN) #3, interviewed at that time, reported the resident was in isolation for extended spectrum beta lactamase (ESBL) in her urine. A review of the medical record for Resident #79 on 04/05/16 at 10:00 a.m., revealed this [AGE] year-old female, admitted on [DATE], was placed on contact precautions for extended spectrum beta lactamase (ESBL) in her urine and prescribed antibiotics in (MONTH) (YEAR). The record was silent for a physician's orders [REDACTED]. During an interview with Registered Nurse/Infection Control Nurse #97 on 04/05/16 at 2:10 p.m., she stated, The physician writes an order for [REDACTED]. After reviewing the medical record for Resident #79, she stated, No she does not have an order for [REDACTED].",2019-08-01
4714,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,469,E,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to maintain an effective pest control program so that the facility is free of pests and insects. Numerous ants were located on a sink counter top in a resident's room. This had the potential to affect more than an isolated number of residents. Room number: #203. Facility census: 92. Findings include: a) Room 203 Observations on 03/23/16 at 2:25 p.m., found numerous small black ants crawling on the sink counter top by the wall and near the water faucets in room #203. During an interview on 03/23/16 at 2:26 p.m., Resident #83 (one (1) of two (2) residents residing in the room) stated, They are always there, told people, but they come in and kill them with a paper towel, but they (ants) just keep coming back. On 03/23/16 at 2:29 p.m., during an observation with the Director of Nursing (DON), he agreed there were live crawling ants. He stated, I will take care of that immediately and contact maintenance to spray. A review of the facility's pest control system by a contracted company revealed: -- a pest inspection dated 02/25/16, the contractor provided treatment for [REDACTED]. -- On 01/21/16, the contractor treated the perimeter for pest activity and inspected outside for rodent entry area. -- On 12/23/15, Treated perimeter for pest activity, inspected outside for rodent entry area. cockroaches heavy infestations. The inspection reports did not include evidence of inspection and/or treatment for [REDACTED].",2019-08-01
4715,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,490,J,0,1,TULX11,"Based upon observation, record review, staff interview, and policy review, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. The facility failed to make an appropriate corrective response to concerns identified by the consultant pharmacist, failed to operationalize its policies and procedures for the prevention, reporting, and investigation of abuse/neglect, and was cited for immediate jeopardy for insufficient monitoring and supervision to ensure residents' safety. These deficient practices had the potential to affect all residents. Facility census: 92. Findings include: a) The facility was cited for failure to recognize and implement corrective measures for pharmacy reviews that identified blank signature/initial areas for reconciliation of the shift to shift controlled substances counts for five (5) of five (5) hallways/units. b) The facility failed to implement and operationalize its policies to prevent neglect. Written reports of incidents or accidents in which a resident was involved were not consistently completed, and injuries of unknown origin were not reported or investigated. c) An immediate jeopardy was identified related to the failure of the facility to ensure the residents' environment remained as free of accident hazards as possible and each resident received adequate supervision to prevent accidents. The citations related to elopements and injuries of unknown origin on the 500 wing. d) The review found Administration should have been aware of the concerns reported by the consultant pharmacist and working to ensure those concerns were addressed. Administration should also have been aware of the concerns regarding abuse/neglect including injuries of unknown origin, and the concerns regarding incidents/accidents including elopements, falls, and injuries of unknown origin. Systemic failures such as the failure to consistently complete a written report of any incident or accident involving a resident and to investigate all injuries of unknown origin caused some of the usual means of communication to management to miss critical information, including instances resulting in actual harm to residents. There was evidence staff were oriented and received education on abuse/neglect reporting, investigation, and prevention, review facility policies and incidents reported to the appropriate State agencies and investigated, found although each staff member was a mandatory reporter, there was a failure to consistently recognize, report, and investigate injuries of unknown origin. There was also a failure to consistently recognize the critical system need to complete Written reports for resident elopements, falls, and injuries of unknown origin.",2019-08-01
4716,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,492,D,0,1,TULX11,"Based upon record review and staff interview, the facility failed to operate and provide services in compliance with all applicable State laws, regulations, and codes. One (1) of ten (10) personnel files did not have license verification for a nurse. Facility census: 92. Findings include: a) Review of ten (10) personnel files on 03/28/16 at 1:30 p.m., found one (1) of the files did not contain a verification of a current professional license for Licensed Practical Nurse #13. During an interview on 03/31/16 at 11:25 a.m., Human Resources/Payroll Manager #78 confirmed the personnel files did not contain all information required by West Virginia State Code Title 64 Series 13.",2019-08-01
4717,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,514,E,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure physician orders included a time orders were written for Resident #105. Resident #102's medication record was not revised in accordance with accepted professional standards when the start date of an order for [REDACTED].#105 and #102. Facility census: 92. Findings include: a) Resident #105 A review of the medical record for discharged Resident #105 on 04/05/16 at 4:40 p.m., revealed the hard copies of the physician's orders did not consistently identify the time the order was written. This was found for nine (9) of eleven (11) physician orders written between 12/08/15 and 12/11/15. During an interview with the DON on 04/06/16 at 10:45 a.m., he verified the physician orders did not contain a time the order was obtained. The DON stated, every order should have a time with the date it was written. b) Resident #102 Review of the resident's medical record on 03/30/16 at 11:30 a.m., revealed Resident #102 was a [AGE] year-old woman with dementia, admitted to the facility after falling and fracturing her hip. On 02/17/16, the physician prescribed [MEDICATION NAME]-25 micrograms (mcg) per hour patch to be applied every seventy-two (72) hours. The pre-printed Medication Administration Record [REDACTED]. The sheet was not re-written or reprinted when the starting date was changed to 02/18/16. On 02/18/16 and 02/21/16, two (2) nurses initialed under the x's indicating the patch was applied. The next scheduled seventy-two (72) hour due date should have been 02/24/16. The MAR indicated [REDACTED]. The forth [MEDICATION NAME]-25 patch was applied on 02/25/16 after the facility was unable to locate the third/previous pain patch (applied 02/23/16). The nurse's writing over the x's on 02/25/16 was difficult to interpret: Patch ____Reapplied. The scheduled administration date of 02/26/16 was crossed out and a handwritten notation was placed over the x's on 02/28/16 stating: Due here. The nurse's progress note dated 02/26/16 8:54 p.m., stated (typed as written): Late entry for 2/24/16.5pm (5:00 p.m.) unable to locate [MEDICATION NAME] 25mcg (microgram) patch which was place by (initials) and (RN#92) on 02/23/16 evenings & secured with paper tape . The medical record was silent in regards to any documentation by the nursing staff verifying the location of the [MEDICATION NAME]-25 patch on each shift. Licensed Practical Nurse (LPN) #94 reviewed the MAR indicated [REDACTED]. The one on 02/23/16 was forty-eight (48) hours since the last dose, and on 02/25/16, it was again forty-eight (48) hours after the last dose because the patch was missing. The Director of Nursing reviewed the narcotic records and the MAR indicated [REDACTED].",2019-08-01
4718,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2016-04-06,520,F,0,1,TULX11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and policy review, the facility quality assurance committee failed to identify and correct quality deficiencies issues of which they had knowledge or should have had knowledge. The facility failed to implement corrective actions in response to concerns identified by the consultant pharmacist, failed to operationalize its policies and procedures for the prevention, reporting, and investigation of abuse/neglect, the failure to ensure the resident environment was safe. These deficient practices had the potential to affect all residents. Facility census: 92. Findings include: a) Completion of the Quality Assessment and Assurance review found the facility had a committee that met at least quarterly. All the Department heads, the Medical Director, and the Consultant Pharmacist attended the meetings. The QAA process was discussed with and it was explained there were daily morning meetings during which pertinent events were discussed including incidents/accidents, abuse/neglect concerns, infection control issues, etc. Each department head provided items related to their department for each formal meeting. The line staff could bring concerns to their supervisors which could be presented to the committee as applicable. b) The facility was cited for failure to implement corrective measures for pharmacy reviews that identified blank signature/initial areas for reconciliation of the shift to shift controlled substances count for five (5) of five (5) hallways/units. Additionally, the facility failed to ensure that medication carts were clean and free of loose, unlabeled pills. 1. Medication carts On [DATE] at 7:52 a.m., an observation of the 400 hall medication cart with Licensed Practical Nurse (LPN) #8 found two (2) loose white pills, along with tiny pieces of debris (paper, dust, and crumbs) in the top drawer of the medication cart among other medication bottles. LPN #8 discarded the unlabeled loose pills and acknowledged the cart needed cleaned. The 500 hall medication cart was reviewed with LPN #30 on [DATE] at 3:12 p.m. An unlabeled loose green tablet was found in the second drawer along with multiple specks of debris (paper and crumbs). LPN #30 discarded the loose pill and agreed the medication cart needed cleaned. On [DATE] at 3:55 p.m., inspection of the 100 hall medication cart with Registered Nurse (RN) #118 found four (4) loose white pills among the residents' pill punch cards. RN #118 stated: There's lots of loose pills in here, as she discarded the loose medication. She agreed the medication cart needed cleaned and stated she was unaware of who should do this. 2. On [DATE] at 2:30 p.m. after observing a shift to shift narcotic count with Licensed Practical Nurse (LPN) #30 and LPN #3, they both explained the procedure for counting the narcotics. LPN #30 stated, At the end of a shift and beginning of a shift, the on coming nurse and off going nurse count all of the narcotics in the cart. LPN #3 stated, This is done at each change of shift and the two (2) nurses initial the narcotic sheets. Even though it says a signature, we just initial that it is done and correct. Review of the shift change controlled substance inventory logs, dated (MONTH) (YEAR) through (MONTH) (YEAR), on [DATE] at 2:45 p.m., found there were 148 blank signature/initial spaces for reconciliation of the controlled medication counts at the change of shifts identified. The Director of Nursing (DON) reviewed the controlled substance logs during an interview on [DATE] at 3:05 p.m. He stated, There should not be be any blanks for initials on the narcotic sheets. We do not sign our signatures, just our initials, even though it says signature on the sheet. I am sure my nurses counted at each shift change, but I can't swear to it. This could pose a problem as far as accuracy of the narcotic count. A review of the Pharmacy Services Procedure and Policy on [DATE] at 3:45 p.m. revealed on page 255 titled Shift Verification of Controlled Substances: -- Two licensed nurses shall reconcile all doses of controlled substances stored in the assigned medication cart at the change of shift. -- Each nurse performing the reconciliation shall place his/her signature on the appropriate line for the date and shift. The monthly consultant pharmacy reports for January, February, and (MONTH) (YEAR) stated the controlled substance logs were not reconciled according to facility procedures and there were concerns with inaccurate and incomplete controlled substance documentation. On [DATE] at 4:20 p.m., during a follow-up interview the DON stated, Yes I am told about the reviews monthly by the Pharmacist and she talks about it in QA (Quality Assurance), but nothing is in place to correct this or to prevent it from happening. I understand it is narcotics, but I don't think we have a problem. He did not reply when asked if no checks or balances were in place, how could he tell that he did not have a problem. c) The facility was cited for failure to implement and operationalize it abuse/neglect policies to prevent neglect. Incidents were not consistently documented, and injuries of unknown origin were not reported or investigated. Record review, review of facility documents, staff interview, personnel file review, and review of facility policies and procedures, found the facility failed to implement and operationalize its policies regarding abuse/neglect, including injuries of unknown origin. The facility failed to investigate and report occurrences of possible neglect and/or injuries of unknown origin for four (4) of thirty (30) Stage 2 residents. 1. 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 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 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 4cm (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 (Situation, Background, Assessment, Recommendation) 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. 2. 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. During an interview with Speech/Language Pathologist (SLP) #38 on [DATE] at 7:45 a.m., she provided copies of Speech/Language Pathology 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. 3. 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. 4. 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. 5. Review of the facility's policies and procedures for abuse prohibition on [DATE] at 1:20 p.m., found they included: -- efforts to prevent abuse and/or neglect through employee screening and training, -- taking appropriate action when abuse or neglect was suspected, -- thorough investigation of suspected or possible abuse/neglect, including injuries of unknown origin, by review of incident reports and interviews with any possible persons who might have been aware of any pertinent information, all of which was to be put in writing, -- and immediate reporting of any allegations or possible abuse/neglect, including injuries of unknown origin by anyone in the facility who becomes aware. For injuries of unknown origin, the policy and procedure required the completion of an incident report, and compiling a list of all personnel, including consultants, contract employees, visitors, family members, etc., who had had contact with the resident during the past 48 hours to be interviewed. d) The facility was cited for failure to ensure that the residents' environment remains as free of accident hazards as possible, and failure to ensure each resident received adequate supervision to prevent accidents. 1. Seven (7) residents resided on the 500 hall/Memory Care Unit (MCU), a separate unit isolated from other parts of the building. The T shaped department was staffed every shift by two (2) people, a nurse and a nurse aide (NA), and contained multiple unsecured, out of sight areas for the residents to wander into unobserved. Three (3) residents (Residents #61, #93, and #75) of the seven (7) residents had care plans for wandering. The front door, an alarmed egress, malfunctioned intermittently, preventing anyone from exiting the building or turning off the alarm if it sounded. Additionally, staff had difficulty hearing the alarm. Observations on [DATE] at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. A faint alarm sounded, but no staff approached in response. Therapy Staff #35 was able to get the door to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. Therapy Staff #37 attempted to enter the unit by pushing the red button, but the door would not open. No staff were observed on the unit except the two therapy employees. The alarm sounded throughout the time. Therapy Staff #37 came in through the door at the end of that hall. When Maintenance Director #6 entered the unit by the back door, Therapy Staff #35 said to Maintenance Director #6, You need to look at the front door. It won't open, and the alarm won't turn off. This happened last week. After reviewing incident reports and medical records, conducting staff interviews, and multiple observations on the 500 hall/memory care unit, it was determined an immediate jeopardy (IJ) existed for seven (7) of seven (7) residents residing on the 500 hall. On [DATE] at 1:45 p.m. the Administrator was notified of the immediate jeopardy. A written notice of the findings and request for a plan to correct the immediacy of the findings was provided to the administrator at 1:45 p.m. p.m. on [DATE]. At 2:30 p.m., the administrator provided a written corrective action plan for the immediate jeopardy situation. Two tours were conducted by the surveyors to verify corrective measures had been implemented as planned. Observations during the second tour of the unit on [DATE] at 3:09 p.m., Dietary Aide #101 walked up to the nurses' station and informed LPN #30 that a resident had walked past the dumbwaiter and entered room [ROOM NUMBER] (a closed room). LPN# 30 admitted she would have never known Resident #93 had left the unit during an interview on [DATE] at 3:13 p.m. The surveyor team met with the Administrator on [DATE] at 3:44 p.m. When advised of the incident for Resident #93's, the administrator prepared a second plan of abatement which stated All seven residents on 500 hall will be brought up to the 400 wing in main part of building. This was presented on [DATE] at 3:44 p.m. 2. Memory care unit/500 hall During the initial tour of the Memory Care Unit (MCU)/500 hall with the Director of Nursing (DON) on [DATE] at 8:45 a.m., the DON said they closed the assisted living unit and plans were in place to renovate this wing in anticipation of licensure for an Alzheimer's unit. To gain entrance to the unit from the main part of the building required exiting the main building to the outdoors, walking down a paved hill and entering through the front door. The DON reported there was no internal access to this unit. The seven (7) residents resided in rooms 501 through 508, in the main hall between the front door of the unit and the television lounge. A follow up observation of the MCU/500 hall on [DATE] at 12:00 p.m. found the following: == Main hall -- Several unsecured and unused resident rooms located beyond the unlocked and unalarmed fire doors past the television lounge and room [ROOM NUMBER]. -- An alarmed egress was located at the end of this hall between rooms [ROOM NUMBERS], which was not visible from the nurses' desk because of the closed fire doors, -- Outside of this door was a small-unsecured cement patio. A three (3) foot high fence with two (2) unlocked gates surrounded the patio. -- Immediately in front of the patio was a water treatment pond surrounded by a six (6) foot high locked fence. -- The left unlocked gate in the fence around the patio led to a grassy area between other sections of the building and the right unlocked gait had four (4) steps that led to a gravel road and construction zone. -- In the construction zone, there was a ladder to the roof of the building, a dump truck, and a dumpster containing old roofing material. -- Beyond the gravel road was an unpopulated wooded area. == Second hall -- A second unsecured hall, located between the nurses' station and the television lounge, across from room [ROOM NUMBER], had two (2) yellow and black cones with a detachable barrier strip between them blocking the hall. -- This hall contained the laundry services, the food dumbwaiter, a beauty shop, a lounge, a storage area, and five (5) unsecured resident rooms. -- There was a secured exit door, not visible from the nurses' station, located at the end of this hall. The door exited to a grassy area between other sections of the main building. On [DATE] at 11:45 a.m., review of the nursing schedules for (MONTH) and (MONTH) (YEAR) verified the unit was staffed every shift with two (2) staff members, a nurse and a nurse aide. Observations on [DATE] at 10:03 a.m., found the main door at the front of the unit would not open. An incorrect exit code was entered and then the door locked and required maintenance to come and try to get it to open. The door had a doorknob and a metal latch at the top. The door had a sign that said there was no push bar, but one was ordered. A faint alarm sounded, but no staff approached in response. Then at 10:05 a.m., Therapy Staff #35 came to the front door from outside and was able to get it to open by pushing the red button near the door on the outside. According to the staff member, this had happened on other occasions, once just the week before. At 10:08 a.m., Therapy Staff #37 approached the door. She was told to push the red button. She did, but the door would not open. At 10:13 a.m., she was told to go around the back way. Observations during this time, found no staff except the two therapy employees. The alarm sounded throughout",2019-08-01
6133,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2015-02-25,456,E,0,1,6CVI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of two (2) of 33 Stage 2 sampled residents (Residents #6 and #60) and two (2) residents discovered through random opportunities for observation (Residents #25 and #59), staff interview, record review, and review of facility records, the facility failed to ensure all essential resident care equipment was maintained according to manufacturer's recommendations. Oxygen concentrators were not cleaned and maintained according to manufacturer's guidelines. resident identifiers: #6, #60, #25, and #59. Facility census: Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The clinical record included a 03/27/14 physician's orders [REDACTED]. On 02/23/15, at 12:00 p.m., Resident #6 was observed in the dining room. His oxygen was running at 2L per N/C. The oxygen concentrator model was an Invacare Perfecto, serial number 10bf 3. Observation revealed there was no air filter on the concentrator. The humidifier bottle was dated 02/18/15. At 8:20 a.m. on 02/25/15, Resident #6's oxygen concentrator was observed, with Employee #130, a registered nurse (RN). He confirmed there was no air filter, and stated he would obtain an air filter for the oxygen concentrator. At that time, observation revealed there was no readable preventative maintenance (PM)sticker on the machine. RN #130 confirmed there was no readable PM sticker on the machine. On 02/25/15, at 10:30 a.m., Employee #138, respiratory technician (RT) was interviewed. He provided the service log which indicated the humidifier bottle was changed on 02/18/15. RT #138 stated he changed the nasal cannula and humidifier bottle on 02/18/15. This oxygen concentrator was owned by the facility. b) Resident #60 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The clinical record included a 09/26/14 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the respiratory services company. On 02/23/15 at 11:46 a.m., the air filter on Resident #60's oxygen concentrator was observed with white dust on it. The concentrator was an Invacare Model, serial number 09gf 6. The PM tag not readable. Observation revealed the nasal cannula and humidifier bottle were dated as changed on 02/18/15. At 8:00 a.m. on 02/25/15, observation revealed Resident #60's oxygen concentrator air filter still had white dust on it. On 02/25/15 at 10:30 a.m., RT #138 indicated Resident #60's oxygen concentrator, Invacare Model Platinum XL had 38,063 hours of use. RT #138 confirmed the PM tag was not readable. c) Resident #25 This resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record contained a 02/22/14 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the facility,. The nasal cannula and humidifier bottle were last changed on 02/18/15. On 02/25/15 at 8:10 a.m., observation of Resident #25's Invacare concentrator, serial number 08gf 3, revealed the air filter had white matter on it. The PM tag was not readable. The humidifier bottle was dated 02/18/15. Resident #25 was in the dining room on portable oxygen at time of this observation. At 10:30 a.m. on 02/25/15, RT #138 indicated Resident #25's oxygen concentrator, Invacare XL, had 397,233 hours of use and the PM tag was not readable. d) Resident #59 This resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record included a 01/02/15 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the facility. The nasal cannula and humidifier bottle were last changed on 02/18/15. On 02/25/15 at 8:00 a.m., along with Licensed practical nurse (LPN) #87, Resident #59's oxygen concentrator air filter was observed with dust on it. The Invacare Perfecto, serial number 10af 1, machine was off. The oxygen tubing was not dated and the PM sticker was not readable. At 10:30 a.m. on 02/25/15, RT #138 indicated Resident #59's oxygen concentrator, Invacare Perfecto, had 161,578 hours of use. He confirmed the PM tag was not readable. e) During an interview, on 02/25/15 at 08:06 a.m., LPN #142 stated respiratory services were supplied on a weekly basis. The LPN said the respiratory company changed all tubing and humidifier bottles weekly. On 02/25/15 at 8:16 a.m., LPN #87 stated a respiratory company came to the facility on ce a week to change oxygen tubing and nebulizer kits. RN #87 provided the name and phone number of the respiratory provider. f) Review of the Invacare Operators Manual, dated 4/99, page 18, Preventative Maintenance (PM), indicated the following services be done: -- Each inspection: Record date of service, hours on hour meter, clean cabinet filters, check prescribed flow rate. -- Every 90 days: Check oxygen concentration. -- Annually: Check power loss alarm. -- As required: Replace cabinet filters, clean heat exchanger, replace bacteria filter, replace exhaust muffler, replace compressor inlet filter, rebuild top end of compressor. -- Every 20,000 hours: Replace In-line filter. g) During an interview, on 02/25/15 at 10:05 a.m., the Director of Nursing (DON)stated the respiratory company provided disposable equipment and provided PM on equipment owned by the facility and the respiratory company. The DON said the provider came to the facility on a weekly basis, and if needed for additional issues. On 02/25/15, at 10:09 a.m., RT #138 stated he changed oxygen tubing, humidifier bottles and cleaned the air filters on a weekly basis. RT #138 stated he was last in the building on 02/18/15. He said he did not do PM on oxygen concentrators. RT #138 said the date on the PM sticker on the machine indicated when the last PM was performed. RT #138 also stated he did not check the calibration on the oxygen flow meters on any of the oxygen concentrators. On 02/25/15 at 10:17 a.m., the DON and RT #138 Respiratory aide confirmed Residents #6, #25 and #59 oxygen concentrators were owned by the facility. They confirmed Resident #60's oxygen concentrator was owned by the respiratory company. The DON stated the facility did not maintain any logs of PM performed on the oxygen concentrators. Review of the facility contract with the respiratory company, dated 11/01/11 with an automatic annual review, revealed it did not address the performance of PM on oxygen equipment. Review of respiratory equipment technician (RT) job description, which was not dated, included the responsibility to Perform routine and preventative maintenance on a scheduled basis to meet state requirements. During an interview, on 02/25/15 at 11:15 a.m., the Administrator and the DON stated the contract with the respiratory company had been in place for at least [AGE] years. The DON stated the respiratory provider did not perform PM on the facility owned oxygen concentrators. The DON was also unable to provide PM records for the provider owned oxygen concentrators. The DON stated she did not know when the last PM was done on any of the oxygen concentrators. The administrator stated the facility contract was unclear related to the company providing PM on facility owned equipment. The Administrator stated she would be reviewing and updating the facility contract based on the findings from the survey.",2018-05-01
6134,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2015-02-25,490,E,0,1,6CVI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, record review, and review of facility records, the facility was not administered in a manner which ensured each resident attained or maintained the highest practicable well-being. Administrative personnel failed to ensure all essential resident care equipment was maintained according to manufacturer's recommendations. Required preventative maintenance (PM) for cleaning and maintaining functionality of oxygen concentrators was not performed according to the manufacturer's maintenance service guidelines. The facility had no means of determining when PM had last been performed or whose responsibility it was to perform the PM. The contract with the reparatory company was unclear related to the company providing PM on facility owned equipment. Two (2) of 33 Stage 2 sampled residents (Residents #6 and #60) and two (2) residents discovered through random opportunities for discovery (Residents #25 and #59) were affected; however, the practice had the potential to affect all residents who required oxygen. resident identifiers: #6, #60, #25, and #59. Facility census: 89. Findings include: a) Resident #6 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The clinical record included a 03/27/14 physician's orders [REDACTED]. On 02/23/15, at 12:00 p.m., Resident #6 was observed in the dining room. His oxygen was running at 2L per N/C. The oxygen concentrator model was an Invacare Perfecto, serial number 10bf 3. Observation revealed there was no air filter on the concentrator. The humidifier bottle was dated 02/18/15. At 8:20 a.m. on 02/25/15, Resident #6's oxygen concentrator was observed, with Employee #130, a registered nurse (RN). He confirmed there was no air filter, and stated he would obtain an air filter for the oxygen concentrator. At that time, observation revealed there was no readable preventative maintenance (PM)sticker on the machine. RN #130 confirmed there was no readable PM sticker on the machine. On 02/25/15, at 10:30 a.m., Employee #138, respiratory technician (RT) was interviewed. He provided the service log which indicated the humidifier bottle was changed on 02/18/15. RT #138 stated he changed the nasal cannula and humidifier bottle on 02/18/15. This oxygen concentrator was owned by the facility. b) Resident #60 This resident was admitted to the facility on [DATE]. His [DIAGNOSES REDACTED]. The clinical record included a 09/26/14 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the respiratory services company. On 02/23/15 at 11:46 a.m., the air filter on Resident #60's oxygen concentrator was observed with white dust on it. The concentrator was an Invacare Model, serial number 09gf 6. The PM tag not readable. Observation revealed the nasal cannula and humidifier bottle were dated as changed on 02/18/15. At 8:00 a.m. on 02/25/15, observation revealed Resident #60's oxygen concentrator air filter still had white dust on it. On 02/25/15 at 10:30 a.m., RT #138 indicated Resident #60's oxygen concentrator, Invacare Model Platinum XL had 38,063 hours of use. RT #138 confirmed the PM tag was not readable. c) Resident #25 This resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record contained a 02/22/14 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the facility,. The nasal cannula and humidifier bottle were last changed on 02/18/15. On 02/25/15 at 8:10 a.m., observation of Resident #25's Invacare concentrator, serial number 08gf 3, revealed the air filter had white matter on it. The PM tag was not readable. The humidifier bottle was dated 02/18/15. Resident #25 was in the dining room on portable oxygen at time of this observation. At 10:30 a.m. on 02/25/15, RT #138 indicated Resident #25's oxygen concentrator, Invacare XL, had 397,233 hours of use and the PM tag was not readable. d) Resident #59 This resident was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. The clinical record included a 01/02/15 physician's orders [REDACTED]. Review of respiratory service records indicated the oxygen concentrator was owned by the facility. The nasal cannula and humidifier bottle were last changed on 02/18/15. On 02/25/15 at 8:00 a.m., along with Licensed practical nurse (LPN) #87, Resident #59's oxygen concentrator air filter was observed with dust on it. The Invacare Perfecto, serial number 10af 1, machine was off. The oxygen tubing was not dated and the PM sticker was not readable. At 10:30 a.m. on 02/25/15, RT #138 indicated Resident #59's oxygen concentrator, Invacare Perfecto, had 161,578 hours of use. He confirmed the PM tag was not readable. e) During an interview, on 02/25/15 at 08:06 a.m., LPN #142 stated respiratory services were supplied on a weekly basis. The LPN said the respiratory company changed all tubing and humidifier bottles weekly. On 02/25/15 at 8:16 a.m., LPN #87 stated a respiratory company came to the facility on ce a week to change oxygen tubing and nebulizer kits. RN #87 provided the name and phone number of the respiratory provider. f) Review of the Invacare Operators Manual, dated 4/99, page 18, Preventative Maintenance (PM), indicated the following services be done: -- Each inspection: Record date of service, hours on hour meter, clean cabinet filters, check prescribed flow rate. -- Every 90 days: Check oxygen concentration. -- Annually: Check power loss alarm. -- As required: Replace cabinet filters, clean heat exchanger, replace bacteria filter, replace exhaust muffler, replace compressor inlet filter, rebuild top end of compressor. -- Every 20,000 hours: Replace In-line filter. g) During an interview, on 02/25/15 at 10:05 a.m., the Director of Nursing (DON)stated the respiratory company provided disposable equipment and provided PM on equipment owned by the facility and the respiratory company. The DON said the provider came to the facility on a weekly basis, and if needed for additional issues. On 02/25/15, at 10:09 a.m., RT #138 stated he changed oxygen tubing, humidifier bottles and cleaned the air filters on a weekly basis. RT #138 stated he was last in the building on 02/18/15. He said he did not do PM on oxygen concentrators. RT #138 said the date on the PM sticker on the machine indicated when the last PM was performed. RTF #138 also stated he did not check the calibration on the oxygen flow meters on any of the oxygen concentrators. On 02/25/15 at 10:17 a.m., the DON and RTF #138 Respiratory aide confirmed Residents #6, #25 and #59 oxygen concentrators were owned by the facility. They confirmed Resident #60's oxygen concentrator was owned by the respiratory company. The DON stated the facility did not maintain any logs of PM performed on the oxygen concentrators. Review of the facility contract with the respiratory company, dated 11/01/11 with an automatic annual review, revealed it did not address the performance of PM on oxygen equipment. Review of respiratory equipment technician (RTF) job description, which was not dated, included the responsibility to Perform routine and preventative maintenance on a scheduled basis to meet state requirements. During an interview, on 02/25/15 at 11:15 a.m., the Administrator and the DON stated the contract with the respiratory company had been in place for at least [AGE] years. The DON stated the respiratory provider did not perform PM on the facility owned oxygen concentrators. The DON was also unable to provide PM records for the provider owned oxygen concentrators. The DON stated she did not know when the last PM was done on any of the oxygen concentrators. The administrator stated the facility contract was unclear related to the company providing PM on facility owned equipment. The Administrator stated she would be reviewing and updating the facility contract based on the findings from the survey.",2018-05-01
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
6658,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,246,D,1,0,9WU111,"Based on observation and staff interview, the facility failed to accommodate a resident's needs for one (1) of nine (9) residents reviewed. A resident who experienced pain did not have the call bell within her reach. Resident identifier: Resident #81. Facility census: 85. Findings include: a) Resident #81 An observation and interview, on 12/02/14 at 9:07 a.m., revealed Resident #81 positioned in bed in high Fowler's position, and leaning to her right side. Her call bell was attached to the bed rail on her right side, and hung down toward the back of the bed, out of her reach. Upon inquiry, the resident related she had just finished with the speech therapist. She said the speech therapist returned about ten (10) minutes later to collect items, but did not reposition the resident or place the call bell within reach. During the interview, the resident related she could not move due to a stroke, and she had chronic back pain. Resident #81 related she currently had pain, and requested the nurse be notified. Upon further inquiry, the resident related she was physically able, and knew how to use the call bell if it was within her reach. Employee #32, a licensed practical nurse (LPN), was notified immediately of Resident #81's request for pain control. During the interview, the LPN related the resident was alert, coherent and able to make her needs known. An observation with the nurse, on 12/02/14 at 9:42 a.m., revealed the resident remained in the same position, as at 9:07 a.m. The LPN confirmed the call bell was not within the resident's reach and related, She couldn't ring it if she wanted to.",2017-12-01
6659,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,272,D,1,0,9WU111,"Based on medical record review, observation, and staff interview, the facility failed to develop an accurate comprehensive assessment for two (2) of twelve (12) residents reviewed. The minimum data sets (MDS) for two (2) residents who had contractures and/or paralysis affecting one (1) side of their bodies, were incorrectly coded as having the contractures and/or paralysis on the opposite sides. Resident identifiers: #11 and #24. Facility census: 84. Findings include: a) Resident #11 The medical record was reviewed on 12/02/14 at 1:00 p.m. The annual MDS with an assessment reference date (ARD) of 09/14/14, Section S noted a contracture of the right hand. The dominant side was coded as left, with no use of the left arm and hand. Observation of the resident, on 12/02/14 at 1:55 p.m., found she had a deformity of the right hand or wrist area. Her right arm was flaccid. She was able to move and use her left hand and arm independently. Upon inquiry, she said she was right-handed, but was unable to use it. On 12/02/14 at 3:30 p.m., an interview was conducted with registered nurse (RN) #16. He said he should have coded the right side as her dominant side, and that she had no use of the right arm and hand. He said he would correct this error. b) Resident #24 On 12/02/14 at 4:00 p.m., the medical record was reviewed. The annual MDS, with an ARD of 11/02/14, Section S noted this resident had contractures of the right wrist, right elbow, right shoulder, right neck, right ankle, right knee, and right hip. His dominant side was the left. According to the MDS, he had full use of the left hand/arm. At 5:25 p.m. on 12/02/14, Resident #24 was observed in the dining room. His left hand/wrist and multiple areas on the left side had contractures. He used his intact right hand to self-propel his wheelchair. The right hand had no contracture. Licensed practical nurse (LPN) #5 provided a copy of the 11/02/14 MDS Section S on 12/03/14 at 9:15 a.m. She said the MDS was coded incorrectly as his contractures were on the left side. She said this would be corrected to show the contractures were on the left side of his body rather than the right side. She said the MDS nurse who completed the 11/02/14 MDS was off work at that time. An interview was completed with the administrator, on 12/03/14 at 12:45 p.m. She acknowledged the MDSs for Residents #11 and #24 were coded anatomically on the incorrect side of their bodies. She said staff should have made sure they were looking at the residents on the correct sides.",2017-12-01
6660,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,273,D,1,0,9WU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete a comprehensive admission assessment in a timely manner for one (1) of twelve (12) residents reviewed. The resident's minimum data set (MDS) was not completed within 14 days after admission. Resident identifier: #66. Facility census: 84. Findings include: a) Resident #66 On 12/01/14 at 5:00 p.m., a review of the medical record for Resident #66 revealed she was admitted to the facility on [DATE]. Review of the admission MDS assessment identified the assessment had not yet been completed, and was in process. The MDS should have been completed by 11/28/14. At 8:45 a.m. on 12/02/14, Registered Nurse (RN) #16, who was the clinical care coordinator (CCC), confirmed the MDS should have been completed by 11/28/14, the fourteenth (14) day after admission. He said he had been off due to the Thanksgiving holiday, and had gotten behind.",2017-12-01
6661,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,280,D,1,0,9WU111,"Based on observation, record review, and staff interview, the facility failed to revise the care plan for one (1) of nine (9) residents whose care plans were reviewed. The care plan identified the potential for alteration in skin integrity. It was not revised with needed interventions when pressure ulcers were identified. Resident identifier #22. Facility Census: 84. Findings include: a) Resident #22 On 12/03/14 at 11:20 a.m., during a review of the facility's weekly wound logs, pressure ulcers were identified for Resident #22. From 07/07/14 through 11/10/14, the resident acquired four (4) separate pressure ulcer occurrences. A review of the resident's care plan, on 12/03/14 at 2:30 p.m., revealed a problem area indicating a potential for alteration in skin integrity. The goal, with interventions to achieve the goal, was for the resident's skin to remain intact. At 5:00 p.m. on 12/03/14, upon inquiry, the director of nursing (DON) said it was the facility's protocol to revise residents' care plans to reflect each occurrence of pressure areas, as well as noting the dates of occurrences and the dates of resolution. A review of the care plan for Resident #22 was conducted with the DON. She verified the care plan had not been revised when the resident acquired pressure ulcers. She further verified it should have been revised to reflect the resident's condition, as that was her expectation.",2017-12-01
6662,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2014-12-03,314,G,1,0,9WU111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, resident interview, and record review, the facility failed to ensure four (4) of five (5) residents reviewed, who had pressure ulcers, were provided necessary treatment and services to prevent the development of avoidable pressure ulcers and/or the worsening of existing pressure ulcers. Residents developed Stage III pressure ulcers, suspected deep tissue injury (SDTI) or unstageable pressure ulcers before staff identified skin impairment. Additionally, staff failed to complete skin assessments and/or conduct accurate skin evaluations. Resident identifiers: Resident #81, #48, #22 and #32. Facility census: 85. Findings include: a) Resident #81 Review of the pressure ulcer list, provided by the director of nursing (DON), indicated Resident #81 had a Stage III pressure ulcer on her left buttocks, a Stage III pressure ulcer on her right buttocks, and a Stage III pressure ulcer on her coccyx. The list did not identify if the resident was admitted with the areas, or whether they were acquired in-house. During an observation and interview with Resident #81, at 9:07 a.m. on 12/02/14, she nodded yes she was admitted with a pressure ulcer, and indicated staff provided peri-care and assisted with repositioning in bed. She related she did not take showers. The resident related she experienced pain daily. Resident #81 related her backside hurts. Although the resident was on a pressure relieving mattress, she indicated it was not really comfortable. Observation revealed the resident resting in high Fowler's position, leaning to her right, with a wedge beneath her lower legs. Her heels were resting on the bed. Resident #81 related she did not get out of bed, related to personal choice. At the conclusion of the interview, Resident #81 requested staff be notified she needed something for pain in her back and buttocks. Observation of the wounds, at 9:58 a.m. on 12/02/14, revealed three (3) pressure ulcers. Licensed practical nurse (LPN) #66 related the pressure area on the coccyx was acquired in-house. She related she identified it during wound rounds. Observation of the coccyx wound revealed an elongated area with slough and dark brown/black tissue. Upon inquiry as to whether the facility utilized treatment nurses, LPN #66 related, A lot of days nurses do their own treatments. During an interview with LPN #22, on 12/03/14 at 3:00 p.m., the nurse related the pressure ulcer on the coccyx started as a small abraded area. The LPN confirmed she did not note the area, report it, or complete an assessment at the time of discovery, Because it was covered by the same dressing as other wounds. Further review of the electronic record, on 12/02/14 at 3:00 p.m., revealed a physician's orders [REDACTED].#81's left outer foot. An interview with LPN #66, on 12/03/14 at 1:45 p.m., revealed she found the blister while assisting Nurse Aide (NA) #36 to pull the resident up in bed and cover the resident's feet. LPN #66 said staff turned and positioned the resident every hour. The LPN related all staff should have been observant of the resident's skin and should have immediately reported any change in condition. The nurse related she reported it to LPN #22. An interview with NA #110, on 12/02/14 at 5:00 p.m., revealed the resident required assistance of two (2) for activities of daily living (ADL) care. She indicated the resident received a bed bath on the 2-10 shower shift. She also related the resident had a wedge to float her heels. NA #110 related she should report any changes in condition to the nurse, such as redness or any change, and the wound nurse would look at the area. An interview with the clinical care manager (CCC) #16, on 12/03/14 at 5:00 p.m., revealed he updated the care plan and sometimes discussed an issue with the nurse floor nurse, about appropriate interventions. He indicated the wound care nurse became involved. Upon inquiry, he related he did not recall when wounds were last discussed, but confirmed they were not discussed within the previous two (2) days. He reported he approved treatment plans and PUSH (pressure ulcer scale for healing) tools. He said he was not aware of a new pressure area acquired on 12/02/14. Upon inquiry, the clinical care supervisor related communication was relayed verbally, via 24 hour reports, and in skin audit records. Review of the 24 hour reports revealed no evidence of communication regarding the blister to the resident's left outer heel. Additionally, the CCC asked medical records staff to assist with finding skin audits completed on shower days. Medical records employee #100 reviewed the records and related she could find no skin observation reports for Resident #81 for the months of October, November, and December 2014. The facility's procedure was for nursing assistants to document skin observations, and for nurses to review them. Licensed nursing staff did not complete routine skin audits. b) Resident #48 Review of the pressure ulcer list, on 12/01/14, indicated Resident #48 had developed two (2) pressure ulcers. An interview with NA #43, on 12/03/14 at 9:45 a.m., revealed Resident #48 required total care with assistance of two (2) persons. She related he was tough to roll and staff usually worked in pairs. She indicated the resident received a complete bed bath on Tuesdays and a shower on Fridays, affording staff a minimum of twice weekly skin audits. Review of the skin observation reports from October 2014 - December 2014, with Registered Nurse (RN) #16, revealed evidence of only one (1) observation, dated 10/31/14. At that time, staff noted the resident's skin as normal. Employee #16 confirmed he had no evidence to indicate staff monitored and reported skin impairments in a timely manner. c) Resident # 22 Review of the weekly skin ulcer report revealed Resident #22 developed three (3) pressure ulcers identified as a Stage 3 at the time of discovery. Review of the resident's skin observation reports for November 2014 and December 2014 revealed skin observation reports were completed for only two (2) of nine (9) opportunities. Upon inquiry, RN #16 could provide no evidence staff completed and reported skin conditions in a timely manner. The interview with LPN #66 revealed there were standing orders for treatment orders, including physician notification for Stage 3 or Stage 4 wounds. The nurse related either nursing assistants were not reporting, or licensed staff were not completing a follow-up. The LPN related some wounds were identified when the dressings were changed. An interview with the administrator and director of nursing (DON), on 12/03/14 at 3:30 p.m., revealed quality assurance meetings were usually conducted monthly and risk management meetings were held weekly. They indicated facility acquired pressure ulcers which were first identified as a Stage III, suspected deep tissue injury (SDTI), or unstageable was an identified issue; however, the affected residents were viewed independently, and the in-house acquisition of these areas was not identified as a systems failure. Review of the weekly pressure ulcer reports revealed the facility acquired new or re-opened areas as follows: -- August 2014: (3) Stage III and one (1) SDTI -- September 2014: (4) Stage III -- October 2014: four (4) Stage III and one (1) SDTI -- November 2014: one (1) Stage III, two (2) SDTI, and one (1) stage IV reopened The DON and CCC were unable to provide evidence staff had been educated about pressure ulcers since February 2014. They confirmed the facility should have monitored skin, and identified and treated the pressure ulcers before they reached a Stage III, SDTI or unstageable status. d) Resident #32 On 12/03/14 at 9:00 a.m., review of Resident #32's medical record revealed the resident was identified with a new onset Stage III pressure ulcer to the right lower buttock on 10/27/14. The pressure ulcer measured 0.5 centimeters (cm) by 0.9 cm by 0.2 cm. New treatment orders included Santyl to debride the wound, and collagen border foam dressings. The area closed the week of 11/04/14. During an interview with LPN #66, on 12/03/14 at 11:50 a.m., she said a Stage III pressure ulcer on the ischial area of Resident #32 was first discovered on 10/27/14. Upon inquiry, Employee #66 clarified that on 10/27/14, she was alerted by a staff member to look at the resident's newly discovered wound. LPN #66 said she assessed the wound immediately, and found that it was already at a Stage III level. She said the wound contained slough at that time, but she could still see the wound bed. She said there was no known discoloration of the skin, or pressure ulcer treatment, prior to the wound's discovery at the Stage III level on 10/27/14. On 12/03/14 at 3:30 p.m., an interview was conducted with the administrator and with the director of nursing (DON). They acknowledged Resident #32 developed a pressure ulcer in October, 2014, which advanced to a Stage III pressure ulcer before it was initially discovered by facility staff. They said Resident #32 had decreased mobility, and the pressure ulcer came on quickly. They said the ulcer also healed quickly. The DON said she did not know why it was at a Stage III level when it was initially discovered.",2017-12-01
7174,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,225,D,0,1,MK7111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon personnel file review and staff interview, the facility failed to check the State nurse aide registry to ensure a prospective employee, Employee #9, a registered 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 ten (10) employees whose files were reviewed. Employee identifier: #9. Facility census: 87. Findings include: a) Employee #9 A review of ten (10) employee personnel files was conducted on 08/27/13 at 8:30 a.m. The personnel file of a registered nurse (RN), Employee #9, had no evidence the State nurse aide registry had been checked to determine whether the individual had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of [REDACTED]. b) During an interview, on 08/28/13 at 4:37 p.m., the administrator, Employee #83, confirmed there was no evidence the required check had been completed prior to permitting Employee #9 to provide care to residents.",2017-07-01
7175,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,280,D,0,1,MK7111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to revise a resident's care plan when there were changes in the care needs due to a change in the health care status and physician's plan of care. The care plan did not address the resident's foot pain, isolation, or her behaviors, or the medications being given for these problems. This was found for one (1) of twenty-nine (29) residents in the Stage 2 sample. Resident identifier: #74. Facility census 87. Findings include: a) Resident #74 Resident #74 was a [AGE] year old female admitted on [DATE]. Her active [DIAGNOSES REDACTED]. Her monthly summary on 08/07/13 described her as Alert, confused, friendly, cooperative,/can be loud and disruptive. A review of the medical record of Resident #74 revealed the initiation of Contact Isolation on 08/01/13, due to a positive wound culture [MEDICAL CONDITION]. She was started on antibiotics. The nurses' notes reveal verbal behaviors starting on 08/10/13, including: . vocal all night on 8/10/13; . yells out @ X's (at times) on 08/12/13; Awake yelling, calling out. on 08/16/13; awake yelling out 'Hey Hey' on 08/17/13; . yelling 'Hey Hey' on 08/18/13; . yells out 'Hey Hey'. on 08/21/13; and Continues to yell out 'Hey Hey' @ (at) long intervals of time. The resident was on the following medications per physician's orders [REDACTED]. when [MEDICATION NAME] was started; 08/01/13 Xarelto 20mg po qhs for [MEDICAL CONDITION] ([MEDICAL CONDITION]; and 07/26/13 [MEDICATION NAME] 5/325mg PO every 6 hours for pain. A review of her care plan, on 08/28/13, failed to find the identification of foot pain; the identification of behaviors, including the psychosocial aspects of isolation; or identification of the medications as either potential or active problems requiring the establishment of measurable goals and nursing interventions to ensure the highest level of functioning the resident might be able to maintain. During an interview with the director of nurses, Employee #95 (Registered Nurse), and Employee #68 (social worker), at 3:50 p.m. on 08/28/13, they reviewed the care plan and acknowledged the care plan should be revised. Employee #95 stated the initial care plan had included [MEDICATION NAME], but it had been discontinued in March when the medication was discontinued and they failed to restart the problem of drug related complications. The following day a copy of the additions to the care plan were presented that addressed all of the noted deficits.",2017-07-01
7176,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,329,D,0,1,MK7111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, medical record review, and staff interview, the facility failed to ensure a resident's medication regimen was free of unnecessary medications. Resident #13 received a [MEDICAL CONDITION] medication without adequate indications for its use. There was no evidence of assessment of possible causal factors prior to increasing the dose of [MEDICATION NAME] (an antipsychotic medication). This was found for one (1) of five (5) sampled residents reviewed for unnecessary medications. Resident identifier: #13. Facility Census: 87. Findings include: a) Resident #13 Observation of the resident, on 08/27/13 at 9:25 a.m., and again at 10:30 a.m., revealed Resident #13 resting quietly in bed. No agitated behaviors or restlessness was observed. During an interview at 1:30 p.m. on 08/27/13, the resident was alert and attempted to answer questions. Her mood was pleasant and calm. A medical record review, on 08/27/13 at 9:31 a.m., revealed Resident #13 was receiving [MEDICATION NAME] 15 mg orally daily. The physician's orders [REDACTED]. On that date, [MEDICATION NAME] was decreased from 10 mg to 5 mg orally daily. Employee #1, a licensed practical nurse (LPN ), was interviewed on 08/28/13 at 10:00 a.m. She said Resident #13 had an appointment with the psychiatrist on 08/21/13 and he increased her medication because of increased behaviors. She said the resident would lie in bed screaming, cursing and hitting. Behavioral flow sheets, dated July and August 2013 were reviewed on 08/28/13 at 10:06 a.m. They revealed the resident exhibited no behaviors in July 2013. One (1) isolated episode of aggression occurred on 08/05/13, prior to the dose reduction. There was no further evidence of aggressive behaviors until the three (3) consecutive dates of 08/16/13, 08/17/13, and 08/18/13. No further notation was present. According to the medical record, on 08/17/13, the resident was treated for constipation. The orders indicated milk of magnesia was to be given if the resident had not had a bowel movement for three (3) days with a protocol to followed for additional treatment if needed. Further review of the medical record revealed a psychiatric consultation, dated 08/21/13. It indicated the resident was not exhibiting agitated or aggressive behaviors during the appointment. Based on information provided by he facility, [MEDICATION NAME] was increased from 5 mg to 15 mg orally. An interview with Employee #16, a nurse aide (NA), and Employee #60 (NA), on 08/28/13 at 2:00 p.m., revealed the resident sometimes bawls and complains about pain in her back and her legs. Employee #60 said the resident had a history of [REDACTED]. She said the behaviors were usually because the resident wanted to lie down. Both nursing assistants said Resident #13 did not usually become agitated during care. Employee #46, a registered nurse (RN), unit manager and minimum data set (MDS) coordinator, was interviewed on 08/28/13 at 10:00 a.m. He indicated the resident's behaviors were sporadic. He said he was unable to provide additional information related to why the [MEDICATION NAME] was increased from 5 mg to 15 mg po daily. When asked what triggered the behaviors, he referred to the intervention section of the behavior monitoring sheets. He said staff utilized those items. Further inquiry confirmed none of the interventions were effective. When questioned further about underlying causes of behavior, he acknowledged physical ailment could be a trigger for behaviors. Employee #46 reviewed the resident's medical record and agreed constipation could have been a trigger for the resident's behavior. He agreed her behavior had improved after administration of the bowel regimen treatment for constipation. He acknowledged the medical record did not provide a clear picture related to the severity of the resident's behaviors, which were generally limited to one time a day, and occurred on day shift. He also agreed no evidence was available to indicate possible causative factors were addressed, prior to increasing the dose of [MEDICATION NAME].",2017-07-01
7177,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,428,D,0,1,MK7111,"Based on medical record review and staff interview, the facility failed to act on a pharmacy recommendation for one (1) of five (5) sampled residents. The pharmacist had recommended Resident #13 have a gradual dose reduction for Wellbutrin. The physician did not indicate why he declined a gradual dose reduction for a psychotropic medication. Resident identifier: #13. Facility census: 87. Findings include: a) Resident #13 Medical record review, on 08/27/13 at 10:18 a.m., revealed on 03/21/13, the pharmacist had made a recommendation for a gradual dose reduction (GDR) for Wellbutrin. The physician had declined the recommendation, noting stability, but did not elaborate with resident specific information as requested by the recommendation. Further review of the medical record revealed a successful GDR had been completed in September 2012. Employee #46, a registered nurse (RN), was interviewed on 08/28/13 at 10:00 a.m. He reviewed the medical record, including the physician's progress notes. The RN confirmed the physician had not provided resident specific information related to the refusal for a GDR of Resident #13's Wellbutrin.",2017-07-01
7178,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,431,E,0,1,MK7111,"Based on observation and staff interview, the facility failed to ensure all medications were stored in a locked compartment to prevent unauthorized access to the medications. The medication storage refrigerator in the 400 hall nursing station was left unlocked and was not visible to attending staff, providing an opportunity for unauthorized access. This had the potential to affect more than a limited number of residents. Facility census: 87. Findings include: a) On 08/29/13 at 8:33 a.m., an observation on the 400 hall nursing unit revealed an unattended and unlocked refrigerator in the nurses' station. The refrigerator was found to contain three (3) unopened vials of insulin, an open box of acetaminophen suppositories, and an open tuberculin test vial dated 07/31/13. The area of the nurses' station could easily be accessed by anyone. During an interview with a licensed practical nurse (LPN), Employee #101, on 08/29/13 at 8:38 a.m., she confirmed the refrigerator on the 400 hall was unlocked and stated she had problems with the lock that morning, but thought she had locked it. She then locked the refrigerator. The director of nursing (DON), Employee #131 examined the lock on 08/29/13 at 9:00 a.m. and confirmed it was difficult to engage the lock. The DON requested Employee #131 complete a work order on the same day for a padlock to be placed on the refrigerator.",2017-07-01
7179,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,441,E,0,1,MK7111,"Based on observation, staff interview, and policy review, the facility failed to implement hand hygiene practices consistent with accepted standards of practice (such as those set forth by the Centers for Disease Control) and in accordance with the facility's policy. A nurse did not wash her hands between glove changes, after contact with environmental objects, and did not wash her hands sufficiently when exiting the room. A random observation noted an employee left an isolation room and failed to wash his hands. Resident Identifier: #52. Facility Census: 87. Findings Include: a) Resident #52 On 08/29/13 at 8:56 a.m., a dressing change by Employee #72, an LPN, was observed. The nurse identified herself as one (1) of the two (2) most common wound care nurses in the facility. The nurse entered the room and donned gloves without washing her hands. She removed the soiled dressing and discarded it, and removed her gloves. She did not wash her hands. She donned clean gloves and applied a new clean dressing. She had left part of her supplies outside of the room. She removed the gloves and left the room without washing her hands. She got some tape, returned to the room, put on fresh gloves, applied the tape, then removed her gloves. Again without washing her hands. She gathered the remaining supplies, washed her hands in a quick rinse style, and left the room. When asked about handwashing, she apologized and did agree she had not washed her hands as she should have. She said the facility does review proper techniques with the staff periodically. The lack of handwashing was discussed with the DON at 9:15 a.m. She said the nurse doing the dressing change should have washed her hands for 10 sec or more in between glove changes and after the dressing change. She provided a policy to confirm her statement b) Random Observation During a random observation, on 08/26/13 at 12:30 p.m., Employee #116, a licensed practical nurse (LPN), entered an isolation room to administer medications. Upon completion of this task, he removed his gloves and isolation gown. After disposing of them, he exited the room with out sanitizing his hands. He assisted a resident in the hallway, then returned to the medication cart and opened the medication administration record. Employee #116 was interviewed on 08/29/13 at 11:25 a.m. He acknowledged he had not sanitized his hands. He said according to facility policy, he should have washed them prior to exiting the room. During an interview with the DON, on 08/29/13 at 11:40 a.m., she said she expected staff to wash their hands prior to exiting a resident's room. The facility handwashing policy was reviewed at 11:40 a.m., and indicated hands must be sanitized after removing gloves. It noted the use of gloves did not replace handwashing/hand hygiene.",2017-07-01
7180,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2013-08-29,514,D,0,1,MK7111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the legibility of a medical record for one (1) of twenty-nine (29) Stage 2 sample residents. The pain assessment record for a resident with chronic pain contained illegible entries. Resident identifier: #51. Facility census: 89. Findings include: a) Resident #51 During a resident interview, on 08/26/13 at 2:41 p.m., Resident #51 said she had pain in her right leg. Review of the physician's orders [REDACTED]. It also noted an order for [REDACTED]. Review of the Medication Administration Record [REDACTED]. It indicated Resident #51 was assessed twice a shift for the presence of pain. The as needed (PRN) medication sheet noted the resident had been treated three (3) times for pain in the month of August. The MAR, reviewed on 08/28/13 at 9:24 a.m., noted Resident #51 complained of pain in the right leg. The resident's pain was rated on a numeric scale at 8/10 (a rating of 8 to10 would indicate intense pain), on 08/23/13 at 4:00 p.m. Follow up on the pain scale form revealed the medication and interventions were ineffective as of 8:00 p.m. Review of the pain monitoring record revealed what had been done after that could not be discerned due to illegible entries. Employee #46, RN, unit manager, Employee #1, a licensed practical nurse (LPN), and Employee #72 (LPN), were interviewed on 08/28/13 at 9:41 a.m. They confirmed the notations on the pain monitoring record were illegible and confusing. They acknowledged they were unable to accurately identify the rate of pain, interventions, or outcome.",2017-07-01
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
8405,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,226,E,0,1,5RWC11,"Based on staff interview, incident record and policy review, the facility failed to implement their policies related to the abuse program. The facility failed to report the results to the State Survey Agency (SSA) within five working days of the incident for two of three abuse/neglect investigations reviewed. The facility failed to implement procedures to prevent further potential abuse while the investigation was in progress for one of the three investigations reviewed. Findings: 1. Review of an Adult Protective Services Reporting Form revealed on 01/20/2012, an unsampled resident was found to have a purple bruise under her eye. The initial report of this injury of unknown origin was made to the State Survey Agency (SSA) on the same day; however, the results of the facility ' s investigation were not reported to the SSA until 02/01/2012. Review of the facility ' s policy, Complaint Investigation Protocol - Abuse and Neglect, revealed All agencies, as listed, will be notified of the results of the facility ' s findings within five (5) working days of the incident. Review of the list of agencies revealed it included the survey agency, Office of Health Facility Licensure and Certification. Interview on 04/12/2012 at 2:00pm with the Social Worker (SW) confirmed she was the person designated to complete investigations and make the final reports. She further stated she had no documentation and did not recall what caused the delay in making the final report to the SSA. 2a. Review of an Adult Protective Services Reporting Form revealed that on 03/14/2012, the facility made an initial report to the SSA of an allegation that a nurse had been rude to an unsampled resident. Review of the five-day follow-up report to the SSA, which contained the results of the investigation, revealed that it was dated 03/13/2012. Interview with the SW on 04/12/2012 at 3:15pm revealed that the allegation had been considered possible verbal abuse and therefore, reported to the SSA. However, she related she had no evidence as to when the results of the investigation were actually sent to the SSA. She stated that the five-day report date of 03/13/2012 was not accurate, as the investigation did not begin until 03/14/2012, when she became aware of the allegation. b. Review of the Complaint Investigation Protocol - Abuse and Neglect revealed All incidents of suspected abuse/neglect shall be reported to the RN (Registered Nurse) on call and referred to the Director of Social Services and the Administrator immediately. Interview on 04/12/2012 at 2:30pm with the Licensed Practical Nurse (LPN) who received the allegation on 03/13/2012 revealed that the family reported their concern as she was finishing her shift, and she did not inform anyone of it until the next day. Interview on 04/12/2012 at 3:15pm with the SW confirmed that she was not made aware of the allegation until 03/14/2012. The SW stated that the family's allegation met the definition of suspected verbal abuse and should have been reported to both the Administrator and SW immediately. c. Review of the Complaint Investigation Protocol - Abuse and Neglect revealed that all Employees suspected of abuse/neglect shall immediately be removed from resident contact and placed on administrative leave pending completion of the investigation. Interview on 04/12/2012 at 2:30pm with the nurse who received the initial allegation revealed that the alleged perpetrator was working on 03/13/2012. However, since she was working at the other end of the hall from the resident involved, no further action was taken and she was allowed to continue working with other residents. Interview with the SW on 04/12/2012 at 3:15pm revealed the alleged perpetrator should not have been allowed to work on the floor with residents until the allegation had been investigated.",2016-06-01
8406,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,241,E,0,1,5RWC11,"Based on observation and staff interview, it was determined that the facility failed to maintain dignity for two of eighteen sampled residents (R1, R11) and all residents in the Cathedral Dining Room (CDR) during meal service. Findings: 1. On 04/10/2012 at 11:15am staff was observed bringing residents into the CDR for lunch which was scheduled to be served at 11:25am. Meals were served to all but four of the residents in the dining room between 11:30am and 11:35am. At 11:50am a staff member moved an un-identified resident from table one, after which she moved one of the four unfed residents into the still dirty place just vacated at table one. Other staff members were soon observed retrieving the remaining three unfed residents and relocating them to places recently vacated by other diners. Staff was observed standing at all tables while assisting residents with meals. 2. On 04/11/2012 at 11:35am, observation of the Independent Dining Room (IDR) revealed staff removed the plated food from the serving trays and placed it on placemats. Observation of the dependent diners in the CDR on 04/10/2012, 04/11/2012, and 04/13/2012 revealed staff served all of the residents including R1 and R11 their meals on the plastic serving trays without placemats. 3. On 04/12/2012 in the CDR at 7:30am, the facility Occupational Therapy Assistant (OTA) was observed speaking over R11 to another staff member. The therapist stated I ' m going to move her (she pointed to R11) to another table, could you move her tray? During an interview with the OTA at 7:40am, she stated she had not asked R11 if she wanted to move. When the OTA asked R11 about the move, R11 stated she did not want to move. 4. On 04/12/2012 at 8:35am in the CDR a staff member made multiple attempts to remove a cup of coffee from an unidentified male resident. He became increasingly agitated with each attempt. After several minutes the resident picked up his cup, drank it in one swallow and stated fine, I ' m done now, you can have it. The staff member removed the cup and pushed the resident ' s wheelchair from the room. 5. The following was observed in the Cathedral Dining Room (CDR) on 04/13/2012 between 7:17am and 7:57am: R1 was brought to the main dining room at 7:14am and placed at a table with an unidentified resident. Both residents were served coffee at 7:18 a.m. R1 and the unidentified resident were not served breakfast until 7:57am. No other beverages or coffee were offered during the observation. Several staff members passed by and spoke but none of the staff offered either R1 or the other resident coffee or food. 6. During an interview with the Administrator on 04/11/2012 at 5:20pm, she stated staff had been trained to provide appropriate service in the dining room, she did not know why some of the residents were not served timely, and she stated she was aware the independent diners were provided with a dining experience that differed from the one provided to the dependent diners.",2016-06-01
8407,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,272,D,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and clinical record review, the facility failed to complete accurate assessments for 1 of 18 sampled residents (R5.) Findings: Review of R5's clinical record revealed a quarterly assessment was completed on 01/06/2012. The Minimum Data Set (MDS) showed an Assessment Reference Date (ARD) of 01/01/2012, and documented that the resident had sustained no falls since the previous quarterly assessment in October, 2011. However, a review of nurses' notes and a Falls Assessment revealed that the resident sustained [REDACTED]. The next quarterly MDS assessment, dated 04/06/2012, (ARD-04/01/2012) revealed that R5 was restrained on a daily basis, and had no falls since the previous assessment. However, review of physician orders [REDACTED]. Observation of R5 on 04/10/2012 at 12:52pm; 04/11/2012 at 11:50am, 12:15pm, 12:30pm; and 04/12/2012 at 7:40am, 7:55am, 8:05am, and 8:40am revealed the resident ambulating independently or sitting in a chair with no restraints present. Interview on 04/11/2012 at 10:30am with the Clinical Care Coordinator (CCN1) responsible for these MDS revealed that both quarterly assessments had been coded inaccurately. He stated that the 01/06/2012 MDS should have documented the fall of 01/01/2012, since the fall occurred on the ARD. He related that the fall of 01/27/2012 should have been included on the 04/06/2012 MDS and Section P should have shown no restraints in use during the look-behind period used for this assessment. Further review of the quarterly assessment, dated 04/06/2012, revealed that as of 04/11/2012, it had not been signed as complete (Section Z0500.A.). Interview on 04/11/2012 at 10:30am with the CCN revealed that although Section Z0500.B stated that Date RN Assessment Coordinator signed assessment as complete was 04/06/2012, he did not sign assessments as complete until the care plan meeting was held so that changes could be made to the MDS if needed.",2016-06-01
8408,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,280,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff/resident interview, the facility failed to ensure that comprehensive care plans were developed with the participation of the resident. The facility failed to provide participation of alert and oriented residents in care plan meetings. Findings: 1. A group interview was conducted on 04/10/2012 at 1:00pm with eight residents whom the facility had identified as alert, oriented, and credible historians. Interview with residents during this meeting revealed that two of eight residents stated they had never been invited to the quarterly care plan meetings in which their plan of care was reviewed/revised, and expressed interest to attend. Clinical record review of the two un-sampled residents from group revealed that neither had been present at their most recent care plan meeting. Although their records contained invitations to the care plan meeting for their family/Power of Attorney, there was no evidence that either resident had been invited to the meeting. Both residents' records indicated that after the meeting, staff met with them to inform them of the decisions made during the care plan meeting. 2. Review of the closed clinical record for R16 revealed the resident was admitted on [DATE] for a short-term stay for therapy. The Minimum Data Set ((MDS) dated [DATE] showed the resident had no cognition or memory loss. A review of the resident ' s Care Plan Team Meeting Notes revealed the resident was not present at this meeting. A note indicated the resident was at a MD appointment and unable to attend the care plan meeting. Although a letter was sent to the resident ' s family, inviting them to the meeting, there was no evidence that the resident was informed prior to the meeting, or given the opportunity to have the meeting rescheduled at a time where she could be present. 3. Facility staff identified R13 as alert, oriented, and a credible historian during the initial tour on 04/10/2012 at 09:30am, and also when she was brought to the Group Meeting at 1:00pm on 04/10/2012. A review of the resident ' s clinical record revealed that her admission care plan meeting was conducted on 03/18/2012. Further review of the resident's record revealed no evidence that the resident was invited to or attended the meeting. Interview with R13 on 04/12/2012 at 10:45am revealed the resident had not attended her admission care plan meeting. Interview with Clinical Care Coordinator #1 (CCC1) on 04/11/2012 at 10:30am revealed that if a resident is invited to their care plan meeting, it should be documented in their chart. Interview with CCC2 on 04/12/2012 at 4:45pm revealed alert and oriented residents are not consistently invited to their care plan meetings, although staff will inform the resident of what was discussed after the meeting is over. Both CCCs stated that care plan meetings are routinely held at times during the day when residents are not available (due to medical appointments, therapy sessions, or bathing) and the facility had not attempted to reschedule the meetings at times convenient to the residents' schedule.",2016-06-01
8409,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,282,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, clinical record review, and staff interviews, the facility did not provide services in accordance with the written plan of care for 3 of 18 sampled residents (R5, 6, 13.) Findings: 1. Clinical record review revealed R5 had [DIAGNOSES REDACTED]. A review of the resident ' s comprehensive care plan, dated 01/12/2012 a goal of maintaining adequate nutritional status, and one intervention was for staff to provide a maroon spoon on tray for all meals. a. Observation on 04/11/2012 at 8:10 revealed the resident had not been provided a maroon spoon with the breakfast meal. Interview on 04/11/2012 at 9:05am with a Licensed Practical Nurse (LPN) described the maroon spoon as an aspiration prevention measure so that residents take smaller bites. Further review of the care plan, dated 01/12/2012, revealed the resident was to receive nectar thick liquids. Observation on 04/11/2012 at 8:10am, 9:10am, and 9:45am revealed a pitcher of water at the resident ' s bedside that had not been thickened. Interview at 9:45am, with LPN5 confirmed the resident, who is ambulatory, and could reach the water, should not have thin liquids at bedside. b. Review of nurses' notes revealed R5 had a history of [REDACTED]. Per the care plan, the resident was to wear a personal alarm while in bed. Observation on 04/11/2012 at 4:10pm revealed the resident lying asleep in bed. The clip to the personal alarm was not attached to the resident, and was on the sheet next to her. c. Review of R5's Minimum Data Set (MDS) of 01/06/2012 revealed R5 required total assistance with bathing. Review of the care plan revealed that she was to be provided with a bath or shower 2-3 times per week or more often as desired. Review of the shower record confirmed that the resident did not receive a bath/shower from 03/07 - 03/14/2012, or from 03/25 - 04/04/2012. Interview with a unit LPN on 04/13/2012 at 9:10am revealed that if a resident does not receive or refuses their shower, the NA should inform the nurse so that action can be taken. 2. Weight record review of R13 revealed that since admission on 02/17/2012, the resident had lost 23.5 pounds, a weight loss of over 10%. Review of the resident ' s care plan, dated 03/01/2012, revealed that staff was to monitor weight per protocols/as ordered. Notify physician, Registered Dietitian (RD) of weight loss/gain greater than 5 pounds. Review of the clinical record revealed no evidence the RD had been notified of the weight loss. Interview on 04/12/2012 at 11:25 with the Certified Dietary Manager (CDM) confirmed the RD had not been notified of the weight loss. Clinical record review revealed R6 had [DIAGNOSES REDACTED]. Review of the resident ' s care plan, reviewed 02/12/2012, revealed R6 had a potential for altered skin integrity. In response, the resident was to wear Geri-leggings at all times. Observation of R6 on 04/10/2012 at 3:00pm, and on 04/11/2012 at 8:12AM and 11:00AM, revealed that the resident was not wearing a Geri- legging on the right leg. Interview with CCC1 on 04/10/2012 at 11:00am revealed that R6 should be wearing Geri-leggings on both legs, as the resident is susceptible to skin tears. a. R6 also was diagnosed with [REDACTED]. A care plan update of 03/30/2012 noted the resident was to be provided with two-handled flow control cups on each tray. Observation on 04/11/2012 at 8:12am revealed that the resident had been provided a two-handled cup for her thickened juice. The resident ' s thickened milk was in a Styrofoam cup. Observation on 04/11/2012 at 11:45am revealed that the resident was served a two-handled cup of thickened milk. The resident also received Styrofoam cups of thickened water and juice. No two-handled cups were provided for these liquids. Observation throughout the meal revealed that the resident did not drink any of the fluids that had been served in the Styrofoam cups, and total fluid consumptions was 240cc (the milk in the two-handled cup.) Interview on 04/11/2012 at 12:35pm with an aide revealed that the dietary department sent out only one two-handled cup for the resident, and she had not wanted to use the cup after it was soiled for other drinks. Interview with the Administrator and Director of Nursing on 04/11/2012 at 5:00pm confirmed that multiple cups should be sent out so that each drink can be placed in its own container.",2016-06-01
8410,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,325,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff/resident interview, and clinical record review, the facility failed to ensure that residents maintained acceptable parameters of nutritional status such as body weight. Facility policies and interventions were not implemented for three of eighteen sampled residents (R3, 11, and 13) who sustained weight loss. Facility staff failed to record food consumption accurately. Findings: 1. Clinical record review revealed R13 was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. The resident ' s admission weight on 02/17/2012 was 224 pounds. The resident ' s care plan, dated 03/01/2012, revealed a goal of gradual weight loss (1-2 pounds) per month. However, interview with R13 on 04/12/2012 at 2:10pm revealed I ' m not interested in being on a diet. R13 was identified by facility administration as alert, oriented, and a credible historian to discuss life in the facility during a group meeting on 04/10/2012 at 1:00pm. A review of the weight record in the resident ' s chart revealed the following: 02/17/2012 - 224 02/23/2012 - 217 03/01/2012 - 213.5 03/08/2012 - 205.5 03/15/2012 - 205.9 Although no further weights were documented in the resident ' s chart, interview with the Restorative Supervisor on 04/12/2012 at 10:05am revealed that two weights had been obtained but not yet charted in the medical record: 04/02/2012 - 201.7 and 04/11/2012 - 200.5. Review of these weights revealed a total loss of 23.5 pounds, a weight loss of greater than 10% in less than two months in the facility. Review of physician orders [REDACTED]. Review of the Weight assessment and Intervention Policy revealed, Any weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietitian in writing. Verbal notification must be confirmed in writing. The Dietitian will respond within 24 hours of receipt of written notification. The policy noted that The Dietitian will also review the unit Weight Record by the 15th of the month to follow individual weight trends over time. Negative trends will be assessed and addressed by the Dietitian whether or not the definition of Significant Weight Change is met. Review of the resident ' s clinical record revealed no evidence reweighs had been completed or that the Registered Dietitian (RD) had been notified of the weight loss. Review of Nutrition Notes revealed the RD had not reviewed the resident ' s status since 02/22/2012. Interview on 04/12/2012 at 11:25 with the Certified Dietary Manager (CDM) revealed that the facility had not been completing reweighs according to the facility policy. She stated that the RD does not receive anything in writing about resident weight losses. The CDM stated that because the resident had [MEDICAL CONDITION] and was above her Ideal Body Weight (IBW) upon admission, she had not identified her weight loss as significant, or taken any action. Interview on 04/12/2012 at 1:50pm with the Director of Nursing (DON) revealed nursing staff was not notifying the RD of changes in weight. Further interview with the DON indicated the thought was the CDM was making this notification. 2. Clinical record review revealed R3 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A review of the medical record revealed the following: The Weigh Record revealed: 1/1/2012 130.5 pounds, 2/5/2012 120 pounds, and 3/8/2012 120.8 pounds. Review of Nutrition Notes dated 02/15/2012 revealed the RD documented, weight loss review CBW (current body weight) 120 pounds, 11 pounds (8%) loss in 1 month. Will leave note for CDM to speak with Restorative to try and obtain reweight. Further review of Nutrition Notes dated 03/6/2012 stated DM visit with resident during lunch meals, resident refuses any food offered, however will eat sliced tomatoes. Resident also refusing any sweets stated they are bad for my teeth , resident has no teeth or dentures. Offered resident supplements to taste, refused. Will continue providing sliced tomatoes. Nutrition Notes entered on 03/15/2012 by the RD revealed [MEDICATION NAME] ordered 03/14/2012 Physician order [REDACTED]. Review of Medication Administration Record [REDACTED]. A review of the facility ' s Weight Assessment and Intervention reviewed on 1/17/2012 indicated; A weight change of greater than or less than 5 pounds within 30 days will be retaken the next day for confirmation. If the weight is verified, nursing will immediately notify the Dietician in writing. Verbal notification must be confirmed in writing. An interview was conducted with the DM on 04/11/2012 on 03/11/2012 at 11:00 a.m. The DM acknowledged that the weight loss from 130.5 pounds in January down to 120 pounds in February was greater than 5 pounds and an 8% loss in one month. The DM stated she was aware of the weight loss and had entered those weights on the Weight Record . The DM could not explain why a reweigh was not completed in February or March. The DM was unable to provide documentation that the Dietician was notified immediately. The DM also stated I was not aware that the resident was refusing the [MEDICATION NAME]. An interview was conducted with the DON on 04/11/2012 at 11:00am. The DON acknowledged that it is the facility policy to reweigh residents the next day when there is a weight difference of five or more pounds. The DON stated. I don ' t know why the resident was not reweighed and I was not aware that the resident was refusing to take the [MEDICATION NAME] . 3. Clinical record review revealed R11 was admitted to the facility on [DATE] and readmitted on [DATE] with the following diagnoses; Alzheimer ' s Disease, dementia, diabetes, hypertension, [MEDICAL CONDITIONS] reflux, and mild mental [MEDICAL CONDITION]. The most recent Minimum Data Set ((MDS) dated [DATE] stated the resident had short and long term memory problems and was moderately impaired in decision-making skills. Review of the clinical record revealed R11 weighed 163 pounds (lbs.) on admission. The weight record documentation stated her weight remained stable through December of 2010. On 02/01/2011 her weight was 163 lbs. Each month thereafter, the weight record documentation showed a steady and continued loss, the most recent weight documentation dated 03/01/12 showed the resident ' s weight was 127lbs. This most recent documented weight confirmed R11 had a loss of 36 pounds in one year amounting to an approximate 20% loss of body weight. On 04/10/2012 at lunch, R11 was observed to eat less than 50% of her meal. She drank 120cc of juice. Staff documented R11 ate 75% of the meal and drank 180cc of the 660cc of fluids on her tray. Observation of R11 at breakfast on 04/12/2012 revealed staff failed to offer R11 additional food although she ate 100% of her meal. When the resident finished eating, she had consumed only 180cc of the 660cc of liquids on her tray. Staff documented R11 consumed 100% of her liquids. During an interview with the Certified Dietary Manager (CDM) on 04/12/2012 at 1:30 pm, she stated all of the interventions the RD put in place were based on the documentation received from staff via the daily meal consumption log. She further stated she was unaware staff documentation was incorrect, and she would have reported the continued weight loss of R11 to the RD if she had received accurate information regarding R11 ' s daily intake. 4. Review of the clinical record of R5 revealed [DIAGNOSES REDACTED]. On 01/10/2012 the CDM documented that the resident had weight loss within the past 3 months, and the 01/12/2012 care plan noted the resident was at risk for potential nutritional problems as evidenced by poor intake and coughing during meals. Per the Minimum Data Set of 04/06/2012, R5 required extensive assistance with feeding. Observation on 04/11/2012 at 8:10am revealed the resident lying in bed, with the remains of her breakfast meal on a nearby table. R5 had been served hot cereal, toast, and scrambled eggs. None of the cereal or eggs had been consumed. Although the resident had eaten only the toast, review of intake records revealed that staff documented R5 consumed 40% of her meal. Observation on 04/11/2012 at 11:50am revealed R5 was served a meal of ground meat, noodles, broccoli, fruit, and magic cup, a supplement. Observation at 12:30pm revealed that the resident ate none of the meat, noodles, or fruit. One spoon of broccoli and 3/4 of the magic cup were consumed. Interview with the staff removing the tray from her room at 12:30pm revealed R5 refused her lunch. Review of intake records revealed that staff documented R5 consumed 30% of the meal. Interview with the Administrator and DON on 04/11/2012 at 5:00pm revealed they were unaware that staff was not accurately documenting food intake records.",2016-06-01
8411,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,332,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review the facility failed to ensure that medications were administered according to physician orders [REDACTED]. Findings: 1. Observation on 04/11/2012 at 9:30am revealed that LPN 1 administered Calcium 500 mg with Vitamin D to UR1. Review of this resident ' s physician orders [REDACTED]. The physician signed the order on 02/29. No other orders for calcium preparation appeared in the chart after 02/08/2012. Review of this resident ' s Medication Administration Record [REDACTED]. Interview with LPN1 on 04/11/2012 at 2:00pm stated that on 02/08/2012, she wrote the order to discontinue the [MEDICATION NAME] she was to have written the order for [MEDICATION NAME] (calcium) but forgot to do this. She confirmed that because this step was not completed, there was no current order for the medication administered to UR1. 2. Observation on 04/11/2012 at 12:30pm revealed that UR2 received Humalog (insulin) 5 units by subcutaneous injection (SQ) in the left upper arm. The resident was noted to have just returned from dining room after eating her noon meal. Interview with LPN 2 on 04/11/2012 at 12:3pm in which he stated he knew that the insulin was due before she ate but that the resident was off the unit. Review of the resident MAR ' s revealed that the medication, [MEDICATION NAME] 5 units, was to be given SQ with each meal at 11:30am. 3. The following was observed during Medication Pass on the 300 Hall on 4/11/2012 at 8:20am: [MEDICATION NAME] ([MEDICAL CONDITION] medication) 112 micrograms (mcg) was administered to R3. A review of the MAR indicated [REDACTED]. An interview was conducted with LPN3 on 04/11/2012 at 10:00am. The nurse acknowledged that the medication was ordered for administration at 6:30 a.m. and stated I see that the medication is ordered at 6:30 but I gave it with the other morning medications at 8:20am. During an interview with the Director of Nursing (DON) on 04/11/2012 at 10:15am she stated, [MEDICATION NAME] is scheduled to be administered at 6:30 a.m. on an empty stomach.",2016-06-01
8412,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,333,D,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and clinical record review the facility failed to ensure that residents were free from significant medication errors for one of fifteen residents (UR1) observed during the medication pass. Findings: Observation on 4/11/12 at 9:30am revealed that LPN1 administered Calcium 500 mg with Vitamin D to UR1. Review of this resident ' s Medication Administration Record [REDACTED]. Review of this resident ' s physician orders [REDACTED]. The physician signed the order on 02/29/2012. No other orders for calcium preparation appear in the chart after 02/08/2012. There was not an order for [REDACTED]. Interview with LPN1 on 04/11/2012 at 2:00pm stated that on 02/08/2012 she wrote the order to discontinue the [MEDICATION NAME]. She was to have written the order for [MEDICATION NAME] (calcium) but had forgotten to do this. She confirmed that because this step was not completed, there was no current order for the calcium that was administered to UR1.",2016-06-01
8413,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,371,F,0,1,5RWC11,"Based on observation and staff interview the facility failed to maintain a clean, sanitary kitchen to prevent food contamination when storing and serving foods. Findings: 1. On 04/10/2012 at 9:15am during the initial kitchen tour, the following was noted: A. Directly above the dishwashing station a supplementary hot water tank with tape wrapped piping was observed covered in grey dust/dirt. As the clean dishes came out on the right side of the drain board, the racks of clean dishes were allowed to air dry. Due to the constant change of temperature in the pipes above, heavy condensation was noted. As the dishes sat beneath the dirty piping, large drops of contaminated water were observed dropping onto the cleaned dishes. B. In the clean dish storage area the shelving was observed to be thick with dust and the clean beverage pitchers were stored upside down on the dirty shelving. C. The coffee station had a heavy coating of dust/debris on the tops of the coffee machines. D. The light switch cover plates adjacent to the stove, near the coffee station, and at the dish washing station were heavily soiled. E. The tops of both ovens were heavily crusted with what appeared to be grease and dust. 2. On 04/11/2012 at 1:15pm an interview with the Certified Dietary Manager (CDM) revealed the expectation was all kitchen staff would keep their work areas clean. The CDM confirmed the kitchen needed a thorough cleaning. Review of documentation provided failed to indicate a cleaning schedule or responsibility to maintain a clean environment. 3. During a brief kitchen tour with the Administrator on 04/11/2012 at 5:30pm, the above conditions were again observed and the Administrator agreed the kitchen was in need of a thorough cleaning.",2016-06-01
8414,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,431,F,0,1,5RWC11,"Based on observation and staff interview, the facility failed to ensure narcotic boxes were affixed to the medication cart on four of four medication carts. Finding: Observation on 04/10/2012 at 1:45pm revealed the medication cart on the 400 hall contained a narcotic box that was not secured to the medication cart. Surveyor was able to lift the box free from the drawer where it was located. Interview on 4/10/2012 at 1:45pm with LPN1 revealed that he did not realize it was not screwed down and would call maintenance to secure the narcotic box. Observation on 04/11/2012 at 11:15am revealed that the narcotic box on 100-hall medication cart was not secured to the drawer in which it sat. The 100-hall medication nurse was able to lift the box free of the drawer. Interview on 04/11/2012 at 11:45am with LPN2 confirmed that although the box was still locked, it should be secured to the cart. Interview on 04/11/2012 at 12:3pm with maintenance supervisor revealed that the narcotic boxes in 4 medication carts were not screwed to the drawer and needed to be secured to the cart.",2016-06-01
8415,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,441,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of facility policy and procedure, the facility failed to follow the infection control policy for Employee Screening and Hand washing. Findings: 1. Review of the facility policy Employee Screening for [DIAGNOSES REDACTED] revealed for newly hired employees, the initial TB testing will is a two-step [MEDICATION NAME] skin test (TST) performed by injecting 0.1ml (5 [MEDICATION NAME] units) of purified protein derivative (PPD) intradermally. If the reaction to the first skin test is negative, the facility will administer a second skin test 1 to 2 weeks after the first test. Review of health records revealed the second step of testing was not completed in a timely manner for four of six employees (LPN4, NA6, E1, E2.) Three employees (LPN4, E1, E2) who were hired and had their first test administered on 03/21/2012 did not have a second skin test administered as of 04/12/2012. A fourth employee (NA6), whose first step was administered on 01/20/2012, did not have the second step administered until 02/12/2012, twenty-three days later. Interview on 04/12/2012 at 3:00pm with the Infection Control Nurse revealed that during orientation, newly hired staff are informed of the need for the second skin test. She confirmed that she was behind in monitoring staff to assure that the testing was completed as required. 2. Observation in the Cathedral Dining Room (CDR) on 04/11/2012 at 11:30am revealed an unidentified staff member touched the handle of a male resident ' s wheel chair then, without cleansing her hands, proceeded to pick up the bread on R11 ' s plate. This same staff member put margarine on one slice of bread and meat on the other slice. She folded the bread and placed the half sandwiches on the plate for R11 to eat. The staff member proceeded to assist all four of the residents at Table One to eat without cleansing her hands between contacts. General observation during lunch in the CDR on 04/11/2012 (11:30am-12:30pm) and breakfast in the CDR on 04/12/2012 (7:30am-8:15am) revealed all staff in the dining room fed and assisted multiple residents without cleansing their hands between contacts. Observation revealed three hand sanitizing stations were available for use in the dining room. 3. On 04/11/2012 in the CDR at 11:50am, the staff person at Table One removed a male resident from the table after he finished eating. She then brought an unidentified resident from another table and placed her in the recently vacated spot at Table One. The table cloth had remnants of food from the previous resident on it and the staff person did not remove the cloth or attempt to wipe it off before she placed the next resident ' s tray on top of the soiled cloth. 4. An interview with the Administrator and the Director of Nursing (DON) on 4/12/12 at 5:30pm revealed the facility had a policy and procedure for hand washing that included using hand sanitizer before direct contact with residents and after contact with a resident ' s intact skin and after contact with objects in the immediate vicinity of the resident . The Administrator stated staff had been trained on how and when to sanitize their hands and should know not to handle a resident ' s food. She further stated hand sanitizer was readily available in the facility.",2016-06-01
8416,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,456,E,0,1,5RWC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review of glucometer (blood sugar meters) quality control logs and interviews with facility staff the facility failed to ensure three of four glucometers were checked for accuracy on a daily basis. The facility failed to check glucometers on units 200, 300, and 400 daily. The facility had twenty-one of eighty-eight residents with the [DIAGNOSES REDACTED]. Findings: Review of record titled Daily Quality Control Record on 04/11/2012 revealed that no check had been performed on 04/10 or 04/11, on the glucometer that was in use on the 400-hall. Further examination revealed that this check for accuracy was not performed on 04/01, 04/03, 04/04, 04/05, 4/06, and 04/07. There were also numerous dates for March when the accuracy was not tested . Review of 300-hall record titled Daily Quality Control Record revealed that no check had been done on 04/01, 04/02, 04/03, 04/05, and 04/06. There were also numerous dates for March when the accuracy of the glucometer was not tested . Review of 200- hall record titled Daily Quality Control Record revealed that in April accuracy checks of the glucometer were not done on 04/01, 04/02, 04/04, 04/07, 04/08, 04/08, and 04/10. There were also numerous dates for March when the accuracy was not tested . Interview on 04/11/2012 at 3:3pm with LPN 4 stated, Glucometer checks are to be done every night and recorded. Interview with the Director of Nursing (DON) on 04/12/2012 at 3:30pm, indicated that the sheet of paper titled Glucometer Control Testing Log was the facility's policy and that testing was required every night and recorded on the log. The DON further stated another policy was not available the time of the survey.",2016-06-01
8417,BERKELEY SPRINGS CENTER,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2012-04-13,497,E,0,1,5RWC11,"Based on interview and personnel training record reviews, it was determined the facility failed to ensure five of ten Certified Nursing Assistants (CNA) (NA 1, 2, 3, 4,5) received at least twelve hours of in-service education per year and address areas of weakness identified through annual performance reviews. Findings: Review of personnel records for CNAs ' employed for more than one year revealed five of the ten reviewed had not received the required twelve hours of in-service education during the year of 2011. During an interview on 04/13/2012 at 9:45am, the Staff Development Coordinator confirmed that she was aware that the five CNAs reviewed had not completed all twelve hours. Interview with the Staff Development Coordinator and the Director of Nursing on 04/13/2012 at 10:30am revealed that although nurse aide performance reviews were completed, the program of in-service education was not based on areas of weakness identified during these reviews.",2016-06-01
10402,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,323,E,0,1,86JH11,"Based on record review and staff interview, the facility did not ensure fifty-five (55) residents with skin tears and forty-four (44) residents with bruises, out of one hundred-twenty (120) incident reports reviewed for a period of three and one-half (3.5) months were provided supervision to prevent accidents. Facility census: 89. Findings include: a) A review of the facility's incident reports for the months of June, July, August, and part of September 2009 revealed residents had received fifty-five (55) skin tears and forty-four (44) bruises. The bruises and skin tears were primarily found on the extremities (arms, hands, fingers, legs, and feet). An interview with the director of nursing (DON - Employee #1), on 09/23/09 at 3:00 p.m., revealed that a lack of adequate staffing was not the reason for so many bruises and skin tears at the facility. She related the staff may have been hurrying to get done, and she did not understand why the staff felt they needed to rush when providing care to the residents. She further related some of the bruises and skin tears were of an unknown origin and were submitted to the appropriate State agency. She identified that most of the residents at the facility required extensive or total assistance with transfers, and the facility had provided education for transfers to the nursing assistants, but she did not understand why there were so many bruises and skin tears. She stated the administrator, who was on sick leave, had started to track the incidents of bruises and skin tears and had began to put into place a prevention plan. However, no evidence was provided for the tracking, plan of action to prevent, or an evaluation of the plan of action. An interview with the acting administrator, on 09/23/09 at 3:00 p.m., revealed that when he arrived at the facility and reviewed the incidents of bruises and skin tears, he was concerned as to the number of incidents involving the residents.",2015-04-01
10403,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,309,E,0,1,86JH11,"Based on observation, review of operating / use instructions for BRODA Chairs (chairs used for safety reasons to prevent falls due to attempted unassisted ambulation), and staff interview, the facility failed to ensure two (2) of fifteen (15) sampled residents and three (3) randomly observed residents were provided the necessary care and services to maintain their highest practicable physical well-being. Residents #13, #9, #31, and #62 were seated in BRODA chairs with vinyl straps without padding to prevent injury and skin breakdown. Resident #23 was not positioned properly to prevent skin breakdown. Resident identifiers: #13, #9, #31, #62, and #23. Facility census: 89. Findings include: a) Resident #13 During meal service in the main dining room on 09/22/09 at 11:45 a.m., observation found this resident seated in a BRODA chair with vinyl straps in the back and seat and no padding. The resident's skin and clothing were pressed through the straps in the back due to unrelieved pressure. Further observations of this resident, on 09/23/09 at 3:40 p.m., found the resident seated in her room in the BRODA chair. The resident was wearing a hospital gown with the back open, and the resident's skin and curved spine were pressed against the vinyl straps of the chair due to the lack of protective padding. Review of incident / accident reports, on 09/22/09, found that, on 08/11/09, a report recorded the resident had a small abrasion on the mid-back due to the back rubbing against the strap of the BRODA chair. Review of operating instructions for the BRODA chairs, provided by the manufacturer of the chairs, found on page 5, item 1.10 titled ""Risk of Injury to Resident's Skin"", the following directions: ""We recommend that residents only be seated while they are fully dressed in clothing that meets the needs of their specific condition. If after being fully dressed, a resident's bare arms, legs, or body could still come into direct contact with the vinyl straps or vinyl pads, we recommend the use of a covering, such as the BRODA terry cloth covered seat and/or back pad or a folded cloth bed sheet to prevent contact. Direct contact of bare skin on the straps over a period of time could cause moisture on the resident, and/or cause the skin to stick to the straps."" In an interview on 09/23/09 at 4:15 p.m., the director of nursing (DON - Employee #1) confirmed this resident, while seated in the BRODA chair, was inappropriately dressed and no padding was present in the chair to protect her from injury. b) Resident #9 During meal service in the main dining room on 09/22/09 at 11:45 a.m., observation found this resident seated in a BRODA chair with vinyl straps in the back and seat and no padding. Further observation found the resident was wearing a hospital gown open in the back, and the resident's back was exposed through the straps in the back of the chair. During the meal service in the main dining room on 09/22/09 at 5:30 p.m., this resident was again seated in the BRODA chair while wearing a hospital gown. The back of the hospital gown was open, and the resident's back and adult incontinence brief were visible through the vinyl straps. During an interview in the dining room on 09/22/09 at 5:30 p.m., Employee #13 agreed the chair had no padding for the straps, and the resident's bare skin was against the vinyl straps. This practice had the potential to promote injury and/or skin breakdown. c) Residents #31 and #62 Observations in the facility, on 09/22/09 and 09/23/09, found Residents #31 and #62 seated in BRODA chairs with vinyl straps and no protective padding. During each of these observations, the resident's clothing and skin were pressed through the vinyl straps in the back and seat of the chairs due to the lack of padding. In an interview on 09/23/09 at 4:15 p.m., the DON confirmed these chairs lacked padding over the straps to prevent injury or skin breakdown to these residents. d) Resident #23 Observation, on 09/22/09 at 9:05 a.m., found this resident lying on her right side in a fetal position. A registered nurse (RN - Employee #9) uncovered the resident's legs to reveal the resident did not have a barrier between her knees, causing the knees to rub together. The resident was observed to be very emaciated. The RN stated the resident needed to have a pillow between her legs to prevent skin breakdown. .",2015-04-01
10404,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,250,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of the resident's medical record and staff interviews, the facility did not ensure one (1) of fifteen (15) sampled residents received medically-related social services to address his aggressive behaviors and verbals statements of a violent nature. Resident identifier: #80. Facility census: 89. Findings include: a) Resident #80 A nursing note, dated 06/16/09 at 2:00 p.m., recorded, ""Resident became upset and verbal with resident sitting next to him in dining room when another resident touched his coffee. Had to remove him from dining room. The resident calmed down."" On 07/31/09 at 6:45 p.m., a nurse recorded, ""Resident was sitting in middle of hallway after dinner blocking traffic when an aide moved him into his doorway. He reached up and slapped her across the left cheek. CNA (certified nursing assistant) had a red hand print across her cheek."" On 08/03/09 at 7:30 p.m., a nurse recorded, ""Resident called daughter to tell her he is dying of a broken heart and is going to die and is coming to haunt her, because she doesn't come to see him any more."" On 08/22/09 at 4:15 p.m., a nurse recorded, ""Resident was sitting in front of his room door. His roommate's daughter was trying to get into room and this resident did not want to move. CNA told resident that daughter was trying to get in room to visit and this resident stated I don't give a f*** about her. The CNA moved (Resident #80) out of doorway and he began cursing. Resident stated, I want to get the f*** out of this place."" On 08/29/09 at 4:00 p.m., a nurse recorded, ""(Resident #80) and another resident from 200 hall in hallway face to face having a verbal confrontation. (Resident #80) cursing and had fist drawn back threatening to hit 200 hall resident. (Resident #80) taken back to his room and told that he was to eat supper in his room. Continued to be agitated, stating he wasn't going to eat supper or take his pills. Also stated, he wanted his wheelchair which is motorized. Attempted to explain to resident that physical therapy would have to evaluate to determine if he can use his motorized wheelchair."" On 08/29/09 at 5:40 p.m., a nurse recorded, ""Resident sitting in hall outside of room. When told that his supper tray will be brought to his room. Resident stated you told me I couldn't eat. This nurse explained to him that he was told he would eat in his room at supper and that he was never told he couldn't eat. Continued to refuse supper stated, if his tray was brought to his room, he would throw it down the hall. Also stated, he would break the jaw of the resident from 200 hall."" On 08/29/09 at 6:00 p.m., a nurse recorded, ""Resident told station II nurse that he didn't want his nails cut anymore, because he wanted them to grow longer and sharp so he could rip 200 hall resident's throat out."" Further review of Resident #80's medical record revealed this [AGE] year old was admitted on [DATE], with [DIAGNOSES REDACTED]. He was evaluated by a psychiatrist on 03/24/09. with an assessment of anger and agitation. There was no evidence to reflect he was seen again by the psychiatrist. An interview with the director of nursing (DON), on 09/23/09 at 3:40 p.m., revealed she was unaware of the resident's behavior or the statement that he did not want his nails cut anymore, that he wanted them to grow long and sharp so he could rip the throat out of the resident on 200 hall. An interview with the social worker (Employee #86), on 09/23/09 at 3:45 p.m., revealed the social worker was not aware of the resident's escalating behaviors. She stated that nursing staff did not tell her the resident was making threats against another resident. She further stated she would immediately get the psychiatrist to see the resident for an evaluation A review of the resident's care plan, with a revision date of 08/05/09, revealed the following: - Problem - ""Potential for mood disturbance."" - Goal - ""Will remain free of signs and symptoms of distress, symptoms of depression, anxiety or sad mood."" - Intervention - ""Notify physician as soon as possible for any suicidal ideations or self-harming behaviors."" .",2015-04-01
10405,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,520,E,0,1,86JH11,"Based on record review and staff interview, the facility's quality assessment and assurance committee failed to implement corrective measures to address the facility's high prevalence of bruises and skin tears. The facility's incidents reports indicated that, over a three and one-half (3.5) month period, residents received fifty-five (55) skin tears and forty-four (44) bruises. Facility census: 89. Findings include: a) A review of the facility's incident reports for the months of June, July, August, and part of September 2009 revealed residents had received fifty-five (55) skin tears and forty-four (44) bruises. The bruises and skin tears were primarily found on the extremities (arms, hands, fingers, legs, and feet). An interview with the director of nursing (DON - Employee #1), on 09/23/09 at 3:00 p.m., revealed that a lack of adequate staffing was not the reason for so many bruises and skin tears at the facility. She related the staff may have been hurrying to get done, and she did not understand why the staff felt they needed to rush when providing care to the residents. She further related some of the bruises and skin tears were of an unknown origin and were submitted to the appropriate State agency. She identified that most of the residents at the facility required extensive or total assistance with transfers, and the facility had provided education for transfers to the nursing assistants, but she did not understand why there were so many bruises and skin tears. She stated the administrator, who was on sick leave, had started to track the incidents of bruises and skin tears and had began to put into place a prevention plan. However, no evidence was provided for the tracking, plan of action to prevent, or an evaluation of the plan of action. An interview with the acting administrator, on 09/23/09 at 3:00 p.m., revealed that when he arrived at the facility and reviewed the incidents of bruises and skin tears, he was concerned as to the number of incidents involving the residents. The facility's quality assessment and assurance committee failed to implement interventions to decrease the number of skin tears and bruises.",2015-04-01
10406,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,329,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of OBRA's ""Unnecessary Drugs in the Elderly"", and staff interview, the facility failed to ensure the drug regimen of one (1) of fifteen (15) sampled residents was free from unnecessary drugs. Resident #55 was receiving the sedating drug [MEDICATION NAME] in a dosage higher than recommended for use in the elderly. The resident had a recent dose increase on 08/17/09, from 0.25 mg TID (three-times-a-day) to 0.5 mg TID for increased anxiety without adequate indications for this increase documented in the resident's record. Resident identifier: #55. Facility census: 89. Findings include: a) Resident #55 Medical record review, on 09/22/09, disclosed this [AGE] year old resident had a recent dose increase in the sedating drug [MEDICATION NAME]. On 08/17/09, the physician increased the [MEDICATION NAME] from 0.25 mg TID to 0.5 mg TID for increased anxiety. Review of physician's progress notes found no reference to the resident exhibiting an increase in anxiety and no mention of the clinical rationale for doubling the resident's daily dose of [MEDICATION NAME].. Review of nursing notes for the month of August 2009 found no contemporaneous documentation in the resident's medical record to reflect the resident was exhibiting an increase in anxiety. Review of a psychiatric consult, dated 08/17/09, revealed the following: ""Pt. (patient) alert, oriented to self only, pleasant & cooperative, restless, got out of w/c (wheelchair) a lot /c (with) shuffled gait, thought processes consistent /c dementia."" The psychiatrist recommended increasing the [MEDICATION NAME] to 0.5 mg TID. During the review of OBRA's ""Unnecessary Drugs in the Elderly"" revealed the recommended maximum daily dose for [MEDICATION NAME], a short acting Benzodiazapine sedating drug, was 0.75 mg for the elderly. With the dose increase, this resident was now receiving 0.5 mg TID for a total daily dose of 1.5 mg, twice the amount recommended. A comparison of the resident's most recent quarterly minimum data set (MDS), with an assessment reference date (ARD) of 08/02/09, and a significant change in status MDS, with an ARD of 09/04/09, revealed the resident had experienced a decline in the self-performance of transfer and ambulation, a decline in continence, a decline in moods / behaviors, and the use of a physical restraint. The resident had been placed in the BRODA chair to prevent independent ambulation, the resident's [MEDICATION NAME] dosage was doubled on 08/17/09, and the decline in self-performance of ADLs began, resulting in the need to complete a significant change in status assessment. In an interview on 09/23/09 at 4:30 p.m., the director of nursing (Employee #1) confirmed the resident's [MEDICATION NAME] had been increased. .",2015-04-01
10407,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,363,D,0,1,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record and planned menu reviews and staff interview, the facility failed to prepare menus for two (2) therapeutic diets as ordered by the physician (an 1800 ADA Vegetarian Diet and a Low Potassium Diet) for one (1) of fifteen (15) sampled residents and one (1) randomly selected resident. Resident identifiers: #68 and #85. Facility census: 89. Findings include: a) Resident #85 Review of Resident #85's medical record, on 09/22/09, revealed she was admitted to the facility on [DATE], with the order for an 1800 ADA Vegetarian Diet. Review of the care conference notes of 09/17/09 revealed the resident had requested that she have one (1) veggie burger a day. The resident and a family member, on 09/22/09, expressed concern to the surveyor as to whether she was receiving the daily recommended amount of protein in her diet. b) Resident #68 Review of Resident #68's medical record, on 09/23/09, revealed her current diet order was a Low Potassium (K) Diet (60 meq/day). Review of the tray card with the lunch meal on 09/23/09 revealed ""Mech Sft. Lo K"" and no plan for the food items she should receive for this diet, especially in view of the twenty-nine (29) food dislikes listed on the tray card. c) Planned Menus Review, on 09/22/09, of the Spring / Summer menus for Week 1 found no planned menus for the 1800 ADA Vegetarian or the Low K (60 meq/day) diets. Interview with the dietary manager, on the afternoon of 09/23/09, confirmed there were no planned menus for these two (2) therapeutic diets for any of the four (4) weeks of the Spring / Summer cycle. .",2015-04-01
10408,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,431,E,0,1,86JH11,"Based on observation, staff interview, and review of the facility policy on medication administration, the facility failed to document the dates multi-dose vials were opened. This was true for one (1) of two (2) medication rooms observed. Multi-dose vials of insulin and tuberculin derivative vials were not labeled with the date opened. This practice has the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) On 09/22/09 at 5:45 p.m., observation of the medication room on the 100 hallway found four (4) opened vials of Lantus insulin and three (3) opened multi-dose vials of Tuberculin Purified Protein Derivative. The vials were not labeled with the date they were opened. A licensed practical nurse (LPN - Employee #18), when interviewed on 09/22/09 at 5:45 p.m., confirmed the multi-dose vials of medication were not labeled with the date each vial was opened. The LPN discarded the medications and ordered new insulin medication from the pharmacy. The LPN further stated it was the facility's policy to labeled all multi-dose vials with the date opened. The director of nursing (DON - Employee #1), when interviewed on 09/24/09 at 8:30 a.m., provided a copy of the facility's policy titled ""Administering Medications"". The policy stated, ""When opening a multi-dose container, place the date on the container."" .",2015-04-01
11242,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,241,E,1,0,86JH11,"Based on observation, staff interview, and resident interview, the facility did not ensure eleven (11) of forty-five (45) randomly observed residents received care in an environment that enhanced each resident's dignity and respect. The noise level in the dining room did not promote a pleasurable and social experience. Independent diners were seated in the dining room with residents required extensive or total assistance with eating; these independent diners had to wait thirty-five (35) minutes before they were served their meals, while having to watch the dependent diners eat. Additionally, Resident #9 was exposed in the dining room. These practices have the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) Observations, on 09/21/09 at 6:20 p.m. and 09/22/09 at 12:30 p.m., of the meal service in the main dining room found the noise level was loud. Residents were observed banging on tables, and other residents were yelling out. Residents #22, #54, #72, #8, #16, #51, #63, #84, #67, and #15 were sitting at various tables in the first section of the dining room. These residents were not socializing with the other residents at the table. An interview with Resident #44, on 09/23/09 at 2:00 p.m., revealed he refused to eat in the main dining room because of the noise level. He related having enjoyed, in the past, the opportunity to eat in the little dining room with other residents who needed some assistance, and he enjoyed sitting with the residents for socialization. The resident stated the facility did not use the little dining room any more. He stated he had asked the facility's administration why they could not continue to go to the little dining room. He was told the facility did not want to have to place an aide in the little dining room and that the big dining room was suitable for all residents. Resident #44 stated that, after he was told the little dining room was no longer available for use by the residents, he ate in his room. He further stated that he had really enjoyed the small group setting; it was quiet and relaxing. An interview with a nurse (Employee #8), on 09/22/09 at 5:40 p.m., revealed the facility brought all of the residents together in the main dining room, because they did not want to divide the staff. It was easier to have all of the staff in one (1) location where they could feed and assist the residents instead of having to staff a second dining area. b) Observation during the noon meal on 09/23/09 found the main dining room (Cathedral Gardens) was divided into two (2) sections. Interview with Employee #12 revealed one (1) section was being used for the residents who required staff for ""total feeding or assistance"", and the second section was designated as the ""cueing dining"" area for all other residents not eating in their rooms. Employee #12 acknowledged that residents who required only tray set up (and who were otherwise independent with eating) were seated in the cueing dining section. c) Resident #9 During the lunch meal on 09/22/09 at 11:45 a.m., observation found this resident seated in the main dining room in a BRODA chair with vinyl straps and no padding. Further observations revealed the resident was wearing a hospital gown open in the back. The resident's back was exposed through the straps in the back of the chair. When employees noted this surveyor looking at the resident, two (2) employees went to the resident and arranged the hospital gown to cover the resident in the back. During further observations in the main dining room on 09/22/09 at 5:30 p.m., this resident was again seated in the BRODA chair and wearing a hospital gown. The back of the gown was open, and the resident's back and adult incontinence brief were visible through the chair straps. During an interview in the dining room at 5:30 p.m. on 09/22/09, Employee #13 agreed the chair had no padding for the straps, and the resident was exposed in this public area of the facility. d) During the confidential resident group meeting held on 09/22/09, four (4) of seven (7) residents in attendance complained about sitting in the dining room, watching as the residents in the adjoining dining area receive their meal trays and are being fed, while they have to wait to be served their meals. During the evening and noon meal services in the main dining room on 09/22/09 and 09/23/09, observation found staff serving meals to and assisting the dependent residents before ensuring the alert, oriented residents who required no assistance received their meal trays. The alert, oriented residents (who required no assistance with eating) waited approximately thirty-five (35) minutes, while seated in the dining room watching others eat, before their food was served. Interview with the director of nursing (DON - Employee #1), on 09/23/09 at 4:30 p.m., confirmed the residents who required no assistance with meals had to wait for their food while watching others eat. .",2014-07-01
11243,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,225,E,1,0,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Part I -- Based on a review of facility records, staff interviews, and family interview, the facility did not ensure allegations of abuse involving two (2) of fifteen (15) sampled residents and one (1) unidentified resident of random opportunity were immediately reported to the appropriate State agencies and/or thoroughly investigated, with protection offered to the residents during the investigation. Resident identifiers: #30 and #25, and an unidentified resident discovered during review of an employee's personnel file. Facility census: 89. Findings include: a) Resident #30 A review of a facility form ""Immediate Reporting of Allegations - Nursing Home Program"" revealed, ""Resident alleges a staff member hurt his arm and was nasty to him when forcing him to go to bed after he refused. The resident pointed to his right arm. LPN (licensed practical nurse) checked right arm and did not see any bruising or redness. The resident described staff member as being short, heavy and having blonde hair."" The allegation of abuse was made on 03/05/09 at 7:30 (did not include a.m. or p.m.). The ""Five Day Follow-up - Nursing Home Program"" report indicated, ""After interviewing and gathering witness statements the resident had several interactions with different staff members during the time alleged mistreatment took place. The resident was unable to clearly identify the staff member who allegedly forced him to go to bed or who allegedly hurt his arm."" The incident was reported by the resident on 3-5-09 at 7:30 (did not include a.m. or p.m.) and the facility's Immediate Reporting of Allegations form listed information on the size and hair color of the alleged perpetrator. The facility conducted an investigation of the staff that had worked on the day and shift that the alleged abuse occurred. The facility obtained a witness statement from one (1) nursing assistant that indicated another nursing assistant had attempted to put the resident to bed, because the resident was trying to get out of bed on his own. There was no evidence that this or other residents were protected during the course of the facility's investigation into this allegation, there was no evidence found in the facility's records describing the nursing assistant identified as the person attempting to put the resident to bed, and there was no Immediate Reporting of Allegations submitted to the Nurse Aide Registry after the facility became aware of the identity of the alleged perpetrator. b) Unidentified Resident A witness statement found in an employee's personnel record revealed, ""On 4-7-08 around 7:30 p.m. I heard the resident in (room number) yelling you do this out of goddamn spite. As I rounded the corner I observed (Employee #44, a nursing assistant) with a handful of towels walking out of the resident room headed toward another room. I then asked what was going on and she strongly stated, he can kiss my f***** a**. I told her to calm down and I would speak with her in a minute. I then noticed resident in (room number) by his bathroom door. So I went to see what he needed and he stated I asked that damn girl to drain my bag (catheter) and she told me she had more important things to do right now. As I was draining the catheter bag the resident stated, you told me if I needed anything to put my light on and that's what I did. The aide told me I will have to wait. I told her I will do it myself and she said she didn't care if I fell and broke my hip. I went back to the nurses station and on the way I heard (Employee #44) shouting something from the room of (number). She was shouting from room (number). She was saying he does this s*** all the time, he acts like this is the goddamn Hilton. I ain't nobody's (n word) I motioned for her to come out of the room and she stated that he wants things right now. She then stated he can go to hell and kiss my a**. The DON can get her f****** write-up papers."" This was reported to a registered nurse. The facility did not protect the resident during the investigation or report these allegations of abuse and neglect to the appropriate State agencies. c) Resident #25 Resident #25's medical record, when reviewed on 09/22/09 at 10:00 a.m., disclosed at [AGE] year old female who was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. Review of the social service progress notes, dated 06/23/09, found, ""There has been an instance where it was suspected that (name listed) may have poured water on her mother's lap..."" There was no evidence in the social worker's progress notes that this suspected physical abuse, by a family member while at the facility, was reported to State agencies as required. Review of the facility's self-reported allegations for June 2009 did not find evidence to reflect the alleged abuse was reported to adult protective services or the State survey agency as required. The social worker (Employee #85), when interviewed on 09/23/09 at 3:00 p.m., confirmed the allegation of physical abuse was not immediately reported as required. The social worker stated the allegation was ""sent approximately two weeks after the incident"". --- Part II -- Based on review of sampled personnel records and staff interview, the facility did not ensure that criminal background information was completed for five (5) employees of a sample of ten (10). Employee identifiers: #6, #7, #8, #9, and #10. Facility census: 89. Findings include: a) Employee #6 Personnel record review revealed this employee had a work history in the Commonwealth of Pennsylvania. Further review of the personnel file found no evidence of a criminal background check having been done in a reasonable effort to uncover any criminal record in that state. In an interview of 09/23/09 at 2:30 p.m., Employee #130 confirmed a criminal background check had not been done in the Pennsylvania prior to hiring Employee #6. b) Employee #7 Personnel record review revealed this employee had a work history in the Commonwealth of Pennsylvania and held nursing licenses in the Commonwealths of Pennsylvania and Virginia. Further review of the personnel file found no evidence of criminal background checks having been done in a reasonable effort to uncover any criminal record in these states. Additionally, there was no evidence to reflect the facility had verified the status of Employee #7's licenses with the nursing boards in Pennsylvania and Virginia. In an interview of 09/23/09 at 2:30 p.m., Employee #130 confirmed no criminal background checks had not been done or verifications of nursing license in Pennsylvania and Virginia prior to hiring Employee #7. c) Employee #8 Personnel record review revealed this employee had lived and worked in the State of Maryland. Further review of the personnel file found no evidence of a criminal background check or nurse aide registry check having been done in a reasonable effort to uncover any criminal record in Maryland or findings of resident abuse / neglect which would indicate this individual was unfit for service. In an interview of 09/23/09 at 2:30 p.m., Employee #130 confirmed these background checks had not been done prior to hiring Employee #8. d) Employee #9 Personnel record review revealed this employee had worked in the State of Maryland. Further review of the personnel file found no evidence of a Maryland nurse aide registry check having been done in a reasonable effort to uncover findings of resident abuse / neglect which would indicate this individual was unfit for service. In an interview of 09/23/09 at 2:30 p.m., Employee #130 confirmed a check of the Maryland nurse aide registry had not been done prior to hiring Employee #9. e) Employee #10 Personnel record review revealed this employee had presented evidence of residence in the State of Florida and prior employment in the State of Texas and the Commonwealth of Virginia. Further review of the personnel file found no evidence of criminal background checks or nurse aide registry checks having been done in these states in a reasonable effort to uncover any criminal record or findings of resident abuse / neglect which would indicate this individual was unfit for service. In an interview of 09/23/09 at 2:30 p.m., Employee #130 confirmed the criminal background and registry checks had not been done in these states prior to hiring Employee #10. .",2014-07-01
11244,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,368,E,1,0,86JH11,"Based on observation, resident interview, confidential resident group interview, and staff interview, the facility failed to offer evening snacks to all residents. This was true for one (1) of fifteen (15) sampled residents and four (4) of seven (7) residents attending the confidential group meeting, who reported the facility staff did not offer evening snacks to all residents. Resident identifier: #68. Facility census: 89. Findings include: a) On 09/21/09 at 8:00 p.m., snacks were observed delivered on a tray and placed on the 100 hallway nurses' desk. The snacks were labeled with specific residents' names. There was approximately twenty (20) snacks on the tray. The nursing assistants were observed picking up the snacks and delivering them to individual residents. Multiple residents on the 100 hallway were observed to not have been offered an evening snack. b) Resident #68 Resident #68, when interviewed on 09/23/09 at 10:15 a.m., reported she was not offered a bedtime snack. The resident stated, ""I guess it is because I am at the end of the hall. They must forget me."" The resident reported she would like to be offered a snack every night at bedtime. c) Four (4) of seven (7) residents, attending a confidential group meeting on 09/22/09 at 1:30 p.m., reported only certain residents received an evening snack. One (1) of the residents stated, ""The staff does not offer snacks to all residents, unless the physician has ordered them in the care plan meeting."" d) Interview with the dietary manager, on the afternoon of 09/23/09, revealed therapeutic bedtime (HS) snacks were prepared in the dietary department and labeled with these residents' names. A variety of foods (cookies, crackers, ice cream, and sandwiches) for the HS snacks for the residents with a regular diet order were stocked and available in the nutrition pantry at the nursing stations to be distributed by the nursing staff. e) When interviewed on 09/23/09 at 4:40 p.m., Employee #82 confirmed that, if a resident on a regular diet tells a nursing assistant they are hungry, snack foods at the nutrition station (like sandwiches, cookies, and ice cream) are available and are given to the resident. .",2014-07-01
11245,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,246,D,1,0,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to ensure one (1) randomly observed resident's adaptive equipment was within reach. A non-verbal resident's communication device was not placed within the resident's reach. Resident identifier: #84. Facility census: 89. Findings include: a) Resident #84 Observation, on 09/21/09 at 6:30 p.m., found Resident #84 in a low bed with bilateral floor mats. A ""light-writer"" communication device was observed turned off and sitting on the night stand, not within the resident's reach. A communication board was observed on a clip board hanging from the foot board, also not within the resident's reach. On 09/22/09 at 8:30 a.m., the resident was observed awake in bed. The communication board was located on a clip board hanging from the foot board of the bed, and the light writer device was observed on the nightstand beside the bed. Neither device was within the resident's reach. On 09/22/09 at 11:40 a.m., the resident was observed in a low bed. The light writer device was observed turned off and located on the bedside stand, not within the resident's reach. The communication board was on a clip board hanging from the footrest, also not within the resident's reach. The licensed practical nurse (LPN - Employee #26), when interviewed on 09/22/09 at 11:45 a.m., stated she ""was not sure"" if the resident still was able to use the communication device. The LPN turned on the light writer device, and the resident was able to use her fingers and answer all questions. Resident #84, when interviewed on 09/22/09 at 11:45 a.m., used the device and answered ""yes"" when asked if she would prefer the communication device left on the bed near her hand and within reach. Resident #84's medical record, when reviewed on 09/23/09 at 3:00 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE] with Von Willebrand's disease. The resident required total assistance with activities of daily living and was non-verbal. Review of the resident's current care plan, dated 07/30/09, found a problem statement about the resident's [MEDICAL CONDITION] and impaired communication. One (1) of interventions listed for impaired communication stated, ""Encourage use of communication board and light writer."" Review of the ""Care Plan Team Meeting Summary"" sheet, dated 07/21/09, found, ""Res(ident) alert, @ x's will use call light when she needs something - uses communication board and light-writer to communicate needs."" .",2014-07-01
11246,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,312,D,1,0,86JH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, and staff interview, the facility failed to provide personal care for one (1) of fifteen (15) sampled residents and one (1) randomly observed resident. A resident who required assistance with oral care was observed in need of oral care, and a resident's toe nails were not trimmed. Resident identifiers: #25 and #84. Facility census: 89. Findings include: a) Resident #84 Resident #84, when observed in bed on 09/21/09 at 6:45 p.m. and on 09/22/09 at 11:40 a.m., had a thick film of yellowish-brown debris noted caked on her upper teeth. A licensed practical nurse (LPN - Employee #26), when interviewed on 09/22/09 at 11:45 a.m., acknowledged the resident was in need of oral care. Resident #84's medical record, when reviewed on 09/22/09 at 3:00 p.m., disclosed a [AGE] year old female who was admitted to the facility on [DATE]. Review of the quarterly minimum data set (MDS), with an assessment reference date (ARD) of 07/19/09, found the resident was totally dependent on staff for hygiene. The care plan, with a revision date of 07/30/09, identified the resident had a self-care deficit and required total care. An intervention listed on the care plan was to ""provide oral care BID (twice daily) and PRN (as needed)"". Resident #84, when interviewed using the light writer communication device on 09/22/09 at 3:30 p.m., replied ""no"" when asked if staff provided mouth care daily. b) Resident #25 Resident #25's medical record, when reviewed on 09/22/09 at 2:30 p.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was currently receiving hospice services. The admission MDS, with an ARD of 06/28/09, reported the resident was totally dependent on staff for personal hygiene. The director of nurses (DON - Employee #1), when interviewed on 09/24/09 at 8:15 a.m., reported it was the facility's policy to have licensed nurses trim the residents' toe nails. Resident #25, when observed in bed on 09/24/09 at 8:30 a.m., had toe nails that were long, chipped, and in need of trimming. .",2014-07-01
11247,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2009-09-24,226,E,1,0,86JH11,"Based on staff interviews, record review, and policy review, the facility failed to operationalize its policies and procedures for preventing resident abuse / neglect, by failing to ensure all staff addressed concerns and complaint voiced by residents and families in a consistent, systematic manner. Five (5) of six (6) employees interviewed related different mechanisms by which the facility addressed complaints voiced residents or families, with no consistency between them. This has the potential to affect more than an isolated number of residents. Facility census: 89. Findings include: a) An interview with one (1) of two (2) social workers (Employee #86), on 09/22/09 at 10:00 a.m., revealed the facility did not have a complaint file. Any complaints brought by residents or families to the attention of the social service department were addressed in the social service notes and placed on the individual chart of each resident. Nursing staff would also record complaints in the nursing notes on each individual resident's medical record. The social service department would decide if a complaint were an allegation of abuse or neglect, and if it were determined that the complaint contained such allegations, the information was forwarded to the appropriate State agency. The social worker also related they would ask the individual if he or she wanted to make this a formal complaint or a concern. If the complainant asked the complaint to be addressed as ""formal"", the complaint would be written up. If the complainant stated this was only a sharing of ""concerns"", the concern was not written up. b) In an interview on 09/22/09 at 10:30 a..m., a nurse (Employee #14) revealed that if a resident or family member had a concern or grievance, the nurse would handle the problem immediately. The nurse further stated he would not necessarily let social services know about the complaint. c) In an interview on 09/22/09 at 10:45 a.m., another nurse (Employee #9) revealed that any complaints made by residents or family members would be submitted to the ""care coordinator"" who was the supervising registered nurse. She did not know what happened after the complaint was submitted to the care coordinator. d) In an interview on 09/22/09 at 11:15 a.m., a third nurse revealed that complaint forms were located at each nursing station, and this form was to be filled out by any of the nursing staff and submitted to the care coordinators or to social services. e) An interview with the director of nursing (DON), on 09/22/09 at 11:30 a.m., revealed she was unaware of the use of these complaint forms. If the nurse received a complaint from a resident or family member, the nurse was to write the information in the nursing notes for the individual resident, and this was located on the resident's chart. The DON was repeatedly asked for any complaint forms that were submitted from the nursing staff. No evidence was supplied that a complaint file existed. f) In an interview on 09/23/09 at 4:30 p.m., another nurse (Employee #28) revealed she personally handled any concern a resident or family member would have. The nurse did not mention filling out a complaint form or submitting the concern to a care coordinator or social worker. g) A review of the facility policies for abuse revealed, ""Section III. Prevention. Provide residents, families and staff with information on how and to whom they may report concerns, incidents, and grievances without the fear of retribution, and provide feedback. Protect residents from harm during an investigation."" .",2014-07-01
11248,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2010-07-28,425,D,1,0,K95111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and resident interview, the facility failed to acquire medications in a timely manner to meet the needs of each resident. The facility did not have in place an effective system to ensure the availability of narcotic analgesics for two (2) of two (2) sampled residents who had physician's orders [REDACTED]. Resident identifiers: #89 and #50. Facility census: 91. Findings include: a) Resident #89 Record review revealed Resident #89 was admitted to the nursing facility at 11:00 a.m. on 06/18/10, for rehabilitation following orthopedic surgery. Upon admission, her physician ordered the administration of a narcotic analgesic (Dilaudid) on an as needed basis (PRN); her Dilaudid was later changed from PRN to scheduled doses every six (6) hours. According to the Medication Error Report, the medication was not available for administration to Resident #89 at 2:00 a.m. on 06/23/10. The medication did not arrive by courier from the primary vendor pharmacy until after 4:00 a.m. on 06/23/10. According to documentation on the report, the resident was described as ""angry"", because the medication was not available for administration as scheduled. Review of the Individual Resident's Controlled Substance Record found the medication was administered to the resident at 6:30 a.m. on 06/23/10. This equates to a ten and one-half (10-1/2) hour lapse between doses of scheduled analgesic for this resident. Subsequently, the resident signed herself out of the facility later that same morning. During an interview on 07/28/10 at 8:45 a.m., the director of nursing (DON - Employee #1) said she had contacted the primary vendor pharmacy more than three (3) times over the past six (6) months regarding times of medication delivery, as she preferred and had requested the pharmacy to deliver medications between 12:00 a.m. and 2:00 a.m. daily. Previously, she said it was more an aggravation, and they did not have a real issue until this happened. She said their pharmacy was on call ""24/7"", but there was a five (5) hour commute from the pharmacy to the facility for delivery. Also, their community had only two (2) local pharmacies, both of which had set hours of operation. She said the dose and interval change for this resident created a shortage of the medication, and she agreed that, if the pharmacy had not been late delivering the Dilaudid, there would not have been a problem. The DON further stated there were two (2) instances whereby they would potentially have a problem getting a narcotic analgesic: (1) when a resident arrives at the facility after hours (after 5:00 p.m.), when the physician has left his office for the day and the pharmacy stops taking faxed orders; and (2) when a resident's dosage changes and there is not enough left in stock until pharmacy delivers. When asked, she said nurses are not supposed to sign out (""borrow"") medications prescribed for a resident to give to another resident. Also, the facility did not stock Class II controlled substances (including Dilaudid) in their emergency drug box. -- b) Resident #50 1. Review of Resident #89's Individual Resident's Controlled Substance Record revealed that, after Resident #89 discharged herself from the facility on 06/23/10, there were three (3) separate occasions when staff ""borrowed"" from Resident #89's supply of Dilaudid for administration to Resident #50 (once on 06/25/10 and twice on 06/26/10). 2. In an interview on 07/26/10 at 4:40 p.m., a registered nurse (RN - Employee #11) revealed Resident #50 was out of her Class II narcotic analgesic used for orthopedic pain, and she was waiting for pharmacy to deliver it. This medication was scheduled to be given every four (4) hours and a dose was due at 4:00 p.m. During an interview with Resident #50 at this time, she rated her pain when moving at ""6"" on a scale from ""1"" to ""10"" (with ""10"" being the worst), and rated her pain at ""4-1/2"" when lying still. In a subsequent interview on 07/26/10 at 5:00 p.m., Employee #11 revealed the vendor pharmacy delivered the medication at 4:55 p.m. and the resident just received her dose. In an follow-up interview with Resident #50, she agreed she received her 4:00 p.m. medication exactly at 5:00 p.m. on 07/26/10. 3. During an interview on 07/27/10 at 8:45 a.m., the DON said day shift staff ordered Resident #50's narcotic pain medication yesterday morning (07/26/10), saying they needed it at 4:00 p.m. The DON said, had the pharmacy not guaranteed they would deliver by 4:00 p.m., the facility would have gone to the physician's office to obtain a written prescription and had it filled at the local pharmacy. 4. During interview with a pharmacist from the primary vendor pharmacy at 07/27/10 at 2:00 p.m., he confirmed the DON had asked that medications be delivered between 12:00 a.m. and 2:00 a.m. daily, but he said this was not always possible. He said Resident #50 should have gotten the medication on time yesterday, as the courier left at 10:00 a.m., and it was a five (5) hour drive. When informed that, on three (3) occasions last month, nurses signed out Class II narcotics prescribed to Resident #89 (who discharged to home) and gave them to Resident #50, the pharmacist said this was not best practice. He clarified they take faxed orders until 5:30 p.m. daily and said, if a resident is admitted to the facility after hours and is in pain, the nurse can call the doctor and get an order for [REDACTED]. 5. During an interview on 07/28/10 at 11:30 a.m., the DON said nurses should not ""borrow"" from another resident's medications. After looking at the Individual Resident's Controlled Substance Record that showed where five (5) Dilaudid doses belonging to Resident #89 were signed out to Resident #50 in the evening and early morning hours following her 5:30 p.m. admission to the facility, she said the nurse probably did this due to an emergent situation or at the resident's insistence. The DON did not disagree when this surveyor noted that the primary vendor pharmacy had no apparent plan in place to ensure those residents who arrived after hours and who were in a lot of pain received narcotic analgesics to achieve effective pain control. .",2014-07-01
11249,BERKELEY SPRINGS REHABILITATION AND NURSING,515137,456 AUTUMN ACRES ROAD,BERKELEY SPRINGS,WV,25411,2010-07-28,309,E,1,0,K95111,". Based on medical record review, policy review, and staff interview, the facility failed to follow its own policy on pain management. Facility policy states residents will be assessed using a scale to rate the severity of pain, and nurses will return after pain medication administration to rate the effectiveness of the medication and record the time of this post-administration assessment. This was not done at all for one (1) of three (3) sampled residents and was done inconsistently for two (2) of three (3) sampled residents. This practice has the potential to affect all residents in the facility who receive pain medication on an ""as needed"" basis, as it relates to evaluation of the treatment effect on patient comfort and functionality Resident identifiers: #50, #89, and #90. Facility census: 91. Findings include: a) Resident #50 Review of notes on the reverse side of the June 2010 Medication Administration Record [REDACTED]. Additionally, the pain scale was not used either before or after pain medication administration to assess the severity level of pain the resident perceived, nor was it used to assess for effectiveness after the medication was administered. Review of notes on the reverse side of the July 2010 MAR indicated [REDACTED]. -- b) Resident #89 Review of notes on the reverse side of the June 2010 MAR indicated [REDACTED]. The total on the Individual Resident's Controlled Substance Record revealed she received the pain medication thirteen (13) times on an ""as needed"" basis before going on schedule dosing, with no documentation in either the notes on back of the MAR indicated [REDACTED]. -- c) Resident #90 Review of notes on the reverse side of the April 2010 MAR indicated [REDACTED] Review of May 2010 nursing notes revealed one (1) of three (3) opportunities to record results of pain medication administration was omitted on 05/03/10 at 4:00 p.m. Review of the care plan revealed a goal for this resident to ""report relief of pain within one (1) hour of receiving pain meds or treatment through review date"", and an intervention on page 10 of the care plan to ""Administer medications as ordered and monitor for side effects, effectiveness and document.... provide alternative comfort measures, i.e. heat / cold applications, massage, relaxation, positioning, PRN."" During interview with the director of nursing (DON - Employee #1) on 07/28/10 at 9:40 a.m., she said she would expect nurses to document the effectiveness of pain medications after administration, and said they were to use a scale to rate pain from ""1"" to ""10"" (with ""10"" being the worst) or pictures of faces for some resident who cannot use the scale. She acknowledged that blanks were left in the notes of the MARs for the above residents, where staff was to document the effectiveness of pain medication and the time the nurse did the assessment. At 11:30 a.m., she returned and agreed the forms reviewed for the above three (3) residents were indeed the forms the facility was using to document the time and results of ""as needed"" pain medication administration; she also agreed the nurses needed to assess the residents' pain both before and after the administration of pain medication. .",2014-07-01
5302,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,246,D,0,1,90J611,"Based on observation, resident interview, and staff interview, the facility failed to provide reasonable accommodation of individual needs for two (2) of twenty-two (22) sample residents. The physical environment was not maintained in a manner which allowed for independent functioning, as the residents were unable to turn their over-the-bed lights on and off as desired. Resident identifiers: #158 and #136. Facility census: 100. Findings include: a) Resident #158 On 06/25/15 at 10:09 a.m., during Stage 1 resident interviews, Resident #158 was asked if there were any issues regarding lighting in the room related to his comfort. Resident #158 stated the lighting was fine, if he could turn his over-the-bed light on and off as needed, but there was no way to do that. An observation of the over-the-bed light at that time revealed a three (3) inch chain hanging from the over-the-bed light. There was no cord attached which Resident #158 could reach to turn the light on and off as he desired. b) Resident #136 During Stage 1 resident interviews on 06/25/15 at 11:16 a.m., Resident #136 was asked if there were any issues regarding light in the room related to her comfort. Resident #136 stated No. Observation of the over-the-bed light at that same time revealed a three (3) inch chain with a four (4) inch piece of cord attached. When Resident #136 was asked if she was able to turn her over-the-bed light on and off as she wished, the resident stated she just kept it on all the time. She said if she needed it turned off, she had to put on her call light. c) In an interview with the administrator on 07/01/15 at 4:00 p.m., she stated she was not aware of any issues with the over-the-bed light cords. She said she would inform the maintenance department to check all residents' light cords and replace them as needed. d) On 07/02/15 at 9:15 a.m., the administrator confirmed there were missing over-the-bed light cords in the rooms of Residents #158 and #136, and those were being replaced. In addition, the administrator said all residents' rooms had been checked, and the over-the-bed light cords were being replaced as needed.",2019-01-01
5303,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,247,D,0,1,90J611,"Based on medical record review, resident interview, facility policy and procedure review, and staff interview, the facility failed to provide a notice before a room change to one (1) of two (2) residents reviewed for admission, transfer and discharge during Stage 2 of the survey. The resident was moved from a room on Hall 2 to Hall 1 without prior notice of the room change. Resident identifier: #19. Facility census: 100. Findings include: a) Resident #19 On 06/25/15 at 9:11 a.m., during Stage 1 of the survey, Resident #19 was asked if she had been moved to a different room or had a roommate change in the last nine (9) months. Resident #19 answered Yes. The resident was asked if she was given notice before the room change or a change in roommate. Resident #19 responded No. She stated, They came in and told me I was moving and threw my things on the bed and moved me down here (first floor). In an interview with the director of nursing (DON), on 07/02/15 at 8:53 a.m., she stated she talked with Resident #19 regarding moving to another room, but she did not have evidence of the conversation. There was also no evidence Resident #19 agreed to the room change. A request was made at that time, for a copy of the facility's policy and procedure regarding in-house resident transfers. The facility's policy and procedure titled, In-house Resident Transfers Between Units, Room to Room, was reviewed on 07/02/15 at 9:27 a.m. The policy included, under the section titled Procedure: 6. Prior to a transfer or room change, the resident is provided with preparation and orientation appropriate to their level of comprehension. 7. Prior to a room/roommate change, the . and documented on the 'Notification Room/Roommate Change' form. No evidence was found by the facility that this form was completed. In addition, a nurse's note, dated 02/27/15 at 1930 (7:30 p.m.), noted the patient was moved from 2__B to 1__B.",2019-01-01
5304,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,257,E,0,1,90J611,"Based on observation, resident interviews, family interview, random resident observations, thermostat and room temperature gauges observations, and staff interviews, the facility failed to ensure safe and comfortable ambient temperatures were maintained to minimize residents' susceptibility to loss of body heat and risk of hypothermia. During a family interview and resident interviews during Stage 1 of the survey, Residents #79, #101, #175, #21, and #14 stated the environment was cold. Random observations of ambient room temperatures in the day rooms on the first and second floors and the dining room/activity room revealed temperatures of 66 degrees F (Fahrenheit) to 68 degrees F. This practice had the potential to affect more than a limited number of residents residing in the facility. Resident identifiers: #79, #101, #175, #21, and #14. Facility census: 100. Findings include: a) Resident #79 During a family interview on 06/25/15 at 12:29 p.m., the family member stated her mother always complained about the building being cold. A random observation of Resident #79, in the first floor day room on 07/02/15 at 9:14 a.m., revealed the resident sitting in a wheelchair with a bath blanket wrapped around her shoulders. When asked if the room temperature was comfortable, she stated, Of course it is cold, but that is the way it has to be. b) Resident #101 On 06/24/15 at 3:37 p.m., during Stage 1 interviews, Resident #101 was asked do you have any problems with the temperature, lighting, noise or anything else in the building that affects your comfort? Resident #101 responded, Gets cold. c) Resident #175 During observations of the first floor day room on 07/02/15 at 9:14 a.m., when asked if the room temperature was comfortable, Resident #175 stated, It is cold. d) Resident #21 On 07/02/15 at 9:14 a.m., Resident #21 was observed with two (2) bath blankets around her shoulders and a blanket over her legs. When asked if the room temperature was comfortable, she stated, I am cold. This interview was conducted in the first floor day room. e) Resident #14 When Resident #14 was asked if the room temperature was comfortable, she stated it was cold. This interview was conducted in the first floor day room on 07/02/15 at 9:14 a.m f) On 07/01/15 at 1:10 p.m., in an interview with Nurse Aide (NA) #21, when asked if the first floor day room was usually that cold, she stated it was like that all the time and we are not allowed to touch the thermostat. In addition, she stated the thermostat was located in the supply room. An observation of the thermostat in the first floor supply room revealed the wall thermostat set at 70 degrees Fahrenheit (F) with a sign posted above the thermostat stating DO NOT TOUCH THERMOSTAT. The thermometer on the wall thermostat registered 68 degrees F. The administrator and maintenance director were interviewed on 07/01/15 at 4:00 p.m. Both were in agreement the first floor day room temperature needed adjusted and they would see if there was a problem with the cooling system. On 07/02/15 at 7:52 a.m., observations of the first floor day room revealed the thermostat set on 75 degrees F and the ambient room temperature was 70.7 F. b) The second floor day room thermometer registered 66 degrees F on 07/02/15 at 7:55 a.m The portable ambient thermometer registered 65.8 degrees F. Both temperatures were confirmed by Licensed Practical Nurse (LPN) #82. c) At 7:57 a.m. on 07/02/15, an observation in the dining room/activity room, revealed there were two (2) wall mounted thermostats/thermometers. The thermostat located on the wall entering the room was set on 78 degrees F, with the thermometer reading 64 degrees F. The other thermostat/thermometer, located next to dietary entrance door, was set on 75 degrees F and indicated the temperature was 68 degrees F. These findings were confirmed by Restorative Nurse Aide (RNA) #117. d) On 07/02/15 at 9:00 a.m., an interview with the maintenance director revealed two (2) dampers were found to be defective and parts were ordered. He stated these dampers were located in the first floor dining room/activity room. In addition, defective thermostats were found and replacements were ordered. He further stated lock boxes were order to prevent anyone from changing the settings without contacting the maintenance department.",2019-01-01
5305,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,272,D,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, minimum data set (MDS) assessment review, review of the Long-Term Care Facility Resident Assessment Instrument User's Manual, and staff interview, the facility failed to conduct a comprehensive assessment as part of an ongoing process for a Resident #31 who had dental caries. During Stage 2 of the survey, one (1) of three (3) residents reviewed for dental status found the annual MDS failed to identify dental caries in Item L0200D. Resident identifier: #31. Facility census: 100. Findings include: a) Resident #31 On 06/24/15 at 3:01 p.m., an observation of Resident #31 revealed dental caries of the back lower left teeth. A review of the medical record on 07/01/15 at 1:20 p.m., revealed Resident #31 was admitted on [DATE] with [DIAGNOSES REDACTED]. The attending physician deemed Resident #31 had capacity to make medical decisions on 08/22/12. The annual MDS with an assessment reference date (ARD) of 11/05/14, identified the resident's Brief Interview for Mental Status (BIMS) score was 13, indicating the resident was cognitively intact. A continued review of the medical record revealed an oral assessment completed on 04/09/14 by dental hygienist students, and signed by the supervising dentist, found a traumatized lesion in the left oral mucosa. A dental consult, dated 04/16/14, stated teeth were cleaned and heavy plaque was present. In addition, two (2) teeth were noted to need extraction due to root tip exposure and a large cavity. An additional note by the dentist stated patient 'states' does not want teeth removed. A review of the annual MDS, with an ARD of 11/05/14, revealed for Dental Status, Item L0200G was marked as none of the above were present. Item L0200D, which would identify the resident had obvious or likely cavity or broken natural teeth, was not marked. In an interview on 07/01/15 at 3:23 p.m., the director of nursing (DON) stated the information for coding the MDS was obtained from the annual dentist visit and evaluation. When asked if there was an oral assessment completed by nursing, she stated only if the resident complained of pain or informed the nursing staff there was a problem with their teeth. She agreed after the 04/16/14 dentist assessment, the MDS should have been coded as the resident having dental caries. On 07/01/15 at 4:00 p.m., in an interview with the MDS coordinator, she stated she obtained information to code Section L for any resident from the annual dental assessment. When asked if the dentist codes one annual visit as the resident having dental caries with no interventions and the next annual dental assessment states there is no problem, how would this be coded in the MDS? The MDS coordinator stated Section L would be coded from the first visit as having dental caries, but on the next annual dental visit, she would code as having no problems. In addition, she stated she did not complete an oral examination on any resident, but relied on the annual dental assessment completed by the dentist. The instructions for completing Section L: Oral/Dental Status in the Long-Term Care Facility Resident Assessment Instrument User's Manual - Version 3.0 include, 4. Conduct exam of the resident's lips and oral cavity with dentures or partials removed, if applicable. Use a light source that is adequate to visualize the back of the mouth. Visually observe and feel all oral surfaces including lips, gums, tongue, palate, mouth floor, and cheek lining. Check for abnormal mouth tissue, abnormal teeth, or inflamed or bleeding gums. The assessor should use his or her gloved fingers to adequately feel for masses or loose teeth.",2019-01-01
5306,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,279,D,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive care plan for one (1) of twenty-one (21) Stage 2 sample residents. A care plan was not developed for a resident with dental caries. Resident identifier: #136. Facility census: 100. Findings include: a) Resident #136 An observation on 06/25/15 at 12:53 p.m., revealed Resident #136 had a broken front tooth with brown discoloration. During an interview with the resident, she related she had tooth problems. The resident said her teeth had broken off, and some of them have come out. The resident further added she had chewing and eating problems related to the broken teeth. An [MEDICAL CONDITION] screening, dated 03/26/15, noted a slightly swollen submandibular node .slightly red under max denture .The mandibules anterior teeth are severely decayed. (Severely decayed was circled in red ink.) . Patient states pain sometimes, but not often. Also, the answer Yes was circled in relation to the statement, This patient needs a follow up dental examination. Another oral assessment, dated 10/25/13, also indicated Resident #136 was missing teeth and had a total of six (6) caries. The exam indicated the teeth were sharp and jagged. An interview with Registered Nurse (RN) #9, on 06/29/15 at 12:52 p.m., revealed all registered nurses (RN) and licensed nurses (LPN) were responsible for updating care plans. The RN confirmed a comprehensive care plan had not been developed related to dental care for this resident.",2019-01-01
5307,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,280,E,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to revise care plans for four (4) of twenty-one (21) residents reviewed in the Stage 2 sample. Revisions were not initiated in relation to accidents, pressure ulcers, non-pressure related skin conditions, and medication changes. Resident identifiers: #157, #127, #136, and #70. Facility census: 100. Findings include: a) Resident #157 During an interview with Licensed Practical Nurse (LPN) #11 on 06/24/15 at 3:50 p.m., the nurse related Resident #157 fell on [DATE] when climbing out of bed. Incident and accident forms, reviewed on 07/01/15 at 12:32 p.m., revealed the resident had fallen on 01/29/15, 02/01/15, 02/05/15, 02/09/15, 03/23/15, 03/24/15, 05/20/15, 05/25/15, 06/13/15, 06/15/15, and 06/23/15. Each report, with the exception of the one for 02/09/15, indicated the care plan had been updated. An observation on 06/24/15 at 4:21 p.m., noted Resident #157 had a bruise around her left eye. The incident report, dated 06/23/15 indicated the resident obtained a hematoma on the left temple when she fell and was treated for [REDACTED]. The care plan, reviewed on 07/01/15 at 2:30 p.m., revealed a comprehensive care plan with a review date of 05/10/15, and noted the next review date as 08/05/15. During a review of the care plan with Registered Nurse (RN) #9, on 07/01/15 at 3:30 p.m., the RN confirmed the care plan only indicated the resident had a potential for falls, but had not been revised to reflect the interventions for ten (10) of the eleven (11) actual falls. Additionally, the care plan did not address the hematoma, bruising around the left eye, or pain related to the fall. b) Resident #127 1. Licensed Practical Nurse (LPN) #11, interviewed on 06/24/15 at 3:53 p.m., related Resident #127 had a pressure ulcer on his coccyx which was unstageable at the deepest anatomical level. Review of the medical record, on 06/25/15 at 9:40 a.m., revealed the resident was readmitted from the hospital with an unstageable wound. A physician's progress note, dated 05/06/15, diagnosed the pressure ulcer as an unstageable wound. A nursing progress note, dated 06/24/15, indicated the wound remained unstageable. A progress note, dated 04/17/15, indicated the resident had a healed Stage 2 pressure ulcer on his coccyx. The care plan, reviewed on 06/29/15 at 2:30 p.m., indicated Resident #127 had a Stage 2 pressure ulcer. Registered Nurse (RN) #9 reviewed the care plan and confirmed it had not been revised to resolve the initial Stage 2 pressure ulcer, nor had it been revised to indicate the resident had an unstageable pressure ulcer on his coccyx. The care plan was updated on 06/29/15 after speaking with RN #9. 2. Further review of the medical record, on 06/25/15 at 9:38 a.m., revealed Resident #127 required isolation precautions for [MEDICATION NAME] resistant [MEDICATION NAME] (VRE), a multi-drug resistant organism, and the resident was also receiving antibiotic therapy related to infected dental gums/swelling. During an interview with RN #9 on 06/29/15 at 4:52 p.m., she confirmed the care plan was not revised to indicate Resident #127 had a current urinary tract infection, required isolation precautions for VRE, and had a dental infection. The care plan was revised by RN #128 to include [MEDICATION NAME] (an antibiotic), after a discussion with RN #9. c) Resident #136 Review of the medical record, on 06/24/15 at 3:11 p.m., revealed Resident #136 had acquired a pressure ulcer on the right coccyx area. Further review, on 06/29/15 at 11:29 a.m., revealed a physician's orders [REDACTED]. RN #9 reviewed the care plan on 06/29/15 at 3:19 p.m., and confirmed it had not been revised to indicate Resident #136 had an actual pressure ulcer; nor had it been updated to include the current wound treatment. d) Resident #70 According to the incident report, dated 06/23/15, Resident #70 sustained a hematoma to the left temple when she fell . The report indicated the resident was sent to the emergency room for a computerized axial tomography (CAT scan) and was medicated for pain. A Stage 1 interview with LPN #11, on 06/24/15 at 3:44 p.m., revealed Resident #70 had fallen on 06/23/15 and was sent to the emergency room for evaluation. Review of the medical record also revealed a physician's orders [REDACTED]. The x-ray report indicated the resident had displaced ribs along the anterolateral ribs inferiorly. RN #9 reviewed the care plan on 06/30/15 at 3:18 p.m., and confirmed it did not address the fall with injury on 04/26/15, nor the fall with injury on 06/24/15. The RN agreed the falls with injury should have been addressed.",2019-01-01
5308,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,282,E,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility failed to implement the care plans for two (2) of two (2) residents who had pacemakers, in the Stage 2 sample of twenty-one (21) residents. The interventions for pacemaker checks were not implemented. Resident identifiers: #73 and #162. Facility census: 100. Findings include: a) Resident #73 Resident #73's clinical record was reviewed on 06/29/15 at 4:00 p.m The resident was admitted on [DATE] with cumulative medical [DIAGNOSES REDACTED]. An 08/04/12 admission nursing assessment indicated Resident #73 had a pacemaker located in the left chest area. The current care plan, dated 04/27/15, included the problem: Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD (medical doctor) prn (as needed) signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. Review of the clinical record revealed no evidence of pacemaker checks. During an interview on 06/29/15 at 4:30 p.m., Registered Nurse (RN) #5 confirmed Resident #73's medical record contained no evidence of an assessment of her pacemaker. On 06/30/15 at 11:00 a.m., RN #57 provided documentation from Resident #73's physician which stated the resident had a dual chamber pacemaker implanted on 06/17/08. The last evidence a pacemaker function test was performed was on 03/27/12. b) Resident #162 Resident #162's clinical record was reviewed on 06/30/15 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. The current care plan, dated 05/17/15, included the problem: Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD prn signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. The clinical record contained no evidence of pacemaker checks. During an interview, on 06/29/15 at 4:30 p.m., RN #5 confirmed the resident's medical record contained no evidence of an assessment of his pacemaker. On 06/30/15 at 2:15 p.m., RN #57 provided documentation from Resident #162's physician which stated the resident had a dual chamber pacemaker implanted in 2001, and a battery replacement on 07/26/11. The last evidence of an assessment of pacemaker function was on 08/06/13. A follow-up assessment was to be performed in six (6) months, in (MONTH) 2014.",2019-01-01
5309,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,309,E,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interviews and clinical record review, the facility failed to ensure two (2) of two (2) residents who had pacemakers, in the Stage 2 sample of twenty-one (21 residents, were provided services to maintain the highest practicable well-being. Pacemaker checks were not performed to ensure ongoing function of their cardiac pacemakers. Resident identifiers: #73 and #162. Facility census: 100. Findings include: a) Resident #73 Resident #73's clinical record was reviewed on 06/29/15 at 4:00 p.m The resident was admitted on [DATE] with cumulative medical [DIAGNOSES REDACTED]. An 08/04/12 admission nursing assessment indicated Resident #73 had a pacemaker located on the left chest area. The current care plan, dated 04/27/15, included the problem : Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD (medical doctor) prn (as needed) signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. During an interview, on 06/29/15 at 4:00 p.m., Licensed Practical Nurse (LPN) #56 stated she did not know if Resident #73 had a pacemaker. On 06/29/15 at 4:30 p.m., Registered Nurse (RN) #57 stated the facility relied on the physician to call when a resident was due for a pacemaker check. RN #57 stated the facility provided no telephonic monitoring of pacemaker function. She stated a resident would have to go to a physician's office for assessment of pacemaker function. RN #57 confirmed Resident #73's medical record contained no evidence of an assessment of her pacemaker. At 5:15 p.m. on 06/29/15, RN # 57 provided a [DIAGNOSES REDACTED]. Resident #73 was not included on this list. During an interview on 06/30/15 at 12:05 p.m., the Director of Nursing (DON) confirmed until 06/29/15, the facility relied on the physician's office to track follow-ups for residents with pacemakers. The DON acknowledged the facility was responsible for ensuring this medical follow-up was provided. The DON confirmed no pacemaker follow-ups were done for Resident #73. On 06/30/15 at 11:00 a.m., RN #57 provided documentation from Resident #73's physician which stated the resident had a dual chamber pacemaker implanted on 06/17/08. The last evidence an assessment of pacemaker function was performed was on 03/27/12. b) Resident #162 Resident #162's clinical record was reviewed on 06/30/15 at 12:00 p.m. The resident's [DIAGNOSES REDACTED]. The current care plan, dated 05/17/15, included the problem: Potential for pacemaker malfunction/failure or altered cardiac output related to implanted pacemaker. The interventions were: Observe/record/report to MD prn signs/symptoms of altered cardiac output or pacemaker malfunction. Monitor for signs/symptoms: [MEDICAL CONDITION], irregular heart rhythm, chest pain, shortness of breath, report to MD. Monitor vital signs as ordered/per facility protocol and record, notify MD of significant abnormalities. Pacemaker checks as ordered and document in chart. The clinical record contained no evidence of pacemaker checks. An interview, on 06/30/15 at 12:05 p.m., with the DON confirmed until 06/29/15, the facility relied on the physician's office to track follow-ups for residents with pacemakers. The DON acknowledged the facility was responsible for ensuring this medical follow-up was provided. The DON confirmed there was no evidence of an assessment for Resident #162's pacemaker. Resident #162 was included on a list provided by RN #57, on 06/29/15 at 5:15 p.m., a [DIAGNOSES REDACTED]. RN #57 provided, on 06/30/15 at 2:15 p.m., documentation from Resident #162's physician. The documentation stated Resident #73 had a dual chamber pacemaker implanted in 2001 and had battery replacement done 07/26/11. The last assessment of pacemaker function was performed on 08/06/13 and a follow-up assessment was to be in 6 months.",2019-01-01
5310,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,314,D,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide care and services to promote healing and prevent infection of pressure ulcers. This was true for three (3) of three (3) residents reviewed for pressure ulcers. Resident identifiers: #101, #127, and #136. Facility census: 100. Findings include: a) Resident #101 Resident #101 had two (2) pressure ulcers, a Stage II on his right buttock and a Stage II on his left buttock. There was a physician's orders [REDACTED]. An observation of wound care was performed with Registered Nurse #128 at 8:15 a.m. on 06/30/15. She wore gloves and touched Resident 101's skin around both of the ulcers around his buttocks and two (2) non-pressure open areas on the back of his right thigh. She measured all four (4) areas, removed a paper towel from the dispenser, pulled a pen out of her pocket with her gloved hand and wrote down the measurements. She then put the pen back in her pocket and applied medication to all four (4) areas without cleansing them first. Next, she reapplied the resident's brief. This allowed for transfer of microorganisms from the pen to the nurse's gloved hand, and potentially to the resident's wounds, and from the resident's wounds, to the pen from nurse's gloved hand, to the nurse's pocket, and potentially to other residents.) RN #128 stated the nursing staff would clean the areas and reapply the medication when they gave him his morning care and got him up for the day. This matter was discussed with Licensed Practical Nurse (LPN) #11, at 1:00 p.m. She said she was the nurse responsible for applying medication to Resident #101 when the treatment nurse, RN #128, did not. She said she had not applied medication to Resident #101 that morning because RN #128 applied it already. She said she (LPN #11) would apply the medication at 3:00 p.m. that afternoon when the resident went back to bed. This concern was discussed with RN #128 and the director of nursing (DON), as well as the administrator, at 2:20 p.m. on 06/30/15. They all agreed it was poor technique to apply medication to a wound without cleansing it first and also to touch other objects with gloved hands both before and after touching a wound. According to the Wheeling Hospital Administrative Policy and Procedure Manual, section infection control policy number 5, Subject Hand Hygiene, Section II C: Decontaminating Hands: is necessary After contact with body fluids or excretions, mucous membranes, non-intact skin and wound dressings if hands are not visible soiled and also, After contact with inanimate objects (including medical equipment) in the immediate vicinity of the patient. b) Resident #127 An interview with Licensed Practical Nurse (LPN) #11, on 06/24/15 at 3:53 p.m., indicated Resident #127 had a Stage II pressure ulcer on his coccyx. Registered Nurse (RN) #128 related the wound looked worse, but was now moist. Review of the medical record, on 06/25/15 at 9:40 a.m., revealed the coccyx wound was noted as unstageable. Further review of the medical record revealed a progress note indicating Resident #127 was readmitted to the facility on [DATE] with a necrotic pressure ulcer which measured one centimeter long by one centimeter wide (1 cm x 1 cm). A progress note dated 06/24/15 indicated the wound remained unstageable and measured 1.2 cm long x 1.6 cm wide. Observation of a pressure ulcer dressing change, on 06/29/15 at 1:51 p.m., with RN #128, revealed the coccyx wound appeared the size of a nickel, with a yellow center. The peri wound was dark pink and raised in a mound like shape. RN #128 cleansed the wound by wiping across the wound bed. She then patted/daubed the wound bed with clean gauze. Without changing gloves, the RN measured the wound, removed a pen from her pocket, utilized the pen to document the measurements, and placed it back in her pocket. Still, without changing gloves, RN #128 applied ointment and placed a clean dressing on the wound. c) Resident #136 A Stage 1 interview on 06/24/15 at 3:11 p.m., with LPN #3, revealed Resident #136 had developed an in-house acquired pressure ulcer on the right coccyx. Review of the medical record found the ulcer was assessed as unstageable on 06/24/15 and measured 2.5 centimeters (cm) long (L) x 0.7 cm wide (W) x 0.2 cm deep (D). During an observation of the wound dressing change on 06/30/15 at 9:31 a.m., RN #128 removed two (2) sets of gloves from the wall container and placed them on the sink without a barrier. The nurse donned one pair of gloves, positioned the resident on her left side, repositioned the Foley catheter from the right side of the bed to the left, and removed the soiled dressing before changing gloves. The nurse donned the other set of gloves from the sink and measured the wound. RN #128 removed the gloves, sanitized her hands with a very small amount of hand sanitizer, rubbing for a count of five (5) seconds, donned new gloves, and cleansed the wound bed, with a wiping movement across the wound bed. The nurse daubed the wound bed with clean gauze Without changing the soiled gloves and sanitizing her hands, the RN applied the new dressing. Observation of the pressure ulcer, revealed a wound about the size of a quarter, and covered with slough. RN #128 measured the wound bed and indicated the wound measured 2.1 cm (L) x 2.5 cm (W) x 0.3 cm (D). Review of the medical record, on 06/29/15 at 11:29 a.m. revealed a progress note dated 04/29/15. The progress note indicated the wound was acquired on that date and measured 0.5 cm (L) x 1.0 cm (W) x 0.1 cm (D). Wound measurements on 06/30/15 at 9:31 a.m. revealed the wound measured 2.1 cm (L) x 2.5 cm (W) x 0.3 cm (D). The RN confirmed the wound had deteriorated. c) During a follow-up interview, on 06/30/15 at 2:30 p.m., RN #128 confirmed the use of improper technique when cleansing Resident #127's and #136's pressure ulcers. The nurse related she should have cleansed from the inner to outer wound bed. RN #128 acknowledged the technique posed a potential for cross contamination and transmission of infection and delayed wound healing. d) An interview with the director of nursing (DON) and administrator, at 2:38 p.m., confirmed the nurse utilized improper technique. The DON related she expected the nurse to prepare the set up, utilizing a barrier, and indicated the nurse should have had a disposable plastic bag readily available to dispose of used dressings and equipment. Upon inquiry, the DON related the facility utilized Lippincott Procedures as the standards of practice. e) The facility's Lippincott Procedures - Pressure ulcer management, long term care, reviewed on 06/30/15 at 4:30 p.m., indicated the wound should be cleansed from the center of the wound, working in a circular pattern toward the edge of the wound, then pat dry.",2019-01-01
5311,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,334,D,0,1,90J611,"Based on staff interview, clinical record review, and review of facility policy, the facility failed to provide influenza vaccination education for one (1) of five (5) census sampled residents (Resident #45) prior to administration of the influenza vaccine. Facility census: 100. Findings include: a) Resident #45 Review of Resident #45's clinical record on 06/30/15 at 10:00 a.m., found the 2014-2015 consent to administer the influenza vaccine did not indicate education was provided prior to giving the vaccine on 10/02/14. During an interview, on 06/30/15 at 9:00 a.m., Registered Nurse (RN) #130 could not provide any evidence that Resident #45 had been provided education prior to administration of the influenza vaccine on 10/02/14. On 06/30/15 at 9:00 a.m., a review of facility's policy entitled Immunizations, revised 07/2014, found the policy included, The facility recommends that the influenza vaccine be given annually to all residents. The policy stated, Each resident or the resident's legal representative receives education regarding the benefits and potential side effects of the influenza immunization before the vaccine is offered. .",2019-01-01
5312,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,371,F,0,1,90J611,"Based on observation, review of facility policy, and staff interview, the facility failed to store and distribute food under sanitary conditions. Personal food items were stored with resident food products and proper sanitation practices were not utilized when washing dishes. This practice had the potential to affect all residents. Facility census: 100. Findings include: a) Kitchen 1. During an initial tour with the dietary manager, on 06/24/15 at 10:03 a.m., observation revealed a drink in a disposable cup stored on the top shelf of the walk-in refrigerator with containers of residents' food. Shelves below contained boxes of fresh fruit and other items. Another observation on 06/29/15 at 10:30 a.m., again revealed a drink stored on the shelf. 2. An interview with Dietary Aide (DA) #94 on 06/24/15 at 10:15 a.m., revealed the dish wash temperature must reach 150 degrees and 180 degrees rinse. Upon inquiry, the DA related she was unable to find test strips, and related the facility never utilized the manual method for sanitizing dishes. She related, We always use the machine. DA #94 related the machine did not usually reach the proper temperature until three to four (3-4) loads were completed. Observation of the sanitation procedure on 06/24/15 at 10:15 a.m., revealed the temperature only reached a level of 140 degrees Fahrenheit (f). DA #94 washed a tray of plates, a tray of silver-colored bases, a tray of flatware, and a tray of lids. The DA continued to wash dishes. A label on the machine noted a label of ES2000HT and indicated the wash temperature should reach 160 degrees. A discussion with the dietary manager, on 07/01/15 at 10:45 a.m., confirmed the washer was a high temp machine, and according to the manufacturer's notation, the appropriate wash temperature was 160 degrees. Additionally, the dietary aide continued to wash dishes without the machine reaching the appropriate temperature. An alternate method of sanitation was not utilized to ensure proper sanitizing of plates and other items. The DA was also unable to find the test strips for the manual method, and related she did not know where they were kept. b) Second floor day room refrigerator During the initial tour at 06/24/15 at 10:05 a.m., the second floor day room refrigerator had a thermometer that was clearly broken and unable to be read. A Dairy Queen cup with no name or date labeled on it was in the freezer. This matter was discussed with Nurse Manager #57 at 10:09 a.m. She said the night shift nurses checked the refrigerator. She threw away the unlabeled food from the freezer and attempted to read the refrigerator thermometer. She said It looks like it's 60 degrees, but it also looks like it's up in the 40's and then the higher up it gets, it gets speckled. She agreed it could not be read accurately and provided a copy of the refrigerator logs up until that day, 06/24/15. Review of the policy of Infection Control, #31, Refrigerator Cleaning and Maintenance found Procedure 2 stated, . Food items designated for patients' use should be properly wrapped and labeled with a date it was placed in the refrigerator. Procedure 4. stated . An accurately calibrated thermometer should be kept in each food refrigerator and freezer at all times.",2019-01-01
5313,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,431,E,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to store drugs in accordance with currently accepted professional principles. Two (2) of six (6) medication carts contained internal medications stored with external medications, staff failed to remove discontinued medications from the medication cart, failed to date vials/bottles of multi-dose containers, a controlled substance was not returned to the pharmacy in a timely manner, and the pharmacist failed to provide oversight of drug storage areas which consisted of two (2) medication rooms and six (6) medication carts. This practice affected six (6) residents, but had the potential to affect all residents. Resident identifiers: Residents #65, #67, #239, #89, #57, and #140. Facility census: 100. Findings include: a) Controlled substances An observation, on [DATE] at 10:30 a.m., with Registered Nurse (RN) #57, revealed discontinued controlled substances stored in a locked drawer in the second floor medication room. The RN related controlled substances were returned to the pharmacy within 72 hours, but indicated the pharmacy picked up medication daily. Review of the medication storage area revealed a card of Hydrocodone for Resident #140, with a discontinuation date of [DATE]. b) North back hall med cart Review of the north back hall medication cart, on [DATE] at 11:05 a.m., with Licensed Practical Nurse (LPN) #54, revealed internal medications stored with external medications. Eye drops and ear drops were stored with each residents internal medications. Additional findings included: -- Resident #239 - undated bottle of Latanoprost eye drops -- Resident #89 - undated bottle of Latanoprost eye drops -- Resident #57 - undated bottle of Latanoprost eye drops with a delivery date of [DATE], and a bottle of Prednisone, discontinued on [DATE], and a bottle of Gentamycin eye drops discontinued on [DATE] The LPN related the resident commonly gets eye infections. -- The medication drawer also contained a bottle of ear wax removal drops dated (MONTH) 2014, which LPN #54 related had been discontinued. c) North front hall An observation with LPN #48, on [DATE] at 11:14 a.m., revealed external medications stored with internal medications. Also, discontinued medications had not been removed from the cart. The LPN related discontinued and/or outdated items should be removed from the cart. Findings included: -- Resident #65 - Refresh drops dated [DATE] -- Resident #67 - Betamethasone dated [DATE]. Employee #48 indicated the eye drops had been discontinued. -- Resident #140 - Latanoprost eye drops dated [DATE]. d) During an interview with the consulting pharmacist, on [DATE] at 8:45 a.m., he related the pharmacy did not provide oversight of medication storage areas. The only oversight was directly related to resident care with medication reviews. He and the DON confirmed the pharmacist did not inspect the medication rooms or medication carts for irregularities. e) Review of the medication administration system and Medication Administration Policy #2, with a revision date of ,[DATE] revealed in the section Care of Medications revealed .External preparations are to be kept separated from internal preparations .All drug storage areas within the facility will be inspected monthly. A report of inspection will be maintained by the Pharmacy Department .The Pharmacy will do follow-up reports of discrepancies. Expired, damaged and/or contaminated medications will be removed from drug storage areas within the facility during inspection or any other time they are identified and will be returned to the pharmacy department for proper disposal. The Storage of Medications policy, manual section: Pharmacy, policy number 15, noted EXTERNALS are to be physically separated (underlined) from the internal medications. Internal medications included oral and injectable medications and externals included .eye/ear/nose preparations intended for instillation into these areas respectively",2019-01-01
5314,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,441,F,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, clinical record review, and review of facility policy and procedures, the facility failed to maintain an effective infection control program to help prevent the development and spread of disease and infection. The facility failed to ensure contact precautions were maintained for Residents #32 and #138. The facility failed to ensure staff handled linens properly, used appropriate hand hygiene, and provided wound care using appropriate infection control techniques for Residents #127, #137, and #101. This had the potential to affect all residents in the facility. Resident identifiers: #32, #138, #127, #137, and #101. Facility census: 100. Findings include: a) Resident #32 and #138 - Contact Precautions During a random observation on 06/29/15 at 8:25 a.m., Pastoral Staff #118 was in a room with Resident #32 and Resident #138. Both residents were in contact isolation. Pastoral Staff #118 did not have gloves or a gown on when in the room. The Pastoral Staff #118 exited the room and without washing or sanitizing her hands, entered room [ROOM NUMBER]. A contact precaution sign was posted by the door of Resident #32's and Resident #138's room throughout the survey, starting on 06/24/15. The sign instructed all persons to, Wash hands before entering and leaving patient room, wear gowns when entering the room and wear gloves when entering the room. Licensed Practical Nurse (LPN) #61, on 06/29/15 at 8:30 a.m., confirmed both residents (Residents #32 and #138) were under contact precautions due to active Methicillin Resistant Staphylococcus aureus (MRSA) Infection. Pastoral Staff #118, on 06/29/15 at 8:35 a.m., stated she had not noticed the contact precaution sign by the door of the room. She stated she was not aware Resident #32 and Resident #138 were in isolation. Resident #32's clinical record revealed she was on contact precautions due to an active respiratory MRSA infection. Resident #138's clinical record revealed she was on contact precautions due to an active urinary tract MRSA infection. On 06/29/15 at 12:00 p.m., review of the facility's policy entitled Transmission Based Isolation for Resistant Organisms, revised 07/25/14, found it included, All patients known to have a multi drug resistant organism history, current colonization and/or infection will be placed in transmission based isolation precautions based on transmission risk. The procedures included: Wear isolation gown and gloves for contact with the patient or when working with or around the patient's bedding or personal items . remember always wash hands before and after patient contact. b) Residents #127 and #137 A random observation, on 06/25/15 at 8:46 a.m., revealed two (2) electronic vital sign machines in the bathroom beside the commode shared by Residents #127 and #137. During the observation, Resident #137 utilized the bathroom. Signage on the door indicated contact precautions were required when entering the room. An interview and observation with License Practical Nurse (LPN) #11, immediately following the initial observation, confirmed Resident #137 utilized the bathroom, and agreed the storage of the vital sign machines in the bathroom posed as source of cross contamination for each resident. The LPN related contact precautions were required for Resident #127 related to [MEDICATION NAME] resistant [MEDICATION NAME] (VRE), a multi-drug resistant organism (MDRO). The LPN requested the assistance of Registered Nurse (RN), Nurse Manager #9. The RN also confirmed the vital signs machines should not have been stored in the bathroom related to the potential for cross contamination from Resident #137 urinating, and Resident #127's VRE infection. During a wound dressing change observation, completed on 06/29/15 at 1:51 p.m., RN #128, related the resident's VRE infection was in his urine. He did not have a Foley catheter. Creamy purulent drainage streamed from Resident #127's urethra. Upon completion of the dressing change, Nurse Aide (NA) #18 (NA) asked the RN if the penis was swollen, attempted to pull the foreskin forward, but was unable. She requested the nurse check the resident. After touching the resident's penis, RN #128 opened the closet door with the same soiled gloves contaminated by the purulent drainage, and obtained cleansing wipes. The RN cleansed the penis then proceeded to cleanse dried, cakes of bowel movement from his pubic hair. Without changing gloves and/or sanitizing their hands, the RN and NA each secured a side of the resident's clean brief, pulled down his hospital gown, and pulled the sheet up to cover the resident. The RN again opened the closet door, handed the NA the bottle of Safe-clens (a saline solution utilized to cleanse the pressure ulcer wound bed), contaminating the bottle, which the NA placed in the resident's bottom drawer of the nightstand. The RN and NA each pulled up one side of the resident's side rails, before removing their soiled gloves. Additionally, during the pressure ulcer wound dressing change, RN #128 tossed the soiled gauze, utilized to cleanse the wound bed, toward the garbage can and missed. The gauze landed in the floor in front of the can. Prior to exiting the room, the RN picked up the gauze and placed it in the garbage can. The floor was not sanitized. An interview with the director of nursing (DON) and administrator (ADM) on 06/30/15 at 11:30 a.m., confirmed the RN and NA failed to utilize proper hand hygiene and/or isolation precautions. They agreed gloves should have been changed when moving from a contaminated site to a clean site. c) Hand hygiene During a random observation, on 06/29/15 at 10:57 a.m., NA #18 washed her hands after providing resident care. The NA washed her hands for a count of seven (7) seconds, then proceeded to turn off the faucet with her bare hands. Review of the facility's policy, and an interview with the director of nursing (DON) on 06/29/15 at 4:30 p.m., confirmed NA #18 utilized improper technique. The DON confirmed hands should have been washed a minimum of fifteen to twenty (15-20) seconds, and a barrier should have been utilized when turning off the faucet. d) Resident #101- Hand hygiene An observation of wound care by RN #128 at 8:15 a.m. on 06/30/15, noted the nurse touched the skin around the two ulcers, around his buttocks, and two non pressure areas on his back of right thigh with gloved hands. She measured the areas, got a paper towel, and pulled a pen out of her pocket with the gloved hand and wrote down the measurements. She then put the pen back in her pocket and applied medication to all four areas without cleansing them first, and then reapplied the brief. By touching environmental objects with contaminated gloves, she created a potential for the transfer of microorganisms from the resident's wounds to the environment. Similarly, but touching the resident's wounds after having contact with environmental objects, there was a potential to transfer of nonresident microorganisms to the resident's wounds. By taking a pen out and returning it to her pocket, the nurse contaminated her pocket, creating a potential to spread microorganisms to other residents and staff. This matter was discussed with Employee #128 (RN) and the director of nursing, as well as the administrator at 2:20 p.m on 06/30/15. They all agreed it was poor technique. d) On 06/24/15 at 10:00 a.m., clean towels and washcloths were found on a shower chair in the shower room on the East hall of the first floor. The unit manager confirmed the clean linens might be for the next resident who was to be showered, but agreed they should not be there and removed the towels and washcloths.",2019-01-01
5315,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2015-07-02,514,D,0,1,90J611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate and complete medical records. Resident #128 was receiving Hospice services without an order. The pharmacist's medication reviews were not in Resident #70's and #157's medical records. Additionally, MEDICATION ORDERS FOR [REDACTED]. This practice had the potential to affect three (3) of twenty-one (21) Stage 2 residents reviewed. Resident Identifiers: #128, #70, and #157. Facility census: 100. Findings include: a) Resident #128 Resident #128's name was provided by the facility as one of a list of residents receiving Hospice services. In reviewing the medical record, a physician's orders [REDACTED]. On 06/20/15 Hospice services documented in the resident's medical record and began a care plan, however, the was no order for hospice documented in the medical record by the physician. In an interview with Nurse Manager #57 on 07/02/15 at 10:20 a.m., she said the Hospice company came into review the medical record on Saturday 06/20/15 and the resident was out at [MEDICAL TREATMENT]. She said the Hospice company wanted to speak with the resident before putting orders into effect, and the order for Hospice to provide its services was missed. Resident #128 had been receiving Hospice care since 06/20/15. b) Resident #70 Review of the medical record, on 06/25/15 at 11:01 a.m., revealed physician's orders [REDACTED]. Review of pharmacy recommendations revealed no evidence the pharmacist completed a review for (MONTH) (YEAR) or (MONTH) 2014. Behavior flow sheets, related to [MEDICAL CONDITION] medication use, revealed no evidence a behavioral flow sheet, tracking behaviors and side effects of [MEDICAL CONDITION] medications, was completed for the month of (MONTH) (YEAR). An interview with Licensed Practical Nurse (LPN) #14, Registered Nurse (RN) #9, and Medical Records Clerk #104 at 11:15 a.m., confirmed neither the recommendations, nor the flow sheets were in the medical record. Additionally, physician's orders [REDACTED]. - Ordered 05/20/15: [MEDICATION NAME] 20 milligrams (mg) every other day (qod) did not provide a route of administration - Ordered 05/23/15: [MEDICATION NAME] 25 mg am (morning) and 12.5 mg p.m. (evening/night) (as written) did not provide a route of administration - Ordered 01/24/15: [MEDICATION NAME] 25 mg bid (twice daily) did not provide a route of administration -Ordered 09/15/14 Milk of Magnesia 30 cubic centimeters (cc) po (by mouth) prn (as needed) did not indicate how often the medication could be administered or provide a maximum dosage - Ordered 09/08/14 (as written) Tylenol (650 mg [MEDICATION NAME]) PO (by mouth) Q (every) 6 HRS (hours) PRN Dx (diagnosis): MILD PAIN OR TEMP(temperature) > (greater than) 101 (Do not exceed 3,000 mg/24 hr of [MEDICATION NAME] in elderly, 2,000 mg/24 hr if hepatic impairment. Adjust per renal fxn (function): CrCl (Creatinine clearance)=10-50: q6h (prn); CrCl - Ordered 04/26/15: (as written) [MEDICATION NAME] Tabs (325 mg [MEDICATION NAME]/5 mg [MEDICATION NAME]) (Do NOT exceed 3,000 mg/24 hr of [MEDICATION NAME] in elderly, 2,000mg/24 hr if hepatic impairment. Adjust per renal fxn: CrCl=10-50: q6h (prn); CrCl Upon inquiry on 06/25/15 at 11:30 a.m., LPN #6 confirmed the routes of administration and/or dosages were unclear; and related she did not know what dosage of Tylenol was appropriate. Additionally, the LPN related she was unsure of which frequency should be utilized for the administration of [MEDICATION NAME]. RN #9 related she would follow up with the director of nursing (DON) for clarification. During an interview with the pharmacist, DON, and administrator, at 5:00 p.m. on 06/25/15, the pharmacist related the additional information was not intended to be part of the order. He indicated he had provided the information as a guideline when obtaining orders. The pharmacist, DON, and administrator acknowledged the orders for administration were unclear. c) Resident #157 Review of the medical record, on 06/25/15 at 9:46 a.m. revealed Resident #157 received the [MEDICAL CONDITION] medications of Bursar 5 mg PO 3 times a day and [MEDICATION NAME] 5 mg PO every morning for mood disorder. The medical record revealed no evidence the pharmacist completed a medication review for the month of (MONTH) (YEAR). d) An interview with RN #9, on 06/25/15 at 10:15 a.m., and RN #130, on 07/01/15 at 8:32 a.m., confirmed the recommendations were not present in the medical record for Residents #70 and #157. RN #130 related the pharmacist kept all reports, had been contacted, and would send them over. Each nurse had related several reports had been missing and were requested last month. RN #130 related she had not realized the reviews were not in the medical record. On 07/02/15 at 9:49 a.m., the pharmacist supplied reviews for the dates in question. Each review noted a time of entry as 12:00 a.m. Upon inquiry, the pharmacist reviewed the records on his database, back dated an order, then related he did not realize the time changed to 12:00 a.m. when backdated. He agreed the notations in question, for Resident #70 and Resident #157, during the months of (MONTH) (YEAR) and (MONTH) 2014 did not contain an accurate time of entry.",2019-01-01
6611,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-12-22,278,D,1,0,FW7Q11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the accuracy of the quarterly minimum data set (MDS) assessment for one (1) of (7) residents whose assessments were reviewed. The individual who completed Section J signed the assessment, certifying its accuracy; however, item J1800, related to falls since admission or the last assessment, was incorrectly coded to indicate the resident had no falls since admission or the last assessment. Resident identifier: #33. Facility census: 103 Findings Include: a) Resident #33 On 12/22/14 at 10:25 a.m., review of the resident's medical records identified the resident sustained [REDACTED]. As a result of the fall, the resident was sent to the hospital emergency department for evaluation and treatment. Further review of the medical records revealed the fall was not identified or included on the resident's quarterly minimum data set (MDS) assessment with the assessment reference date (ARD) of 10/15/14. Section J1800 was coded as 0, indicating there were no falls since admission/entry or reentry or prior assessment, whichever was more recent. The resident's previous quarterly MDS assessment had an ARD of 07/16/14. At 2:40 p.m. on 12/22/14, the resident's MDS with an ARD of 10/15/14, was reviewed with MDS Nurse #84. Employee #84 said she had somehow overlooked the fall that occurred on 07/21/14. She agreed the fall should have been identified and coded on the quarterly MDS with the ARD of 10/15/14, as it was the most recent MDS completed.",2017-12-01
6612,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-12-22,282,D,1,0,FW7Q11,"Based on observation, medical record review, and staff interview, the facility failed to implement the care plan for one (1) of seven (7) residents whose care plans were reviewed. The resident was observed sitting in a geri-chair for two (2) hours and forty-five (45) minutes without repositioning and without being checked for incontinence in accordance with the interventions in her care plan. When checked by staff after this length of time, the resident was found incontinent of bowel and bladder. Resident identifier: #5. Facility census: 103. Findings include: a) Resident #5 On 12/22/14, from 8:40 a.m. until 11:30 a.m., Resident #5 was observed in the dining/activity room sitting in a geri-chair. At 9:47 a.m., a volunteer asked the resident if she would like to go to devotions. Resident #5 declined the invitation. A review of Resident #5's care plan, on 12/22/14 at 9:58 a.m., revealed a goal statement to be clean and dry with use of incontinence products and prompt incontinence care through the review date. Interventions included checking the resident at least every two (2) hours for incontinence and to offer/assist to toilet/bedpan or urinal at scheduled intervals during the day, every two (2) hours, before and after meals and on as needed basis. On 12/22/14 at 11:20 a.m., this resident became restless and started moving in the geri-chair. Nurse #55 was informed of the restlessness and stated he would find Resident #5's nursing assistants (NA). Nurse #55 returned and stated one (1) of the NAs was at lunch, then he left. At 11:25 a.m., Nurse #139 asked if she could help. After explaining Resident #5 had been sitting for almost three (3) hours, was observed restless, and one (1) of her NAs was at lunch, Nurse #139 said she would get help for the resident. At 11:30 a.m., two (2) NAs, #43 and #9, assisted the resident into bed, using a mechanical lift, and provided incontinence care. The resident was incontinent of bowel and bladder. On 12/23/14 at 3:15 p.m., an interview with the director of nursing (DON), revealed she was aware Resident #5 had not been repositioned or provided/offered incontinence care as identified in her care plan. She stated the staff were very proud of the care they provided to residents and she was not sure what had happened. She stated this resident was usually very restless and staff were frequently checking the resident. She stated the resident was unusually quiet during this time period.",2017-12-01
6613,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-12-22,441,D,1,0,FW7Q11,"Based on observation, policy review, and staff interview, the facility failed to maintain an infection control program to help prevent the development and transmission of disease and infection. Observation during a dressing change found the nurse placed the dressings on an unsanitary wheelchair and applied a new dressing while wearing contaminated gloves. Resident identifier: #5. Facility census: 103. Findings include: a) Resident #5 On 12/22/14 at 11:40 a.m., Resident #5 was transferred to her bed, with a lift, by two (2) nursing assistants (NA), #43 and #9. Licensed Practical Nurse (LPN) #55 entered the room and stated he was going to change the dressing on the resident's coccyx. He placed the treatment administration record (TAR), and the dressings, on the yellow gel cushion in the resident's wheelchair. While wearing gloves, LPN #55 cleaned the resident's anal and coccyx area. Wearing the same, now contaminated gloves, the nurse picked up the TAR and dressings, retrieved a flashlight out of his pocket, and inspected the resident's skin. He placed the flashlight back into his pocket, applied the dressing, helped to adjust the resident's clothing, and checked the lift sling. At that time, LPN #55 removed his gloves and washed his hands. In an interview, at 12:03 p.m. on 12/22/14, LPN #55 agreed he contaminated his gloves when he touched items/objects. He also confirmed he had applied the dressing wearing contaminated gloves. A review of the facility's policy titled Hand Hygiene, on 12/23/14 at 3:15 p.m., with the director of nursing (DON), revealed gloves were to be changed during care if moving from a contaminated body site to a clean body site. The DON agreed LPN #55 should have changed gloves after cleaning the resident's anal and coccyx area and before touching the flashlight, dressings, the resident's clothing, and the TAR. In addition, she stated the LPN had been trained and staff had reviewed the correct procedure prior to him entering Resident #5's room to change the dressing.",2017-12-01
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
6714,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,253,E,0,1,B5L311,"Based on resident interview, observation, and staff interview, the facility failed to provide effective housekeeping and maintenance services in one (1) of two (2) shower rooms on the first floor. Resident #145 complained the shower room smelled of old urine. This practice had the potential to affect more than an isolated number of residents. Resident identifier: #145. Facility census: 109. Findings include: a) Resident #145 A random observation of the first floor shower room, located on the 120 hallway, on 03/04/14 at 11:05 a.m., revealed a strong sewer odor. During an interview with Resident #145, on 03/06/14 at 9:09 a.m., the resident expressed concern about the odor in the shower room. The resident said the shower room smelled like old urine, and she hated taking a shower. She frowned as she made this comment and shook her head in disgust. An interview with Employee #935, a registered nurse (RN), on 03/06/14 at 4:35 p.m., confirmed the shower room had a foul odor. The nurse said she was aware of the odor, she thought it was from the drains. She said she would have the housekeeping and/or environmental department evaluate the odor.",2017-11-01
6715,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,272,D,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, record review, and staff interview, the facility failed to ensure the accuracy of the comprehensive assessment for three (3) of thirty-five (35) Stage 2 sample residents. The comprehensive assessment for Resident #136 lacked a [DIAGNOSES REDACTED].#138 did not reflect his [DIAGNOSES REDACTED].#2 did not reflect his [DIAGNOSES REDACTED]. Resident identifiers: #136, #38, and #2. Facility census: 109. Findings include: a) Resident #136 Review of the resident's medical record, on 03/05/14 at 4:11 p.m., found the resident was admitted to hospice services for a [DIAGNOSES REDACTED]. The care plan meeting summary form, dated 10/10/13, stated the resident had a significant change due to the admission to hospice for [MEDICAL CONDITION]. The significant change minimum data set (MDS), with an assessment reference date (ARD) of 10/04/13, was not marked in Item I0100 to indicate the resident [MEDICAL CONDITION] (with or without metastasis). In an interview on 03/06/14 at 2:20 p.m., with the MDS nurses, Employees #925 and #965, they verified Resident #136 had [MEDICAL CONDITION]. The significant change MDS was completed when hospice services were started. Employee #965 reviewed the significant change MDS with an ARD of 10/04/13, and agreed item I0100 should have been marked to indicate the resident's active [DIAGNOSES REDACTED]. b) Resident #38 During a family interview, on 03/03/14 at 11:15 a.m., Resident #38's wife reported the resident's history of [MEDICAL CONDITION]. Review of the resident's medical record, on 03/05/14 at 1:30 p.m., found an acute care center history and physical note written on 12/29/13. The note stated Resident #38 had a history of [REDACTED]. The admission MDS, with an ARD of 01/10/14, was coded incorrectly in the neurological portion of Section I - Active Diagnoses. Item I4200, titled [MEDICAL CONDITION], was not marked and Item I4800 was incorrectly checked indicating the resident had Non-Alzheimer's Dementia. During an interview, on 03/05/14 at 3:30 p.m., with MDS nurse #965, she reviewed the resident's admission MDS. She confirmed the neurological portion of Section I of the MDS was coded incorrectly. Nurse #965 said item I4200 [MEDICAL CONDITION] should have been marked instead of Item I4800 Non-Alzheimer's Dementia. c) Resident #2 Review of this resident's medical record, on 03/06/14 at 10:10 a.m., found a physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. The history and physical, dated 04/21/12, stated the resident had [MEDICAL CONDITION] and was in need of a Foley catheter. A review of the MDS assessment, with an ARD of 01/15/14, revealed a code for unspecified retention of urine in Section I, Item I7900 G. In an interview with the medical records coordinator (Employee #89), on 03/06/14 at 2:23 p.m., the coordinator said when a resident was transferred from the hospital to this unit with a catheter, a [DIAGNOSES REDACTED]. Employee #89 stated a transcription report, dated 10/25/10, revealed Resident #2 had a cystoscopy which revealed the resident had [MEDICAL CONDITIONS] requiring a Foley catheter. Employee #89 agreed the MDS did not reflect the [DIAGNOSES REDACTED].",2017-11-01
6716,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,278,D,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the health professional who completed sections of the minimum data set (MDS) failed to ensure the sections they completed were accurate for three (3) of thirty-five (35) Stage 2 sample residents. Section I Active [DIAGNOSES REDACTED]. Resident identifiers: #136, #38, and #2. Facility census: 109 Findings include: a) Resident #136 Review of the resident's medical record, on 03/05/14 at 4:11 p.m., found the resident was admitted to hospice services for a [DIAGNOSES REDACTED]. The care plan meeting summary form, dated 10/10/13, stated the resident had a significant change due to the admission to hospice for [MEDICAL CONDITION]. The significant change MDS, with an assessment reference date (ARD) of 10/04/13, was not marked in Item I0100 to indicate the resident [MEDICAL CONDITION] (with or without metastasis). The resident's MDS was certified as accurate by the professional who completed the section. In an interview on 03/06/14 at 2:20 p.m., with the minimum data set (MDS) nurses, Employees #925 and #965, they verified Resident #136 had [MEDICAL CONDITION]. They said a significant change MDS was completed when hospice services were started. Employee #965 reviewed the significant change MDS with an ARD of 10/04/13, and agreed Item I0100 should have been marked to indicate the resident's active [DIAGNOSES REDACTED]. b) Resident #38 During a family interview, on 03/03/14 at 11:15 a.m., Resident #38's wife reported the resident's history of [MEDICAL CONDITION]. Review of the resident's medical record, on 03/05/14 at 1:30 p.m., found an acute care center history and physical note written on 12/29/13. The note stated Resident #38 had a history of [REDACTED]. Although the resident's MDS was certified as accurate by the professional who completed the section, the admission MDS, with an ARD of 01/10/14, was coded incorrectly in the neurological portion of Section I - Active Diagnoses. Item I4200, titled [MEDICAL CONDITION] was not marked and item I4800 was incorrectly checked indicating the resident had Non-Alzheimer's Dementia. During an interview, on 03/05/14 at 3:30 p.m., with MDS nurse #965, she reviewed the resident's admission MDS. She confirmed the neurological portion of Section I of the MDS was coded incorrectly. Item I4200 [MEDICAL CONDITION] should be marked instead of item I4800 Non-Alzheimer's Dementia. c) Resident #2 Review of this resident's medical record, on 03/06/14 at 10:10 a.m., found a physician's orders [REDACTED]. The resident's [DIAGNOSES REDACTED]. The history and physical, dated 04/21/12 stated this resident had [MEDICAL CONDITION] in need of a Foley catheter. A review of the MDS assessment, with an ARD of 01/15/14, revealed in Section I, Item I7900 G had a code for unspecified retention of urine. The resident's MDS was certified as accurate by the professional who completed the section In an interview with the medical records coordinator (Employee #89), on 03/06/14 at 2:23 p.m., the coordinator said when a resident was transferred from the hospital to this unit with a catheter, a [DIAGNOSES REDACTED]. This employee stated a transcription report, dated 10/25/10, revealed Resident #2 had a cystoscopy which revealed the resident had [MEDICAL CONDITIONS] requiring a Foley catheter. Employee #89 agreed the MDS did not reflect the [DIAGNOSES REDACTED].",2017-11-01
6717,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,280,D,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to revise the care plans for (2) of thirty-five (35) sample residents. The facility also failed to ensure one (1) of the residents was afforded the opportunity to participate in planning care and treatment. The care plan for Resident #139 was not revised after she experienced multiple falls. Resident #138's care plan was not revised as needed related to the use of a Foley catheter. The resident was also not afforded the opportunity to participate in planning care and treatment and/or to select from alternate treatments. Resident identifiers: #139 and #188. Facility census: 109. Findings include: a) Resident #139 Medical record review revealed the resident fell on the day of admission, on 02/13/14. A care plan, initiated on 02/14/14, addressed the problem of falls with the information assessed at that time. The resident fell again on 02/19/14, 02/20/14, and 03/09/14. On 03/10/14 at 9:00 a.m., a review was conducted of the incident reports and the fall review forms which were completed on the four (4) falls. The review revealed the resident's blood pressure was noticeably lower in two (2) of the post-fall assessments, than the recorded routine blood pressures which were obtained the same day. All of the falls occurred when the resident had risen to ambulate. The resident's care plan addressed the monitoring of the resident for [MEDICAL CONDITION] ([MEDICAL CONDITION], accidents, dizziness or [MEDICAL CONDITION]) as an intervention under the problem heading of Potential for drug related complications associated with use of [MEDICAL CONDITION] medications r/t (related/to) [MEDICATION NAME]. A review of the care plan interventions addressing the problem of falls, at 9:45 a.m. on 03/06/14, revealed no interventions which addressed the potential for falls related to [MEDICAL CONDITION]. The facility did not revise the care plan after the resident continued to fall. b) Resident #188 A Stage 1 interview and medical record review with Employee #655, a licensed practical nurse (LPN), on 03/03/14 at 10:51 a.m., revealed Resident #188 had an indwelling Foley catheter inserted on 09/23/13. The LPN said the reasons documented for the catheter were [MEDICAL CONDITION], acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. The care area assessment note, dated 10/10/13, indicated the resident was at risk for complications related to the use of the Foley catheter. Nurses' notes and physician's orders [REDACTED]. He also was treated for [REDACTED]. The resident's current care plan did not address the recurring infections as possible complications related to use of the Foley catheter. On 03/05/14, medical record review revealed a physician's determination of capacity, dated 09/18/13. This determination was made prior to the insertion of the Foley catheter on 09/23/13. Although the resident should have been involved in planning his care and treatment, there was no evidence staff discussed the risks and benefits of the Foley catheter, or alternative treatments with the resident. The care plan was reviewed with Employee #935, a registered nurse (RN) on 03/06/14 at 9:00 a.m. The care plan indicated the Foley catheter was to be removed when clinically indicated. The RN said the resident wanted the catheter and, He didn't want to let go of it. She confirmed there was no revision of the care plan to reflect the resident requested the use of the catheter. Employee #655 (LPN), said the facility utilized a communication calendar and book related to care planning. She reviewed them and confirmed there was no evidence which indicated the care plan was reviewed and revised for use of the Foley catheter. Employee #655 confirmed the information did not note the resident refused the removal of the catheter. She also confirmed there was no evidence of a discussion with the resident regarding the risks in the use of the catheter. The LPN was also unable to provide evidence other approaches to address the incontinence were offered or discussed with the resident. An interview with Resident #118, on 03/05/14 at 12:30 p.m., revealed he had not utilized a catheter at home. He also verbalized the facility had not offered other alternatives, and denied he had requested continued use of the catheter. When interviewed on 03/06/14 at 4:30 p.m., the administrator confirmed the resident's care plan was not reviewed or revised for the use of the Foley catheter.",2017-11-01
6718,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,315,D,0,1,B5L311,"**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 three (3) residents reviewed for the use of an indwelling Foley catheter was reassessed to ensure continued use was necessary. There was no evidence the resident's clinical condition demonstrated the use of a catheter was necessary. Resident #188 had an indwelling catheter inserted during an acute illness. He had not been evaluated for continued need once the acute illness resolved. In addition, the facility failed to ensure this resident received care and services to prevent, to the extent possible, infections associated with the use of the catheter. Resident identifier: #188. Facility census: 109. Findings include: a) Resident #188 A Stage 1 interview and medical record review with Employee #655, a licensed practical nurse (LPN), on 03/03/14 at at 10:51 a.m., revealed Resident #188 had an indwelling Foley catheter inserted on 09/23/13. After reviewing the record, at 12:01 p.m., the LPN indicated the reason for the catheter was [MEDICAL CONDITION], acute [MEDICAL CONDITION], and [MEDICAL CONDITION]. She said she was unable to find a [DIAGNOSES REDACTED]. Review of the medical record, on 03/05/14, revealed a physician's progress note, dated 09/23/13. It indicated the resident complained of having a difficult time urinating. The note described a basic metabolic panel showed increased creatinine and blood urea nitrogen. These blood levels are used to assess renal function. The physician also noted the resident's extremities were positive for [MEDICAL CONDITION]. A [DIAGNOSES REDACTED]. The insertion of a Foley catheter was ordered. In addition, the resident was ordered normal saline intravenously at 80 cubic centimeters per hour (cc/hr). According to the medical record, with the use of the intravenous saline solution, the resident's blood urea nitrogen and creatinine levels improved. A physician's progress note, dated 11/24/13 noted, Foley ok. The note did not contain a rationale for continued use of the Foley catheter. Review of the interdisciplinary treatment notes, dated 12/26/13, provided no evidence of an assessment for the use of the Foley catheter. The care area assessment note, dated 10/10/13, indicated the resident was at risk for complications related to the use of the Foley catheter. Review of nurses' notes and physician's orders [REDACTED]. He was also treated for [REDACTED]. There was no evidence these infections were assessed to determine if the use of the catheter was a contributing factor. The care plan, reviewed with Employee #935, a registered nurse (RN) on 03/06/14 at 9:00 a.m., revealed the Foley catheter was to be removed when clinically indicated. She said the resident wanted the catheter and, He didn't want to let go of it. Employee #935 confirmed there was nothing in the care plan which reflected the resident requested the use of the catheter. review of the resident's medical record revealed [REDACTED]. was assessed for removal. There was no evidence of an attempt to discontinue the catheter and/or an attempt to restore or improve normal bladder function to the extent possible. In addition, there was no evidence the resident refused the removal of the catheter. Review of the medical record, on 03/05/14, revealed a physician's determination of capacity, dated 09/18/13, which indicated the resident demonstrated capacity to make medical decisions. An interview with Resident #118, on 03/05/14 at 12:30 p.m., revealed he had not utilized a catheter at home. He also verbalized the facility had not offered other alternatives, and denied he had requested continued use of the catheter. He said the facility informed him, on 03/04/14, an appointment was made with a urologist for an assessment for possible removal of the catheter. An interview with the administrator, on 03/06/14 at 4:30 p.m., revealed Resident #188 had fallen off the radar when he was transferred from upstairs to downstairs. The administrator said she spoke with the nurse responsible for quality assurance, and confirmed the resident was not reassessed for continued need of the catheter. She said the facility ordered a consult with a urologist on 03/04/14, after the Stage 1 staff interview related to use of the catheter.",2017-11-01
6719,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,323,D,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure the environment was as free from accident hazards. For Resident #139, the facility failed to identify the risk of postural hypotension, and failed to ensure staff were aware of the approaches to use to prevent falls. Resident #145 had a can of Butane, a highly flammable colorless, odorless gas, in her room. Resident identifiers: #139 and #145. Facility census 109. Findings include: a) Resident #139 Resident #139 was admitted to the facility on [DATE]. Her admission followed a hospitalization related to a recent cerebral vascular accident which resulted in aphasia and weakness of the lower extremities, increased by the presence of osteo[DIAGNOSES REDACTED] of the left foot/toe. Her admission physician's orders [REDACTED]. A review of the record revealed the resident fell on the day of admission, 02/13/14. A care plan, initiated on 02/14/14, addressed the problem of falls with the information assessed at that time. The resident fell again on 02/19/14, 02/20/14, and 03/09/14. A review of the medical record for Resident #139 revealed the care plan had not been revised after the falls on 02/19/14, 02/20/14, and 03/09/14. The need for a pharmacist's evaluation of the resident's medications was stated as an action on the fall reviews after the 1st, 2nd, and 3rd falls in February 2014. The evaluation was not obtained until after the 4th fall, in which the resident sustained [REDACTED]. A review of the incident reports and the fall review forms, completed for the four (4) falls, at 9:00 a.m. on 03/10/14, revealed the resident's blood pressure was noticeably lower on two (2) of the post-fall assessments. The resident's blood pressure was 90/60 after the fall on 02/13/14, and 88/60 after the fall on 02/19/14. These blood pressures were appreciably lower than blood pressures taken the same day as part of routine monitoring. All of the falls occurred when the resident had risen to ambulate. Each fall review indicated a needed review of the resident's medication regime by the pharmacist. There was no evidence the reviews were done. A review of the resident's medications on 03/06/14, revealed the resident was receiving Lisinopril, Neurontin, Coreg, Lexapro, Alprazolam, and Tegretol, all of which may lower blood pressure. The resident's care plan addressed the monitoring of the resident for Hypotension (syncope, accidents, dizziness or vertigo) as an intervention under the problem heading of Potential for drug related complications associated with use of psychotropic medications r/t (related/to) lexapro, restoril, xanax. Staff took the resident's blood pressures twice daily, but there was no indication whether the resident was lying, sitting, or standing when the blood pressures were taken. This is a common practice for monitoring postural hypotension. A review of the care plan interventions addressing the problem Falls, at 9:45 a.m. on 03/06/14, revealed no interventions related to correlations between the resident's medications and the potential for falls. A review at the same time, of the resident care instructions for the nurse aides providing direct care, revealed no safety interventions related to hypotension and the potential for falls. An interview was conducted with Employee #6 (aide providing care to the resident), at 11:10 a.m. on 03/07/14. She stated the resident was unsteady on her feet and did not wait for assistance when she wanted to get up from the chair or bed. The aide said she had been told to remind the resident to wait for assistance and to offer to toilet her frequently. She said no one had told her to have the resident sit up slowly or pause after rising before ambulation. These are common interventions for fall prevention with postural hypotension. On 03/10/14 at 10:00 a.m., an interview was conducted with Employee #94 (Nurse Manager). When asked if the pharmacy assessment after the previous three (3) falls had been done, Employee #94 said they had not been done. She stated she referred it to the pharmacist earlier today (03/10/14), after she learned of the last fall. She stated, I think before this they (the falls) were thought to be due to the recent stroke and poor safety awareness. After review of the resident's records, she agreed the possibility of postural hypotension should have been addressed in the care plan. Employee #94 returned at 11:20 a.m. on 03/10/14, presenting a copy of the pharmacy review report, completed by the consultant pharmacist. The report contained the following statements: Medications that may cause orthostatic hypotension: lisinopril 5 mg daily and carvedilol (Coreg) 3.25 mg daily. After Employee #94 relayed this information to the physician, the physician ordered the lisinopril dosage reduced from 5 mg to 2.5 mg and the alprazolam (Xanax) discontinued. b) Resident #145 During a random observation, on 03/06/14 at 9:09 a.m., a large can of Butane was observed sitting on top of the resident's tall dresser/armoire. During another observation, on 03/06/14 at 4:30 p.m., the can of Butane remained on top of the dresser/armoire. Employee #935, a registered nurse (RN), said the Butane should not be in the room because it was combustible, and removed it from the armoire. Another interview with the administrator, at 4:45 p.m. on 03/06/14, confirmed the Butane was a potential accident hazard. She said it should have been kept in a red container for combustible items, located in the basement.",2017-11-01
6720,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,441,E,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, family interview, policy review, and staff interview, the facility failed to maintain an Infection Control Program to prevent and control, to the extent possible, the onset and spread of infection for four (4) residents identified during random opportunities for discovery. The arm rests on Resident #141's cardiac chair were torn, preventing proper sanitization. A licensed practical nurse (LPN) failed to wash / sanitize her hands during medication administration and resident care for Residents #234, #85 and #219. The LPN also failed to maintain effective infection control practices during tracheostomy care for Resident #85. Resident identifiers: #141, #234, #85, and #219. Facility census: 109. Findings include: a) Resident #141 On 03/03/14 at 2:30 p.m., Resident #141 was observed sitting in her cardiac chair in the hall. Both arm rest covers were torn exposing rough hard plastic edges. The foam padding was exposed and the under sides of the clear plastic covers on the arm rests were discolored. The condition of the arm rests prevented them from being adequately sanitized. During a family interview, on 03/03/14 at 3:30 p.m., Resident #141's daughter pointed out the torn covers and exposed padding on the resident's cardiac chair. She voiced concerns about the cleanliness of the chair. In an interview with Nurse Aide #155, on 03/06/14 at 11:00 a.m., she agreed the torn arm rests on Resident #141's cardiac chair needed repaired. On 03/07/14 at 10:22 a.m., observations found the resident sitting in a cardiac chair with intact armrests. b) Resident #234 During an observation of medication administration on 03/05/14 at 8:50 a.m., an LPN, Employee #675, retrieved a pill she dropped on the floor. She placed the pill in the trash, then opened the medication cart drawer and obtained a replacement pill for Resident #234. Without washing her hands, she proceeded to the resident's room, poured water from his pitcher into a glass, and handed him the water and pills . In an interview with LPN #675, on 03/05/14 at 9:00 a.m., she confirmed she picked the pill up off the floor with her bare hands and continued to pass medications without washing her hands. c) Residents #85 and #219 During observations on 03/06/14 at 8:40 a.m., LPN #565 put on clean gloves to administer a nebulizer treatment to Resident #219. She removed her gloves, applied a clean pair without washing / sanitizing her hands, and proceeded to Resident #85's bedside to suction and clean her trachea and [DEVICE]. LPN #565 again changed her gloves without washing / sanitizing her hands and returned to Resident #219's bedside to check her nebulizer treatment and change a dressing on her left elbow. LPN #565 peeled off the dressing, removed her gloves, exited the room and proceeded to the linen cart to obtain clean linen without first washing / sanitizing her hands. She returned to Resident #219's bedside, donned clean gloves, and cleaned the resident's seeping lesion and applied a new dressing. During an interview on 03/06/14 at 9:20 a.m., LPN #565 confirmed she had not washed her hands between glove changes and after removing her gloves. The facility's policy titled Hand Hygiene included in section 2 titled, Indications for hand washing and hand antisepsis, Hands are to be decontaminated after removing gloves. d) Resident #85 On 03/06/14 at 8:40 a.m., LPN #565 was observed providing tracheostomy care to Resident #85. After donning gloves and removing the trachea collar, she obtained a clean catheter and suctioned the tracheal secretions off the resident's neck and chest prior to inserting the suction catheter into the resident's trachea. During an interview on 03/06/14 at 9:20 a.m., LPN #565 acknowledged she had not washed her hands between glove changes and prior to suctioning the resident. This information was shared with the facility administrator, on 03/06/14 at 4:30 p.m. She confirmed this was improper technique for tracheostomy care.",2017-11-01
6721,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2014-03-11,465,D,0,1,B5L311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure a safe and/or sanitary environment by allowing storage of personal items directly on the floor of one (1) of thirty-eight (38) residents in the sample, where cleanliness could not be assured and the storage became a safety hazard for anyone entering the room. Resident identifier: #79. Facility census: 109. Findings include: a) Resident #79 During the general tour of the facility, at 8:20 a.m. on 03/03/14, an observation of room 106, a private room belonging to Resident #79, revealed many personal items stored directly on the floor. There was a stack of approximately a dozen stuffed animals on the floor underneath a table and a stack of blankets, [MEDICATION NAME], and/or throws on the floor in another place. There were care items (her wash basin with her personal hygiene items) sitting on the floor in the bathroom. Additional observations on 03/04/14 at11:00 a.m. and 03/05/14 at 9:30 a.m. found the items remained stored directly on the floor. When this was reported to Employee #93 (Nurse Manager) at 8:45 a.m. on 03/11/14, she stated she was aware of the storage and had tried to move it, but the resident objected. She agreed that it was not sanitary storage and said she would arrange something on which to place the items.",2017-11-01
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
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
8038,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,225,E,0,1,8KXK11,"Based on review of the personnel records, review of facility policy, and staff interviews, the facility failed to thoroughly screen four (4) of ten (10) sampled employees to ensure there had been no actions by a court of law or findings entered into a state nurse aide registry in other states where the individuals had resided, worked, or receive their training. Employee identifiers: #22, #31, #138, and #75. Facility census: 127. Findings include: a) Employees: #22, #31, #138, and #75 The personnel files of these employees were reviewed at 12:30 p.m. on 08/20/12. No evidence of verification of a valid out-of-state license and/or certification being done prior to their hire could be found. Employee #22 - a Licensed Practical Nurse hired on 07/02/12. Employee #31 - a Nursing Assistant hired on 05/07/12. Employees #138 and 75 - Nursing Assistants hired on 04/09/12. All of these employees stated on their applications they had either reside, were educated, were licensed/certified, and/or had been employed in the health-care field in a state other than West Virginia. During an interview with the Administrator and the Human Resources staff (Employees #177 and 178), they acknowledged, after reviewing the files, that the information was not included. The policy entitled Internal and External Recruitment and Job Placement was reviewed during the interview and revealed that an out-of-state verification of licensure/certification was not required. The Administrator stated she would explore this.",2016-10-01
8039,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,242,D,0,1,8KXK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review, observations, and staff interview, it was determined the facility failed to allow three (3) of thirty-six (36) sampled residents the right to make choices about aspects of their life in the facility that were significant to the them. Residents #289 and #17 were not given the choice to have a tub bath versus a shower even though their comprehensive assessments indicated this was very important for them to have this choice and care plans indicated the residents would be given the choice. Resident #217 was given a notice the facility was going to become a non-smoking and informed her she would have to stop smoking by 09/10/12. This resident indicated she had smoked most of her life and it was one of the last pleasures she had left in life. This had the potential to affect more than a limited number of residents. Resident identifiers: #289, #217 and #17. Facility census: 127. Findings include: a) Resident #289 On 08/14/12 at 9:48 a.m., during a resident interview, it was revealed this resident stated she always had showers. The resident stated she had never been asked if she preferred a bath or a shower. During a review of the resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/03/12, in Section F, item F-0400, it was discovered the resident had indicated it was somewhat important that she be given the choice to choose between a shower, tub bath, bed bath, or sponge bath. Review of the resident's current comprehensive care plan discovered the care plan approach was to assist with bath or shower 2-3 times weekly or more often if desired. During another interview with this resident, on 08/21/12 at 1:45 p.m., she again stated she had never been asked if she would like a tub bath, and was unaware there was a bath tub/whirlpool available. The resident indicated she would love to have the choice of a tub bath or whirlpool bath Observations on the second floor found there was a small shower room, with only a shower, on each hallway. Further observations revealed a larger shower room was located on each floor, which included a bath/whirlpool tub. These observation also revealed the larger tub/shower rooms were being used to store geri-chairs and other equipment. During random interviews conducted with direct care staff on second floor, on 08/21/12, it was revealed the tub/shower rooms were rarely used. b) Resident #217 During an interview with this resident, on 08/20/12 at 1:30 p.m., the resident stated the nursing home administrator (NHA), Employee #116, had presented her with a copy of the facility's new smoking policy which prohibited smoking on the facility property, and informed her she would have to quit smoking. The resident reported she was admitted to the facility on [DATE], as a smoker. The resident stated she had been smoking for many years and it was her only pleasure left in life and she did not know how she was going to quit. The resident stated the nursing home administrator told her the facility would help her quit smoking, or she would have to smoke off nursing home grounds. This [AGE] year old resident, with a [DIAGNOSES REDACTED]. She was unable to take herself off of the nursing home grounds to smoke. During an interview with the NHA, on 08/22/12 at 2:00 p.m., it was confirmed this resident had been provided with the non-smoking information. According to the guidance to surveyors at F242, If a facility changes its policy to prohibit smoking, it must allow current residents who smoke to continue smoking in an area that maintains the quality of life for these residents. Additionally, the Center for Medicare and Medicaid Survey and Certification Letter ( SC12-04 ), dated 11/10/11, included a reminder of this guidance at F242. c) Resident #17 Resident #17 was an [AGE] year old alert and oriented female admitted on [DATE]. She had scored 15 on her Brief Interview for Mental Status (BIMS) on her annual comprehensive assessment completed for the Minimum Data Set (MDS). (The maximum score for the BIMS is 15. A score of 15 indicated the resident was cognitively intact.) During an interview with the resident, at 3:30 p.m. on 08/13/12, she stated she had not been asked how often she preferred to bathe. She also said she had been told the facility did not have a tub in which to bathe. A review of her annual MDS, with an assessment reference date (ARD) of 01/18/12, revealed her choice between a tub bath, shower, bed bath, or sponge bath was very important to her. When re-interviewed, at 11:20 a.m. on 08/22/12, she stated she had told the girl that she would like to take a tub bath when she was asked, but had never been offered one and had never seen a bathtub since she had been there. During an interview with Employee #119 (Activities Director), at 5:00 p.m. on 08/21/12, she confirmed she had done the interest assessment interview with Resident #17 prior to her annual MDS. She explained that when she asked a resident how important it was to choose the type of bath they received and they answered very important, then she asked which they preferred and circled it on the form. The activities director left the interview to retrieve the form and returned with it to the interview. She agreed she had failed to circle any choice on the question and admitted she did not recall the resident's choice. Employee #119 explained that after the form was completed, it was taken to the care plan meeting, where it was discussed, and then turned over to nursing for use in developing the care plan. The care plan established on 01/19/12, and reviewed on 07/24/12, indicated the following intervention: Provide/assist with bath or Shower 2-3 times weekly, More often as desired by Resident , to be carried out by the CNA. The care plan did not reflect the resident's preference. During the morning of 08/21/12, Employees #63 and #21 (nurse aides) were asked individually if they asked residents if they wanted either a tub bath or a shower. Both stated that none of the residents had asked for a bath, but admitted they did not ask. They stated there was a whirlpool tub on each floor and it could be used if needed. Neither remembered the last time those tubs were used. During an interview with the director of nurses (Employee #131) and the administrator, at 11:30 a.m. on 08/22/12, the director of nurses acknowledged she had not been aware the resident wanted to take a tub bath.",2016-10-01
8040,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,253,E,0,1,8KXK11,". Based on observations and staff interviews, the facility failed to ensure maintenance services were provided to maintain a sanitary, orderly, and comfortable environment. Seven (7) rooms, housing fourteen (14) residents, were found to have sinks that were in disrepair, rendering them unable to be sanitized properly. Rooms 114, 115, 121, 123, 127, 130, and 133. Facility census: 127. Findings include: a) Rooms 114, 115, 121, 123, 127, 130, and 133 Observations on 08/27/12, found the sinks in these rooms had cracked and peeling surfaces. The condition of the sinks prohibited sanitization, as well as being unattractive. This was discussed with the maintenance supervisor on this date.",2016-10-01
8041,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,280,D,0,1,8KXK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure a revision of the care plan as the resident's health and/or mental status declined for one (1) of thirty-six (36) sampled residents. Resident identifier: #109. Facility census: 127. Findings include: a) Resident #109 A review of the clinical record for Resident #109 revealed she was an [AGE] year old female, admitted on [DATE], and re-admitted on [DATE]. Her [DIAGNOSES REDACTED]. She was legally blind and hard of hearing. The following entries to the record are from the Quarterly Interdisciplinary Team meeting on 06/21/12: -- Activities: Speech impaired, hard of hearing. Sleeps a lot no progress to date. -- Social Services: .overall decrease in health and weight loss. -- Nursing: Aphasic - poor hearing - poor vision - complete care - seems peaceful. All medications d/cd (discontinued) .has steady loss of weight. On 06/11/12, the physician stopped all oral medications because the resident had stopped taking them. He also discontinued the use of splints, hand rolls, and floating her heels on 07/31/12. During an interview with Employee #16 (registered nurse), at 1:30 p.m. on 08/20/12, she stated the resident had no safety awareness and was checked often. She also said the resident was deaf and blind and could not state her needs. Employee #16 stated the resident refused to eat and kept her hands and legs curled up, refusing to let them use hand splints, rolled wash cloths, or to float her heels. During an interview with Employees #123 (RN) and #89 (LPN), at 2:45 p.m. on 08/20/12, they stated Resident #109 maintained a fetal position, but was not tight. They said staff could straighten her without symptoms of pain, but that she did have contractures of the knees and back. They agreed she did not respond to questions and her speech was not understood. When asked if they considered her care at present to be for comfort only, they both indicated it was. A review of the active care plan for Resident #109 revealed the plan had been reviewed on 06/21/12, but there was no evidence the plan had been revised to reflect the present health status of the resident. 1. All oral medications were discontinued by physician's orders [REDACTED]. 2. The resident's goals for the problem of communication were not applicable to this resident whose speech was not understood and who could not communicate her needs. Likewise, the nursing interventions were not appropriate. They included: Turn off TV/radio prior to conversation (she is deaf), Make eye contact when speaking (she is blind), and Ask for clarification (she does not respond). 3. Nutrition interventions included: When setting up meal tray, uncover plate, assist with opening containers as needed or as desired (the resident was totally dependent on staff for feeding). 4. The interventions for the resident's anxiety included: Assist resident in developing a program of activities (the resident was not capable of this). 5. A problem of altered skin integrity was changed to indicate total dependence, but the interventions still included: Encourage use of bed rails, trapeze bar, etc. for resident to assist with turning. 6. The problem of self care deficit had 5 of 10 interventions that were inappropriate to the resident. These were discussed with Employee #35 (MDS nurse), and the Administrator, at 3:55 p.m. on 08/20/12. After reviewing the care plan, they acknowledged it should be revised.",2016-10-01
8042,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,354,C,0,1,8KXK11,"Based on observation and staff interview, the facility failed to ensure a registered nurse served as the director of nurses (DON) on a full time basis without serving as a charge nurse and supervising the provision of resident care. This had the potential to affect all residents. Employee identifier: #131. Facility census: 127. Findings include: a) Employee #131. Employee #131, who was identified to the survey team on the day of entry (08/13/12) as the director of nurses, was observed working as the 2nd floor charge nurse for the day shift on both 08/20/12 (census = 107) and 08/21/12 (census = 101). According to this requirement, The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents. During an interview with the DON, at 5:45 p.m. on 08/21/12, she admitted that she was working as the charge nurse because of the absence of the employee scheduled to serve in that position. She stated that she was unaware that this was not allowed. At 5:55 p.m. on 08/21/12, the Administrator was interviewed and also stated that she was unaware that having the DON serve as the charge nurse was a deficient practice and stated this would be rectified.",2016-10-01
8043,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,371,E,0,1,8KXK11,"Based on observations, review of facility policy, and staff interviews, it was determined the facility had not ensured foods were stored, distributed and served under sanitary conditions. Observations of the food preparation and delivery identified multiple unsanitary food condition services. Kitchen staff failed to wash their hands upon re-entering the kitchen and failed to maintain sanitary practices when serving meals as evidenced by picking up glasses from the rim; staff was observed holding lap towels on their shoulder while carrying trays; and an expired open loaf of bread was found on top of the refrigerator in the nutrition pantry used for residents in the skilled care unit. These practices had the potential to affect all residents receiving foods from the kitchen. Facility census: 127. Findings include: a) During the initial tour of the kitchen, on 08/13/12 at 11:35 a.m., four (4) staff members were observed preparing meal trays. A dietary aide (Employee #12) was observed licking her finger each time she picked up a resident's meal ticket and placing it on the tray to be served. b) During the initial dining room observation, on 08/13/12 at 12:05 p.m., a dietary aide (Employee #12) picked up the residents' glasses from the top to make room on the table to serve the meal. This was observed for three (3) residents. c) A follow up observation of the kitchen staff, on 8/20/12 at 12:05 p.m., found two (2) dietary aides preparing resident trays and carrying them to the dining room. They moved the residents' cups by picking them up by the rim, and then serving the meal. These aids then returned into the kitchen food service area for another tray without washing their hands. d) A review of the kitchen policies obtained from dietary manager (Employee #110) found the food handling policy stated staff were to wash their hands before handling food and they were to pick up the glasses by the base. The handwashing policy stated hands were to be cleaned frequently before, during and after food preparation or service. Hands were to be washed frequently when beginning work, immediately after going to the bathroom, after breaks, after contact with the face, nose, mouth, or hair, and before handling and serving food. During a staff interview, on 8/20/12 1:25 p.m., with the dietary manager (Employee # 110), it was agreed Employee #12's practice of licking her finger to pick up the meal slip when setting up a tray was unsanitary and against their handwashing policy which stated hands will be immediately washed after contact with face. The dietary manager also agreed the staff members were not to pick up the cups from the rim and acknowledged their food handling policy stated glasses are to be picked up by the base. The dietary manager stated it would take a lot of time to wash hands between serving residents and she would have to reevaluate the policy. e) During the inspection of the nutrition pantry on the skilled unit, on 08/14/12 at 4:30 p.m., bread was observed stored on top of the refrigerator. Inspection of the bread found the loaf had been opened. The expiration date on the bread wrapper was 07/28/12. A licensed practical nurse (Employee # 143) was present during the inspection of the kitchen area and verified the expiration date. During an interview with the Unit Nurse Manager (Employee #150), on 08/14/12 at 4:45 p.m., it was agreed this bread should have been removed from the unit kitchen. f) During an observation of tray pass of the noon meal, at 12:05 p.m. on 08/13/12, on the 100-North hall, Employee #21 was seen carrying a full food tray down the hall with a lap cover over her shoulder held in place at one point by bracing it against her hair. She entered the room, set down the tray, took the lap cover off her shoulder, and placed the cover over the resident's chest. During an interview with the DON and the Administrator, at 11:30 a.m. on 08/22/12, this finding was reviewed, with no comment.",2016-10-01
8044,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,431,F,0,1,8KXK11,"Based on observations and staff interviews, the facility failed to ensure medications were stored at the proper temperature, were properly labeled, that expired medications were disposed of timely, and that medications for a resident who was no longer in the facility were removed. This had the potential to affect all residents. Facility census: 127. Findings include: a) First floor medication preparation and storage room During a tour of the medication preparation and storage room on the first floor of the facility, at 10:55 a.m. on 08/16/12, the following observations were made: 1. There were opened multi-dose vials of insulin belonging to Residents #150, #193, #153, and #186 that had not been labeled with the date they were opened. 2. There were 2 multi-dose vials of Humalog with no identification or date of opening. 3. There was one multi-dose vial of Novalog insulin with an identification label of a resident who was not on the current census list and which had no date of opening. 4. There were 15 pre-filled syringes of flu vaccine with a factory expiration date of 06/30/2011 and seven (7) syringes of flu vaccine with a factory expiration date of 06/30/2012. 5. The medication storage refrigerator temperature was 28 degrees according to the thermometer mounted inside of the refrigerator. A sign had been placed in the refrigerator instructing staff the dial was to be at the marked blue line to maintain the temperature within allowable limits. The dial was not on the blue mark. All drugs listed above and the temperature were verified by Employee #126 (Licensed Practical Nurse) at 11:00 a.m. on 08/16/12. b) Second floor medication preparation and storage room The medication preparation and storage room on the second floor of the facility, was toured, accompanied by Employee #131 (Director of Nurses), at 11:05 a.m. on 08/16/12. Four (4) full and/or opened packages of pre-filled syringes of flu vaccine (37 syringes) were observed in the refrigerator with a factory expiration date of 06/30/12. c) The issues found on the first floor were also discussed with the DON, who stated she would have all undated and outdated items removed immediately and would investigate the temperature control.",2016-10-01
8045,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,441,F,0,1,8KXK11,"Based on observation and staff interview, it was determined the facility failed to ensure medical equipment was protected from contamination when used in an isolation room for one (1) of one (1) residents observed in an isolation room during medication pass observation in the skilled unit. The facility also failed to maintain a sanitary environment by not maintaining basic cleaning procedures in the long term care building. This had the potential to spread harmful organisms to all residents and staff. Resident identifier: #316. Facility census: 127. Findings include: a) Resident #316 During medication pass observation on the skilled unit, on 08/15/12 at 4:30 p.m., the medication nurse, a registered nurse (RN) (Employee #165) was observed providing medication to Resident #316, who was in an isolation room. A droplet precautions sign was posted on the room door. There were also instructions for dedicated medical equipment posted on the door of the resident's room. The nurse prepared the resident's medications, then took the scanner from the medication cart into the resident's room. She scanned the resident's wrist band then returned the scanner to the medication cart which was parked outside the resident's room. It was observed the nurse did not place the scanner in a protective covering before entering the resident's room, then the nurse returned the scanner to the medication cart and failed to sanitize the scanner after exiting the room and proceeding with the medication pass. During an interview with the director of nursing (Employee #131), and the Nursing Home Administrator (Employee #116), on 08/23/12 at 10:30 a.m., it was confirmed the medication nurse should have at least sanitized the medication scanner after using it in an isolation room and before replacing it on the medication cart for others to touch. b) Medication pass observation During observation of the passing of medications, at 9:05 a.m. on 08/16/12, Employee #142 (LPN) was seen to wash her hands after administering medications to a resident. She then reached up and ran her hand through her hair before starting to pour medications for another resident and administering them. c) Medication carts At 9:15 a.m. on 08/16/12, the two medication carts on 2-West, and the medication cart on 2-North, were observed to be soiled. All crevices and edges on the carts were covered with grime. Medication carts labeled 1-W and 1-N were observed at the nurses' station on first floor. Adhesive tape had been used to mend the trash container on the side of the 1-W cart and was very dirty. The bottom areas of both carts was dirty with debris present. These were shown to the DON (Employee #131) who was present on the floor. d) Medication rooms 1) The medication preparation and storage room on first floor was toured at 10:30 a.m. on 08/16/12. -- The floor was observed to be dirty around all edges, with debris in the corners. -- The ceiling vent was dirty with lint hanging from the grate. -- The handwashing sink was also dirty with calcium build-up around the fixtures. 2) The medication preparation and storage room on second floor also had a dirty ceiling vent with lint hanging from the grate. These findings were immediately relayed to the DON and the Administrator, who stated that all areas would be cleaned immediately. e) During the morning of 08/21/12, the bathroom used by the nursing staff and located behind the nurses' station on second floor was observed to have several crevices around the perimeter of the handwashing sink which were loose from the wall in places and missing caulk. Dirt and grime could be seen in the crevices. f) There were no dust covers on the eye-wash stations on 2-N and the faucets were corroded. All of the above findings were reviewed again with the DON and the Administrator at 11:30 a.m. on 08/22/12. They stated that many of the areas, including the medication carts, had already been cleaned.",2016-10-01
8046,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,463,E,0,1,8KXK11,"Based on observations, interview with a representative of the call light system company, and staff interview, the facility failed to ensure all call lights in resident rooms were functioning. Four (4) rooms were found to have call lights that did not work. This had the potential to affect any resident residing in those room should they need to summon assistance. Facility census: 127. Findings include: a) Rooms 115b, 116a, 121b, and 215a During a room by room check of the call lights, the morning of 08/20/12, the call lights for one of the beds in these four (4) rooms were found to be nonfunctioning. On 08/20/12 at 12:45 p.m., the non-working call lights were verified by the maintenance director and a representative of the call light system company.",2016-10-01
8047,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,468,E,0,1,8KXK11,"Based on observations and staff interview, the facility failed to ensure handrails were firmly secured on each side of the hallway. Handrails on the first and second were found to be loose. This had the potential to affect more than a limited number of residents. Facility census: 127 Findings include: a) On Monday, August 20, 2012 at 12:15 p.m., the handrails of first floor and second floor were observed with the maintenance director. He acknowledged the handrails were loose in the following areas: First floor, behind the stairway door, behind room 125, by the fire door on the left side and by room 105. The second floor had loose handrails noted on the right corner under the sign for the floor plan and the left side of the door by room 200. The loose handrails were corrected by maintenance at that time.",2016-10-01
8048,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,600 MEDICAL PARK,WHEELING,WV,26003,2012-08-22,492,D,0,1,8KXK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview the facility failed to notify the family about the option of palliative care when the resident's health status had declined to the point that the resident was receiving comfort measures only, as required by West Virginia Code, 16-5C-20, Hospice palliative care required to be offered for one (1) of thirty-six (36) sampled residents. Resident identifier: #109. Facility census: 127. Findings include: a) Resident #109 A review of the clinical record for resident #109 revealed that she was an [AGE] year old female, admitted on [DATE], and re-admitted on [DATE], with [DIAGNOSES REDACTED]. She was legally blind and hard of hearing. The following entries to the record are from the Quarterly Interdisciplinary team meeting on 06/21/12: -- Activities: Speech impaired, hard of hearing. Sleeps a lot no progress to date. -- Social Services: .overall decrease in health and weight loss. -- Nursing: Aphasic - poor hearing - poor vision - complete care - seems peaceful. All medications d/cd (discontinued) .has steady loss of weight. On 06/11/12, the physician stopped all oral medications because the resident had stopped taking them. He did continue the [MEDICATION NAME] dermal patch for pain. He also discontinued the use of splints, hand rolls, and the order to float her heels on 07/31/12. During an interview with Employee # 16 (registered nurse), at 1:30 p.m. on 08/20/12, she stated the resident had no safety awareness and was checked often. She said the resident was deaf and blind and could not state her needs. During an interview with Employees #123 (RN) and #89 (LPN), at 2:45 p.m. on 08/20/12, they stated that Resident #109 maintained a fetal position, but was not tight. They said staff could straighten her without symptoms of pain, but that she did have contractures of the knees and back. They agreed that she did not respond to questions and her speech was not understood. When asked if they considered her care at present to be for comfort only, they both indicated it was. Also during this interview, with Employee #23 (nurse manager) and Employee #89 (LPN) at 2:45 p.m. on 08/20/12, they both agreed the resident was total care, non communicative, blind, and deaf. She was fed by staff and ate a small amount before refusing at each offering. Her care was discussed with Employee #35 (MDS nurse) and the Administrator at 3:55 p.m. on 08/20/12. They both acknowledged that her care was geared to keeping her comfortable at present. During an interview with Employee #33 (Social Worker), at 3:00 p.m. on 08/20/12, he was asked if information about hospice care had been given to the family after the physician had made the changes to the resident's care. He acknowledged that there was no evidence in the record that this had been done, but stated that he thought the charge nurse had spoken to the family after the care plan meeting on 06/15/12. He added that all residents were given hospice information on admission, but admitted that he was aware of the requirement to re-offer information when comfort measures only were ordered. During a second meeting with the Administrator and Employee #35, at 3:55 p.m. on 08/20/12, the Administrator stated that she had spoken to the past nursing supervisor on the phone, and she admitted she had failed to relay information to the physician and ask him to request a hospice consult, in June when the meds were stopped. The West Virginia State Code includes: An amendment to the Code of West Virginia (03/10/2007): 16-5C-20 (a) When the health status of a nursing home facility resident declines to the state of terminal illness or when the resident receives a physician's orders [REDACTED].",2016-10-01
9859,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2010-12-02,280,D,0,1,NE1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to review the care plan for one (1) of thirty-three (33) Stage II sampled residents as the treatment modalities being used were changed by direct care staff. Posey cone hand splints (suggested by the occupational therapist and subsequently ordered by the physician), to maintain the highest level of range of motion and to prevent further decline of a resident with contractures, were not being used and had been replaced with rolled wash cloths, although the care plan indicated that the cone splints were still to be used. Resident identifier: #170. BJH facility census: 111. Findings include: a) Resident #170 A review of Resident #170's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No contractures were noted on his admission history and physical, but on 03/04/10, the attending physician ordered the application of a Posey palm cone splint to the left hand for contractures of fingers to be used during waking hours, after identification of the contractures by an occupational therapy assessment. On 07/26/10, the attending physician ordered, ""Occupational therapy: For right hand cone splint due to right 4th and 5th finger contractures. DX (diagnosis): Finger contractures."" On 08/27/10, the orders were clarified to state, ""Bilateral Posey cones to right and left hands on during awake hrs (sic) off at HS (bedtime)."" The care plan, completed on 09/09/10, did not include these ordered splints in their interventions, and there was no evidence that their use had been discussed at the care plan conference on that date. But the use of the cone hand splints had been handwritten on the care plan on an undetermined date after that day as an intervention to prevent ""altered skin integrity"" and under the stated problem of ""self-care deficit"". A review of the care plan conference schedule revealed the next conference for Resident #170 after 09/09/10 was to be held on 12/09/10, but the review date scheduled on the care plan for 12/08/10 had been marked through and a new review date of 03/11/11 had been added. The resident's active care plan (with review date of 09/09/10 and next review of 03/11/11) revealed the nursing intervention of: ""Cones to Rt & left hands."" Observations of Resident #170, at 2:30 p.m. on 11/30/10 (when the resident was awake in bed) and at 8:30 a.m. on 12/01/10 (when the resident had been gotten up to his chair after his bath) failed to find the presence of any type of splints being used, although on both days the treatment sheet had been signed off on both day and evening shifts to indicate these splints had been used. During an interview with a nurse (Employee #43) at 8:30 a.m. on 12/01/10, she stated they did not use the cones any more, because the resident's wife preferred the use of rolled washcloths. Employee #43 also stated there were no rolled washcloths in use at present, because staff waits until the resident's wife to come in for her to do them. A review of the nurses' notes from August 2010 through the survey date of 12/01/10, and review of the care plan meeting minutes, failed to reveal any evidence that the wife had refused the use of the cone supports or that she had assumed this care of the resident. A third observation was made at 3:00 p.m. on 12/01/10, in the presence of the nurse manager (Employee #1) as the resident was returned to bed. There were no splints of any kind present. The nurse manager and the aide searched the room and did find the cone splints stored in a container on the resident's chair, but both declared that the cone splints were not used, although neither could remember when they had ceased to use them. Employee #1 had no explanation for the continuation of documentation on the treatment sheet to indicate the cones were being used. During an interview with the director of nurses (DON - Employee #145) and Employee #1 at 3:00 p.m. on 12/01/10, the DON stated, after reviewing the resident's care plan that it should have been revised to show that the rolled washcloths were being used at the wife's request. Employee #1 agreed that the physician should have been notified and a new order received. Neither could explain why the care plan indicated a review prior to the care plan conference scheduled for 12/09/10. .",2015-08-01
9860,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2010-12-02,318,D,0,1,NE1Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure hand splints recommended by the occupational therapist and subsequently ordered by the physician (to maintain the highest level of range of motion and to prevent further decline of a resident with contractures) were being used consistently as instructed for one (1) of thirty-three (33) Stage II sampled residents. Resident identifier: #170. BJH facility census: 111. Findings include: a) Resident #170 A review of Resident #170's medical record revealed a [AGE] year old male who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. No contractures were noted on his admission history and physical, but on 03/04/10, the attending physician ordered the application of a Posey palm cone splint to the left hand for contractures of fingers to be used during waking hours, after identification of the contractures by an occupational therapy (OT) assessment. In an OT completed on 07/28/10, the therapist described the worsening of the resident's contractures as follows: ""R (right) hand 4th and 5th digits held clenched throughout the day (sign for 'with') indentation in palm from 5th digit fingernail, causing concern for skin integrity in the future. Resident has full PROM (passive range of motion) of all digits R hand. Resident has tolerated a palm cone during waking hours in the L (left) hand since March 2010 for similar problems, therefore I recommend use of a R hand palmcone to provide passive stretch to the 4th and 5th digits as well as to promote palmar skin integrity in the future."" On 07/26/10, the attending physician ordered, ""Occupational therapy: For right hand cone splint due to right 4th and 5th finger contractures. DX (diagnosis): Finger contractures."" On 07/30/10, the OT daily progress notes stated the cone was being tolerated and that therapy services were being discontinued. This was verified in an interview with the occupational therapist (Employee #176) at 2:50 p.m. on 12/01/10. She stated that, after that date, therapy would not see resident until the next annual screening unless requested by nursing. When questioned, she stated she assumed the splints were being used as ordered. On 08/27/10, the orders were clarified to state, ""Bilateral Posey cones to right and left hands on during awake hrs (sic) off at HS (bedtime)."" The use of these cones was present on the resident's active plan of care, and documentation on the treatment sheets indicated by nurse signature twice daily that the cones were being used as ordered. Observations of Resident #170, at 2:30 p.m. on 11/30/10 (when the resident was awake in bed) and at 8:30 a.m. on 12/01/10 (when the resident had been gotten up to his chair after his bath) failed to find the presence of any type of splints being used, although on both days the treatment sheet had been signed off on both day and evening shifts to indicate these splints had been used. During an interview with a nurse (Employee #43) at 8:30 a.m. on 12/01/10, she stated they did not use the cones any more, because the resident's wife preferred the use of rolled washcloths. Employee #43 also stated there were no rolled washcloths in use at present, because staff waits until the resident's wife to come in for her to do them. The resident's hands were observed to be tightly clenched on all observations with obvious finger deformities, and the imprint of his fingernails can be seen on his palms when his hands were opened, although there was no skin breakdown. A review of the nurses' notes from August 2010 through the survey date of 12/01/10, and review of the care plan meeting minutes, failed to reveal any evidence that the wife had refused the use of the cone supports or that she had assumed this care of the resident. The resident's active care plan (with review date of 09/09/10 and next review of 03/11/11) revealed the nursing intervention of: ""Cones to Rt & left hands."" A third observation was made at 3:00 p.m. on 12/01/10, in the presence of the nurse manager (Employee #1) as the resident was returned to bed. There were no splints of any kind present. The nurse manager and the aide searched the room and did find the cone splints stored in a container on the resident's chair, but both declared that the cone splints were not used, although neither could remember when they had ceased to use them. Employee #1 had no explanation for the continuation of documentation on the treatment sheet to indicate the cones were being used. .",2015-08-01
9861,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2010-12-02,356,C,0,1,NE1Z11,". Based on observation and staff interview, the facility failed to ensure the posted nurse staffing information included all of the requirements in Federal statute 42 CFR 483.30 (e), by failing to include the number of actual hours worked by nursing staff. This had the potential to affect all residents and visitors. BHJ facility census: 111. Findings include: a) During a tour of the environment at 1:00 p.m. on 12/01/10, the ""Nursing Staffing / Resident Census"" forms were observed posted on each floor. The posting included the facility's name, the current date, the resident census, and the total number of registered nurses, licensed practical nurses, and certified nurse aides. However, the number of actual hours worked by each of these categories of nursing staff were not listed on the form. During an interview with the director of nurses (DON) and the 100 hall nurse manager at 3:50 p.m. on 12/01/10, the DON expressed surprise that the hours were required and stated they had never included them in their posting. At her request, she was provided with the Federal statute 42 CFR 483.30 (e) at 9:00 a.m. on 12/02/10. .",2015-08-01
9862,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2010-12-02,431,E,0,1,NE1Z11,". Based on observation and staff interview, the facility failed to maintain the secure storage of medications and syringes on the medication cart at a time when it was unattended and located in a hallway traveled by residents and/or visitors. This had the potential to affect anyone who could reach the top of the cart on the 100 hall. BHJ facility census: 111. Findings include: a) During medication pass by a licensed practical nurse (LPN - Employee #8) on the 100 hall on the afternoon of 11/29/10, observation found multiple vials of insulin and syringes located on top of the medication cart. The nurse left the cart unattended on four (4) separate occasions while she entered rooms 124, 125, 127, and 134, to administer medications to those residents. The cart was left unattended and out of line of sight of the nurse in the hallway intermittently from 1:30 p.m. to 1:59 p.m., and the items on top of the cart were accessible to anyone passing in the hallway. During an interview with Employee #8 at 2:15 p.m. (at the conclusion of the observation), she acknowledged the medications and syringes were left out on the top of the cart, and she placed them inside of a drawer.",2015-08-01
10736,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,282,G,1,0,H2M211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- 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. ..."" . --- Part II -- Based up record review, observation, and staff interview, the facility failed to ensure that all physician-ordered medications (including medical gases) were administered by qualified personnel, by permitting (contrary to State law) unlicensed staff to start, regulate, and administer oxygen. This was found to have affected one (1) former resident (#106) and has the potential to affect five (5) current residents who were prescribed continuous oxygen (#108, #109, #68, #111, and #24) and more than a minimal number of future residents. Facility census: 104. Facility census: 104. Findings include: a) Resident #106 1. Review of the facility's self-reported allegations of abuse / neglect, on 08/09/11 at 9:00 a.m., disclosed a report involving Resident #106, with an incident date of 10/26/10. The date of the immediate FAX reporting of allegations was 10/26/10. The allegation was stated (quoted as written): ""Pt (patient) states 11-7 CNA (certified nursing assistant) that worked last night got her ready for [MEDICAL TREATMENT] Early AM (morning) and did not put pt's oxygen on her. Pt asked CNA to connect her to her oxygen and CNA said 'Oh, you don't need that.' Pt stated that she had said this before to her."" The five day follow-up report, dated 10/28/10 and completed by the facility's unit manager (Employee #83), stated (quoted as written): ""I showed resident pictures of the 2 nursing assistants that worked 11-7 shift on North hall on 10/25/2010-10/26/2010. (Resident #106) pointed to (Employee #159)'s photo picture. 'She is the one who did not put oxygen on me, even after I asked her for it.' I called (Employee #159) at home with the DON (director of nursing - Employee #7) present (on speakerphone) to question her about the incident. (Employee #159) admitted that she did not put oxygen on the patient. 'No one ever puts oxygen on her when she goes to [MEDICAL TREATMENT]. They put it on her in [MEDICAL TREATMENT]. (Resident #106) never asked me to put oxygen on her. She just asked me if the oxygen was connected.' I called four other nursing assistants that work 11-7 shift that get the resident ready for [MEDICAL TREATMENT] and asked them if (Resident #106) goes to [MEDICAL TREATMENT] with oxygen. All four aides stated that they disconnect (Resident #106)'s oxygen from the wall oxygen system and reconnect it to a portable oxygen tank prior to transferring her from her room to the [MEDICAL TREATMENT] unit. I also called a [MEDICAL TREATMENT] nurse and asked her if (Resident #106) comes to [MEDICAL TREATMENT] with oxygen on. She says most of the time (Resident #106) does come with oxygen on but once in a while she doesn't. (Employee #159) will be counseled for not following through with resident's request and not maintaining delivery of oxygen to this resident as ordered by the resident's physician. "" -- b) Employee #159's personnel file, when reviewed on 08/09/11 at 11:30 a.m., disclosed that she had resigned with no notice on 04/25/11. Her personnel file contained a ""Corrective Action Form"" dated 11/24/10, which indicated it was the expectation that nursing assistants maintain residents' oxygen administration according to physicians' orders. The corrective action summary stated: ""(Employee #159) was responsible for getting resident ready for [MEDICAL TREATMENT]. This includes resident transfer from bed to chair, hooking the resident up to a portable oxygen tank and pushing the resident in her chair to the [MEDICAL TREATMENT] unit. (Employee #159) did not hook the resident up to a portable oxygen tank and took her to [MEDICAL TREATMENT] with no oxygen even after the resident had asked her for the oxygen. The patient is ordered oxygen at 3 liters per nasal cannula continuously. (Employee #159) has previously received a verbal warning on February 23, 2010 for 52 hours of absenteeism. (Employee #159) is receiving a final written warning for not following through on the patent's request and respecting the resident's right to make decisions and not following the patient's plan of care."" The action plan on the form stated: ""(Employee #159) has been counseled on listening to a patient's request and respecting their needs. (Employee #159) will be re-educated on the requirement to maintain a patient's oxygen administration per Doctor's orders and the need to always follow all doctor's orders."" -- 3. Employee #83, when interviewed on 08/10/11 at 8:30 a.m. about the corrective action form for former nursing assistant Employee #159, confirmed the nursing assistant did not administer oxygen to the resident. When asked what her expectations were had the nursing assistant proceeded correctly, she stated the nursing assistant would have removed the oxygen tubing from the wall and hooked it up to a small portable tank prior to transporting the resident to [MEDICAL TREATMENT]. When asked if she could enlist a nursing assistant on duty to perform a return demonstration of the correct procedure, she agreed and enlisted the assistance of Employee #157 at 8:40 a.m., to demonstrate the correct procedure to be followed for transport of a resident on continuous oxygen at three (3) liters per nasal cannula from their room to [MEDICAL TREATMENT]. Employee #157 went to the physical therapy room, to a locked closet, and obtained a small portable oxygen tank. She showed how she determined that the tank was full by viewing a meter on the tank. She entered a chosen unoccupied room and demonstrated that she would check the setting for the oxygen flow administration in the wall oxygen system, remove the tubing from the wall, affix it to the portable oxygen tank, set the portable tank at the correct flow rate, and place the cannula on the resident prior to transport. She stated the procedure would be reversed upon return. She indicated that, if the resident would be remaining in the day room area, they would utilize a large portable oxygen tank maintained for that purpose. When asked to demonstrate that process, she returned to the physical therapy room and pointed out a large oxygen tank. She referred to a tag that documented that the tank contained sufficient oxygen for use. She performed the procedure for turning the tank on and regulating the flow at the appropriate administration rate by use of a dial on the tank. She stated that, after she had the large tank set at the ordered flow rate, she would apply it to the resident via nasal cannula. Employee #83 subsequently expressed that Employee #157 had demonstrated the procedures in accordance with the facility's expectations to be followed by nursing assistants. -- 4. Employee #83, when asked on 8/10 11 at 9:55 a.m. when facility nursing assistants would receive training in the application of oxygen, stated this would take place in orientation and reported the facility's director of nursing (DON - Employee #7) would have the most recent orientation checklist. Employee #7 was asked for the current nursing assistant orientation materials. She provided a 10-page form entitled ""Performance Skills Review Certified Nursing Assistant"". The form listed skills required to perform the position and included an initial assessment at time of orientation, an ongoing assessment at ninety (90) days, and three (3) annual reviews for each area. Section 24 on Page 7 assesses the nursing assistant for the skill of ""Applying oxygen via nasal cannula, face mask, [MEDICAL CONDITION]."" -- 5. Review of the facility's ""Nursing Administrative General Policy Manual"", on 08/10/11 at 10:50 a.m., found the following in the section titled ""Medications"" - Policy #2 ""Medication Administration System and Medication Administration Record [REDACTED] ""Following professional and legal guidelines and restrictions, the registered nurse and licensed practical nurse will administer medications prescribed for residents' care by a licensed qualified physician, surgeon, dentist, podiatrist, or other person duly licensed or authorized to prescribe by the state of West Virginia and who has been a member of the medical staff of Wheeling Hospital."" Under the section titled ""Procedure"", the third paragraph states in part (quoted as typed): ""The nurse administering the medication is to initial the resident's. Medex in the space provided under the date and on the line for that drug, dose, and time of administration. The nurse is responsible for verifying the initial with a full signature and title in the space provided on the MAR."" -- 6. A review of the MAR for Resident #106, on 08/09/11, found that, on 10/26/11, nurses' initials were affixed next to the order for application of oxygen on night shift (N), day shift (D), and evening shift (E), thereby confirming that the oxygen was recognized as a physician-ordered medication under their policy. -- 7. A review of 2010 West Virginia Code Chapter 30, Professions and Occupations, Article 7, Registered Professional Nurses, Section ?30-7-1, Definitions on 8/10/11 at 3:30 p.m. found the following: ""?30-7-1. Definitions. As used in this article the term: (a) 'Board' shall mean the West Virginia board of examiners for registered professional nurses; (b) The practice of 'registered professional nursing' shall mean the performance for compensation of any service requiring substantial specialized judgment and skill based on knowledge and application of principles of nursing derived from the biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments as prescribed by a licensed physician or a licensed dentist, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others ..."" -- 8. The facility's procedure, as documented and demonstrated in this instance, is that nursing assistants are to start - and regulate - the flow of oxygen administration per physician's orders [REDACTED]. Oxygen is a physician-ordered medical gas and is viewed as a medication; the facility recognized oxygen as a medication by its inclusion on the Medication Administration Record [REDACTED]. Administration of medications by non-licensed assistive personnel is not permitted in nursing homes. .",2014-12-01
10737,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,225,D,1,0,H2M211,". Based on review of facility complaint records, review of allegations of abuse / neglect, and staff interview, the facility failed to report four (4) allegations of abuse / neglect / misappropriation of property received in the previous six (6) months to the State agency and other appropriate agencies according to State law. Resident identifiers: #24, #107, and #105. Facility census: 104. Findings include: a) Resident #24 Review of all self-reported allegations of abuse / neglect submitted to State agencies by the facility in the previous six (6) months revealed a document identified as a ""Patient Complaint"", which contained a summary of complaints registered by a family member of Resident #24 on 05/19/11. The document stated Resident #24 had been ""assaulted by another resident"", was not being taken to the bathroom, was not receiving assistance when the call light was activated, and was experiencing repeated falls due to lack of supervision and assistance. The facility's administrator (Employee #9) had contacted the family member by phone to discuss this complaint, but there was no evidence to reflect the allegations of abuse and neglect contained in the complaint had been reported to the appropriate State agencies. When interviewed on 08/10/11 at approximately 4:00 p.m., the facility's administrator confirmed these allegations had not been reported as required. -- b) Resident #107 Review of all self-reported allegations of abuse / neglect submitted to State agencies by the facility in the previous six (6) months revealed a document identified as ""Patient / Family Complaints"", which was written on 06/20/11. The document stated that, while Resident #107 was no longer at the facility, the facility received a report from a family member of events the resident stated had occurred while at the facility. The resident alleged that ""when he asked to be put to bed they wouldn't do it and when they did put him in bed they didn't care how the got him in bed - just threw him in and kicked him."" Facility staff had documented having a conversation with the family member who registered the complaint for the resident, but there was no evidence to reflect these allegations of abuse and neglect had been reported to State agencies as required by law. When interviewed on 08/10/11 at approximately 4:00 p.m., the facility's administrator confirmed these allegations had not been reported as required. -- c) Resident #105 Review of all self-reported allegations of abuse / neglect submitted to State agencies by the facility in the previous six (6) months revealed a document identified as ""Patient / Family Complaints"", which was written on 05/04/11. The document stated a family member of Resident #105 alleged that staff did not ""turn her often enough since she has breakdown on her bottom."" On response to this allegation, the facility's director of nursing (DON - Employee #7) reviewed the medical record of the resident and determined the resident did not have skin breakdown. There was no evidence to reflect this allegation of neglect had been reported to State agencies as required by law. When interviewed on 08/10/11 at approximately 4:00 p.m., the facility's administrator confirmed this allegation had not been reported as required. .",2014-12-01
10738,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,505,D,1,0,H2M211,". Based on closed record review and staff interview, the facility, failed for one (1) of thirteen (13) sampled residents, to promptly notify the attending physician of the abnormal findings of lab reports. Resident #105 had a urinalysis on 04/30/11 and blood work on 04/18/11. Both lab studies yielded abnormal results, with the urinalysis yielding critically elevated results, and there was no evidence to reflect staff had promptly notified the physician of the findings of either lab. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 disclosed a nurse's note dated 04/30/11 at 1830 (6:00 p.m.), which stated: ""St (straight) cathed (catheterized) for U/A (urinalysis) /c (with) reflex. Sent to lab at 1815 (6:15 p.m.)."" Further review revealed no result for this lab test was found on the resident's record. When interviewed on 08/10/11 at 8:30 a.m., the facility's director of nurses (DON - Employee #7) was not aware that lab results were not on the record. Employee #7 obtained the result from the lab and provided evidence that the test had been completed as ordered. The results of this urinalysis, once obtained, disclosed that the resident had glucose in her urine. The report stated ""C - Critical Result"", and the level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL. 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. - Other lab studies, completed earlier on 04/18/11, also contained abnormal results - with blood glucose level was 301 (normal reference range is 74 to 106). There was no mention in the resident's medical record of this abnormal lab finding having been called to the resident's physician. .",2014-12-01
10739,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,492,E,1,0,H2M211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to ensure that all physician-ordered medications (including medical gases) were administered by qualified personnel, by permitting (contrary to State law) unlicensed staff to start, regulate, and administer oxygen. This was found to have affected one (1) former resident (#106) and has the potential to affect five (5) current residents who were prescribed continuous oxygen (#108, #109, #68, #111, and #24) and more than a minimal number of future residents. Facility census: 104. Facility census: 104. Findings include: a) Resident #106 1. Review of the facility's self-reported allegations of abuse / neglect, on 08/09/11 at 9:00 a.m., disclosed a report involving Resident #106, with an incident date of 10/26/10. The date of the immediate FAX reporting of allegations was 10/26/10. The allegation was stated (quoted as written): ""Pt (patient) states 11-7 CNA (certified nursing assistant) that worked last night got her ready for [MEDICAL TREATMENT] Early AM (morning) and did not put pt's oxygen on her. Pt asked CNA to connect her to her oxygen and CNA said 'Oh, you don't need that.' Pt stated that she had said this before to her."" The five day follow-up report, dated 10/28/10 and completed by the facility's unit manager (Employee #83), stated (quoted as written): ""I showed resident pictures of the 2 nursing assistants that worked 11-7 shift on North hall on 10/25/2010-10/26/2010. (Resident #106) pointed to (Employee #159)'s photo picture. 'She is the one who did not put oxygen on me, even after I asked her for it.' I called (Employee #159) at home with the DON (director of nursing - Employee #7) present (on speakerphone) to question her about the incident. (Employee #159) admitted that she did not put oxygen on the patient. 'No one ever puts oxygen on her when she goes to [MEDICAL TREATMENT]. They put it on her in [MEDICAL TREATMENT]. (Resident #106) never asked me to put oxygen on her. She just asked me if the oxygen was connected.' I called four other nursing assistants that work 11-7 shift that get the resident ready for [MEDICAL TREATMENT] and asked them if (Resident #106) goes to [MEDICAL TREATMENT] with oxygen. All four aides stated that they disconnect (Resident #106)'s oxygen from the wall oxygen system and reconnect it to a portable oxygen tank prior to transferring her from her room to the [MEDICAL TREATMENT] unit. I also called a [MEDICAL TREATMENT] nurse and asked her if (Resident #106) comes to [MEDICAL TREATMENT] with oxygen on. She says most of the time (Resident #106) does come with oxygen on but once in a while she doesn't. (Employee #159) will be counseled for not following through with resident's request and not maintaining delivery of oxygen to this resident as ordered by the resident's physician. "" -- b) Employee #159's personnel file, when reviewed on 08/09/11 at 11:30 a.m., disclosed that she had resigned with no notice on 04/25/11. Her personnel file contained a ""Corrective Action Form"" dated 11/24/10, which indicated it was the expectation that nursing assistants maintain residents' oxygen administration according to physicians' orders. The corrective action summary stated: ""(Employee #159) was responsible for getting resident ready for [MEDICAL TREATMENT]. This includes resident transfer from bed to chair, hooking the resident up to a portable oxygen tank and pushing the resident in her chair to the [MEDICAL TREATMENT] unit. (Employee #159) did not hook the resident up to a portable oxygen tank and took her to [MEDICAL TREATMENT] with no oxygen even after the resident had asked her for the oxygen. The patient is ordered oxygen at 3 liters per nasal cannula continuously. (Employee #159) has previously received a verbal warning on February 23, 2010 for 52 hours of absenteeism. (Employee #159) is receiving a final written warning for not following through on the patent's request and respecting the resident's right to make decisions and not following the patient's plan of care."" The action plan on the form stated: ""(Employee #159) has been counseled on listening to a patient's request and respecting their needs. (Employee #159) will be re-educated on the requirement to maintain a patient's oxygen administration per Doctor's orders and the need to always follow all doctor's orders."" -- 3. Employee #83, when interviewed on 08/10/11 at 8:30 a.m. about the corrective action form for former nursing assistant Employee #159, confirmed the nursing assistant did not administer oxygen to the resident. When asked what her expectations were had the nursing assistant proceeded correctly, she stated the nursing assistant would have removed the oxygen tubing from the wall and hooked it up to a small portable tank prior to transporting the resident to [MEDICAL TREATMENT]. When asked if she could enlist a nursing assistant on duty to perform a return demonstration of the correct procedure, she agreed and enlisted the assistance of Employee #157 at 8:40 a.m., to demonstrate the correct procedure to be followed for transport of a resident on continuous oxygen at three (3) liters per nasal cannula from their room to [MEDICAL TREATMENT]. Employee #157 went to the physical therapy room, to a locked closet, and obtained a small portable oxygen tank. She showed how she determined that the tank was full by viewing a meter on the tank. She entered a chosen unoccupied room and demonstrated that she would check the setting for the oxygen flow administration in the wall oxygen system, remove the tubing from the wall, affix it to the portable oxygen tank, set the portable tank at the correct flow rate, and place the cannula on the resident prior to transport. She stated the procedure would be reversed upon return. She indicated that, if the resident would be remaining in the day room area, they would utilize a large portable oxygen tank maintained for that purpose. When asked to demonstrate that process, she returned to the physical therapy room and pointed out a large oxygen tank. She referred to a tag that documented that the tank contained sufficient oxygen for use. She performed the procedure for turning the tank on and regulating the flow at the appropriate administration rate by use of a dial on the tank. She stated that, after she had the large tank set at the ordered flow rate, she would apply it to the resident via nasal cannula. Employee #83 subsequently expressed that Employee #157 had demonstrated the procedures in accordance with the facility's expectations to be followed by nursing assistants. -- 4. Employee #83, when asked on 8/10 11 at 9:55 a.m. when facility nursing assistants would receive training in the application of oxygen, stated this would take place in orientation and reported the facility's director of nursing (DON - Employee #7) would have the most recent orientation checklist. Employee #7 was asked for the current nursing assistant orientation materials. She provided a 10-page form entitled ""Performance Skills Review Certified Nursing Assistant"". The form listed skills required to perform the position and included an initial assessment at time of orientation, an ongoing assessment at ninety (90) days, and three (3) annual reviews for each area. Section 24 on Page 7 assesses the nursing assistant for the skill of ""Applying oxygen via nasal cannula, face mask, [MEDICAL CONDITION]."" -- 5. Review of the facility's ""Nursing Administrative General Policy Manual"", on 08/10/11 at 10:50 a.m., found the following in the section titled ""Medications"" - Policy #2 ""Medication Administration System and Medication Administration Record [REDACTED] ""Following professional and legal guidelines and restrictions, the registered nurse and licensed practical nurse will administer medications prescribed for residents' care by a licensed qualified physician, surgeon, dentist, podiatrist, or other person duly licensed or authorized to prescribe by the state of West Virginia and who has been a member of the medical staff of Wheeling Hospital."" Under the section titled ""Procedure"", the third paragraph states in part (quoted as typed): ""The nurse administering the medication is to initial the resident's. Medex in the space provided under the date and on the line for that drug, dose, and time of administration. The nurse is responsible for verifying the initial with a full signature and title in the space provided on the MAR."" -- 6. A review of the MAR for Resident #106, on 08/09/11, found that, on 10/26/11, nurses' initials were affixed next to the order for application of oxygen on night shift (N), day shift (D), and evening shift (E), thereby confirming that the oxygen was recognized as a physician-ordered medication under their policy. -- 7. A review of 2010 West Virginia Code Chapter 30, Professions and Occupations, Article 7, Registered Professional Nurses, Section ?30-7-1, Definitions on 8/10/11 at 3:30 p.m. found the following: ""?30-7-1. Definitions. As used in this article the term: (a) 'Board' shall mean the West Virginia board of examiners for registered professional nurses; (b) The practice of 'registered professional nursing' shall mean the performance for compensation of any service requiring substantial specialized judgment and skill based on knowledge and application of principles of nursing derived from the biological, physical and social sciences, such as responsible supervision of a patient requiring skill in observation of symptoms and reactions and the accurate recording of the facts, or the supervision and teaching of other persons with respect to such principles of nursing, or in the administration of medications and treatments as prescribed by a licensed physician or a licensed dentist, or the application of such nursing procedures as involve understanding of cause and effect in order to safeguard life and health of a patient and others ..."" -- 8. The facility's procedure, as documented and demonstrated in this instance, is that nursing assistants are to start - and regulate - the flow of oxygen administration per physician's orders [REDACTED]. Oxygen is a physician-ordered medical gas and is viewed as a medication; the facility recognized oxygen as a medication by its inclusion on the Medication Administration Record [REDACTED]. Administration of medications by non-licensed assistive personnel is not permitted in nursing homes. .",2014-12-01
10740,BISHOP JOSEPH HODGES CONTINUOUS CARE CENTER,515055,PO BOX 6316,WHEELING,WV,26003,2011-08-11,507,D,1,0,H2M211,". Based on closed record review and staff interview, the facility, failed for one (1) of thirteen (13) sampled residents, to file the results of a urinalysis obtained on 04/30/11. Resident identifier: #105. Facility census: 104. Findings include: a) Resident #105 When reviewed on 08/09/11, the closed medical record of Resident #105 disclosed a nurse's note dated 04/30/11 at 1830 (6:00 p.m.), which stated: ""St (straight) cathed (catheterized) for U/A (urinalysis) /c (with) reflex. Sent to lab at 1815 (6:15 p.m.)."" Further review revealed no result for this lab test was found on the resident's record. When interviewed on 08/10/11 at 8:30 a.m., the facility's director of nurses (DON - Employee #7) was not aware that lab results were not on the record. The results of this urinalysis, once obtained, disclosed that the resident had glucose in her urine. The report stated ""C - Critical Result"", and the level was noted to be 1000 MG/DL, with normal values stated to be 0 MG/DL. 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. .",2014-12-01
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
11359,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,250,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, and interview with a hospital social, the facility failed to provide medically-related social services for two (2) of thirty-two (32) Stage II sample residents. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors and no planned medically-related social service interventions to address the behaviors. Resident #31 missed a medical appointment, because the facility did not remind him so that he was prepared in advance. Resident identifiers: #35 and #31. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 2:21 p.m., the administrator confirmed there was no evidence the facility's social services had initiated a discharge plan related to Resident #35 being transferred to another facility, although the administrator confirmed the facility had started to work on discharging Resident #35 to a facility in Ohio prior to the resident being sent to the hospital on [DATE]. When the administrator was asked for social service notes, she stated, ""Yes, there should be some kind of discharge information started and written in the chart, but there is not, and I can't say why it's not there."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. b) Resident #31 On 12/02/10 at approximately 3:00 p.m., Resident #31 stated he had a medical appointment scheduled for today, but he did not go to this appointment. He said no one told him about the appointment and therefore he did not know he had to go. He said the ambulance attendants came to his room and he did not know why they were there. They informed him they were taking him to a local hospital for some medical test. He chose not to go with them, because according to him, he ""did not know anything about an appointment until the ambulance people came to (his) room."" The nurse aide (Employee #65) said she came to work at 7:30 a.m. on 12/02/10. She indicated no one had informed her Resident #31 had an appointment on 12/02/10. According to Employee #65, the night shift nurse aide had already made the bed, and the resident had his clothes on for the day. Employee #70 (a registered nurse) said the physician had told Resident #31, on 11/29/10, he had an appointment on 12/02/10. She went on to say things were chaotic on the morning of 12/02/10, and she had forgotten to remind Resident #31 of his appointment today. She agreed the resident the nursing staff should remind residents of their scheduled appointments on the day of the appointment. Resident #31 recently had a computed tomography (CT) scan where lesions and tumors were found on his liver. The appointment on12/02/10 was scheduled for further testing related to these issues. .",2014-04-01
11360,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,201,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interview, family interview, and interview with the social worker at the hospital, the facility failed to attempt to meet the needs of one (1) of six (6) sampled residents prior to planning his discharge from the facility. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. There was evidence the facility had no plans to readmit the resident after the evaluation. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causal factors and no planned intervention to address the behaviors. Evidence revealed the facility had prearranged for the resident to be transferred to a local hospital then be transferred to another facility out of state. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. During an interview on 12/09/10 at 11:51 a.m., the administrator confirmed it was her preference to not permit the resident to return to the facility. She said, ""We told the resident it was not appropriate behavior."" On 12/09/10 at 12:59 p.m., the social service department at the hospital was contacted and confirmed the facility had prearranged placement at another facility prior to Resident #35 being transferred to the hospital on [DATE]. The social service staff member confirmed the facility had said they could not take him back. On 12/09/10, the responsible party for Resident #35 was contacted and said he was told the facility could not take Resident #35 back because of his behaviors. He said he would rather Resident #35 stay at this facility, since the new facility was located 120 miles away. The responsible party stated, ""The facility said they could not take him back."" At the time the resident was transferred to the hospital for an evaluation regarding his behaviors on 09/24/10, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. In addition, the care plan did not address the variety of behaviors and/or have interventions which would lead to problem identification and/or correction. There was no evidence to reflect the facility attempted to meet the resident's needs prior to making the determination that they could no longer care for him. .",2014-04-01
11361,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,279,E,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, observation, staff interview, family interview, and resident interview, the facility failed to develop comprehensive care plans and/or interventions for four (4) of thirty-two (32) Stage II sample residents. There was no care plan for intentional weight loss for Resident #43; no care plan for foot care for Resident #5; no interventions for behaviors for Resident #35; and no restorative care plan for Resident #115. Resident identifiers: #43, #5, #35, and #115. Facility census: 83. Findings include: a) Resident #43 During an interview with the resident on 12/08/10 at 3:15 p.m., the resident revealed she was trying to lose weight, stating, ""I really want to get rid of my belly."" Review of the dietary progress notes, dated 08/26/10 and 09/29/10, revealed the registered dietician had noted the resident was trying to lose weight. Review of the dietary progress notes, dated 10/26/10, revealed the dietary supervisor (Employee #68) also noted: ""Resident wants to lose wt (weight)."" Review of the dietary progress notes, dated 11/30/10, revealed the dietary supervisor noted: ""Resident wants to continue to lose wt per her choice due to history of diabetes."" An interview on 12/08/10 at 2:15 p.m., with a registered nurse (RN - Employee #77), revealed the resident frequently requested junk food and had yet to mention to her (Employee #77) that she wanted to lose weight. Review of the resident's care plan found no mention of a plan to assist the resident in achieving intentional weight loss. b) Resident #5 On 12/06/10, a family interview was conducted with this resident's sister. During the interviewed, the sister expressed concern that the resident's feet were not routinely cleaned by facility staff. She stated the resident's feet were often dry and flaky, and that she (the sister) often soaked and cleaned them herself. Interview with the resident, at 1:00 p.m. on 12/07/10, revealed her feet were always cold, so she wore socks all the time. Further interview revealed the resident was rarely showered due to her severe pain, and she preferred bed baths. Upon inquiry, the resident stated she did not feel her feet received the care they required, and that her sister often had to soak them and clean them. She stated staff did not perform this care routinely. Review of the resident's care plan, on 12/07/10, revealed no specific care plan regarding the resident's foot care. On 12/08/10 at 9:00 a.m., this resident's feet were observed with an RN (Employee #20). The resident's feet were dry and flaky. According to Employee #20, the resident needed foot care. Employee #20 stated she would assure the resident received this care. c) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. d) Resident #115 During an observations of the dinner meal on 11/29/10 at 6:00 p.m., Resident #115 was observed to be eating in the area designated as the restorative dining area. She was falling asleep. After the others were served, the restorative nursing assistant fed the resident her meal. The medical record, when reviewed on 11/30/10, found Resident #115 had been evaluated by the speech-language pathologies (SLP) for dysphagia with recommendations made on 11/12/10. The SLP stated the goal for this resident was ""to decrease risk of aspiration and increase PO (by mouth) intake"". The recommendations included: placement of the resident in the restorative feeding program; she was not to have straws in her drinks, she was to be provided verbal cueing to swallow with her meals due to her issue of pocketing food in her mouth; and she was to have two (2) to three (3) bites of food alternated with one (1) drink. The resident's most recent interdisciplinary care plan, dated 11/22/10, was reviewed. This plan did not include a restorative nursing care plan, did not identify this resident was at risk for aspiration, and did not include interventions to prevent aspiration and address the resident's swallowing problems as recommended by the SLP. The restorative nursing assistant (Employee #94) was observed feeding this resident lunch at 12:15 p.m. on 12/02/10. The resident had a straw in her milk and was given four (4) to five (5) bites between drinks, instead of two (2) to three (3) bites as recommended by the SLP. The director of nursing (DON), when interviewed at 3:30 p.m. on 12/03/10, reviewed the resident's care plan and verified there was no restorative care plan. .",2014-04-01
11362,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,319,D,,,GCMN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to provide appropriate treatment and services to assist one (1) of thirty-two (32) Stage II sample residents related to behavioral problems. Resident #35 was sent out to the hospital for a behavioral evaluation on 09/24/10. The resident had several behavioral incidents for which there was no evidence of assessment to determine the causative factors for the behaviors. Resident identifier: #35. Facility census: 83. Findings include: a) Resident #35 Medical record review revealed this resident was admitted to the facility on [DATE] for a long-term stay. According to the facility's interdisciplinary discharge plan dated 2/09/10, the plan for discharge on admission was for ""definite long-term stay"". He was admitted with [DIAGNOSES REDACTED]. Review of the medical record also revealed the resident's vision was poor, and his hearing was so poor he used a communication board to communicate his needs. Medical record review revealed the resident resided at the facility from 02/08/10 until 07/03/10 with no inappropriate behaviors. According to the medical record, on 07/03/10, the resident smashed the light in his room with his trapeze bar. On 07/26/10, he was witnessed hitting the wall with the trapeze bar. On 07/29/10, he slammed the bedside chair and water pitcher into the wall and hit the nurse. On 08/01/10, he was pounding on the wall with the trapeze bar. On 08/08/10, he made vulgar comments to a nursing assistant. On 08/16/10, he was found outside in the courtyard smoking. The cigarette was taken from him and he was told the facility is a non-smoking facility. On 08/17/10, he hit the wall with the trapeze bar. The medical record contained no evidence of efforts by the facility to identify of causative factors and/or interventions for any of the documented behavioral episodes. There was no evidence that staff considered the need for medically-related social services or services from an appropriate mental health professional to address this resident's behavioral issues. The facility did not initiate a care plan to address behaviors until 08/26/10, when the resident exhibited inappropriate sexual behaviors toward staff, and the intervention was to ""redirect resident"". No other behaviors were identified and/or addressed on the care plan. The care plan provided no methods for implementing this redirection. On 09/06/10, the resident was verbally sexually inappropriate with staff, and on 09/07/10, he bit a nursing assistant on the breast. There was no evidence of attempts at redirection. Staff just told this confused resident his behaviors were ""inappropriate"". Further review of the medical record revealed nursing documentation for 09/24/10 at 5:00 a.m., at which time the registered nurse (RN) supervisor (Employee #20) was notified Resident #35 was found on two (2) occasions the previous evening in a female resident's room exhibiting inappropriate sexual behaviors. Staff removed the resident from the female resident's room, but there was no evidence of any other intervention to reduce or prevent these behaviors. On 09/07/10, the resident was seen by his physician. The physician's progress notes on that date contained nothing relative to the resident's behaviors, and there was no evidence the physician had been made aware of the resident's behaviors. In addition, the physician made no recommendations or addressed any of the behaviors the resident had been exhibiting. At the time the resident was transferred to the hospital for an evaluation regarding his behaviors, there was no evidence the facility had made any attempts to determine causal factors which may have contributed to the resident's behaviors, and no evidence of the provision of medically-related social services or services from an appropriate mental health professional to address these behaviors. .",2014-04-01
11363,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-12-09,364,F,,,GCMN12,". Based on observation, test tray temperatures, and staff interview, the facility failed to assure foods were attractive, appetizing, and at the proper temperature when received by the residents. Pureed foods were thin and ran into each other on the plate for twenty (20) residents who were provided pureed diets. Additionally, the temperature of coleslaw was too warm for palatability, at the point of service, for all residents. These practices affected all facility residents who received nourishment from the dietary department. Facility census: 84. Findings include: a) On 02/24/11 during the noon meal, observations were made of residents eating in the activity room. The pureed foods (pinto beans, sauerkraut, and polish sausage) ran together touching each other on the plates. This created an unappetizing presentation for the twenty (20) residents who required pureed foods. There was no form to the foods at all. The foods on the plates were touching each other, edge to edge, with color being the only distinguishing factor from one food to the other. This was shown to the administrator (NHA - Employee #117) and the director of nursing (DON - Employee #118) at the time of the observation. The NHA confirmed the meals served to residents on pureed diets were not appetizing or attractive. -- b) At noon on 03/02/11, pureed meals were observed with the dietary manager (DM - Employee #63). The pureed broccoli mix and pureed ranch style beans were thin, without form, and ran into each other on the plates. At that time, the DM confirmed the foods should have form and not spread into each other. -- c) On 03/02/11 at 12:55 p.m., a test tray was requested to be placed on the cart immediately following the last resident to be served at the noon meal. There was a misunderstanding, and the cart on which the test tray was placed was not the last cart to be served. In addition, it contained only three (3) trays. The meals on this cart had no wait time for service; however, the foods were tested anyway, with the DM. The hot foods were at appropriate temperatures; however, the cold food (coleslaw) was 51.4 degrees Fahrenheit (F). According to State law, cold foods, at the time of receipt, can measure no more than 50 degrees F. Due to the confusion of getting test trays, another test tray was requested. This one was immediately following the last tray served in the dining room. The tray was tested at 1:15 p.m., with the DM. The hot foods were again at appropriate temperatures; however, the coleslaw was 54.7 degrees F. Upon inquiry, the DM stated the coleslaw was prepared that morning. When asked the size and depth of the pan used to chill the coleslaw, the DM showed the surveyor a 6-inch deep 1/2 steam table pan. This pan was not shallow enough to allow for rapid chilling of cold foods. .",2014-04-01
11429,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,314,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, review of product information found on the Internet, and staff interview, the facility failed to provide care and services for one (1) of eleven (11) residents reviewed, to prevent the development of new pressure sores for a resident who entered the facility without a pressure sore. Resident #50, who was admitted to the facility on [DATE] with intact skin, was totally dependent upon staff for bed mobility and transferring, and was identified as being at high risk for developing pressure sores. The interdisciplinary team identified her risk for developing skin breakdown in her care plan dated 06/21/10, and approaches to be implemented by staff to prevent skin breakdown included conducting weekly body audits. On 08/13/10, a nursing assistant identified Resident #50 as having a ""blackened area"" on her left heel. Weekly body audits were not completed in accordance with her plan of care, and the presence of this skin breakdown was not identified and treated at an earlier stage. Facility census: 84. Findings include: a) Resident #50 Record review revealed this [AGE] year old female resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]., and [MEDICAL CONDITION] bladder. The resident's admission nursing assessment, dated as completed on 06/03/10, stated the resident had no skin breakdown present on admission. This document also stated the resident was totally dependent on staff for transfers and she was non-weight bearing. The resident was also incontinent of bowel and had an indwelling Foley catheter at that time (which was removed on 08/15/10). The resident's pressure ulcer risk assessment, completed on 06/03/10, rated her as ""10"", indicating she was at high risk for developing pressure sores. According to her comprehensive admission assessment with an assessment reference date (ARD) of 06/10/10, she was alert but not oriented, with short and long term memory problems and moderately impaired cognitive skills for daily decision making. She was totally dependent on staff for bed mobility, transfers, and toilet use, and she was to be transferred using a mechanical lift. She had no pressure sores during the assessment reference period. Review of the resident's care plan found the following problem statement with an onset date of 06/21/10: ""Potential risk for skin breakdown d/t (due to) decreased physical mobility."" The goal associated with this problem statement was: ""Maintain intact skin integrity thru 09/21/10."" Approaches to be implemented to meet this goal included: ""up (sic) in geri chair as tolerated. weekly (sic) body audit. Provide diet as ordered ... Reposition resident every 2 or 3 hours and PRN (as needed). Instruct resident / family on consequences of noncompliance with therapeutic regime (sic). Cleanse perineal area with peri wash following each bowel and/or bladder episode."" -- Review of the facility's incident / accident reports, on 11/09/10, found an Incident Investigation Report involving Resident #50 and dated 10:00 a.m. on 08/13/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written, ""CNA (certified nursing assistant) (initials) notified this nurse of discoloration area to Resident's (Lt) (left) heel, black in color, measures 2.5 cc diameter (sic) soft to touch. Resident has poor bed mobility. Dr. (name) in facility and aware. New order [MEDICATION NAME] apply (sic) (Lt) heel q (every) shift. Heel lift boots (sic) @ (at) all times."" Under the heading ""Analysis of the Incident: (apparent cause)"" was written, ""Poor bed mobility."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""[MEDICATION NAME] Apply (Lt) heel q shift. Heel lift boots @ all times."" -- Product information for [MEDICATION NAME] (found on the Internet at http://www.udllabs.com/pdfs/[MEDICATION NAME].pdf) revealed the following ""Uses"" for [MEDICATION NAME]: - ""Management of decubitus ulcers."" - ""Forms protective barrier and speeds healing by increasing capillary blood flow into the ulcerated area. "" - Product information for Heelift Suspension Boots (found on the Internet at http://www.heelift.com/) revealed the following product claims: "" The Heelift ? completely eliminates pressure as the heel is floated in protective space. Studies prove Heelift Suspension Boots provide a pressure-free environment to help eliminate and prevent pressure ulcers. "" -- On 11/10/10 at 11:00 a.m., the facility's unit supervisor (Employee #66) was asked to provide evidence to reflect this resident received weekly body audits in an effort to avoid skin breakdown. After review of facility documents, Employee #66 was only able to produce evidence that weekly body audits were performed on Resident #50 on the following Wednesdays: 06/09/10, 06/16/10, and 07/28/10. Employee #66 confirmed there were no additional body audits for this resident. The blackened area to the heel was discovered on 08/13/10. Based on the documentation presented by Employee #66, Resident #50 did not receive weekly body audits on 08/04/10 or 08/11/10 (before the blackened heel was identified by staff). -- A facility nurse (Employee #72) was interviewed on 11/09/10. When asked how residents were evaluated for skin breakdown, this nurse stated, ""We do weekly body audits."" When further questioned about how an area would not be recognized until it had become black, the nurse stated, ""It should have been caught before it was black."" .",2014-03-01
11430,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,157,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed, for one (1) of eleven (11) sampled residents, to notify the resident's legal representative or attending physician of a significant change in the resident's health status. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs and failed to collect / record, monitor, and report to the physician or the resident's legal representative any physical assessment data related to this resident's change in condition. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 5. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's legal representative. -- 6. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 7. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. .",2014-03-01
11431,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,309,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Part I -- Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide the necessary care and services to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, failed to identify a decrease in fluid intake, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""...Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day on [DATE], [DATE], and [DATE]; less than 35% of her estimated fluid needs on [DATE] and [DATE]; and she consumed on 240 cc of fluid on day shift on [DATE], prior to her transfer to the hospital. (See also citation at F327.) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. ---- Part II -- Based on closed record review, the facility failed to provide daily laxatives as ordered by the physician for one (1) of eleven (11) sampled residents who was identified as being at risk for constipation. On [DATE], Resident #45 was treated for [REDACTED]. In [DATE], Resident #45 had orders for four (4) different laxatives to be administered daily: [MEDICATION NAME] 1 tab by mouth daily; Senna Plus 2 tabs by mouth twice daily; [MEDICATION NAME] 15 cc by mouth daily; and Power Pudding 60 cc by mouth at bedtime. Record review revealed found no evidence to reflect the evening dose of Senna Plus was administered as ordered; thirteen (13) doses of [MEDICATION NAME] were not administered as ordered; and fifteen (15) doses of Power Pudding were not administered as ordered, thirteen (13) of which were marked as refused by the resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her care plan, on [DATE], revealed the following problem statement: ""Resident is at risk for constipation: limited mobility; medications; history of constipation."" The goal associated with this problem statement was: ""Resident will have bowel movments (sic) at least every three day s (sic) thru next review."" Interventions to achieve this goal included: ""Monitor bowel movments (sic), if none in three days start bowel regimen. Monitor BM (sic) if none every 3 days notify nurse. [DATE] D/C (discontinue) [MEDICATION NAME] & [MEDICATION NAME], start Senna-S 2 tab po BID. [DATE] Power pudding 1xd (daily). ,[DATE] [MEDICATION NAME] 15 ml PO BID. [DATE] [MEDICATION NAME] 1 tab PO daily x 30 days then re-eval constipation. [DATE] leets enema per rectum x 1 dose D/T 0 (no) BM x 4 days per standing order."" - Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. - Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no evidence to reflect that both doses of Senna Plus were administered daily in September. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. (See citation at F514.) Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on [DATE]. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE] (with the last dose initialed as having been administered on [DATE]). (See also citation at F514.) This represents a total of thirteen (13) doses not administered as ordered. .",2014-03-01
11432,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,327,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, and staff interview, the facility failed to provide the necessary care and services to ensure one (1) of eleven (11) sampled residents to maintain proper hydration and health. Resident #45 had a history of [REDACTED]. She was also identified as being at risk for weight loss related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus, and her diet order and care plan both addressed the need for staff to encourage fluid intake. On [DATE], Resident #45 received a Fleets enema on [DATE], after having no BMs for four (4) consecutive days. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on [DATE]. This was followed nine (9) BMs on [DATE]; three (3) BMs on [DATE]; seven (7) BMs on [DATE]; six (6) BMs on [DATE]; and one (1) large BM on the day shift of [DATE]. There was no evidence the licensed nursing staff identified and reported to the physician or the resident's legal representative that this resident, beginning on [DATE], was having excessively frequent BMs. (See citation at F309.) -- 5. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer them except when the resident refused. (See also citation at F309.) -- 6. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 7. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed less than 50% of her estimated fluid needs per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. -- 8. Review of Resident #45's POST form, signed by the facility's social worker on [DATE], revealed the resident's medical power of attorney representative (MPOA) had indicated, in Section D, the desire for the resident to receive IV fluids and tube feeding for a defined trial period to maintain hydration and nutritional status. There was no evidence in the medical record that staff identified a change in the resident's hydration status for which the administration of IV fluids for a trial period was indicated. -- 9. Resident #45 was sent out to the hospital on day shift on [DATE]. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. .",2014-03-01
11433,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,225,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of incident / accident reports, review of self-reported allegations of abuse / neglect and injuries of unknown source, and staff interview, the facility failed to immediately report and thoroughly investigate injuries of unknown source and/or an allegation of neglect involving one (1) of eleven (11) sampled residents (#23) who was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. Record review, on 11/10/10, found a nursing note dated 10/25/10 at 11:30 a.m., stating staff identified the presence of swelling and bruising to Resident #23's left ankle and coccyx; these injuries were of unknown source. There was no evidence the facility immediately reported these injuries of unknown source to State officials as required or conducted a thorough investigation to identify possible cause(s) of the injuries and/or to ascertain whether they were the result of abuse or neglect. On 11/11/10, the facility's director of nursing (DON) produced an incident investigation report involving Resident #23, dated 10/26/10, stating staff discovered swelling and bruising to the resident's left ankle and bruising to the resident's coccyx at 11:00 a.m. on 10/26/10. Information recorded on this report suggested the bruising to the resident's ""posterior"" was the approximate size of the resident's wheelchair arm rest, and bruising may have been the result of contact between the resident and the arm rest while the resident was being transferred by mechanical lift. There was no evidence the facility immediately reported this to State officials as an allegation of neglect or made reasonable efforts to identify to which staff members may have been responsible. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 1. Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. - Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. - Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" - On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. When asked whether these injuries of unknown source were immediately reported and/or thoroughly investigated, the DON stated she did not feel the injuries were the result of abuse or that they required further investigation (even though the injuries could not have been self-inflicted, given the resident's physical limitations). This interview revealed that neither an incident report or an investigation of the injuries (which were identified on 10/25/10) could be located. There was no evidence the facility thoroughly investigated when the injuries of unknown source occurred. Additionally, there was no evidence of attempts to determine which facility staff members were present when the injuries occurred. -- 2. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report dated 10/26/10. Under the heading ""Describe Circumstances of the Incident (Be very specific):"" was written: ""CNA (certified nursing assistant) (first name of Employee #50) was performing ADL's on resident /c assistance of (first name of Employee #60). They noted swelling & bruising to (L) (left) ankle & bruising to tailbone."" Documentation on the report identified the ""Date of Incident"" and ""Time Incident Occurred"" as 10/26/10 at 11:00 a.m., although the nursing note first recording the discovery of these injuries was written at 11:30 a.m. on 10/25/10. Under the heading ""Witness"" were written the names of two (2) nursing assistants (Employees #50 and #60). (As noted in the description of the incident, these staff members were not reporting the incident as having occurred in their presence; rather, they were the ones who discovered the injuries.) Under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" - The information on this report implied that the resident's injuries found on the morning of 10/25/10 may have been the result of inappropriate and/or unsafe technique by staff while transferring the resident via mechanical lift, which would constitute an allegation of neglect. However, no statements were obtained from the individuals identified listed as witnesses to the incident, nor were statements obtained from any direct care staff that had been assigned to care for the resident during any of the shifts preceding the date and time the injuries were noted. -- 3. Review of the facility's self-reported allegations of abuse / neglect and injuries of unknown source found no evidence of any self-report to State officials involving Resident #23 for either the injuries of unknown source referenced in the resident's nursing notes at 11:30 a.m. on 10/25/10 or the injuries said to have occurred at 11:00 a.m. on 10/26/10, which were attributed to inappropriate / unsafe technique used by staff when transferring the resident via mechanical lift. .",2014-03-01
11434,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,282,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, policy review, and staff interview, the facility failed to ensure licensed nursing staff followed physician's orders for two (2) of eleven (11) sampled residents. For Resident #23 who wore a splinting device on her right lower extremity, the licensed nursing staff failed to collect and record physical assessment data at a frequency of every four (4) hours as orderesd by the physician. For Resident #45, there was a lack of evidence to reflect that three (3) laxatives and two (2) nutritional supplements were administered in accordance with physician's orders. Resident identifiers: #23 and #45. Facility census: 84. Findings include: a) Resident #23 Review of nursing notes, dated 11/03/10 at 1:00 p.m., revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) [MEDICAL CONDITION] ([MEDICAL CONDITION] of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced [MEDICAL CONDITION] fibula accompanies the distal tibia fracture. Osteopenia is apparent."" - Review of physician's orders found telephone order, dated 11/04/10 at 11:00 a.m., for: ""(1) Resident (sic) wear splint to RLE (right lower extremity) @ (at) all x's (times). (2) Resident to be monitor (sic) QS (every shift) to ensure Brace in place properly. (3) RLE to be monitored Q4(symbol for 'hour') (every four (4) hours) and documented for CRT (capillary refill time), Temp (temperature) of skin, Color of skin below splint, Pulse below splint, Presence (sic) of [MEDICAL CONDITION] Above / Below splint. (4) [MEDICATION NAME] 5/500 i (1) PO (by mouth) at 8 AM D/T (due to) pain."" - Review of the facility's policy and procedure titled ""Cast Care and Observation - Medicare Documentation Guidelines"" staff was to monitor capillary refill time, skin temperature, color of digits, ability to move digits, presence of [MEDICAL CONDITION], and for facial grimacing or other signs and symptoms of pain. According to the policy, staff was to monitor and document the findings every four (4) hours. - The first evidence of monitoring of the resident's right lower extremity, in accordance with the above noted physician's order, was found in a nursing note at 2:30 p.m. on 11/04/10. The next entry in the nursing notes containing evidence of monitoring was recorded five and one-half hours later, at 8:00 p.m. on 11/04/10. Subsequent entries containing physical assessment data of the resident's right lower extremity were recorded in the nursing notes on the following dates and times: - on 11/05/10 at 12:30 a.m. - on 11/05/10 at 2:30 p.m. - on 11/05/10 at 8:15 p.m. - on 11/06/10 at 9:00 a.m. - on 11/06/10 at 1:00 p.m. - on 11/06/10 at 5:00 p.m. - on 11/06/10 at 8:00 p.m. - on 11/07/10 at 2:20 p.m. - on 11/07/10 at 6:50 p.m. - on 11/08/10 at 12:00 a.m. (late entry) - on 11/08/10 at 4:00 a.m. (late entry) - on 11/08/10 at 11:30 a.m. - on 11/08/10 at 8:00 p.m. - on 11/09/10 at 12:00 a.m. - on 11/09/10 at 1:30 p.m. - on 11/09/10 at 4:10 p.m. - on 11/10/10 at 3:00 a.m. Review of these entries found multiple gaps between assessments of greater than four (4) hours, with one (1) gap exceeding eighteen (18) hours between consecutive entries containing physical assessment data related to the resident's right lower extremity at 8:00 p.m. on 11/06/10 and 2:20 p.m. on 11/07/10. - During the exit conference, an interview with a registered nurse (Employee #20) revealed she had written these orders to assess Resident #23's leg and document every four (4) hours ""per our policies and procedures, and they (nurses) should have been doing it."" -- b) Resident #45 Review of Resident #45's September Medication Administration Record [MEDICATION ADMINISTRATION RECORD DETAILS REDACTED]. Documentation on the MAR indicated [REDACTED]. - Review of the resident's September 2010 MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on 09/13/10, 09/14/10, 09/15/10, 09/18/10, 09/19/10, 09/20/10, 09/24/10, 09/25/10, 09/26/10, 09/27/10, 09/28/10, 09/29/10, and 09/30/10. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on 09/17/10 and 09/21/10. This represents a total of fifteen (15) doses not administered as ordered. - Review of the resident's September 2010 MAR indicated [REDACTED]. There nurse's initials were circled for the [MEDICATION NAME], indicating the medication was not administered as ordered, on 09/24/10. Documentation on the reverse side of the MAR indicated [REDACTED]."" There were no initials for the [MEDICATION NAME] on 09/05/10, 09/15/10, 09/16/10, 09/17/10, 09/18/10, 09/19/10, 09/20/10, 09/21/10, 09/23/10, 09/26/10, 09/27/10, and 09/28/10 (with the last dose initialed as having been administered on 09/29/10). This represents a total of thirteen (13) doses not administered as ordered. - According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citations at F309, F325, and F514.) .",2014-03-01
11435,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,323,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review, review of the facility's incident / accident reports, review of the facility's self-reported allegations of abuse / neglect, and staff interviews, the facility failed to provide adequate supervision and/or assistance devices to prevent avoidable accidents. One (1) of eleven (11) sampled residents (#23) was totally dependent on staff for the performance of all activities of daily living (ADLs) and had limitations to range of motion and full loss of voluntary movement to both legs and feet. On 10/26/10, she was identified as having swelling and bruising to the left ankle and coccyx; these injuries were of unknown source, although the facility's investigative report revealed the bruising on the resident's coccyx may have been associated with contact with the resident's wheelchair armrest during a transfer within a mechanical lift. On 11/03/10, the resident was identified with swelling and redness to the right leg; she was subsequently diagnosed with [REDACTED]. There was no evidence the facility implemented any measures to protect this totally dependent resident from further injury after the first injury was identified. Resident identifier: #23. Facility census: 84. Findings include: a) Resident #23 Medical record review, on 11/10/10 at 9:10 a.m., disclosed the resident was admitted to the facility on [DATE]. At the time of the review, the resident's current medical [DIAGNOSES REDACTED]. The resident was determined to lack capacity to understand and make informed medical decisions for herself as early as 2003. According to information provided by facility staff, the resident did not possess the ability to participate in an interview. -- Review of the resident's most recent comprehensive assessment, an annual assessment with an assessment reference date (ARD) of 01/24/10, revealed this [AGE] year old female had both short-term and long-term memory problems and her cognitive skills for daily decision-making were severely impaired. In Section G, the assessor identified that Resident #23 was non-ambulatory and totally dependent on for the performance of all ADLs, including bed mobility and transfers. Testing for sitting and standing balance could not be attempted, the resident had limitations to range of motion in both legs and feet with partial loss of voluntary movement in her lower extremities, and she was to be transferred using a mechanical lift. Review of the resident's most recent abbreviated quarterly assessment, with an ARD of 07/16/10, revealed no changes in the resident's cognitive status or ADL self-performance, and the resident was now noted to have limitations to range of motion in both legs and feet with full loss of voluntary movement in her lower extremities. -- Nurse's notes, dated 10/25/10 at 11:30 a.m., revealed staff was performing ADLs for the resident ""when it was noted she had bruising to (L) (left) ankle /c (with) swelling noted & bruising to tail bone."" The resident's responsible party and attending physician were notified, and an order was received to obtain an x-ray. The x-ray report, dated 10/26/10, revealed ""no evidence for fracture or other significant bone, joint, or soft tissue abnormality."" -- On 11/10/10 at 1:00 p.m., the facility's administrator (NHA - Employee #111) and director of nursing (DON - Employee #112) were interviewed regarding Resident #23's injuries identified on 10/25/10. This interview revealed that neither an incident report or an investigation of the injury of known source identified on 10/25/10 could be located. Prior to exit on 11/11/10 at 12:25 p.m., the DON produced an incident investigation report of an incident said to have occurred at 11:00 a.m. on 10/26/10. In the report under the heading ""Analysis of the Incident: (apparent cause)"" was written: ""Upon investigation, noted mechanical lift used for transfers. Resident's usual w/c (wheelchair) seating has bilateral arm rests, (sic) the mechanical lift clearance observed caused resident (sic) posterior to nearly come in contact /c w/c arm rests. Bruise approx size of arm rest."" Under the heading ""Describe Corrective action (sic) or Protective Action Taken: (be specific)"" was written: ""X-ray to ankle (-) (negative). ""Re-educated staff on proper lift use, positioning of w/c and importance of observing clearance of resident /c chair boundaries."" -- On 11/11/10 at 12:25 p.m., the DON was asked to provide evidence of the content of the staff training provided and to whom this education was provided. The DON stated this information was not available, because she ""educated the staff that were on the spot that day."" This process did not assure all staff members who might utilize the mechanical lift with this resident, on all shifts, were educated. -- Review of the facility's abuse / neglect self-reports for the previous three (3) months revealed Resident #23 had sustained another of injury of unknown source on 11/03/10. Review of nursing notes, dated 11/03/10 at 1:00 p.m. (eight (8) days after the injury of unknown source to the left leg), revealed the resident's right leg was assessed by two (2) registered nurse (RN) supervisors. According to the notes, the resident's ""Leg and foot swollen from knee down, warm to touch. Resident /c (with) facial grimacing and yelling upon nurse touching leg."" The resident's attending physician was notified. According to the nurse's note, the resident was transferred to an area hospital to ""... R/O (rule out) DVT (deep vein thrombosis) of R (right) LE (lower extremity)."" At 9:30 p.m. on 11/03/10, nursing notes revealed the resident had returned to the facility with a splint to the right lower leg. Review of the x-ray report, dated 11/03/10, revealed the following findings: ""A nondisplaced fracture of the proximal fibula accompanies the distal tibia fracture. Osteopenia is apparent."" -- Review of facility records and staff interview revealed no evidence to reflect effective measures were implemented to prevent further injury to this totally dependent resident, after the resident was found to have bruising and swelling to her left ankle and coccyx. Eight (8) days, later she sustained fractures to her right leg. .",2014-03-01
11436,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,514,E,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed record review, staff interview, and review of the 2009 long-term care (LTC) documentation guidelines published by the American Health Information Management Association (AHIMA), the facility failed to ensure the clinical record of one (1) of eleven (11) sampled residents was maintained in accordance with accepted professional standards and practices that are complete and accurately documented. Review of the closed record of Resident #45, who was transferred to the hospital on [DATE], found incomplete and/or inaccurate documentation including but not limited to: no entries in the nursing notes describing significant changes in her health status that started on [DATE]; no entries at all after [DATE] (to include no entry related to her transfer); multiple blanks where licensed nurses were to have initialed as having administered ordered medications; multiple instances where the nurses' initials were circled (indicating medication doses were not administered) with no corresponding documentation to explain why; and documentation on the resident's [DATE] activities of daily living (ADL) flowsheet for ADL performance said to have occurred on shifts after the resident had left the faciity on [DATE]. These reflected at pattern of deficient practices affecting a single resident. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. No documentation related to the resident's change in condition During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. - Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. - Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.9 Completeness ""Document all facts and pertinent information related to an event, course of treatment, resident condition, response to care and deviation from standard treatment (including the reason for it). Make sure entry is complete and contains all significant information. If the original entry is incomplete, follow guidelines for making a late entry, addendum or clarification."" ""5.2.15. Condition Changes ""Every change in a resident's condition or significant resident care issues must be noted and charted until the resident's condition is stabilized or the situation is otherwise resolved. Documentation that provides evidence of follow-through is critical."" ""5.2.18 Notification or Communications If notification to the resident's physician or family is required, or a discussion with the resident's family occurs regarding the care of the resident, all such communication (including attempts at notification) should be charted. Include the time and method of all communications or attempts. The entry should include any orders received or responses, the implementation of such orders, if any, and the resident's response. Messages left on answering machines should be limited to a request to return call and does not meet the definition of notification."" -- 2. No documentation on the date of discharge Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to an assessment of the resident prior to her being sent to the hospital. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. - According to Section 5.0 of the AHIMA LTC documentation guidelines: ""5.2.17 Admission / Discharge Notes ""The resident's initial admission note and discharge summary should fully and accurately describe the resident's condition at the time of admission and discharge, respectively. Documentation should include the method / mode of arrival / discharge, resident's response to admission / discharge and physical assessment. When discharging a resident, take special care in documenting resident education when applicable including instructions for self-care, and that the resident / responsible party demonstrated an understanding of the self-care regimen."" -- 3. ADL Flowsheet According to documentation on Resident #45's [DATE] ADL flow sheet, the nursing assistants on all three (3) shifts on [DATE] provided assistance to the resident with dressing, eating / drinking, toilet use, hygiene, and bath / shower on [DATE]. Additionally, the resident was noted to have had at least one (1) bowel movement on each shift. Resident #45 transferred to the hospital before the end of day shift on [DATE] and was not physically in the facility for either the evening or night shift on [DATE]. -- 4. Medication administration records (MARs) Review of the resident's September MAR found an order for [REDACTED]. Documentation on the MAR indicated [REDACTED]. There was no documented evidence to reflect that both doses of Senna Plus were administered daily in [DATE]. - According to the [DATE] MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. - Review of the resident's [DATE] MAR indicated [REDACTED]. The nurses' initials were circled for the Power Pudding, indicating the medication was not administered as ordered, on [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], [DATE], and [DATE]. There was no documentation on the reverse side of the MAR indicated [REDACTED]. Additionally, there were no initials for the Power Pudding on [DATE] and [DATE]. - According to Section 6.0 of the AHIMA LTC documentation guidelines: ""Medication and Treatment Records: ""Medication and treatment records (MARs and TARs) are derived from the physician orders [REDACTED]. ""Nurses place their initials in the blocks of the MARs and TARs form when medication or treatment has been administered. Based on physician orders, there should be no gaps noted in this documentation. ... ""Any medications or treatments given on a PRN (as needed) basis must be initialed, and information pertaining to the need for the PRN, documented either on the back of the MAR/TAR or elsewhere in the chart as defined by facility policy. Separate nurses note may also be required. ... ""Nurses will circle or otherwise indicate which medications or treatments were NOT administered. This would then require a documented explanation as to why the order could not be carried out. ...""",2014-03-01
11437,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,224,G,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on family interview, closed medical record review, staff interview, and review of Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition), the facility failed to provide goods and services necessary to avoid physical harm and to maintain the highest practicable physical well-being for one (1) of eleven (11) sampled residents. Resident #45, who had a history of [REDACTED]. Beginning on [DATE], Resident #45 was noted to have an increased frequency in bowel elimination with three (3) BMs per shift for the next four (4) consecutive shifts; then her high frequency of BMs continued beginning on the day shift of [DATE]. Staff did not identify this increased frequency of BMs, did not describe the characteristics of these frequent BMs in the medical record (e.g., color, consistency, presence of foul or unusual odor, etc.), continued to administer her routine laxatives except when the resident refused, and failed to collect / record, monitor, and report to the physician and the resident's legal representative any physical assessment data related to this resident's change in condition. All nursing documentation stopped with the last entry made at 12:05 p.m. on [DATE]. Staff also did not identify and report to the physician or the resident's legal representative a decrease in Resident #45's daily fluid intake (she was consuming less than 50% of her estimated daily fluid needs based on her weight), and although her physician orders [REDACTED]. On the morning of [DATE], after intervention by the resident's legal representative, Resident #45 was transferred to the hospital due to an altered mental status and was subsequently admitted with [MEDICAL CONDITION] (C. diff.) [MEDICAL CONDITION] and proctitis; urinary tract infection [MEDICAL CONDITION]; altered mental status secondary to the above; acute hemorrhagic stroke in the parietal lobe; and dehydration. Resident #45 expired at the hospital on [DATE]. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 1. During a telephone interview beginning at 5:45 p.m. on [DATE], the daughter of Resident #45 reported that she had visited her mother at the facility and found her with a dry mouth and a foul odor associated with bowel movement and urine; according to her daughter, Resident #45 was not very responsive and could barely say her name. The daughter reported her findings to a nurse at the facility, who ""pinched"" the resident's skin and said she did not believe the resident was dehydrated. The daughter reported her belief that the facility failed to assess her mother for about one (1) week; she had visited her mother on [DATE] and ""everything was fine"", but when she returned on [DATE], she found her mother in a ""gravely ill"" condition. The daughter reported she did not hear from the facility during the period from [DATE] through [DATE] to let her know that her mother was sick. (See also citation at F157.) Her mother was not transferred to the hospital until she brought her mother's condition to the staff's attention on [DATE]. Her mother later expired at the hospital on [DATE]. -- 2. Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. Review of her nursing notes revealed the last entry was made at 12:05 p.m. on [DATE]. Further review of her record revealed a physician's telephone order dated [DATE] (no time written) to transport the resident to the local hospital's emergency room due to ""(symbol for 'change') in mental status"", although there was no corresponding entry discussing when or why this occurred. (See also citation at F514.) -- 3. Information obtained from the hospital history and physical, electronically signed by the physician on [DATE], revealed Resident #45 arrived at the emergency roiagnom on [DATE], with a chief complaint of ""altered mental status"". Under the heading ""History of Present Illness"" was found: ""This is an [AGE] year old white female who resides at Boone Nursing whose history comes from family as well as nursing staff who report (sic) that she had a (sic) altered mental status since last night. She had a decreased appetite, weakness, and diarrhea for several days. ... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" Under the heading ""Physical Examination"" was found: ""... Positive lethargy but no comatose state. Alert. Dehydration with dry mucous membranes. ... Bowel sounds hyperactive. ..."" Under the heading ""Labs"" was found the following abnormal values: glucose 141 (normal range = ,[DATE]); blood urea nitrogen (BUN) 58 (normal range = ,[DATE]); white blood cells 15.3 (normal range = 4XXX,[DATE]); 2+ protein in urine (normal = negative); 2+ leukocyte esterase in urine (normal = negative). Under the heading ""Assessment / Plan"" was found the following: ""1. [DIAGNOSES REDACTED] [MEDICAL CONDITIONS] and proctitis ... ""2. UTI (urinary tract infection) ... ""3. Altered mental status secondary to the above. ""4. Acute hemorrhagic stroke in parietal lobe ... ""5. Dehydration. Given light IV fluids to prevent any kind of fluid overload. ..."" -- 4. A review of the nursing notes recorded in Resident #45's medical record in the days prior to her transfer to the hospital revealed the following: - On [DATE] at 9:00 a.m. - ""N/O (new order) noted for Fleets enema per rectum x i (1) D/T (due to) (symbol for 'no') BM x 4 days. Resident tolerated procedure well /c (with) effective results noted /c med (medium) BM noted."" - On [DATE] at 11:00 a.m. - ""S/T (skin tear) to (L) (left) wrist during AM (morning) care noted. Dr. (doctor) notified /c orders for steri-strips & TAO (triple antibiotic ointment) applied. ...(Symbol for 'no') distress noted, will continue to monitor."" - On [DATE] at 12:05 p.m. - ""Resp (respirations) even & unlabored. (Symbol for 'no') SOB (shortness of breath) or cough noted. ... (Symbol for 'no') distress noted @ (at) present. Will monitor."" According to the hospital history and physical, ""... Symptoms for twenty hours (sic) altered mental status but other symptoms for several days. ..."" However, there was no mention in the resident's nursing notes of any decreased appetite or weakness or of the resident having had ""diarrhea for several days"" in the days preceding the resident's transfer to the hospital on [DATE]. -- 5. Review of Resident #45's nursing notes for [DATE] revealed staff called the physician and obtained an order for [REDACTED]. Review of the nursing notes for [DATE] and [DATE] found no documentation related to the resident's fluid intake and/or bowel elimination, and all nursing documentation stopped after 12:05 p.m. on [DATE]. Review of Resident #45's [DATE] ADL flow sheet revealed she had an extra large BM on the evening shift of [DATE], and then she did not have another BM until the day shift on [DATE], for which a Fleets enema was administered. According to coding on the ADL flow sheet, the resident had two (2) BMs on the day shift of [DATE]. This was followed by: - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; - Three (3) BMs on the day shift of [DATE]; - No (0) BMs on the evening and night shifts of [DATE]; - Three (3) BMs on the day shift of [DATE]; - Three (3) BMs on the evening shift of [DATE]; - One (1) small BM on the night shift of [DATE]; - One (1) large BM on the day shift of [DATE]; - Two (2) large BMs on the evening shift of [DATE]; - Three (3) large BMs on the night shift of [DATE]; and - One (1) large BM on the day shift of [DATE]. Due to an absence of nursing notes after 12:05 p.m. on [DATE], there was no evidence to reflect the licensed nursing staff collected or recorded any physical assessment data regarding the resident's overall health status, including but not limited to data regarding the resident's bowel movements (whether the stool was formed, soft, liquid, or watery and/or whether the color or odor of the stool was abnormal, etc.), the presence and quality of bowel sounds, level of consciousness, and/or hydration status. There was no evidence the licensed nursing staff identified and reported to the physician that this resident, beginning on [DATE], was having excessively frequent BMs. (See also citation at F309.) -- 6. Review of the resident's medication administration records (MARs) for September and [DATE] revealed physician's orders [REDACTED]. - [MEDICATION NAME] 15 cc by mouth twice daily for constipation - Senna Plus 2 tabs by mouth twice daily for constipation - Power Pudding 60 cc at bedtime due to constipation According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE], staff continued to administer Senna Plus and [MEDICATION NAME] on [DATE] and [DATE]; the resident refused the Power Pudding. According to the [DATE] MAR, when Resident #45 continued to have frequent BMs on [DATE] and [DATE], staff did not withhold all doses of laxatives; rather, the facility continued to administer as follows: - [DATE] - [MEDICATION NAME] at 6:00 p.m.; Senna Plus at 6:00 p.m.; Power Pudding at 9:00 p.m. - [DATE] - [MEDICATION NAME] at 10:00 a.m. and 6:00 p.m.; Senna Plus at at 10:00 a.m. and 6:00 p.m.; - [DATE] - [MEDICATION NAME] at 10:00 a.m.; Senna Plus at 10:00 a.m. (The nurses' initials were circled on the MAR for the 10:00 a.m. doses of [MEDICATION NAME] and Senna Plus on [DATE], although no explanation for this was documented on the reverse side of the MAR.) According to Lexi-Comp's Drug Information Handbook for Nursing 2007 (8th Edition): - For [MEDICATION NAME], under ""Nursing Actions: Physical Assessment"" on page 704: ""Monitor ... therapeutic effectiveness (soft formed stools...) ... Monitor frequency / consistency of stools ..."" Under ""Nursing Actions: Patient Education"" on page 704: ""... Report persistent or severe diarrhea or abdominal cramping ..."" Under ""Geriatric Considerations"" on page 704: ""Elderly are more likely to show CNS (central nervous system) signs of dehydration and electrolyte loss. Therefore, monitor closely for fluid and electrolyte loss with chronic use...."" - For Senna Plus, under ""Nursing Actions: Patient Education"" on page 385: ""... Stop use and contact prescriber if you develop nausea, vomiting, persistent diarrhea, or abdominal cramps. ..."" (See also citation at F309.) -- 7. Review of the ""Shift to Shift Report"" forms dated [DATE], [DATE], and [DATE], there was no mention of the resident's increased frequency of bowel elimination, decreased intake of food or fluids, or changes in level of consciousness. The only mention of Resident #45 on these 24-hour reports was related to the skin tear on her left wrist which, according to her last nursing note, she sustained during morning care on [DATE]. -- 8. According to her [DATE] recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""Encourage fluids with meals."" According to her weight record on [DATE], Resident #45 weighed 196# (89.1 kg). Her estimated daily fluid needs, based on a formula of 30 cc/kg, would be 2673 cc of fluid per day. Review of the ADL flow sheets for September and [DATE] revealed Resident #45 consumed 600 cc or less per day as follows: - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 600 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1320 cc) - [DATE] - 520 cc with meals and snacks; 480 cc of Glucerna; 240 cc of Med Pass (daily total fluids = 1240 cc) - [DATE] - 480 cc with meals and snacks; 240 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 840 cc) - [DATE] - 360 cc with meals and snack; 480 cc of Glucerna; 120 cc of Med Pass (daily total fluids = 960 cc) - [DATE] - ADL flow sheet documentation showed resident refused all fluids offered on day shift; 240 cc of Glucerna; 0 cc of Med Pass (total fluids on day shift prior to transfer to hospital = 240 cc) Review of the medical record, on [DATE] at 11:15 a.m., found no evidence to reflect the licensed nursing staff identified the resident's inadequate fluid intake and notified the physician or Resident #45's responsible party. (See also citation at F327.) -- 9. Resident #45 was sent out to the hospital on day shift on [DATE], but no nursing documentation was found related to assessment of the resident prior to her being sent to the hospital. According to her hospital record, she was admitted for [DIAGNOSES REDACTED], [MEDICAL CONDITION], proctitis, urinary tract infection [MEDICAL CONDITION], dehydration, leukocytosis secondary to [DIAGNOSES REDACTED] and UTI, altered mental status secondary to [DIAGNOSES REDACTED] and UTI, hypercalcemia, acute hemorrhagic stroke in the parietal lobe, and lactic acid elevation. -- 10. During a telephone interview on [DATE] at 2:20 p.m. with the licensed practical nurse (LPN) assigned to Resident #45 on [DATE] (Employee #71) and the administrator (Employee #111), Employee #71 confirmed she could not be sure she had documented any nursing assessment data on Resident #45 prior to her being sent to the hospital. Employee #71 stated, ""Her daughter came to me and said she was acting different, and I sent her to the hospital."" -- 11. In an interview on [DATE] at 10:45 a.m., the director of nursing (DON - Employee #112) confirmed she could not locate nursing documentation related to any nursing assessment of Resident #45 prior to her transfer to the hospital. .",2014-03-01
11438,BOONE HEALTH CARE CENTER,515117,P.O. BOX 605,DANVILLE,WV,25053,2010-11-11,325,D,,,IP7Z11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure one (1) of eleven (11) residents, who was identified as being at risk for weight loss, received nutritional supplements in accordance with physician orders. Resident identifier: #45. Facility census: 84. Findings include: a) Resident #45 Closed record review revealed this [AGE] year old female was originally admitted to the facility on [DATE]. Her current [DIAGNOSES REDACTED]. According to her October 2010 recapitulation of physician orders, Resident #45's diet order was as follows: ""LCS / NAS (low concentrated sweets / no added salt) diet w/ ground meats. Encourage fluids w/ meals."" To prevent weight loss, Resident #45's orders also included Glucerna 1 can by mouth twice daily and Med Pass 120 cc by mouth twice daily. According to her care plan, Resident #45 was ""at risk for weight loss"" related to [MEDICAL CONDITION] reflux, dementia, [MEDICAL CONDITION], and diabetes mellitus. Interventions for maintaining her weight at plus / minus 5# through the next review included: ""... Med pass (sic) 120cc (sic) bid. Glucerna 1 can po bid for supplement."" According to the September 2010 MAR, there were orders for Glucerna 1 can PO BID and Med Pass 120 cc BID. Both of the nutritional supplements were grouped together on this MAR indicated [REDACTED]. Because these orders were not listed separately, there was no way to verify, by the nurses' initials, that both daily doses of each product were administered as ordered. (See also citation at F514.) .",2014-03-01
3087,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,561,D,0,1,MQTT11,"Based on a random discovery made during the dining observation, resident interview and staff interview, the facility failed to ensure the resident's preferences were met regarding a dislike for spaghetti. It was discovered during the dining observation Resident #9's food preference had not been honored. Resident identifier: #9. Facility census: 60. Findings included: a) Resident #9 During a random dining observation on 01/09/19 at 11:54 AM, it was discovered R9 had received spaghetti for her noon meal. Her tray card referenced spaghetti as one of her disliked foods. Her food preferences had not been honored. In an interview with Dietary Supervisor #30 on 01/09/19 at 12:27 PM, verified R9 was served spaghetti for her noon meal. She agreed the tray card had not been followed and her food preferences had not been honored.",2020-09-01
3088,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,578,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to properly record a resident's advanced directives in the medical record. This affected one (1) of one (1) sampled residents reviewed for the care area of advanced directives. Resident identifier: #12. Facility census: 60. Findings included: a) Resident #12 On 01/08/19 at 8:15 AM, it was noted that Resident #12's Physician order [REDACTED].#12's face sheet for the length of a trial period of intravenous fluids (IVFs). Resident #12's POST form, signed on 10/24/14, directed to provide IVFs for a trial period, but did not specify the length of the trial period. Resident #12's face sheet, care plan, and orders all directed to provide IVFs for seven (7) days. During an interview on 01/08/19 at 2:11 PM, Social Services Supervisor (SSS) #32 said she was unaware of Resident #12's POST form not matching her face sheet, care plan, and orders. She acknowledged that the advanced directive information on the POST form, face sheet, care plan, and orders should match. On 01/10/19 at 10:01 AM, the facility's Administrator and Regional Director of Operations (RDO) #77 were informed of the issue. No further information was provided prior to the end of the survey.",2020-09-01
3089,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,583,D,0,1,MQTT11,"Based on medical record review and staff interview, the facility failed to maintain the confidentiality of a resident's personal and medical information by placing this information in another resident's chart. This was found during a random opportunity for discovery. Resident identifiers: #13, #37. Facility census: 60. Findings included: a) Resident #13 and #37 On 01/09/19 at 8:31 AM, it was noted that a medication regimen review (MRR) for Resident #37 was scanned into Resident #13's medical record. The MRR contained information about Resident #37, including her first and last name, medications, laboratory results, and information about her health status. On 01/10/19 at 10:01 AM, the facility's Administrator and Regional Director of Operations (RDO) #77 were informed of the issue. RDO #77 stated she didn't feel that this was a confidentiality problem because only nursing home staff have access to the medical records. She further stated that if Resident #13 were to transfer to another facility all of her paperwork would be reconciled and Resident #37's information would be removed at that time. The facility's Administrator then acknowledged that this was a problem and said that Resident #37's information needed to be deleted from Resident #13's record. No further information was provided prior to the end of the survey.",2020-09-01
3090,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,584,D,0,1,MQTT11,"Based on observation, resident interview and staff interview, the facility failed to ensure a clean environment to the extent possible. During a random observation Resident #21's wheelchair was observed to have a lot of built up dirt, dust and debris along the side frame and the wheels. Resident identifier: #21. Facility census: 60. Findings included: a) Resident #21 On 01/07/19 at 5:00 PM an observation of Resident #21's wheelchair revealed a lot of dirt, dust, and debris built up along the side frame and wheels. On 01/09/19 at 10:12 AM Registered Nurse, Clincial Care Supervisor #11 was told about the issue with Resident #21's wheelchair having dirt, dust and debris built up along with side frame. Clinical Care Supervisor (CCS) #11 said Resident #21 would not get out of the chair much during the day. CCS #11 went into the resident's room to ask look at the wheelchair and ask her about having it cleaned. CCS #11 agreed the wheelchair as dirty and needed cleaned. She asked Resident #21 about getting out of it for cleaning and Resident #21 said this would not be a problem and said she would sit in the chair beside her bed while it was cleaned.",2020-09-01
3091,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,585,D,0,1,MQTT11,"Based on resident and staff interviews, review of policy and review of concern documentation, the facility failed to thoroughly investigated allegations of possible abuse. This was evident for one (1) of two (2) allegations noted. Resident identifier: #35. Facility census: 60. Findings included: a) Resident #35 During initial tour with residents on 01/07/18, the resident expressed concern the staff would handle her roughly when trying to change her or help her get up in the mornings. Two (2) reports in the concern file were related to this resident and the allegations were simllar to what she had told surveyors. Interview with the social worker on 01/08/19 at 12:40 p.m. revealed she had not reported any concerns to other agencies regarding possible abuse related to the reported allegations by the resident. She would discuss the allegations and then determine if they needed to be reported. Interview with the administrator on 01/08/19 at 12:45 p.m. indicated that she was in agreement there should have been a more thorough investigation to determine exactly what the resident may have meant by rough when she stated the staff had used that term in the report. Review of the facility policy dated as revised 06//12/18 regarding complaint /grievance reports states grievances are to be thoroughly and promptly investigated (generally with in 5 days). The official has the authority to utilize all resources necessary to ascertain the validity of the complaint received.",2020-09-01
3092,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,623,F,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the Ombudsman with notices of emergency transfers to acute care hospitals. This was true for four (4) of four (4) residents reviewed for hospitalization s. This had the potential to affect all residents with emergency transfers to acute care hospitals. The Ombudsman never received any notifications for these residents. Resident identifiers: #14, #36, #59 and #64. Facility census: 60. Findings included: a) Residents #14, #36, #36 and #59 A review of the medical records on 01/10/19 for #14, #36, #36 and #59 revealed they had been transferred to acute care hospitals. Resident #14 had been hosptalized on [DATE] and 01/02/19. Resident #36 was transferred to the hospital on [DATE]. Resident #59 went to the hospital on [DATE] and Resident #64 was sent to the hospital on [DATE]. There was no evidence the Ombudsman had received any notices for these resident's hospitalization s. In an interview on 01/10/19 at 10:48 AM with Social Services Director #32 reported she had not sent any hospitalization notices to the Ombudsman for several months.",2020-09-01
3093,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,656,D,0,1,MQTT11,"Based on observation, record review and staff interview, the facility failed to implement a care plan in the care area of venous stasis ulcer wound care. This was true for one (1) of one (1) resident observed for venous stasis ulcer wound care. This practice had the potential to affect more than a limited number of residents. Resident identifier: #58. Census: 60. Findings included: a) Resident #58 Observations, on 01/08/19 at 02:15 PM of Registered Nurse (RN) #26 providing wound care to Resident #58's left leg venous stasis wounds, revealed interventions on the resident's care plan was not implemented. Review of the care plan revealed an intervention, under the focus area 'Venous/Stasis Ulcer to left lower leg', that directed nurses to Cleanse open areas to LLE (left lower extremity) with wound cleanser; pat dry . During observation of wound care the nurse did not pat the wounds dry, but briskly rubbed the wound areas using a downward motion. Rubbing instead of patting has the potential to disrupt healing tissue in the wound bed. The downward motion the nurse used is contraindicated in promoting venous blood return. An interview with RN#26, after provision of wound care, revealed RN#26 agreed the objectives for wound healing is to assist in ensuring adequate blood flow for the redevelopment of healthy tissue formation in the wound bed, and protecting the wound bed from any further tissue damage. RN #26 agreed Resident #58's venous ulcer wounds should be patted dry as care planned and ordered, to ensure the healthy tissue is left intact and not disrupted in the wound bed. An interview with the DNS (Director of Nursing Services), on 01/08/19 at 02:42 PM, revealed DNS agreed RN#26 should have followed the orders and care plan, and should not have rubbed downward or use the same gauze, it was a breach in infection control principals and nursing principals. The DNS agreed it was a nursing principal to aid wound healing for the nurse to pat dry instead of rubbing dry the wound. The DNS agreed the care plan should have been followed, and said, The nurse should have patted not rubbed the open wound. Review of records, on 01/10/19 at 11:02 AM, revealed an order dated 01/03/19 Cleanse open areas to LLE (left lower extremity) with wound cleanser; pat dry. Apply silver alginate cut to size of wounds and cover with foam dressing every day shift. Review of the care plan revealed an intervention, under the focus area 'Venous/Stasis Ulcer to left lower leg', that directed nurses to Cleanse open areas to LLE with wound cleanser; pat dry. Apply silver alginate cut to size of wounds and cover with foam dressing every day shift.",2020-09-01
3094,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,684,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to provide the necessary care and services to reach and/or maintain the highest possible level of functioning and well-being of three (3) of twenty-three (23) survey sample residents reviewed during the annual Long-Term Care Survey. The facility failed to follow physician orders [REDACTED].#58. The facility failed to perform proper Blood Pressure measurement techniques for Resident #59, to ensure the blood pressure cuff was not too tight. The facility failed to ensure staff was trained and preformed proper cleaning of Resident #15's Bi-Pap (Bilevel Positive Airway Pressure) machine and failed to follow physician's orders [REDACTED].#15 at three (3) liters per minute. These practices had the potential to affect more than a limited number of residents. Resident identifiers: #58, #59, and #15. Facility census: 60. Findings included: a) Resident #58 Observations, on 01/08/19 at 02:15 PM of Registered Nurse (RN) #26 providing wound care to Resident #58's left leg venous stasis wounds, revealed the nurse did not pat the wounds dry, but briskly rubbed the wound areas using a downward motion. Rubbing instead of patting has the potential to disrupt healing tissue in the wound bed. The downward motion the nurse used is contraindicated in promoting venous blood return. An interview with RN#26, after provision of wound care, revealed RN#26 agreed the objectives for wound healing is to assist in ensuring adequate blood flow for the redevelopment of healthy tissue formation in the wound bed, and protecting the wound bed from any further tissue damage. RN #26 agreed Resident #58's venous ulcer wounds should be patted dry to ensure healthy tissue forming is left intact and not disrupted in the wound bed. RN #26 confirmed she did not follow physician orders [REDACTED]. An interview with the DNS (Director of Nursing Services), on 01/08/19 at 02:42 PM, revealed the DNS agreed RN#26 should have followed the orders and care plan, and should not have rubbed downward or use the same gauze for each open wound. The DNS confirmed the wound care provided breached infection control and nursing care principals. The DNS confirmed a nursing principal to aid wound healing is for the nurse to pat dry instead of rubbing dry the wound. Review of the resident's annual minimum data set (MDS) with an assessment reference date (ARD) 12/11/18, on 01/10/19 at 10:45 AM, revealed the resident's Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident is cognitively intact. The resident needs extensive assistance needed for most activities of daily living, but needs supervision with eating and locomotion, and is totally dependent for bathing and transfers. The resident has range of motion (ROM) impairment in her lower extremities on both sides. Resident has an indwelling Foley catheter and is always incontinent of bowel. Some pertinent [DIAGNOSES REDACTED]. Review of records, on 01/10/19 at 11:02 AM, revealed an order dated 01/03/19 Cleanse open areas to LLE (left lower extremity) with wound cleanser; pat dry. Apply silver alginate cut to size of wounds and cover with foam dressing every day shift. Review of the care plan revealed an intervention, under the focus area 'Venous/Stasis Ulcer to left lower leg', that directed nurses to Cleanse open areas to LLE (left lower extremity) with wound cleanser; pat dry. Apply silver alginate cut to size of wounds and cover with foam dressing every day shift. According to MedlinePlus (the National Institutes of Health's Web site), produced by the world's largest medical library (the National Library of Medicine), Chronic [MEDICAL CONDITION] is a long-term condition in which the veins have problems sending blood from the legs back to the heart. Normally, valves in your leg veins keep blood moving forward toward the heart, with long-term (chronic) [MEDICAL CONDITION], vein walls are weakened, and valves are damaged. This causes the veins to stay filled with blood. Blood pools in the veins of the lower leg. Fluid and blood cells leak out of the veins into the skin and other tissues. This may lead to skin break down to form open sores. Therefore, care should be taken not to disrupt healing wound beds, and any rubbing of the lower legs would need to be in an upward direction toward the heart, to promote venous blood flow. b) Resident #59 On 01/07/19 at 2:05 PM, during an observation/interview with Resident #59 he was asked about the dark red/purplish color on the tops of his hands. He explained that was the blood from the veins in the top of his hands popping out from where they took blood pressure in his arms. He said the cuff was too tight and it hurt him. At 2:35 PM on 01/07/19, Nurse Aide #37 was asked if she took blood pressure on Resident #59. She said she did sometimes and showed the cuff and machine she used. She said she had not taken his blood pressure today. She said Nurse Aide #45 had taken it and she was gone for the day. On 01/07/19 at 4:48 PM, Licensed Practical Nurse (LPN) #21 was asked if the resident had ever complained about the nursing staff causing him pain in his arm when they took his blood pressure. She said she had not heard any complaints but said, they made need to use a different cuff on him. At 4:48 PM on 01/08/19 LPN #21, was again asked if there were any issues with Resident #59 regarding pain with having blood pressure taken. She said she needed to retake it because it had been elevated earlier in the day. At 5:00 PM on 01/08/19 during an observation and interview with LPN #21 present Resident #59 was asked if it hurt when LPN #21 took his blood pressure and he said no. He was asked if had hurt earlier when the nurse aide took it and he said it did. He said he told her but she just wrapped it tighter and tighter. He showed LPN #21 the top of his hand and told her the red/purplish color was from where the cuff had been so tight on his hand. LPN #21 asked him if it would be better to have it taken in the other arm. He showed LPN #21 the other hand and said the same thing had happened there. LPN #21 then said, we need to do an in-service on blood pressure. On 01/09/19 at 8:00 AM the administrator provided documentation of an in-service that was done on 01/08/19 regarding ensuring blood pressure cuffs were not too tight when taking a resident's blood pressure.",2020-09-01
3095,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,690,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of Center for Disease Control and Prevention (CDC) guideline, record review and staff interview, the facility failed to ensure a resident who was incontinent of bladder received appropriate treatment and services to prevent urinary tract infections. Two (2) of three (3) residents reviewed for catheter care/urinary tract infections had catheter bags that were touching the floor. Resident #58 and Resident #59. Facility census: 60. Findings included: a) Resident #59 During an observation at 11:30 AM on 01/07/19 Resident #59's urinary catheter drainage bag was observed sitting directly on the floor. Resident #59's bed was also observed in the lowest position. On 01/07/19 at 2:02 PM Resident #59's urinary catheter bag was again observed sitting directly on the floor. (Alice) Registered Nurse # looked at the urinary catheter drainage bag and agreed it did not need to be sitting on the floor. She said the resident's bed in the lowest position contributed to the bag sitting on the floor. She adjusted the bag to where it did not sit directly on the floor. A review of Resident #59's care plan revealed a focus area for impaired urinary elimination related to [MEDICAL CONDITIONS], urinary leakage, indwelling Foley catheter and history of urinary tract infections. The Center for Disease Control and Prevention's policy titled Guideline for Prevention of Catheter Associated Urinary Tract Infections reflected a guideline stating that catheter bags do not need to rest directly on the floor. b) Resident#58 Observations, on 01/07/19 at 01:18 PM, revealed Resident#58 sitting in her wheel chair in the hallway outside of the dining room. Resident#58's Foley catheter drainage bag was attached and hanging under the center of the resident's wheel chair, with the edge of the drainage bag cover lying on the floor. There appeared to have a significant amount of drainage in the bag. The resident did not sit still in the wheel chair and as she moved the wheel chair around the drainage bag cover would hang up on the floor and cause the bag to also lie against the floor. Nurse Practitioner, NP#1, observing the Foley catheter drainage bag acknowledged the drainage bag cover was indeed against the floor and request registered nurse RN#25 to take the resident back to her room to empty the Foley catheter drainage bag. At 01:21 PM on 01/07/19, RN#25 was observed pushing Resident #58 out of her room in her wheel chair back toward the dining room, with the emptied Foley catheter drainage bag and its cover dragging the floor the entire way. This surveyor followed RN#25 and Resident #58, all the while hearing the soft scraping noise the drainage bag and its cover was making as it was being drug down the hallway. This surveyor asked RN#25 to look at the drainage bag and asked her if that is where the drainage bag belonged. RN#25 replied, That is as high as you can hang it. RN#25 agreed the drainage bag or its cover was not to touch floor, that by touching the floor it was an infection control issue. RN#25 then knelt and adjusted the bag under the wheel chair so it did not touch the floor. Current professional standards of practice for maintenance of Foley Catheters include, Do not let the drainage bag touch or lie on the floor. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor.",2020-09-01
3096,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,695,D,0,1,MQTT11,"**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 one (1) of three (3) residents who required respiratory care was provided such care with professional standards of practice and in accordance with the care plan, the residents goals and preferences. Resident #18's Bi-Pap machine was not cleaned per manufactures instructions and her oxygen was not set on the amount of liters indicated in the care plan. Resident #15. Facility census: 60. Findings included: a) Resident #15 1. Bi-Pap machine On 01/07/19 at 4:19 PM during an interview with the resident she said she did not feel her Bi-Pap machine was cleaned properly. She also did not feel the mask was making a tight enough seal. The medical record revealed a physician's orders [REDACTED]. The record also contained a physician's orders [REDACTED]. The resident's care plan revealed a focus area which reflected [MEDICAL CONDITIONS] embolism, shortness of breath, wheezing, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], low O2 sats, Hx (history) of lung collapse, OSA (obstructive sleep apnea), Prone to seasonal allergy symptoms/cold like symptoms/nasal congestion. The interventions listed included, Clean Bi-Pap weekly every night shift every Sat as ordered. On 01/08/19 at 12:08 PM Licensed Practical Nurse (LPN) #72 was asked if the facility had a policy on cleaning and using the Bi-Pap machine. She said she thought they did but would have to look for it. At 12:30 PM the administrator brought in a schedule which showed the nursing staff were to cleaned the machine each Saturday in December. The treatment administration report (TAR) revealed LPN #20, #18, and #17 were the LPNs who cleaned the machine in (MONTH) and January. The treatment administration record (TAR) for (MONTH) 2019 and (MONTH) (YEAR) reflected the following, Clean Bi-pap weekly, every night, every Sat (Saturday) for Bi-Pap use. On 01/08/19 at 1:56 PM an interview with the Director of Nursing Services (DNS) revealed the respiratory supply company had came to the facility in (MONTH) and conducted an inservice on proper cleaning of the Bi-Pap machine. She said she did not have any further information regarding the content that was presented or who attended because she was not in the facility on that date. The DNS provided a copy of an inservice training she had completed on 08/08/18 regarding the cleaning of the Bi-Pap machine. The inservice attendance record reflected LPN #18 had attended but LPN #17 and #19 had not. The summary of the training session stated, Bi-Pap machine need cleaned every (Saturday) night weekly. It is important to be cleaned to prevent molds etc Only distilled water is to be used in the Bi-Pap machine. This can be found in the Med (medication) Room. On 01/08/19 at 2:24 PM during an interview with the DNS it was explained to her (DNS) that Resident #15 had some concerns about the way the nurses were cleaning her Bi-Pap machine. At 2:30 PM on 01/08/19 the DNS accompanied the surveyor to Resident #15's room to discuss the resident's concerns. During this interview Resident #15 told the DNS she did not like the way the nurses were cleaning her Bi-Pap. She said she did not think they were doing in correctly. Resident #15 said she did not think the mask was fitting correctly and that it was not fitting as tight as it should and air was coming out of it. Resident #15 told the DNS that she felt LPN #18 was the only one that cleaned her machine correctly. She described how LPN #18 cleaned the hoses and the mask. She did not think the other two LPNs who had cleaned the machine in (MONTH) had done it the correct way. On 01/08/19 at 4:40 PM the DNS presented the user manual for the Phillips Respironics DreamStation Bi-Pap Pro/Auto Bi-Pap. She also presented information from inservice held on 10/24/18 from the home medical company that supplied the resident's Bi-Pap machine. The summary stated, On 10/24/18 an inservice was held at (name of facility), to discuss the use of [MEDICAL CONDITION] and Bi-Pap machines. I met with several staff members to go over the difference between the two, the function of both, the humidifier which can be used, the adding of O2, the different masks, the fitting of masks, the cleaning of both masks and machines. The material that was included with the inservice included information on maintenance. The section included the following, Masks should be cleaned with mild soap and water every day. Tubing should be cleaned with mild soap and water every week and allowed to air dry. Unit should be wiped down with damp cloth as needed. Headgear should be hand or machine washed periodically. The humidifier if present, should be cleaned with mild soap and water weekly. [NAME] vinegar may be used to remove deposits if you have hard water. The facility did not have evidence of who attended this inservice. 2. Oxygen On 01/07/19 an observation revealed Resident #15 wore oxygen. Resident #15's oxygen concentrator reflected the oxygen was set at 2.5 liters. A review of the physician's orders [REDACTED].#75 went into Resident #15's room and observed the O2 set on 2.5 liters. LPN #75 checked the physician's orders [REDACTED]. The resident's care plan also revealed an intervention which stated, Give oxygen therapy as ordered by the physician. (MONTH) remove O2 for transfers.",2020-09-01
3097,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,726,E,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record reviews, staff training record review, and staff interviews, the facility failed to assure all nursing staff possess the competencies and skills necessary to provide care and services to meet the residents' needs safely and in a manner that promotes each resident's rights, and well-being. This is true regarding: accurately documenting the time that controlled medication is given in the 'Individual Resident's Controlled Substance Record'; performing appropriate Blood Pressure measurement techniques; properly cleaning and maintaining a resident's Bi-Pap (Bilevel Positive Airway Pressure) machine; and correctly providing oxygen therapy to a resident. These practices have the potential to affect more than a limited number of residents. Resident identifiers: #14, #59, and #15. Census: 60. Findings included: a) Resident #14 Observations of medication administration by Licensed Practical Nurse (LPN #22), on 01/08/19 at 12:50 PM, revealed Resident #14 received the controlled substance [MEDICATION NAME] ([MEDICATION NAME]) 600 mg by mouth. LPN#22 removed medication from the blister pack at 12:45 PM and signed the book, she then gave the medication to the resident at 12:50 PM on 01/08/19, however she signed the 'Individual Resident's Controlled Substance Record' time as 1300 (01:00 PM the scheduled time). When asked LPN#22 said she signs the book (the book with the 'Individual Resident's Controlled Substance Record' sheets) for the time the medication is scheduled. LPN#22 said she has worked at the facility for sixteen (16) years and that is what she was always told to do, .write when it is scheduled not when it was given in the narcotic book. Interview with LPN#21, the nurse passing medication on the other hall, revealed LPN#21 has worked at the facility for thirteen (13) years and said most of the time she does the same thing, records the scheduled time. LPN #21 stated, As a nurse, I know you are supposed to sign out all medications when you give them. On 01/08/19 at 01:16 PM, an interview with DNS (Director of Nursing Services), revealed the DNS was not aware the nurses were documenting the scheduled time. The DNS said, Nurses should write the time it is given, not the time when it is scheduled. Review of Resident #14's current Medication Administration Record [REDACTED]. Review of Resident #14's 'Individual Resident's Controlled Substance Record' dated 12/29/18 through 01/08/19 shows some entries that suggest not all nurses are signing just the scheduled times, on five (5) different days a nurse recorded the time as 1400. On 01/08/19 at 04:55 PM an interview with the administrator and the DNS revealed the facility did not think there was an issue. The Administrator said, I know it is not a nursing standard to record a scheduled time instead of the actual time given, but the resident's actual record is electronically captured on the MAR, showing when the narcotic was given. The Administrator said the 'Individual Resident's Controlled Substance Record' kept in the narcotic books is not part of the resident's records. The Administrator gave this surveyor a copy of the MAR indicated [REDACTED] b) Resident #59 On 01/07/19 at 2:05 PM during an observation/interview with Resident #59 he was asked about the dark red/purplish color on the tops of his hands. He explained that was the blood from the veins in the top of his hands popping out from where they took blood pressure in his arms. He said the cuff was too tight and it hurt him. At 2:35 PM on 01/07/19 Nurse Aide #37 was asked if she took blood pressure on Resident #59. She said she did sometimes and showed the cuff and machine she used. She said she had not taken his blood pressure today. She said Nurse Aide #45 had taken it and she was gone for the day. On 01/07/19 at 4:48 PM Licensed Practical Nurse (LPN) #21 was asked if the resident had ever complained about the nursing staff causing him pain in his arm when they took his blood pressure. She said she had not heard any complaints but said, they made need to use a different cuff on him. At 4:48 PM on 01/08/19 LPN #21 was again asked if there were any issues with Resident #59 regarding pain with having blood pressure taken. She said she needed to retake it because it had been elevated earlier in the day. At 5:00 PM on 01/08/19 during an observation and interview with LPN #21 present Resident #59 was asked if it hurt when LPN #21 took his blood pressure and he said no. He was asked if had hurt earlier when the nurse aide took it and he said it did. He said he told her but she just wrapped it tighter and tighter. He showed LPN #21 the top of his hand and told her the red/purplish color was from where the cuff had been so tight on his hand. LPN #21 asked him if it would be better to have it taken in the other arm. He showed LPN #21 the other hand and said the same thing had happened there. LPN #21 then said, we need to do an in-service on blood pressure. On 01/09/19 at 8:00 AM the administrator provided documentation of an in-service that was done on 01/08/19 regarding ensuring blood pressure cuffs were not too tight when taking a resident's blood pressure. c) Resident #15 1. Bi-Pap machine On 01/07/19 at 4:19 PM during an interview with Resident #15 she said she did not feel her Bi-Pap machine was cleaned properly. She also did not feel the mask was making a tight enough seal. The medical record revealed a physician's orders [REDACTED]. The record also contained a physician's orders [REDACTED]. Resident #15's care plan revealed a focus area which reflected [MEDICAL CONDITIONS] embolism, shortness of breath, wheezing, chronic [MEDICAL CONDITION] with [MEDICAL CONDITION], low O2 sats, Hx (history) of lung collapse, OSA (obstructive sleep apnea), Prone to seasonal allergy symptoms/cold like symptoms/nasal congestion. The interventions listed included, Clean Bi-Pap weekly every night shift every Sat as ordered. On 01/08/19 at 12:08 PM Licensed Practical Nurse (LPN) #72 was asked if the facility had a policy on cleaning and using the Bi-Pap machine. She said she thought they did but would have to look for it. At 12:30 PM the administrator brought in a schedule which showed the nursing staff were to cleaned the machine each Saturday in December. The treatment administration report (TAR) revealed LPN #20, #18, and #17 were the LPNs who cleaned the machine in (MONTH) and January. The treatment administration record (TAR) for (MONTH) 2019 and (MONTH) (YEAR) reflected the following, Clean Bi-pap weekly, every night, every Sat (Saturday) for Bi-Pap use. On 01/08/19 at 1:56 PM an interview with the Director of Nursing Services (DNS) revealed the respiratory supply company had came to the facility in (MONTH) and conducted an inservice on proper cleaning of the Bi-Pap machine. She said she did not have any further information regarding the content that was presented or who attended because she was not in the facility on that date. The DNS provided a copy of an inservice training she had completed on 08/08/18 regarding the cleaning of the Bi-Pap machine. The inservice attendance record reflected LPN #18 had attended but LPN #17 and #19 had not. The summary of the training session stated, Bi-Pap machine need cleaned every (Saturday) night weekly. It is important to be cleaned to prevent molds etc Only distilled water is to be used in the Bi-Pap machine. This can be found in the Med (medication) Room. On 01/08/19 at 2:24 PM during an interview with the DNS it was explained to her (DNS) that Resident #15 had some concerns about the way the nurses were cleaning her Bi-Pap machine. At 2:30 PM on 01/08/19 the DNS accompanied the surveyor to Resident #15's room to discuss the resident's concerns. During this interview Resident #15 told the DNS she did not like the way the nurses were cleaning her Bi-Pap. She said she did not think they were doing in correctly. Resident #15 said she did not think the mask was fitting correctly and that it was not fitting as tight as it should and air was coming out of it. Resident #15 told the DNS that she felt LPN #18 was the only one that cleaned her machine correctly. She described how LPN #18 cleaned the hoses and the mask. She did not think the other two LPNs who had cleaned the machine in (MONTH) had done it the correct way. On 01/08/19 at 4:40 PM the DNS presented the user manual for the Phillips Respironics DreamStation Bi-Pap Pro/Auto Bi-Pap. She also presented information from inservice held on 10/24/18 from the home medical company that supplied the resident's Bi-Pap machine. The summary stated, On 10/24/18 an inservice was held at (name of facility), to discuss the use of [MEDICAL CONDITION] and Bi-Pap machines. I met with several staff members to go over the difference between the two, the function of both, the humidifier which can be used, the adding of O2, the different masks, the fitting of masks, the cleaning of both masks and machines. The material that was included with the inservice included information on maintenance. The section included the following, Masks should be cleaned with mild soap and water every day. Tubing should be cleaned with mild soap and water every week and allowed to air dry. Unit should be wiped down with damp cloth as needed. Headgear should be hand or machine washed periodically. The humidifier if present, should be cleaned with mild soap and water weekly. [NAME] vinegar may be used to remove deposits if you have hard water. The facility did not have evidence of who attended this inservice. 2. Oxygen On 01/07/19 an observation revealed Resident #15 wore oxygen. Resident #15's oxygen concentrator reflected the oxygen was set at 2.5 liters. A review of the physician's orders [REDACTED].#75 went into Resident #15's room and observed the O2 set on 2.5 liters. LPN #75 checked the physician's orders [REDACTED]. The resident's care plan also revealed an intervention which stated, Give oxygen therapy as ordered by the physician. (MONTH) remove O2 for transfers.",2020-09-01
3098,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,756,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed had monitor medications requiring behavior monitoring. Blanks were noted on docuentation of monitoring forms which made it hard to determine if any behaviors occurred on those days. Resident identifier: #10 . This was found for one (1) of five (5) residents who were reviewed for unnecessary medication administration. Findings included: a) Resident #10. The resident is on the medication [MEDICATION NAME] and [MEDICATION NAME]. Review of the medical record for the resident showed there were some days that contained blanks for monitoring behaviors form in October, (YEAR) and December, (YEAR). A review of progress notes did not show any indication if there were any behaviors occurring on the days there were blanks on the form. (MONTH) monitoring form contained blank areas for the days of the 9, and 18. (MONTH) the dates were the 5th. Interview with the administrtor on 01/08/19 at 9:10 a.m. revealed she was unable to determine why there were blanks on the form and no other evidence was available to ensure monitoring on those days had been completed.",2020-09-01
3099,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,790,D,0,1,MQTT11,"**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 one (1) of three (3) residents reviewed for dental received routine dental service to meet the needs of Resident #59. Resident #59 had made a request for dentures and this request was not followed up on in a timely manner. Facility census: 60. Findings included: a) Resident #59 On 01/07/19 at 2:07 PM Resident #79 said he would like to have new top dentures. He said before he came to the facility his brother had lost his (Resident #59's) dentures. He indicated he had told someone at the facility that he would like to have top dentures but was not sure of the time or when he had made them aware. Resident #79 said he did not have any of his natural teeth. A progress note dated 09/28/18 reflected the following, SW (social worker) spoke with resident regarding his request to have dentures made. Resident stated he would like to have an upper denture so he could eat more things. He stated he did wear his upper dentures when he was at home. He does not want lower denture. SW explained the trip to affordable dentures would take most of the ay. Resident stated he felt it would not be a problem for him. SW informed resident what we would speak with his brother again to make necessary arrangements and if is medically able to go. An interview with the Social Worker on 01/08/19 at 2:53 PM revealed she had not spoken with Resident #59 about the dentures until 01/07/19 because he had been hospitalized . A social services note dated 01/08/19 at 9:45 AM stated, Received a call from RP (responsible party) (name). He stated he would agree to go ahead with purchasing his brothers glasses from his Trust Account and wait on dentures until later.[NAME]tated he would hold the facility responsible if they get broken. SW informed him that 360 Care will replace broken or missing glasses at least 2 times per year. The medical record revealed Resident #59 had been in the hospital on two occasions between (MONTH) (YEAR) and (MONTH) 2019. He was hospitalized from [DATE] through 10/12/18 and from 11/24/18 through 11/27/18. The medical record did not reveal any progress notes reflecting the SW's attempts to discuss the resident's request to have upper dentures with Resident #59 after the the discussion on 09/28/18 until 01/07/19.",2020-09-01
3100,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,800,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review and staff interview, the facility failed to provide Resident #15 with a diet that met her nutritional needs. This deficient practice was found during a random opportunity for discovery. Resident identifier: #15. Facility census: 60. Findings included: Record review conducted during the Long-Term Care Survey Process revealed that Resident #15's diet order stated, No Concentrated Sweets diet Regular texture, Regular consistency, No salt packet on tray. The order further directed to provide, Half portions of all menu items at lunch and dinner. The diet order had a start date of 10/03/16. Resident #15's most recent Dietitian Nutritionist Nutritional Assessment from 10/17/18 revealed that Resident #15 had a [DIAGNOSES REDACTED]. At that time, the facility's Registered Dietitian did not recommend any diet changes from the diet ordered on [DATE] in order to meet Resident #15's nutritional needs. On 01/09/19 at 11:59 AM, Resident #15 was observed eating lunch. With Resident #15's permission, her tray card was reviewed. The top of the tray card read, Regular, no added salt. On 01/09/19 at 2:24 PM, CDM #30 was asked why Resident #15's tray card stated that she had received a regular, no added salt diet when she was ordered a no concentrated sweets diet. CDM #30 stated said that she would need to add Resident #15's diet order to her tray card since the tray card did not match the physician's diet order so that Resident #15 could receive her ordered diet.",2020-09-01
3101,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,842,D,0,1,MQTT11,"Based on record review and staff interview, the facility failed to ensure one (1) of 23 resident records were completed accurately. The resident's nutrition profile and review did not reflect the resident's edentulous status. Resident #59. Facility census: 60. Findings included: a) Resident #59 On 01/07/19 at 2:07 PM Resident #79 said he would like to have new top dentures. He said before he came to the facility his brother had lost his (Resident #59's) dentures. He indicated he had told someone at the facility that he would like to have top dentures but was not sure of the time or when he had made them aware. Resident #79 said he did not have any of his natural teeth. A review of the Nutrition Profile and Review dated 09/13/18 section 11 oral/dental status had an option to select for edentulous and this was not marked for the resident. The Minimum Data Set (MDS) comprehensive assessments dated 01/18/18 (significant change) and 12/14/18 (annual) reflected under section L (oral/dental status) that the resident had no natural teeth or tooth fragments. On 01/10/19 at 10:49 AM at 10:40 AM during an interview with the dietary supervisor (DS) she said she would correct the assessment.",2020-09-01
3102,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,867,F,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observations, resident interview, review of diet manual, and policy review the facility failed to identify and correct quality deficiencies of which they should have been aware. Deficient practices were found in the areas of qualify of care, nutrition services, and comprehensive resident centered care plans as well as admission, transfer and discharge. These practices had the potential to affect more than an isolated number of residents. Facility census; 60. Findings included: a) Diet Manual During an interview on 01/09/19 at 9:40 AM, Certified Dietary Manager (CDM) #30 was asked to locate the facility's diet manual to clarify Resident #15's diet. CDM #30 provided a manual titled, 'Liberalized Diet Manual 2007' that was published by Computrition, Inc. Inside the diet manual was a signature page with spaces for signatures of an RD, a Medical Director, a Director of Nurses, an Administrator, and a Foodservice Director or Dietary Manager. The space for the RD signature blank, and the remaining signatures were all dated 2009. On 01/09/19 at 9:45 AM, CDM #30 was informed of the issue and asked if there was possibly another manual in the facility that was newer and approved by an RD. CDM #30 replied that 'Liberalized Diet Manual 2007' was the only manual she was aware of the facility having. On 01/09/19 at 9:54 AM, Nurse #26 was asked to locate the diet manual at the nursing station. After searching through shelves for a period of time, she stated, We do not have it. Nurse #26 was then asked what she would do if she had a question regarding a resident's diet. She replied that she would ask someone in the therapy department if they had a copy of the diet manual. On 01/09/19 at 10:22 AM, the facility's Administrator provided a file folder containing some loose papers describing dysphagia diets. She stated that these papers came from the facility's diet manual. The papers were published by the Academy of Nutrition and Dietetics (AND). At that time, the facility's Administrator was informed that the folder of information did not match the diet manual provided by CDM #30. On 01/09/19 at 11:43 AM, a phone interview was conducted with the facility's RD Nutrition Coordinator #76 for clarification regarding the diet manual. RD Nutrition Coordinator #76 stated that the facility was using the Nutrition Care Manual, which was published by the AND. On 01/09/19 at 1:32 PM, CDM #30 provided log-in information for the online Nutrition Care Manual, published by the AND. She said that she had received this log-in information from RD Nutrition Coordinator #76. CDM #30 further stated that she had been unaware of how to access the Nutrition Care Manual until this day. On 01/10/19 at 12:24 PM during an interview with the Director of Nursing Services (DNS), Clinical Care Supervisor (CCS) #11 and Administrator no further information was presented regarding the quality assessment and assurance committee's identification and attempt to correct the deficient practice related to the outdated diet manual. b) Admission/Transfer and Discharge A review of the medical records on 01/10/19 for R14, R36, R59 and R64 revealed they had been transferred to acute care hospitals. R14 had been hosptalized on [DATE] and 01/02/19. R36 was transferred to the hospital on [DATE]. R59 went to the hospital on [DATE] and 11/24/18. R64 was sent to the hospital on [DATE]. There was no evidence the Ombudsman had received any notices for these resident's hospitalization s. In an interview on 01/10/19 at 10:48 AM with E32, Social Services Director reported she had not sent any hospitalization notices to the Ombudsman for several months. On 01/10/19 at 12:24 PM during an interview with the DNS, CCS #11 and the administrator no further information was presented regarding the facilities identification and actions to correct the deficient practice regarding notification of the ombudsman for hospitalization s. c) Medication Administration Observations of medication administration by Licensed Practical Nurse (LPN #22), on 01/08/19 at 12:50 PM, revealed Resident #14 received the controlled substance [MEDICATION NAME] ([MEDICATION NAME]) 600 mg by mouth. LPN#22 removed medication from the blister pack at 12:45 PM and signed the book, she then gave the medication to the resident at 12:50 PM on 01/08/19, however she signed the 'Individual Resident's Controlled Substance Record' time as 1300 (01:00 PM the scheduled time). When asked LPN#22 said she signs the book (the book with the 'Individual Resident's Controlled Substance Record' sheets) for the time the medication is scheduled. LPN#22 said she has worked at the facility for sixteen (16) years and that is what she was always told to do, .write when it is scheduled not when it was given in the narcotic book. Interview with LPN#21, the nurse passing medication on the other hall, revealed LPN#21 has worked at the facility for thirteen (13) years and said most of the time she does the same thing, records the scheduled time. LPN #21 stated, As a nurse, I know you are supposed to sign out all medications when you give them. On 01/08/19 at 01:16 PM, an interview with DNS (Director of Nursing Services), revealed the DNS was not aware the nurses were documenting the scheduled time. The DNS said, Nurses should write the time it is given, not the time when it is scheduled. Review of Resident #14's current Medication Administration Record [REDACTED]. Review of Resident #14's 'Individual Resident's Controlled Substance Record' dated 12/29/18 through 01/08/19 shows some entries that suggest not all nurses are signing just the scheduled times, on five (5) different days a nurse recorded the time as 1400. On 01/08/19 at 04:55 PM an interview with the administrator and the DNS revealed the facility did not think there was an issue. The Administrator said, I know it is not a nursing standard to record a scheduled time instead of the actual time given, but the resident's actual record is electronically captured on the MAR, showing when the narcotic was given. The Administrator said the 'Individual Resident's Controlled Substance Record' kept in the narcotic books is not part of the resident's records. The Administrator gave this surveyor a copy of the MAR indicated [REDACTED]",2020-09-01
3103,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,880,D,0,1,MQTT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on three (3) random opportunities for discovery, the facility failed to ensure practices and processes designed to prevent infection and/or cross-contamination were implemented. Observations during Resident#58's venous stasis wound care revealed a breach in infection control protocols. Random observations revealed resident's urinary catheter drainage bags sitting directly on the floor. These practices had the potential to affect a limited number of residents. Resident identifiers: #58 and #59. Facility census: 60. Findings included: a) Resident #58's wound care Observations, on 01/08/19 at 02:15 PM of Registered Nurse (RN) #26 providing wound care to Resident #58's venous stasis wounds, revealed the nurse using wound cleanser and only one (1) gauze to clean and dry the left lower leg skin and open wound areas. RN#26 wiped the resident's lower left leg skin area above the open wounds, then using the same gauze wiped the first open area, then proceeded rubbing in a downward motion to rub the second open area, all with the same gauze. RN#26 did not pat the wounds dry, but briskly rubbed the wound areas using a downward motion. Rubbing instead of patting has the potential to disrupt healing tissue in the wound bed. The downward motion the nurse used is contraindicated in promoting venous blood return. An interview with RN#26, after provision of wound care, revealed RN#26 agreed using one (1) gauze and touching each open area and surrounding skin with the same gauze could cause cross contamination and was a breach in infection control principals. RN#26 also agreed the objectives for wound healing is to assist in ensuring adequate blood flow for the redevelopment of healthy tissue formation in the wound bed, and protecting the wound bed from any further tissue damage. RN #26 agreed Resident #58's venous ulcer wounds should be patted dry to ensure healthy tissue forming is left intact and not disrupted in the wound bed. RN #26 confirmed she did not follow infection control or wound care nursing principals. An interview with the DNS (Director of Nursing Services), on 01/08/19 at 02:42 PM, revealed the DNS agreed RN#26 should not have used the same gauze for all the open areas, or rubbed downward instead of patting dry the wounds. The DNS confirmed the wound care provided breached infection control and nursing care principals. Review of the resident's annual minimum data set (MDS) with an assessment reference date (ARD) 12/11/18, on 01/10/19 at 10:45 AM, revealed the resident's Brief Interview for Mental Status (BIMS) with a score of fifteen (15) indicating the resident is cognitively intact. The resident needs extensive assistance needed for most activities of daily living, but needs supervision with eating and locomotion, and is totally dependent for bathing and transfers. The resident has range of motion (ROM) impairment in her lower extremities on both sides. Resident has an indwelling Foley catheter and is always incontinent of bowel. Some pertinent [DIAGNOSES REDACTED]. b) Resident #58's Foley catheter drainage bag Observations, on 01/07/19 at 01:18 PM, revealed Resident#58 sitting in her wheel chair in the hallway outside of the dining room. Resident#58's Foley catheter drainage bag was attached and hanging under the center of the resident's wheel chair, with the edge of the drainage bag cover lying on the floor. There appeared to have a significant amount of drainage in the bag. The resident did not sit still in the wheel chair and as she moved the wheel chair around the drainage bag cover would hang up on the floor and cause the bag to also lie against the floor. Nurse Practitioner, NP#1, observing the Foley catheter drainage bag acknowledged the drainage bag cover was indeed against the floor and request registered nurse RN#25 to take the resident back to her room to empty the Foley catheter drainage bag. At 01:21 PM on 01/07/19, RN#25 was observed pushing Resident #58 out of her room in her wheel chair back toward the dining room, with the emptied Foley catheter drainage bag and its cover dragging the floor the entire way. This surveyor followed RN#25 and Resident #58, all the while hearing the soft scraping noise the drainage bag and its cover was making as it was being drug down the hallway. This surveyor asked RN#25 to look at the drainage bag and asked her if that is where the drainage bag belonged. RN#25 replied, That is as high as you can hang it. RN#25 agreed the drainage bag or its cover was not to touch floor, that by touching the floor it was an infection control issue. RN#25 then knelt and adjusted the bag under the wheel chair so it did not touch the floor. Current professional standards of practice for maintenance of Foley Catheters include, Do not let the drainage bag touch or lie on the floor. According to the CDC's (Centers for Disease Control and Prevention) Guideline for Prevention of Catheter-Associated Urinary Tract Infections, a directive listed under 'Proper Techniques for Urinary Catheter Maintenance' is Keep the collecting bag below the level of the bladder at all times. Do not rest the bag on the floor. According to Lippincott Nursing Center, an authority for the professional development of nurses providing evidence-based procedure guidance; the principles for managing an indwelling catheter include, The collecting bag should be positioned below the level of bladder at all times and never placed on the floor. c) Resident #59 During an observation at 11:30 AM on 01/07/19 Resident #59's urinary catheter drainage bag was observed sitting directly on the floor. Resident #59's bed was also observed in the lowest position. On 01/07/19 at 2:02 PM Resident #59's urinary catheter bag was again observed sitting directly on the floor. (Alice) Registered Nurse # looked at the urinary catheter drainage bag and agreed it did not need to be sitting on the floor. She said the resident's bed in the lowest position contributed to the bag sitting on the floor. She adjusted the bag to where it did not sit directly on the floor. A review of Resident #59's care plan revealed a focus area for impaired urinary elimination related to [MEDICAL CONDITIONS], urinary leakage, indwelling Foley catheter and history of urinary tract infections. The Center for Disease Control and Prevention's policy titled Guideline for Prevention of Catheter Associated Urinary Tract Infections reflected a guideline stating that catheter bags do not need to rest directly on the floor.",2020-09-01
3104,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2019-01-10,883,E,0,1,MQTT11,"Based on record review and staff interview, the facility failed to screen residents to ensure the influenza or pneumococcal vaccinations were not medically contraindicated prior to administering the vaccines. This was true for three (3) of five (5) residents reviewed. This practice had the potential to affect more than a limited number of residents. Resident Identifiers: #2, #9, and #38. Facility Census: 60 Findings included: a) Resident #2, #9, and #38 Review of Resident #2, #9, and #38 influenza vaccination consent forms and pneumococcal vaccination consent forms, on 01/09/19 at 12:09 PM, revealed the screening questions were not completed for all residents. Review of records provided no evidence that the residents were screened prior to receiving the vaccinations. According to the CDC's (Centers for Disease Control and Prevention) vaccine information statement for influenza and pneumococcal some people should not get the vaccine. The CDC recommends screening people by having them answer a few pertinent questions. The facility consent forms have the recommended screening questions, however there is no indication the questions were ever asked. The influenza and pneumococcal vaccination consent forms each have five (5) questions and an area to mark yes or no. Instructions on the influenza vaccination consent states Please answer these 5 questions about the person receiving the flu vaccine. The answers to these questions may disqualify the individual from receiving the vaccine today. Instructions on the pneumococcal vaccination consent states Please circle yes or no for each question. Review of Resident #2's influenza vaccination consent form, dated 10/13/18, none of the questions were answered and the resident did receive the vaccine. Review of Resident #2's pneumococcal vaccination consent forms, dated 01/30/18, revealed she was screened prior to receiving the vaccine. Review of Resident #9 influenza vaccination consent forms and pneumococcal vaccination consent forms revealed no screening for either vaccine, even though resident received both vaccines. Review of Resident #38's influenza vaccination consent form, dated 10/13/18, none of the questions were answered and the resident did receive the vaccine. Review of Resident #2's pneumococcal vaccination consent forms, dated 06/18/18, revealed she was screened prior to receiving the vaccine.",2020-09-01
3105,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,554,D,0,1,PXV011,"Based on observation, medical record review, facility policy and procedure review and staff interview, the facility failed to ensure all residents were evaluated for self-administration of medications prior to the medication being left at the bedside for one (1) resident during a random opportunity for discovery. Resident identifier: #8. Facility census: 62. Findings include: a) Resident #8 On 1/22/18, at 1:49 p.m. and 3:13 p.m., a box of artificial tears was observed laying on Resident #8's bedside table. A review of Resident #8s medical record on 1/23/18 at 11:15a.m., revealed no assessment permitting self-administration of a medication, or instructions to the resident for safe keeping of the medication. A review of the policy and procedure for Self-Administration of Medications, indicated the facility would evaluate the resident using a skill assessment prior to allowing a resident to self-administer medications and evaluate the safety of bedside storage before permitting them to be kept at the bedisde. An interview with the Director of Nursing Services, on 1/23/18, at 11:33 a.m., confirmed there had been no assessment for self-administration of medications prior to the medication being left at the bedside, nor provisions made for the safe keeping of the medication found at the bedside of Resident #8.",2020-09-01
3106,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,558,D,0,1,PXV011,"Based on observation, resident interview, staff interview, record review and facility policy review, the facility failed to provide services with reasonable accommodation of a resident. Resident #45's call light was out of reach and on the floor. This practice affected one (1) of sixty-two (62) residents initially observed during the Long Term Care Survey Process. Resident identifier: #45. Facility census: 62. Findings include: a) Resident #45 An observation of Resident #45, on 01/22/18 at 11:55 AM, revealed the Resident's call light was on the floor behind the bed out of reach of the resident. An interview with Resident #45, on 01/22/18 at 11:58 AM, revealed the Resident did not know where her call light was. An interview with Nurse Aide (NA) #53, on 01/22/18 at 12:00 PM, revealed Resident #45's call light should not be on the floor and should be within reach of the resident at all times. The NA stated the resident does use the call light. The NA placed the call light on the bed within reach of the resident. A review of Resident #45's Care Plan was conducted on 01/22/18 at 12:30 PM. The Care Plan dated 03/28/17 with a focus of Activities of Daily Living Self Care Performance Deficit included the intervention Encourage the resident to use the call bell for assistance and Ensure that call light is within easy reach for resident to be implemented by NAs and Licensed Practical Nurses. A review of the facility policy titled Answering the Call Light with a revision date of 05/01/06 was conducted on 01/23/18 at 2:00 PM. The policy stated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident.",2020-09-01
3107,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,583,D,0,1,PXV011,"Based on observation, staff interview and policy review, the facility failed to protect the personal privacy of a resident including medical and health information. A resident's medication box was left unattended on a medication cart in the hallway. Personal identifiers including the residents' name, medication, and other health information were viewable by any person in the hall. This was a random observation. Resident identifier: #30. Facility census: 62. Findings include: a) Resident #30 An observation during medication administration on 01/23/18 at 8:40 AM, on the 100 Hall, revealed Resident #30's medication box for eye drops was left on top of the medication cart in the hallway. The medication cart was unattended. The medication box for Resident #30 contained the following information: --Resident's name --Medication prescribed --Diagnosis --Physician's name Interview with Licensed Practical Nurse (LPN) #45, on 01/23/18 at 8:45 AM, revealed she should not have left the medication box on top of the medication cart unattended. Interview with the Director of Nursing (DON), on 01/23/18 at 2:00 PM, revealed she educated and counseled LPN #45 concerning the medication box being left unattended on the medication cart.",2020-09-01
3108,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,584,E,0,1,PXV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide maintenance services for four (4) of thirty (30) rooms observed during the Long Term Care Survey Process. The issues identified included paint missing from a wall and a ceiling, a scraped wall, and bathroom sinks with caulking missing. Room identifiers: #204, #205, #209, and #210. Facility census: 62. Findings include: a) Observations The following observations were made on 01/22/18: --room [ROOM NUMBER]-The bathroom sink had a rusted hole where caulking was missing around the base. --room [ROOM NUMBER]-The ceiling above bed-B had paint missing as well as several large paint chips hanging from the ceiling. --room [ROOM NUMBER]-The bathroom sink had a rusted hole where caulking was missing around the base. --room [ROOM NUMBER]-The bathroom ceiling had a crack in it. The wall behind bed-A was scraped in several places and missing paint. b) Interview An interview with the Maintenance Director, on 01/24/18 at 9:30 AM, revealed the issues found in the rooms would be corrected immediately.",2020-09-01
3109,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,607,E,0,1,PXV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of reportable abuse/neglect allegations, grievance and complaint files, staff interview and policy review, the facility failed to ensure they implemented their policy regarding identifying, investigating and reporting allegations of abuse. One (1) of 29 complaint/grievances had an allegation of abuse that was not identified, reported or thoroughly investigated. One (1) of three reportable allegations was also not thoroughly investigated. These practices had the potential to affect more than an isolated number of residents. Resident identifiers: #31 and #63. Facility census: 62. Findings include: a) Resident #31 On 01/23/18 a review of the grievance/complaint files revealed a grievance/complaint form dated 11/23/17. Resident #30 had filed the complaint to report Nurse Aide (NA) #60 had spoke to her roommate (Resident #31) in a rude, hateful manner and was rough with her. During a staff interview, with Social Worker (SW) #75 on 01/23/18 at 1:53 PM, SW #75 said the facility did not report this as an allegation of abuse. SW #75 said the facility did not feel what Resident #30 reported constituted abuse and also said the facility talked with Resident #31 and she denied any issues with NA #60. SW #75 said that was the rationale behind the facility's decision to not report. A review of statements obtained from NA #60, NA #12, and Resident #31 revealed the following: --NA #60, in her statement said, .I cleaned her (Resident #31) up while (NA #12) made up her bed . --NA #12, in her statement said, .I changed her bed. While (NA #60) was washing her (Resident #31) hollered once, but (NA #60) was washing her easy. --In her statement, Resident #31 stated when the girl was cleaning her up it felt like she was ripping her skin off. During the investigation which was unsubstantiated the facility did not clarify if NA #12 was present in the bathroom the entire time NA #60 was providing care (washing up) Resident #31. The facility policy titled, Freedom from Abuse, Neglect, and Exploitation, dated (11/29/17), stated the staff would be educated on what constituted abuse. The policy also stated the investigation conducted by the facility would be immediate and thorough. b) Resident #63 On 01/24/18 at 12:10 p.m. a reportable allegation regarding Resident #63 revealed on 10/22/17 Resident #63 made an allegation of abuse. Resident #63 alleged that a nurse aide threw his leg up on the bed and it was painful when she did this. A review of the investigation revealed the facility had not ensured a clinical examination of the resident occurred following this allegation. The facility policy stated that in conducting an investigation they would ensure a clinical examination for signs of injuries occurred. The policy also stated the investigation into allegations of abuse and neglect would be thorough. At 1:00 PM on 01/24/18, SW #75 was asked if the facility had completed a clinical assessed of the resident following this allegation. She pointed out a statement taken from Licensed Practical Nurse (LPN #15) . A review of LPN #15's statement did not show the LPN had assessed the resident for injuries. SW #75 said she would check to see if LPN #15 documented her assessment in a progress note. SW #75 provided a copy of a progress note dated 10/22/17 at 10:37 AM. The progress note was completed by LPN #15. The progress note was a follow up note to a skin tear that the resident sustained [REDACTED]. The note, dated 10/22/17 at 10:37 AM, stated the resident's skin was warm and dry with no new bruising or skin tears noted. The note did not indicate the LPN had followed up on the resident's concern over the NA throwing his leg on the bed which he described as being painful. The SW felt the progress note from LPN #15, on 10/22/17 at 10:37 AM, established that the LPN had assessed the resident for injuries. The SW was asked what time the resident made the allegation on 10/22/17. The SW did not know what time the resident had made this allegation. Therefore it could not be determined if this note was documented prior to or after the resident alleged the nurse aide threw his leg on the bed which caused him pain.",2020-09-01
3110,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,609,D,0,1,PXV011,"Based on a review of grievance/complaint files, policy review and staff interview the facility failed to ensure they reported an allegation of abuse. One (1) of 23 grievance/complaints reviewed contained an allegation of abuse that was not reported. Resident identifier: #31. Facility census: 62. Findings include: a) Resident #31 On 01/23/18, a review of the grievance/complaint files revealed a grievance/complaint form dated 11/23/17. Resident #30 had filed the complaint reporting Nurse Aide (NA) #60 had spoken to her roommate (Resident #31) in a rude, hateful manner and was rough with her. During an interview, with Social Worker (SW) #75 on 01/23/18 at 1:53 PM, SW #75 said the facility did not report this as an allegation of abuse. SW #75 said the facility did not feel what Resident #30 reported constituted abuse because the facility talked with Resident #31, and she denied any issues with NA #60. SW #75 said that was the rationale behind not reporting. On 01/24/18 at 9:00 AM, the administrator also confirmed the facility did not consider this a reportable issue because Resident #31 denied having experienced any of the issues reported by Resident #30. A review of the facility policy revealed the facility utilized a decision making tree for determining the reportability of an incident or allegation. The first block of the tree stated, Has an event happened involving a resident that is outside of the ordinary? The second block stated, Has an allegation of abuse, neglect, exploitation or misappropriation of resident property been reported to you or do you think one of these has occurred? Abuse was defined as, The willful infliction of injury, unreasonable confinement, intimidation, or punishment with resulting physical harm, pain or mental anguish . If an allegation of abuse, neglect or misappropriation of resident property was reported to the facility, then the decision tree instructed the facility to report this allegation.",2020-09-01
3111,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,610,D,0,1,PXV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a review of grievances/complaints, staff interview and policy review the facility failed to ensure they thoroughly investigated two (2) of three (3) reportable allegations. Resident identifiers: #31, #63. Facility census: 62. Findings include: a) Resident #31 On 01/23/18, a review of the grievance/complaint files revealed a grievance/complaint form dated 11/23/17. Resident # filed the complaint reporting Nurse Aide (NA) #60 had spoken to her roommate (Resident #31) in a rude, hateful manner and was rough with her. The facility gathered statements from Resident #30, Resident #31, as well as Nurse Aide (NA) #12 and NA #60. The statements taken from Resident #31, NA #12, NA #60 and Resident #30 needed clarified to determine if NA #12 was in the bathroom with NA #60 the entire time NA #60 was providing care to Resident #31. Resident #30, in her statement said NA #12 came in to check on Resident #32 after she heard Resident #31 yelling, Quit, Quit. Please stop, It hurts. Help me somebody. Resident #30 said NA #12 stood in the bathroom door for a while and then said to NA #60, Let me do that. NA #60, in her statement said, I cleaned her (Resident #31) up while (NA #12) made up her bed NA #12, in her statement said, I changed her bed. While (NA #60) was washing her (Resident #31) hollered once, but (NA #60) was washing her easy. In her statement, Resident #31 stated when the girl was cleaning her up it felt like she was ripping her skin off. During the investigation which was unsubstantiated the facility did not clarify if NA #12 was present in the bathroom the entire time NA #60 was providing care (washing up) Resident #31. b) Resident #63 On 01/24/18 at 12:10 p.m. a reportable allegation regarding Resident #63 revealed on 10/22/17 Resident #63 made an allegation of abuse. Resident #63 alleged that a nurse aide threw his leg up on the bed, and it was painful when she did this. A review of the investigation revealed the facility had not ensured a clinical examination of the resident occurred following this allegation. The facility policy stated that in conducting an investigation, they would ensure a clinical examination for signs of injuries occurred. The policy also stated the facility's investigation would be thorough. At 1:00 p.m. SW #75 was asked if the facility had completed a clinical assessed of the resident following this allegation. She pointed out a statement that was taken from Licensed Practical Nurse (LPN #15) . A review of LPN #15's statement did not show the LPN had assessed the resident for injuries. SW #75 said she would check to see if LPN #15 documented this in a progress note. SW #75 provided a progress note dated 10/22/17 at 10:37 a.m. The progress note was completed by LPN #15. The progress note was a follow up note to a skin tear that the resident sustained [REDACTED]. The note stated the resident's skin was warm and dry with no new bruising or skin tears noted. The note did not indicate the LPN had followed up on the resident's concern over the NA throwing his leg on the bed which he described as being painful. The SW felt the progress note from LPN #15, on 10/22/17 at 10:37 a.m., established that the LPN had assessed the resident for injuries. The SW was asked what time the resident made the allegation on 10/22/17. The SW did not know what time the resident had made this allegation. Therefore, it could not be determined if this note was documented prior to or after the resident alleged the nurse aide threw his leg on the bed which caused him pain.",2020-09-01
3112,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,659,D,0,1,PXV011,"Based on observation, resident interview, staff interview, record review and policy review, the facility failed to implement care plan interventions for a resident with potential skin issues as well as self-care performance deficits. Resident #45 did not have their heels floated or call light within reach as directed by their care plan. This practice affected one (1) of nineteen (19) residents observed and reviewed during the Long Term Care Survey Process. Resident identifier: #45. Facility census: #62. Findings include: a) Call light An observation of Resident #45, on 01/22/18 at 11:55 AM, revealed the Resident's call light was on the floor behind the bed out of reach of the resident. An interview with Resident #45, on 01/22/18 at 11:58 AM, revealed the Resident did not know where her call light was. An interview with Nurse Aide (NA) #53, on 01/22/18 at 12:00 PM, revealed Resident #45's call light should not be on the floor and should be within reach of the resident at all times. The NA stated the resident does use the call light. The NA immediately placed the call light on the bed within reach of the resident. A review of Resident #45's Care Plan was conducted on 01/22/18 at 12:30 PM. The Care Plan dated 03/28/17 with a focus of Activities of Daily Living Self Care Performance Deficit included the intervention Encourage the resident to use the call bell for assistance and Ensure that call light is within easy reach for resident to be implemented by NAs and Licensed Practical Nurses. A review of the facility policy titled Answering the Call Light with a revision date of 05/01/06 was conducted on 01/23/18 at 2:00 PM. The policy stated When the resident is in bed or confined to a chair be sure the call light is within easy reach of the resident. b) Floating Heels An observation, on 01/22/18 at 11:31 AM, revealed Resident #45's heels were not floated. The resident was laying in bed-under the covers. No staff was present in the room. An observation, on 01/22/18 at 12:58 PM, revealed Resident #45's heels were not floated. The resident was laying in bed. No staff was present in the room. An observation, on 01/23/18 at 1:34 PM, revealed Resident #45's heels were not floated. The resident was sitting up in bed reading. No staff was present in the room. An interview with Resident #45, on 01/23/18 at 1:35 PM, revealed the staff only floats her heels a few times a week. The Resident stated only certain ones float her heels. An interview, on 01/23/18 at 1:38 PM, with CNA #39 revealed the Resident's heels should always be floated while in bed. The CNA stated she forgot to float the heels but would ensure they were floated immediately. A review of Resident #45's Care Plan was conducted on 01/23/18 at 1:45 PM. The Care Plan dated 03/29/17 with the focus of Resident has a potential for pressure ulcer development included the intervention Float heels while in bed.",2020-09-01
3113,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,880,D,0,1,PXV011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review and staff interview the facility failed to ensure they maintained an infection prevention and control program to help prevent the development and transmission of communicable diseases and infection. The facility failed to provide hand hygiene to a dependent resident. Resident identifier: #11. Facility census: 62. Findings include: a) Resident #11 On 01/23/18 at 8:41 AM Resident #11 was asked if she had the opportunity to wash her hands before her breakfast meal. She said she had not been able to clean her hands before the meal. Resident #11 had a dignosis of [MEDICAL CONDITION], which affected her ability to transfer and ambulate safely around her room without assistance. At 12:30 PM at 01/23/18, Resident #11 was asked if she had hand hygiene performed before the lunch meal and again she said she had not. She said she had hand sanitizer and pointed to where it was sitting in the window seal of her room. She said she needed the type of hand sanitizer with a pump rather than the flip top lid due to her limitations and inability to open the flip top. On 01/23/18 at 12:35 PM, Nurse Aide #27 was asked what she did to prepare residents for a meal. She did not mention hand hygiene. She was asked if the resident had hand hygiene before her lunch meal. She said she did not know. The facility's infection control program policy (effective 11/28/17) stated, Hand hygiene is the primary mechanism for preventing the spread of infection. Residents and visitors will be encouraged to practice hand hygiene. At 12:45 PM on 01/23/18, the administrator was informed of Resident #11 not having the opportunity to clean her hands before breakfast and lunch.",2020-09-01
3114,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2018-01-24,921,E,0,1,PXV011,"Based on observation and staff interview, the facility failed to provide a safe environment for residents. A ladder was left unsecured in the hallway as well as a chemical substance and light bulbs. This practice had the potential to affect more than a limited number of residents. Facility census: 62. Findings include: a) Observations An observation, on 01/23/18 at 7:20 AM, revealed an unattended metal ladder extending from the floor into the attic space of the 200 Hall. The ladder was unattended for approximately fifteen (15) minutes. At the base of the ladder was an open box containing the following items: --One (1) container of Fire Barrier Sealant with the warning Keep out of reach of children-May irritate eyes, nose, and throat-If swallowed rinse mouth-If you feel unwell seek medical help. --Three (3) boxes of light bulbs. b) Interview An interview with the Administrator, on 01/23/18 at 7:45 AM, revealed the ladder should not be unattended in the hallway. The Administrator stated the fire sealant and light bulbs should have never been left just sitting in the hallway. The Administrator stated she would ensure someone supervised the ladder and supplies while they are in the hallway.",2020-09-01
3115,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2020-02-05,584,E,0,1,VYLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to clean and/or repair walls, floors, sinks and bathrooms in order to maintain a safe, clean, comfortable and homelike environment. This is true for four (4) of thirty (30) resident rooms, one (1) of two (2) shower rooms, and the resident lounge. This practice has the potential to affect more than a limited number of residents. Facility census: 58. Findings include: An initial tour of the facility on 02/03/20 revealed the following imperfections: --The community shower (room [ROOM NUMBER]), contained a ceiling vent over the shower area full of dust particles, a mold-like substance along the floor and wall joints in the shower and a cracked and porous threshold with chipped tiles along the shower edge. --room [ROOM NUMBER]'s bathroom wall paint was chipped and the floor tile cracked. --room [ROOM NUMBER]'s wall by the door was in disrepair, with multiple holes and areas of chipped paint. In addition, the bathroom wall contained a patch of missing paint. --room [ROOM NUMBER]'s wall was missing a large patch of paint and plaster on the lower left side of the sink. The countertop/vanity was cracked along the front edge of the sink. --room [ROOM NUMBER]'s plaster wall behind the bed was dented and scratched, and there was a large scratch across the closet door. --The floor in Faye's cafe (residents telephone room) contained multiple chips and cracks through out the room. Floor seems were separating and the veneer top was missing in many areas. A tour of the facility was conducted with Housekeeping Supervisor (HS) #17 and Corporate Consultant #111 on 02/04/20 at 3:00 PM. They agreed the above noted wall, floor, sink and shower imperfections need repaired or replaced. Consultant #111, reported the facility is in the process of repairing all walls in the resident's rooms starting on the 200 wing. HS #17 acknowledged the cafe floor needs replaced and added plans are to apply a waterproof vinyl flooring. HS #17 reported the supplies are not ordered or purchased and there is no written plan for the needed building repairs.",2020-09-01
3116,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2020-02-05,761,E,0,1,VYLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility failed to ensure medications and biologicals used in the facility were stored and labeled appropriately, and in accordance with facility policy. Multiple medications stored in the medication room refrigerators were unlabeled and undated. This practice had the potential to affect more than a limited number of residents. Facility census: 58. Findings included: A review of the facility's policy titled Medication Storage in the Facility. Effective date 04/01/19 revealed the following: --Certain medications or package types, such as IV solutions, multiple dose injectable vials, ophthalmic, [MEDICATION NAME] tablets, blood sugar testing solutions and strips, once opened, require both an opened date and an expiration date, which may be shorter than the manufacturer's expiration date to insure medication purity and potency. --When the original seal of the manufacturer's container or vial is initially broken, the nurse shall label the medication with the date opened and the new date of expiration. a) Medication Room Refrigerator An observation of the facility's Medication Room, on 02/05/20 at 8:00 AM, revealed One (1) refrigerator containing the following: -One (1) open container of [MEDICATION NAME] Suppositories not dated or labeled. -Two (2) open container Influenza Vaccine High Dose Prefilled Syringe not dated or labeled. An interview with the Director of Nursing #73, on 02/05/20 at 8:05 AM, revealed the medications should have been labeled with a name and an open date as soon as they were opened by the staff.",2020-09-01
3117,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2020-02-05,812,E,0,1,VYLD11,"Based on observation, staff interview and policy review, the facility failed to serve food in a sanitary manner in accordance with professional standards for food service safety. This failed practice had the potential to affect more than a limited number of residents. Facility census: 58 Findings included: a) Policy A review of the facility policy, titled: Nutritional Services, effective 12/1/2018, showed food service staff would wear a hairnet or appropriate hair covering at all times. b) Observation An observation, on 02/04/20 at 10:38 AM, revealed Dietary Services Assistant #38 and Dietary Services Assistant #96 did not have the front portion of their hair covered with a hairnet or appropriate hair covering. c) Interview An interview with the Food Service Supervisor, on 02/04/20 at 10:38 AM, verified Dietary Services Assistant #38 and Dietary Services Assistant #96 did not have the front portion of their hair contained properly while serving food on the tray line and their hair should have been covered.",2020-09-01
3118,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2020-02-05,842,D,0,1,VYLD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. The facility had a conflicting [DIAGNOSES REDACTED]. This practice affected one (1) of sixteen (16), residents reviewed during the Long-Term Care Survey Process (LTCSP). Resident identifier #11. Facility census: 58. Findings included: a) Resident #11 A medical record review, on 02/05/20, revealed two (2) different physician's orders [REDACTED]. One (1) physician order [REDACTED]. Resident #11's current care plan dated 11/22/19 and pharmacy reviews on 10/02/19 and 11/05/19 revealed, Resident #11's [MEDICATION NAME] orders was for use of the diagnosed condition of muscle spasms. In an interview on 02/05/20at 8:20 AM, the Director of Nursing Services (DON) was made aware of the physician's orders [REDACTED]. During a second interview on 02/05/20 at 08:56 AM, with the DON verified, the HS order for [MEDICATION NAME] with a [DIAGNOSES REDACTED]. She stated that there was no information on why the order noted a [DIAGNOSES REDACTED].",2020-09-01
4291,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2016-10-05,332,D,0,1,BTKF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation of the medication pass, record review, staff interview, and facility's policy, the facility failed to ensure it had a medication error rate less than five percent (5%). Oral Inhalers were administered without allowing any wait time in between administering the medications. In addition, a resident received her anti-hypertensive medication in which the medication should have been held. Medication errors were identified for two (2) of three (3) resident observed during the medication pass. The failed practice affected two (2) resident out of three (3) residents reviewed for a total of twenty-nine (29)opportunities for errors giving the facility a medication error rate of 6.89%. Resident identifiers #66, and #23. Facility census 61. @ Findings include: @ a) Resident #66 During observation of the medication pass, Unit charge nurse - licensed practical nurse (UCN-LPN) #32, administered Resident #66 her 9:00 a.m. medications in her room at 8:22 a.m. on 10/04/16. UCN-LPN #32, administered the resident her [MEDICATION NAME] disc 250/50 microgram (mcg/ dose) an anti-[MEDICAL CONDITION]-[MEDICATION NAME][MEDICATION NAME]. The resident inhaled orally twice, rinsed her mouth with water and spits out the water into a cup. The LPN stated to the resident, You were only to take in one inhalation. The LPN immediately handed the resident her Incruse Ellipta (an anti-[MEDICATION NAME]- [MEDICATION NAME][MEDICATION NAME] 62.5 MCG) for one (1) inhalation orally without allowing any wait time in between administering the two (2) inhalers. The UCN-LPN #32 on 10/04/16 at 8:25 a.m., was asked whether she waits any time in between administering two (2) inhalers. The UCN-LPN stated, I am not aware there is any wait time between given two (2) inhalers. I always give one (1) inhaler and then the other. @ A review of the facility's policy related to administering oral inhalation medication on 10/04/16 at 4:00 p.m., revealed when more than one (1) inhalant medication are ordered the medications must be separated by at least five (5) minutes. The policy directs to administer the steroid inhaler last. @ b) Resident #23 During observation of the medication pass on 10/04/16 at 8:09 a.m. revealed UCN-LPN #32 administered Resident #23 her 9:00 a.m. medication in her room. The resident is to receive the medication [MEDICATION NAME] ER (extended-release) 50 milligrams (mg) by mouth one (1) time a day related to unspecified essential hypertension. Observation found the LPN checked the resident's pulse rate with a pulse oximeter. The resident's pulse measured 56 on the pulse oximeter. The LPN then administered the [MEDICATION NAME] ER 50 mg orally to Resident #23. @ A review of Resident #23's physician orders [REDACTED]. The physician's orders [REDACTED]. @ Review of the MAR revealed UNC-LPN #32 administered the [MEDICATION NAME] ER, on 10/04/16, and the resident's pulse rate was 66 (inaccurately recorded on the MAR), and the resident received her 9:00 a.m. dose of [MEDICATION NAME] ER 50 mg dose. @ In an interview on 10/04/16 at 2:51 p.m. with LPN #32, she was asked whether the pulse rate on the MAR is accurate. The LPN looked at the MAR and stated, The resident's pulse rate was 56, and I inaccurately wrote in 66. The LPN was then asked whether she should have administered the medication [MEDICATION NAME] ER to Resident #23 this morning, and the LPN stated, No. @ UCN-LPN wrote a progress note on 10/04/16 at 3:40 p.m., notifying the physician that Resident #23's pulse rate was 56, and her medication was not held.",2020-02-01
5267,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2015-08-20,272,D,0,1,TGQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident assessment instrument (RAI) manual review, the facility failed to conduct an initial comprehensive, accurate assessment of each resident's functional capacity. A resident who was terminally ill was incorrectly assessed on the Minimum Data Set (MDS). This was true for one (1) of seventeen (17) Stage 2-sample residents. Resident identifier: #65. Facility census: 62 Findings include: a) Resident #65 A medical record review for Resident #65 on [DATE] at 10:05 a.m. revealed Resident #65 was admitted on [DATE] with diagnoses, including acute kidney failure and malignant neoplasm of the bronchus and lung. She expired [DATE]. Her [DATE] history and physical by the acute care facility from where she was admitted stated, She refuses [MEDICAL TREATMENT]. She does want hospices . try and get her where hopefully she can go back home with the help of hospice . The Preadmission Screening and Resident Review (PASRR) form completed [DATE] under Physician's Recommendation stated, Prognosis: deteriorating and Rehab Potential: Poor. A physician's visit progress note dated [DATE] stated . she has been sent to the nursing home to be kept comfortable with the understanding her prognosis is terminal . A physician's contact note dated [DATE] stated, .she is in end stage kidney failure, [MEDICAL CONDITION], and is dying. The admission MDS with an Assessment Reference Date (ARD) of [DATE] question (J1400) (Prognosis) asked, Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? The answer by the facility was No. During an interview with Registered Nurse Assessment Coordinator (RNAC) #45 on [DATE] at 2:00 p.m., she stated she did not code the resident as having a terminal [DIAGNOSES REDACTED]. Examination of the RAI manual revealed the following instructions when coding question (J1400): Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services.",2019-02-01
5268,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2015-08-20,278,D,0,1,TGQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review, and resident assessment inventory (RAI) manual review the facility failed to complete an assessment to accurately reflect three (3) of 17 residents' status. Resident #65 who was terminally ill was incorrectly assessed for Hospice services on the Minimum Data Set (MDS). Resident #74's significant weight loss was not properly identified in his assessment. Resident #43 had activities of daily living (ADLs) assessed at a lower level of independence than they actually were. Resident identifiers: #65, #74, and #43. Facility census: 62 Findings include: a) Resident #65 A medical record review for Resident #65 was conducted, [DATE] at 10:05 a.m. This resident was admitted on [DATE] with [DIAGNOSES REDACTED]. She expired [DATE]. Resident #65's [DATE] history and physical completed by the acute care facility from where she was admitted stated She refuses [MEDICAL TREATMENT]. She does want hospices .try and get her where hopefully she can go back home with the help of hospice The Preadmission Screening and Resident Review (PASRR) form completed [DATE] stated under Physician's Recommendation Prognosis: deteriorating and Rehab Potential: Poor. A physician's visit progress note dated [DATE] stated . she has been sent to the nursing home to be kept comfortable with the understanding her prognosis is terminal A physician's Contact Note dated [DATE] stated, .she is in end stage kidney failure, [MEDICAL CONDITION], and is dying. A Social Services Progress note dated [DATE] described a conversation between the social worker and Resident #65's responsible party. It stated SW (social worker) inquired as to whether she would like Hospice services and she stated she does not wish to have hospice for resident and stated resident would get the same care from the nursing staff here. During an interview with Social Worker #10, on [DATE] at 2:25 p.m., the social worker said the note was written about the possibility of Hospice services because the facility felt it was time in the resident's illness when she required palliative care. She said this decision comes either from the care plan team or the physician tells the nurse and then the nurse comes to her. Although there was no formal documentation regarding when to discuss hospice with the family, she said the process she described was the impetus to have a conversation with residents and families. The 14 day MDS with and Assessment Reference Date (ARD) of [DATE] question J1400. Prognosis asks Does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months? The answer by the facility was No. An interview with Registered Nurse Assessment Coordinator #45 was conducted on [DATE] at 2:00 p.m. She stated she did not code the resident as having a terminal [DIAGNOSES REDACTED]. Examination of the RAI manual reveals the following instructions when coding question J1400: Code 1, yes: if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. b) Resident #74 A review of the medical record for Resident #74 was performed on [DATE] at 9:15 a.m. Resident #74's weight on the Weights and Vitals Summary on [DATE] was reflected as 241 pounds using a full body lift. His weight on [DATE] was 223.6 pounds, again using a full body lift. This 18 pound weight loss was a significant weight loss or 7.4% weight loss in six (6) days. The 14 day Minimum Data Set (MDS) with an assessment reference date (ARD) of [DATE] indicated the resident's weight was 241 pounds. This incorrect weight assessment caused the MDS to reflect no weight loss. An interview was held on [DATE] at 11:20 a.m. with Dietary Supervisor #23 and she agreed the weight entered on the MDS was incorrect. She said she must have thought the weight of 241 pounds from [DATE] was still in the reference window for the 14 day MDS dated [DATE]. She said she could not find any information why she would have entered the weight 241 for the 14 day MDS unless it was just a mistake. According to the Resident Assessment Inventory (RAI) manual, for item K0200B (Weight), you should base weight on the most recent measure in the last 30 days. The weight recorded on [DATE] was more recent that the weight recorded on [DATE]. c) Resident #43 The medical record for Resident #43 was reviewed on [DATE] at 8:30 a.m. A Medicare required minimum data set (MDS) assessment completed after return from a hospitalization , with assessment reference date (ARD) of [DATE], coded the resident as requiring extensive assistance for transfers, limited assistance with dressing, and limited assistance with eating. In comparison, a significant change MDS with ARD [DATE], coded the resident as total dependence with transfers, extensive assistance with dressing, and extensive assistance with eating. The quarterly MDS, with ARD [DATE], also coded the resident as total dependence with transfers, extensive assistance with dressing, and extensive assistance with eating. During interview with MDS assessment coordinator, Registered Nurse #45, on [DATE] at 10:15 a.m., she said the resident was on skilled care and had improved. This change in condition prompted her to complete a significant change MDS, with ARD [DATE]. He improved in cognition, mood, bowel continence, and weight. He was still totally dependent with transfers, required extensive assistance with eating, and extensive assistance with dressing. She said she completed another MDS, with ARD of [DATE], after the resident returned from a hospitalization . She said this MDS was coded incorrectly in the areas of transfer (extensive assistance rather than total dependence), dressing (limited assistance rather than extensive assistance), and eating (limited assistance rather than extensive assistance). She showed the seven (7) day look back period information that proved her point. Registered Nurse #45 said she would complete a MDS modified correction right away for the [DATE] MDS in the areas of transfer, dressing, and eating. This information was shared with the Director of Nursing on [DATE] at noon with no further information received.",2019-02-01
5269,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2015-08-20,309,E,0,1,TGQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. Nursing staff did not follow physician's orders [REDACTED]. The facility did not follow physician's orders [REDACTED]. A physician ordered a laboratory blood test for Resident #50, which was not done. A physician ordered a hemoccult stool test for Resident #29, which was not done in a timely manner. Resident identifiers: #9, #42, #50, #29. Facility census: 62. Findings include: a) Resident #9 During observation of a medication administration, on 08/18/15 at 8:17 a.m., Licensed Practical Nurse #58 administered an anti-hypertensive medication, [MEDICATION NAME] twenty-five (25) milligrams to Resident #9. She did not check the resident's pulse rate prior to giving the medication. Review of the medical record found a physician's orders [REDACTED]. The order directed to check the pulse rate prior to administering the medication, and hold the medication if the pulse is less than sixty (60) beats per minute, and notify the physician if held for three (3) consecutive days. Review of the Medication Administration Record [REDACTED]. Review of the pulse recordings on the computerized graphic sheet found the pulse rate was 88 on 07/30/15, 62 on 08/02/15, 69 on 08/09/15, and 62 on 08/16/15. b) Resident #42 During observation of a medication administration on 08/18/15 at 8:30 a.m., Licensed Practical Nurse #33 gave a corticosteroid inhaler to Resident #42. After the resident inhaled two (2) puffs of the inhaler as the physician had ordered, the nurse returned the hand-held inhaler to the medication cart. She did not offer, or educate, the resident to rinse his mouth with water and spit after the inhalations. Failure to rinse the oral cavity after using an inhaled corticosteroid can potentially lead to candidiasis of the oral cavity. Review of the medical record found a physician's orders [REDACTED]. It also directed to rinse the mouth with water and spit after each use. Review of the Medication Administration Record [REDACTED]. The nurse initialed that she had done so. An interview was completed with the director of nursing (DON) on 08/19/15 at 5:00 p.m. She said she would expect a nurse to encourage a resident to rinse his/her mouth after using an inhaled steroid. She said that nursing staff corrected the Medication Administration Record [REDACTED]. c) Resident #50 On 08/18/15 at 2:09 a.m., a medical record review revealed Resident #50 was admitted on [DATE]. Medical [DIAGNOSES REDACTED]. On 08/18/15 at 2:09 p.m., a medical record review revealed Resident #50 was admitted on [DATE]. [DIAGNOSES REDACTED]. A review of the consulting pharmacist report, dated 03/25/15, on 08/19/15 at 10:35 a.m., revealed a recommendation for a free [MEDICATION NAME] acid level now and every six months. The physician approved this order on 03/26/15. The continued medical record review found no evidence of a free [MEDICATION NAME] acid result. A request was made to the director of nursing (DON) to assist in finding the results of the free [MEDICATION NAME] acid results. The DON stated, at 11:00 a.m. on 08/19/15, the free [MEDICATION NAME] level had not been done as ordered by the physician. In addition, the DON stated she had called the physician for a clarification order and the physician had canceled the order for the free [MEDICATION NAME] acid as this medication was being prescribed for behaviors and not [MEDICAL CONDITION] control. d) Resident #29 On 08/19/15 at 1:50 p.m., review of Resident #29's medical record revealed a physician order [REDACTED]. At 2:20 p.m., on 08/19/15, a request was made to the facility staff to obtain copies of the hemoccult test (method for detecting fecal occult blood) results related to the physician order [REDACTED]. At 3:00 p.m., on 08/19/15, Registered Nurse #32 presented copy of a nursing note by, Licensed Practical Nurse (LPN) # 26 in which one hemoccult test was competed on 08/19/15 at 2:16 p.m., with negative results. At 3:50 p.m., on 8/19/15 p.m., a copy of Resident #29's bowel movements for the month of (MONTH) (YEAR) was obtained. The bowel movement record revealed the facility had nineteen (19) opportunities to obtain hemoccult tests following the date of the physician's orders [REDACTED].>",2019-02-01
5270,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2015-08-20,441,E,0,1,TGQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, medical record review and staff interview, the facility failed to maintain an infection control program designed to provide a sanitary environment to help prevent the development and transmission of disease and infection. A random observation in room [ROOM NUMBER], during the initial tour, revealed clean washcloths placed in a communal sink. In addition the medication for one (1) of six (6) residents observed during the medication pass was observed contaminated before being given to the resident. Two (2) medications were dropped on the medication cart during medication observation. They were, picked up with the nurse's bare hands and given to Resident #42. Room identifier: room [ROOM NUMBER]. Resident identifier: #42. Facility census: 62 Findings include: a) room [ROOM NUMBER] On 08/17/15 1:05 p.m., clean washcloths were observed stored in a communal sink in room [ROOM NUMBER]. Nursing Assistant (NA) #48 was interviewed and stated the washcloths should not be stored in the sink. She immediately removed the washcloths. b) Resident #42 During a medication administration observation, on 08/18/15 at 8:30 a.m., Licensed Practical Nurse (LPN) #33 poured oral medications into a plastic medication cup for Resident #42. When she attempted to place a large capsule into the medication cup, the cup flipped over. Two (2) small yellow tablets that were already in the cup came to rest on top of the medication cart. LPN #33 picked up those two small tablets with her bare hands and placed them back into the plastic medicine cup. LPN #33 failed to maintain the aseptic integrity of the oral medications. LPN #33 then administered the oral medications to Resident #42. During an interview with the Director of Nursing (DON), on 08/19/15 at 5:00 p.m., she said they did not have a policy that stated a nurse may not touch the patients' medications directly, or to prohibit nursing staff from administering oral medications after they have been in contact with an inanimate object such as the top of the medication cart. The director of nursing said would expect a nurse not to perform either of those practices even though the facility did not have a specific policy stating such.",2019-02-01
5271,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2015-08-20,502,D,0,1,TGQD11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to obtain laboratory services to meet the needs of the one (1) of five (5) residents reviewed for unnecessary medications. Resident #50 had a physician's orders [REDACTED]. The facility failed to have the laboratory test completed. Resident identifier: #50. Facility census: 62. a) Resident #50 On 08/18/15 at 2:09 p.m., the medical record review revealed Resident #50 was admitted on [DATE]. [DIAGNOSES REDACTED]. On 08/19/15 at 10:35 a.m. a review of the consulting pharmacist report, dated 03/25/15, revealed a recommendation for a free [MEDICATION NAME] acid level (test to measure the amount of [MEDICATION NAME] acid in the blood) now and every six (6)months. The physician approved this order on 03/26/15. The continued medical record review found no evidence of a free [MEDICATION NAME] acid result. A request was made to the director of nursing (DON) to assist in finding the results of the free [MEDICATION NAME] acid results. The DON stated, at 11:00 a.m. on 08/19/15, the free [MEDICATION NAME] level was not obtained, as ordered by the physician and recommended by the consulting pharmacist. In addition, the DON stated she had called the physician for a clarification order, and the physician had canceled the order for the free [MEDICATION NAME] acid as this medication was being prescribed for behaviors and not [MEDICAL CONDITION] control.",2019-02-01
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
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
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
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
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
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
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
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
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
6360,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,226,E,0,1,OMIN11,"Based on record review, policy review, and staff interview, the facility failed to implement their written abuse/neglect/misappropriation of resident property policies 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. Facility staff also observed abuse of Residents #59 and #62, but did not immediately report the abuse to their supervisor. Policies and procedures related to these situations were contained in the facility's policy titled, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident/Reporting and Investigation. Resident identifiers: #3, #67, #33, #63, #59, and #52. Facility Census: 61. Findings Include: a) Policy Review Review of the facility's policy titled, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident/Reporting and Investigation was reviewed at 9:30 a.m. on 05/26/14. The effective date of the policy was 09/09/11. The review revealed the following policy and procedures for reporting and investigating allegations of abuse and/or neglect: Anyone who witnesses any incident of suspected abuse, neglect, involuntary seclusion, or misappropriation of resident property is to immediately safeguard the resident from further abuse. The person who witnesses the alleged abuse is to then immediately report it to his/her immediate supervisor. . The supervisor who has been notified shall Report the alleged abuse to the Executive Director or Social Services Supervisor designee immediately. . All state specific requirements for reporting any allegation of abuse or neglect shall be followed (see specific requirements under investigation). The facility's policy for investigation included: Upon receiving information regarding an allegation of abuse or neglect the Executive Director or designee shall: . (1) Immediately refer to the Step one: Decision Tree for Determining the Reportability of an Incident or an Allegation . Step two: Internal and External Notification of a Reportable Incident or Allegation (see Steps 1 and 2, pages 13-14 of this policy) to assure notification if the event is reportable and initiate an investigation. . (2) Report the allegations to the appropriate state agencies within the required time frames (see Tables 3 and 4, pages 15-16 of this policy). . 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. The investigation should include but not be limited to the following: Determine if the alleged abuse or neglect occurred and to what extent, clinical examination for signs of injuries, if indicated, a review of (company's name) policies that are related to the incident, causative factors, trends, determine the root cause of the incident, identify interventions to prevent further injury, and identify and implement system issues that can prevent further incidents. (5) The investigation will be completed on the state required forms. For allegations against a Certified Nurse Aide the facility will complete the Nurse Aide Registry- Immediate Fax Reporting of the Allegations - NAR-1 (Rev1/09) and the Nurse Aide Registry - Five Day Follow-Up Report - NAR-2 (Rev01/09). (6) For any other reportable incidents, the facility will use the Immediate Fax Reporting of Allegations- Nursing Home Program - OHFLAC 225 (REV 07/05), Five Day Follow Up - Nursing Home Program - OHFLAC 225A (REV 07/05). (7) Completion of Appropriate state approved reporting forms also includes the appropriate Adult Protective Services form, which is to be completed and sent to the local WVDHHR office attention Adult Protective Services. (8) Other investigative activities may include but are not limited to the following: An interview with the person(s) reporting the incident, documented by the interviewer on the appropriate witness statement form, and signed by the person reporting the incident. According to facility policy, the interviews of witnesses to the incident were to be obtained and documented on a witness statement form, and signed by the witness. A private interview was to be conducted with the the resident, if the resident was able to be interviewed. In addition, a review of the medical record or other documents relevant to the investigation should be completed. The investigation was also to include interviews with staff members who may have had contact with the resident during the time of the alleged incident. Other residents who may have had contact with the staff member during the time of the alleged incident and/or assessment of the resident's physical, psychosocial and mental status should also be interviewed. These policies and procedures were not operationalized regarding allegations of abuse and/or neglect for the following allegations: 1. 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 #25 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. 2. 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. 3. 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. 4. 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 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. 5. 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, SSS, 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. 6. 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 (five) 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
6361,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,244,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interviews, and staff interviews, the facility failed to act upon grievances voiced by the resident council in areas related to resident rights and resident activities. Resident #24 had voiced concerns related to activities and resident privacy in resident council meetings. She felt the facility had not acted upon those concerns. This had the potential to affect more than an isolated number of residents residing in the facility. Resident Identifiers: #56, #48, #76, #41, #13, #9, #4, #10, #24, #15, #46, and #35. Facility Census: 61. Findings Include: a) Resident Council Meeting Minutes Review Review of the resident council meeting minutes for the previous 12 months on 05/30/14 at 9:00 a.m., revealed Resident #24 had raised concerns in regards to trips to the Senior Center on 05/02/13 and 12/05/13. The meeting minutes for 06/06/13 noted the activities director was trying to get a trip to the Senior Center set up for the next week. Further investigation found this trip never occurred. The meeting minutes for 05/02/13 also noted resident complaints related to other residents coming into their rooms. Additionally, a grievance/concern form was initiated on 02/26/14 as a result of the resident council meeting that indicated residents of the facility were concerned about other residents roaming into their rooms, during the day. b) Resident #24 1. Activity Concern Resident #24 was interviewed at 10:30 a.m. on 05/28/14, as part of the Resident Council President interview. During this interview Resident #24 stated some of the residents here at the facility would like to go fishing and the facility had only taken them one (1) time, and that was a long time ago. Resident #24 also stated the residents would like to go on outings to the Senior Center, but the facility had not taken them for quite some time. She stated she understood that in the winter it would be hard to get out and go, but there had not been any mention of these trips since the weather had been nice. She stated she could not recall when they last went to the Senior Center, but it was a lot of fun and she and other residents really enjoyed the visits. Resident #24 was identified by Employee #63, Activities Supervisor, during an interview as a resident who would likely enjoy taking trips out of the facility such as a trip to the Senior Center. Review of Resident #24's medical record at 12:30 p.m. on 05/30/14, found the most recent activity assessment was dated 02/26/07. This assessment identified Resident #24 liked to go on trips, shopping, and being outdoors. In the previous twelve (12) months, the only trip out of the facility for this resident was for one (1) shopping trip. 2. Privacy Concern Also during this interview, Resident #24 was asked, Are resident's able to exercise their rights? Resident #24 responded with, That's a hard one I would say no. Resident indicated she paid the facility $6,000 a month for her private room and she did not have any privacy in her room. She stated, last week there were two separate occasions when she had come into her room and found others residents of the facility in her bathroom. She stated they had tried multiple interventions, but they did not work. She stated staff were supposed to keep her door closed, but it was often left open by the staff, or she might not get it closed because it was difficult to shut sometimes. She stated she felt that she was not able to exercise her right to privacy with others coming in and out of her room when she was not in there. Review of the facility's grievance and complaint files found a Grievance/Complaint Report dated 02/24/14 completed for Resident #24. The resident had told Employee #61, the Social Service Supervisor (SSS) that housekeeping had told her dentures were on the floor of her room when housekeeping went in to mop the floor. Resident #24 also told Employee #61 that her bed had been getting messed up. Under the section Documentation of Facility Follow-up was, SW (social worker) suggested putting safest knob back on door, make sure door is closed. (Resident's name) said they have tried those things as well as a stop sign on the door. Written under the section titled, Resolution of Grievance/Complaint, was, Staff will continue to monitor situation, staff will redirect any resident seen entering (Resident's name) room. Another grievance/complaint form, completed on 02/26/14 as a result of the resident council meeting on that date, also named Resident #24 as the complainant. The concern was, Other residents coming into rooms, mostly during the day. Documented in the section titled Resolution of Grievance/Complaint was, Staff to monitor Resident who roams into others rooms and redirect. Employee #61 had signed both forms as the person completing the forms. In an interview at 12:43 p.m. on 05/30/14 Employee #61, SSS, 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. She stated that keeping the door closed was suggested and should be done. Employee #61 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. She stated 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 residents door closed to the care plan and fix it so the aides could see it on the kiosk and she would follow-up more closely with the resident in the future to ensure her concern was resolved. Multiple observations of the door to Resident #24's room throughout the course of the Quality Indicator Survey were found the door was left open when the resident was not in her room on multiple occasions. c) Interview with Activity Supervisor At 2:00 p.m. on 05/28/14, Employee #63, Activity Supervisor was asked what kind of out of facility activities the facility provided, she stated, We go to the Senior Center, fishing, we took a boat trip last year, and we go shopping. She indicated these were the things the residents had asked to participate in. She commented it had been a while since she had scheduled these trips as they had a van broken down, but she thought it was up and running now. She said it had been a while since she had scheduled these trips because they have to have a van to schedule these activities during the winter months. She stated she was working on getting them scheduled, but it would likely take another month or two to get them scheduled. She said there were only about three (3) residents who enjoyed fishing and named Residents #56, #41, and #13. She identified Residents #56, #48, #76, #13, #9, #4, #10, #24, #15, #46, and #35 as residents who would possibly be interested in going to the Senior Center. She stated they usually went on Thursdays and had lunch. The center usually had music on that day. She stated she would like to take them to the Senior Center at least twice a month. In another interview with Employee #63, Activity Supervisor at 8:30 a.m. on 05/29/14, when asked for a list of all out of facility activities provided in the previous 12 months, she said the residents took a boat trip on 08/28/13. Of the 12 residents identified as liking outings, only three (3), Residents #35, #13 and #56 were able to go on the boat trip. Resident #24 was able to go on a shopping trip. No other out of facility activities were provided to Residents #56, #48, #76, #41, #13, #9, #4, #10, #24, #15, #46, or #35. Employee #63 said they had not been fishing in the previous two (2) years, and had not been to the Senior Center in the previous 12 months. When asked why these activities were not provided, she stated she was waiting on permission for Employee #70, Executive Director to take the residents fishing. She stated I have already bought the poles, I am just waiting on his approval. She commented she had not asked him about the Senior Center yet, but he would have to give permission for them to take this trip. She was asked how many transport vans the facility owned. She replied, We have two (2) vans, but sometimes one of them is broke down. She indicated she and one of the maintenance men were able to drive the vans. At that time, Employee #63 was asked to provide the most recent activity assessments for Residents #56, #24, #48 , #76, #41, #13, #9, #4, #10, #15, #46, and #35. She stated she would have to go and get some of them from the paper files because prior to October 2013, when they became computerized, they did not do an annual activity assessment. She stated some of them would likely not have been completed since their admission to the facility. Employee #63 was also asked to provide the activity calendars for the previous 12 months. Review of the calendars found they did not contain any trips out of the facility. Employee #63 stated she did not include them on the calendar because they could be canceled so often due to inclement weather or other circumstances out of her control. She again confirmed the only out of facility trips were for the boat trip and for one shopping trip for Resident #24 in the previous 12 months. d) Interview with Employee #70, Executive Director In an interview with Employee #70, the executive director, at 8:10 a.m. on 05/29/14, when asked if he had to give permission for out of facility activities, he stated all the activity director had to do was ask and he would approve it. He stated that it was difficult to set up a fishing trip because of the dam and the water being to high, and sometimes it was hard to get the residents down the ramp at the fishing site. He also stated that in the summer time, heat could be an issue to consider. He said the residents would go to the Senior Center occasionally, but not every month because it was hard to coordinate with the van and having someone available to drive the van. He stated occasionally one of the vans would breakdown, then medical appointments would take priority over activities. He was asked if both vans were currently operational and he said they were. He stated it was just hard to coordinate it with the medical appointments they have. When asked if both vans were tied up with medical appointments all day every day he replied, No. When asked if he felt out of the facility activities were important for the residents, he commented he felt out of the facility activities were important to maintain the residents' quality of life. He also stated he had asked the activity director to schedule the fishing activities for June, July, or August. e) Resident #56 Resident #56 was identified by Employee #63, Activities Supervisor as a resident who would likely enjoy taking trips out of the facility, such as trips to the Senior Center, and who would enjoy going fishing. Review of the resident's medical record, at 12:35 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. The assessment indicated Resident #56 liked to be outside and loved to socialize with his friends. In an interview at 1:30 p.m. on 05/30/14, when asked what kind of activities he liked to do in the summer time, he replied he liked to go fishing. When asked if the facility had ever taken him fishing he replied, No. He stated they had not taken the residents out anywhere for a long time. When asked if he liked going to the Senior Center, he stated, I really like the Senior Center. He stated he really liked to go out of the facility and do things. Resident #56 did go on the boat trip in August 2013, but had not been on any other outings in the previous 12 months. f) Resident #48 Resident #48 was identified by Employee #63, Activities Supervisor as a resident who would likely enjoy taking trips out of the facility such as a trip to the Senior Center. Review of the resident's medical record at 12:40 p.m. on 05/30/14, revealed the resident was admitted [DATE]. An activity assessment, dated 01/29/14, identified she had a past interest in trips/shopping, and a present interest in being outdoors. In an interview at 2:15 p.m. on 05/30/14, Resident #48 was asked if she liked to take trips. She stated she did like to take trips. When asked if prior to her admission to the facility, she ever went to the Senior Center located in town, she replied, I would go there a lot. I have friends that go there. It was a lot of fun. She was asked if the facility had talked to her about taking trips to the Senior Center. She stated, They have never mentioned it. I did not think I was going to be able to do that now since I was here. She stated, If they do take you there, I would like to go with them. Resident #48 had not been on any out of the facility activities since her admission to the facility on [DATE]. g) Resident #76 Resident #76 was also identified by Employee #63 as a resident who would likely enjoy taking trips out of the facility such as a trip to the Senior Center. Review of the resident's medical record at 12:45 p.m. on 05/30/14, revealed the resident was admitted to the facility on [DATE]. The activity assessment, dated 05/13/14, identified the resident had a present interest in trips/shopping and being outdoors. In an interview at 2:00 p.m. on 05/30/14, when asked whether taking trips out of the facility was something she would like to do, she replied, I like to take small trips. She added, I would not want to take no long trip anywhere. She stated she liked to socialize with people, so it would be good to get out and meet some new people. When asked if the facility had ever mentioned any trips they take to her, she replied, They have not yet, but maybe they will if they do that sort of thing here. h) Resident #41 Resident #41 was identified by the Activities Supervisor as a resident who would likely enjoy going fishing. According to the activity assessment dated [DATE], reviewed at 2:30 p.m. on 05/30/14, the resident had a past interest in trips/shopping and a current interest in being outdoors. Resident #41 had not been on any out of facility activities in the previous 12 months. i) Resident #13 Resident #13 was also identified as a resident who would likely enjoy taking trips out of the facility, such as a trip to the Senior Center, and identified as a resident who would enjoy going fishing. Review of the resident's medical record, reviewed at 2:25 p.m. on 05/30/14, found an activity assessment dated [DATE]. This assessment indicated Resident #13 had a past interest in trips/shopping and a current interest in being outdoors. Resident #13 was able to participate in the boating activity on 08/2013, but had not been on any other out of the facility activities in the previous 12 months. j) Resident #9 Employee #63, also identified this resident would likely enjoy taking trips out of the facility, such as a trip to the Senior Center. Medical record review at 3:00 p.m. on 05/30/14, found an activity assessment dated [DATE], noting the resident had a past interest in trips/shopping, and a current interest in being outdoors. Resident #9 had not been on any out of the facility activities since her admission 12/13/13. k) Resident #4 Employee #63 identified this resident as one who would likely enjoy taking trips out of the facility, such as a trip to the Senior Center. At 3:10 p.m. on 05/30/14, review of the resident's activity assessment, dated 11/28/13, found the resident had a current interest in being outdoors. Resident #4 had not been on any out of the facility activities in the previous 12 months. l) Resident #10 Employee #63 also identified this resident as likely to enjoy taking trips out of the facility. Review of the resident's record, at 3:05 p.m. on 05/30/14, found the resident had a present interest in trips/shopping and being outdoors according to the activity assessment dated [DATE]. Resident #10 had not been on any out of the facility activities in the previous 12 months. m) Resident #15 Review of the resident's medical record, at 3:10 p.m. on 05/30/14, who was also identified as one who would likely enjoy trips out of the facility, found an activity assessment dated [DATE]. The assessment identified the resident had a current interest in being outdoors. Resident #15 has not been on any out of the facility activities in the previous 12 months. n) Resident #46 This resident, identified by Employee #63 as a resident who would likely enjoy taking trips out of the facility, was found to have an activity assessment dated [DATE] during a medical record review at 3:30 p.m. on 05/30/14. The assessment identified Resident #46 had a past interest in trips/shopping and being outdoors. At 3:05 p.m. on 05/29/14, during an interview, when asked if she liked to take trips or go places out of the facility, she stated she would like to get out of the facility sometimes. The resident said when she lived at home she liked to go to the library, but they had not taken her to the library since she had been at the facility. Resident #46 has not been on any out of the facility activities in the previous 12 months. o) Resident #35 At 3:45 p.m. on 05/30/14, medical record review of this resident identified by Employee #63 as a resident who would likely enjoy taking trips out of the facility found an activity assessment dated [DATE]. This assessment identified Resident #35 had a current interest in trips/shopping and being outdoors. During an interview at 1:25 p.m. on 05/30/14, when asked if she liked to take trips and be outside, she replied I like to get outside for some fresh air. She said she liked to go places as long as they were not too far. Resident #35 was able to go on the boat trip in 08/2013, but had not been on any other outings in the previous 12 months.",2018-04-01
6362,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,248,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and resident interview, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessments and/or voiced interests for twelve (12) of thirteen (13) residents reviewed for activities during Stage 2 of the survey. The residents were not provided activities for which they were assessed and/or expressed interest. Resident #3 expressed a desire to attend Sunday school at the facility each Sunday, but was not afforded the opportunity to do so. Residents #56, #48, #41, #13, #9, #4, #10, #24, #15, #46, and #35 expressed interest in attending activities outside the facility; however, the facility had not provided out of the facility activities on an on-going basis. The comprehensive minimum data set (MDS) assessments for each of these residents indicated these residents' activity preferences for religious activities and/or for out of the facility activities. Resident identifiers: #3, #56, #48, #41, #13, #9, #4, #10, #24, #15, #46, and #35. Facility Census: 61 Findings Include: a) Resident #3 Resident #3 was interviewed on 05/21/14 at 4:15 p.m. This interview revealed Resident #3 liked to attend Sunday School on Sunday mornings in the facility dining room. She stated she loved to go to Sunday School, but only got to go about one (1) time a month. The resident stated staff often set her up to get her bath, but did not come back to help her get dressed so she could get to the dining room by 9:30 a.m. She stated, They know I like to go, but they just don't help me. Employee #70, the Executive Director, was interviewed at 8:00 a.m. on 05/21/14. He stated they had an employee in housekeeping who held Sunday School every Sunday in the dining room. Employee #29, a housekeeper, was interviewed at 8:17 a.m. on 05/22/14. He stated he had been holding Sunday school at this facility for the past [AGE] years. He stated the services started at 9:30 a.m. and lasted until 10:45 a.m. Employee #29 stated Resident #3 attended the services and seemed to enjoy them. When asked how often Resident #3 attended, he stated she was there about 33 percent of the time. Employee #29 said Resident #3 seemed like a real religious person and really enjoyed the services. On 05/22/14 at 4:29 p.m., the Point of Care (P(NAME)) documentation for Resident #3 was reviewed for the previous six (6) months. The P(NAME) documentation indicated Resident #3 attended the religious activity on Sunday only 16 of 29 opportunities to attend the services during the previous six (6) months. The facility's activity calendar for the previous six (6) months was reviewed. This review revealed Sunday School was scheduled at 9:30 a.m. every Sunday for the previous six (6) months. Employee #63, the Activity Supervisor, was interviewed at 2:00 p.m. on 05/28/14. When asked if Resident #3 liked religious activities, she stated Resident #3 liked to attend religious activities. Employee #63 stated she did not know exactly why Resident #3 did not go to Sunday School each on Sunday. She stated it might be because the resident got caught up doing things like mending dresses or looking at her magazines. Employee #63 said it could also be because Resident #3 was not dressed and ready to go, as she liked to have her hair a certain way and other things a certain way before she went out. b) Resident #24 Resident #24 was interviewed at 10:30 a.m. on 05/28/14. During the interview, the resident stated some of the residents at the facility would like to go fishing, but the facility had only taken them once a long time ago. Resident #24 also indicated the residents would like to go on outings to the senior center, but the facility had not taken them there for quite some time. She stated she understood that in the winter, it would be hard to get out and go; however, there had been no mention of these trips since the weather had been nice. The resident stated she could not recall when they last went to the senior center. She said it was a lot of fun, and she and the other residents really enjoyed it. At 12:30 p.m. on 05/30/14, review of the resident's medical record revealed [REDACTED]. This was the most recent activity assessment in the resident's medical record. The assessment indicated Resident #24 liked to go on trips, shopping, and being outdoors. Record review revealed the resident was only out of the facility for an activity once (a shopping trip) in the past twelve (12) months. c) Interview with the Activity Supervisor At 2:00 p.m. on 05/28/14, Employee #63, the Activity Supervisor (AS) was interviewed. When asked what kind of out of facility activities the facility provided, she stated, We go to the senior center, fishing, we took a boat trip last year, and we go shopping. She indicated these were the things the residents at the facility asked to participate in. The AS said it had been a while since she had scheduled out of the facility activities, because a van was broken down. She said she thought was now up and running. She stated she was working on getting them scheduled, but it would likely take another month or two to get them scheduled. Employee #63 said there were only about three (3) residents (#56, #41, and #13) who enjoyed fishing. She indicated Residents #56, #48, #76, #13, #9, #4, #10, #24, #15, #46 and #35 liked to go out to the senior center. Employee #63 said they usually went on Thursdays for lunch and the center usually had music on that day. She said she would like to take the residents at least twice a month. The AS was interviewed again at 8:30 a.m. on 05/29/14. When asked to provide a list of all out of facility activities there had been in the previous 12 months, she said the residents took a boat trip on 08/28/13. Of the 12 residents identified as liking outings, only Residents #35, #13, and #56 were able to go on the boat trip. She indicated Resident #24 was able to go on a shopping trip. Residents #56, #48, #76, #41, #13, #9, #4, #10, #24, #15, #46 or #35 were not provided an out of facility activities. Employee #63 indicated they had not been fishing in the previous two (2) years and had not been to the senior center in the previous 12 months. When asked why these activities were not provided she stated she was waiting on permission from the Executive Director (ED) to take the residents fishing. She stated she already bought the poles and was just waiting on approval. The AS said she had not yet asked the ED about a trip to the senior center, but he would have to give permission for them to take the trip. When asked how many transport vans the facility had, she replied, We have two (2) vans,but sometimes one of them is broken down. She indicated she and one of the maintenance men were able to drive the vans. Employee #63 was asked to provide the most recent activity assessments for Residents #56, #24, #48 , #76, #41, #13, #9, #4, #10, #15, #46, and #35. She stated she would have to get some of them from the paper files. She said prior to October 2013, when the facility became computerized, they did not do annual activity assessments. The activity supervisor stated some of the residents likely had not had an activity assessment since their admission to the facility. The AS was asked to provide the activity calendar for the previous 12 months. Upon review, the calendar contained no trips out of the facility. Employee #63 stated she did not include them on the calendar because they were canceled so often due to inclement weather or other circumstances out of her control. She again confirmed the only out of facility trips in the past 12 months were a boat trip and a shopping trip for Resident #24. d) Interview with Employee #70, the Executive Director Employee #70, the ED, was interviewed at 8:10 a.m. on 05/29/14. When asked if he had to give permission for out of facility activities, he stated all the activity supervisor had to do was ask, and he would approve it. He stated it was difficult to set up a fishing trip because of the dam and the water being too high. The ED said it was also sometimes hard to get the residents down the ramp at the fishing site to which they go. In addition, he said in the heat in the summertime was also an issue of concern. Employee #70 stated the residents went to the senior center occasionally, but not every month because it is hard to coordinate with the van and having someone available to drive the van. He stated occasionally one of the vans was broken down, so medical appointments took priority over activities with the other van. When asked if both vans were currently operational, he indicated they were. The ED stated it was just hard to coordinate it with the medical appointments they had. When asked if both vans were tied up with medical appointments all day every day he replied, no. The ED was asked if he felt out of the facility activities were important for the residents. He indicated he felt out of the facility activities were important to maintain the residents' quality of life. Employee #70 stated he had asked the AS to schedule the fishing activities for June, July or August. e) Resident #56 Resident #56 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Resident #56 was also identified as a resident who would enjoy going fishing. Resident #56's medical record was reviewed at 12:35 p.m. on 05/30/14. This review revealed an activity assessment dated [DATE]. The assessment indicated Resident #56 liked to be outside, and loved to socialize with his friends. On 05/30/14 at 1:30 p.m., Resident #56 was interviewed. When asked what kind of activities he liked to do in the summertime, he stated he liked to go fishing. When asked if the facility had ever taken him fishing, he replied, No. The resident also stated the facility had taken them to the senior center a few times and he really liked that. He stated they had not taken them out anywhere for a long time. When asked if he liked going to the senior center, he stated, I really like the senior center. He stated he really liked to go out of the facility and do things. Resident #56 went on the boat trip in August 2013, but had not been on any other outings in the previous 12 months. f) Resident #48 Resident #48 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Review of the resident's medical record, at 12:40 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. The resident was admitted to the facility on [DATE]. Her assessment indicated she had a past interest in trips/shopping, and a present interest in being outdoors. Resident #48 was interviewed at 2:15 p.m. on 05/30/14. When asked if she liked to take trips, she said she did. She was asked if she had ever gone to the senior center located in town prior to her admission to the facility. Resident #48 replied, I would go there a lot. I have friends that go there. It was a lot of fun. She was asked if the facility had talked to her about taking trips to the senior center. She stated, They have never mentioned it. I did not think I was going to be able to do that now, since I was here. She stated, If they do take you there, I would like to go with them. Resident #48 had not been on any out of the facility activities since her admission to the facility on [DATE]. g) Resident #41 Resident #41 was identified by the AC as a resident who would likely enjoy going fishing. Review of the resident's medical record, at 2:30 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. This assessment indicated the resident had a past interest in trips/shopping and a current interest in being outdoors. Resident #41 had not been on any out of facility activities in the previous 12 months. h) Resident #13 Resident #13 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Resident #13 was also identified as a resident who would enjoy going fishing. Review of the resident's medical record, at 2:25 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. This assessment indicated Resident #13 had a past interest in trips/shopping and a current interest in being outdoors. Resident #13 participated in the boating activity in August 2013, but had not been on any other out of the facility activities in the previous 12 months. i) Resident #9 Resident #9 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Resident #9's medical record was reviewed at 3:00 p.m. on 05/30/14. This review revealed an activity assessment dated [DATE]. This assessment indicated Resident #9 had a past interest in trips/shopping and a current interest in being outdoors. Resident #9 had not been on any out of the facility activities since admission. j) Resident #4 Resident #4 was identified by the AS as a resident who would likely enjoy taking trips out of the facility,such as a trip to the senior center. At 3:10 p.m. on 05/30/14, review of the resident's medical record revealed [REDACTED]. This assessment indicated Resident #4 had a current interest in being outdoors. Resident #4 had not been on any out of the facility activities in the previous 12 months. k) Resident #10 Resident #10 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Medical record review, at 3:05 p.m. on 05/30/14, revealed revealed an activity assessment dated [DATE]. This assessment indicated Resident #10 had a present interest in trips/shopping and being outdoors. Resident #10 had not been on any out of the facility activities in the previous 12 months. l) Resident #15 Resident #15 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Review of the medical record, at 3:10 p.m. on 05/30/14, revealed revealed an activity assessment dated [DATE]. This assessment indicated Resident #15 had a current interest in being outdoors. Resident #15 had not been on any out of the facility activities in the previous 12 months. m) Resident #46 Resident #46 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Medical record review, at 3:30 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. This assessment indicated Resident #46 had a past interest in trips/shopping and being outdoors. Resident #46 was interviewed at 3:05 p.m. on 05/29/14. When asked if she liked to take trips or go places outside the facility, she stated, I would like to get out of the facility sometimes. The resident said when she lived at home, she liked to go to the library, but had not been to the library since she had been at the facility. Resident #46 had not been on any out of the facility activities in the previous 12 months. n) Resident #35 Resident #35 was identified by the AS as a resident who would likely enjoy taking trips out of the facility, such as a trip to the senior center. Medical record review, on was reviewed at 3:45 p.m. on 05/30/14, revealed an activity assessment dated [DATE]. This assessment indicated Resident #35 had a current interest in trips/shopping and being outdoors. Resident #35 was interviewed at 1:25 p.m. on 05/30/14. When asked if she liked to take trips and be outside, she replied, I like to get outside for some fresh air. She said she liked to go places as long as they were not too far. Resident #35 went on the boat trip in August 2013, but had not been on any other out of the facility outings in the previous 12 months.",2018-04-01
6363,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,250,D,0,1,OMIN11,"Based on resident interview and staff interview, the facility failed to provide medically-related social services for one (1) of one (1) resident reviewed for the care area of social services during Stage 2 of the survey. The facility did not assist the resident in finding an option to meet her physical and emotional needs. There was no attempt to help resolve a conflict with the resident's roommate, who was disturbing the resident's ability to sleep well at night. Resident Identifier: #67. 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.",2018-04-01
6364,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,253,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and staff interview, the facility failed to provide maintenance and housekeeping services to maintain a comfortable and sanitary interior in eight (8) resident rooms/bathrooms and a resident common area. Resident rooms/bathrooms were observed with walls, ceilings, and/or doors in disrepair. The 100 Hall shower room was observed with dirty exhaust fans. Oxygen concentrators for six (6) residents (#32, #15, #29, #63, #41, and #19) of 14 residents who received oxygen therapy had dirty filters and/or outdated tubing. The wheelchairs for Resident #3 and #46 were not clean. It addition, Resident #46 ' s wheelchair had cracks in the seat, rendering it unable to be effectively cleaned and sanitized. These practices affected more than an isolated number of residents. Room Identifiers: #104, #107, #108, #111, #113, #114, #205, and #208. Resident Identifiers: #32, #15, #29, #63, #41, #19, #3, and #46. Facility Census: 61 Findings Include: a) Resident Rooms 1. Room #205 Room #205 was observed at 1:44 p.m. on 05/20/14, during Stage 1 of the Quality Indicator Survey (QIS). There was cracked tile in the floor of the bathroom. Employee #70,the Executive Director, was interviewed at 2:15 p.m. on 05/29/14 regarding the cracked tile in the bathroom of room #205. He agreed the tile was cracked. He stated he did not know whether or not the tile could be cleaned because he could not tell how deep the cracks were, or if cleanser could get into the cracks to clean the area. 2. Room #114 Room #114 was observed at 10:43 a.m. on 05/20/14, during Stage 1 of the QIS. The bathroom door was scuffed and the varnish on the edge of the door was missing. Employee #53, the Maintenance Supervisor, was interviewed at 2:30 p.m. on 05/29/14. He confirmed the bathroom door was scuffed and the varnish was missing. Employee stated the wheelchairs caused this, and they were in need of constant repairs. 3. Room #104 Room #104 was observed at 11:29 a.m. on 05/19/14 during Stage 1 of the QIS. The varnish was missing from the board behind the bed. The bathroom door was also scuffed and had missing varnish. When interviewed at 2:30 p.m. on 05/29/14, Employee #53 confirmed the bathroom door was scuffed and the varnish was missing. He also confirmed the board behind the bed was missing varnish and was scuffed. Employee #53 indicated the beds caused this, requiring constant repair. He stated he would sand them and reapply varnish. 4. Room #108 Room #108 was observed at 10:56 a.m. on 05/20/14, during Stage 1 of the QIS. The bathroom door was scuffed and had missing varnish. The Maintenance Supervisor was interviewed at 2:30 p.m. on 05/29/14. He confirmed the bathroom door was scuffed and the varnish was missing. 5. Room #208 Room #208 was observed at 1:58 p.m. on 05/19/14, during Stage 1 of the QIS. The varnish was missing from the board behind the bed. The ceiling above the A-bed was bright white, a different color than the remainder of the ceiling. Employee #70 was interviewed at 2:15 a.m. on 05/29/14. He stated the ceiling in Room #208 was a repair in progress. He stated it did not appear to have been painted, to complete the repair. When asked how long the ceiling had been in this stage of repair, Employee #70 stated, About one and half months. The Maintenance Supervisor was interviewed at 2:22 p.m. on 05/29/14. When asked about the ceiling he stated he had to repair the ceiling because of a leak. Upon inquiry, he stated the repair was complete. He said he had painted the ceiling. When asked if the area which was repaired was the same color as the rest of the ceiling, he stated, No, I would have to repaint the whole ceiling to make it match. When asked about the board behind the bed, he stated, the beds made marks on the board, requiring constant sanding and new varnish to the board. 6. Room #107 Room #107 was observed at 1:41 p.m. on 05/19/14, during Stage 1 of the QIS. The board behind the bed was scuffed and had missing varnish. Employee #53 was interviewed at 2:30 p.m. on 05/29/14. He confirmed the board behind the bed was scuffed and was missing varnish. 7. Room #111 Room #111 was observed at 11:02 a.m. on 05/20/14, during Stage 1 of the QIS. The bathroom door was scuffed and the varnish was missing off the edge of the door. When interviewed at 2:30 p.m. on 05/29/14, Employee #53 confirmed the bathroom door was scuffed and the varnish was missing. 8. Room #113 Room #113 was observed at 10:13 a.m. on 05/20/14, during Stage 1 of the QIS. The flooring around the commode was discolored. Employee #53 was interviewed at 2:30 p.m. on 05/29/14. He stated the flooring was discolored because a different type of handrail was previously in use. This handrail sat on the floor, and did not connect to the wall. Employee #53 stated he recently changed that hand rail to a type which connected to the wall, and had not changed the flooring. b) 100 Hall Shower Room The 100 hall shower room was observed at 6:30 p.m. on 05/21/14. The exhaust fans were observed dusty. When interviewed regarding the condition of the exhaust fans, at 8:17 a.m. on 05/22/14, Employee #70 stated, They could use some work done to them. c) Oxygen Concentrators 1. Resident #32 Resident #32's oxygen concentrator was observed at 10:40 a.m. on 05/20/14. The tubing currently in use was dated 04/2(?)/14. The date was not legible to determine the exact date (somewhere between the 20th and the 29th.) The filter on the oxygen concentrator, which was supposed to be black in color, was white due to the amount of dust which had collected in the filter. Employee #73, the Clinical Care Supervisor (CCS), a Registered Nurse (RN), was interviewed at 10:45 a.m. on 05/20/14. She said all residents who had orders for oxygen should have their tubing changed every two (2) weeks. The CCS stated the tubing should not be dated 4/2(?)/14. She stated they could either date it for the date they changed it, or they can put the date in which the tubing needed to be changed. The CCS stated either way, the tubing was outdated and should not have been on the machine. Employee #73 also confirmed the filter was dirty and needed cleaning. The resident's medical record, reviewed at 10:06 a.m. on 05/21/14, revealed an order for [REDACTED]. Resident #32's treatment administration record (TAR) was reviewed for the months of April 2014 and May 2014. The TAR indicated Change Humidifier and tubing q (every) week. It indicated this was to be done on the night shift every seven (7) days. The TAR also contained a directive to Clean Filters on concentrator q week and prn (as needed). According to the TAR, the resident's tubing was changed on 04/23/14, 04/30/14, 05/07/14, and 05/14/14; however, when observed on 05/20/14, the tubing had a date of 4/2?/14. The TAR also indicated the filter was last cleaned on 05/14/14. It was questionable the filter was cleaned as ordered, because observation on 05/20/14 revealed the black filter was white with dust. At the very least, the filter was not cleaned prn. 2. Resident #15 Resident #15's oxygen concentrator was observed on 05/20/14 at 1:21 p.m. The filter on the oxygen concentrator was covered with dust. When interviewed at 1:25 p.m. on 05/20/14, the CCS confirmed the filter on the resident's oxygen concentrator was dirty. She removed the filter and a plume of dust went into the air. The resident's medical record was reviewed at 10:50 a.m. on 05/20/14. Resident #15 had an order, dated 11/02/13, for oxygen via a nasal cannula at bedtime due to sleep apnea. The TAR for May 2014 contained an order to change the humidifier bottle and tubing every week. According to the TAR, this was last done on 05/13/14. The TAR did not contain an order to clean the filter on the oxygen concentrator. 3. Resident #29 Observation, at 10:50 a.m. on 05/20/14, revealed the resident's oxygen tubing was dated 04/19/14. An additional observation was conducted at 10:55 a.m. At that time, Employee #41, a Licensed Practical Nurse (LPN), was observed in the resident's room changing the oxygen tubing. She confirmed she had just changed the tubing which was dated 04/19/14. She also confirmed the tubing should have been changed prior to 05/20/14. Review of the resident's TAR, on 05/21/14, for the month of May 2014 revealed an order to change tubing q week and clean filter q week. These orders were not placed on the resident's TAR until 05/21/14. 4. Resident #63 Resident #63's oxygen concentrator was observed 11:00 a.m. on 05/20/14. Employee #41, LPN, was present during the observation. She confirmed the resident's filter on the oxygen concentrator was dirty and needed cleaning. Resident #63's medical record was reviewed at 11:15 a.m. on 05/21/14. It showed the resident had an order for [REDACTED]. This order was dated 12/15/13. The resident's TAR contained an order to clean the filter every week and as needed. 5. Resident #41 Resident #41's oxygen concentrator was observed at 10:42 a.m. on 05/20/14. The oxygen concentrator filter was dusty. On 05/20/14 at 10:57 a.m., the filter was wet to the touch. Employee #41 stated she had just cleaned the filter because it was dusty. The resident's medical record was reviewed at 11:20 a.m. on 05/21/14. There were no orders related to changing the oxygen tubing and/or regarding when the filter on the oxygen concentrator should be cleaned. 6. Resident #19 At 11:02 a.m. on 05/20/14, Resident #19's oxygen concentrator was observed with a dusty filter. The CCS confirmed the filter was dirty. She said the resident was just started on oxygen that day; therefore, it was set up with a dusty filter in place. The resident's medical record was reviewed at 10:54 a.m. on 05/21/14. Resident #19 had an order, dated 05/20/14, for oxygen at 2 liters per minute via a nasal cannula. This order was given at 9:37 a.m., which was one (1) hour and 25 minutes prior to the time the dusty filter was observed. k) Resident Wheelchairs. 1. Resident #3 and Resident #46. On 05/29/14 at 5:00 p.m. observations were made of two (2) wheelchairs. Resident #3 and Resident #46 both had dirty wheelchairs. The wheelchairs were dusty and dirty around the frame and wheels of the wheelchairs. The seat in Resident #46's wheelchair also had cracks in the material, rendering it unable to be effectively cleaned. At 5:15 p.m., the administrator (Employee #70), observed the wheelchairs. He said he would have someone from housekeeping look at the wheelchairs. During an interview with Employee #60 (housekeeping supervisor), she said she guessed the nurse aides just did not see the dirty wheelchairs. She indicated she would have someone clean the wheelchairs. The housekeeping supervisor said maintenance would take care of the cracks in Resident #46's wheelchair seat.",2018-04-01
6365,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,272,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to complete the required documentation for the care area assessments and triggers for twenty-four (24) of forty-nine (49) residents whose Minimum Data Set (MDS) assessments were reviewed in Stage 2 of the Quality Indicator Survey (QIS). The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. Resident identifiers: #26, #73, #25, #29, #53, #36, #61, #33, #66, #13, #9, #10, #31, #17, #3, #12, #5, #60, #18, #51, #28, #27, and #40. Facility census: 61. Findings include: a) Resident #26 Review of the resident's medical record, on 05/22/14 at 10:15 a.m., found a MDS with the ARD of 12/12/13. Review of the CAA summary, Section V, found the assessment had triggered the care areas of visual function, activity daily living (ADL) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer and [MEDICAL CONDITION] drug use. Review of the CAA worksheets found no documentation of the source, location and date of the information utilized to complete the additional assessment of the triggered areas. b) Resident #73 Review of the resident's medical record, on 05/27/14 at 10:15 a.m., found the MDS assessment, with an ARD of 04/17/14, triggered area of falls. The CAA worksheets were reviewed and found no documentation of the source, location and date of the information utilized to complete the MDS. c) Resident #25 Review of the resident's medical record, on 05/22/14 at 12:15 a.m., found the MDS, with an ARD of 02/10/14, triggered for cognitive loss/dementia, ADL functional/rehabilitation potential, urinary incontinence, and indwelling catheter, falls, nutritional status, dental care, pressure ulcer and [MEDICAL CONDITION] drug use. The CAA worksheets were reviewed and found no documentation of the source, location and date of the information utilized to complete the CAAs. d) Resident #29 Review of this resident's medical record, on 05/27/14 at 2:15 p.m., found an MDS with an ARD of 01/10/14. The CAA summary, Section V, indicated the areas of cognitive loss/dementia, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dental care, pressure ulcers, and [MEDICAL CONDITION] drug use triggered for additional assessment. The CAA worksheets had no documentation of the source, location and date of the information utilized to complete the CAA. e) Resident #53 Review of the resident's medical record on 05/29/14 at 12:15 p.m., found an MDS, with an ARD of 01/25/14. Section V indicated the areas of cognitive loss/dementia, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dental care, pressure ulcer and [MEDICAL CONDITION] drug use triggered for further assessment. Review of the CAA worksheets found no documentation of the source, location and date of the information utilized to complete the CAAs. f) Resident #36 On 05/28/14 at 9:48 a.m., review of the MDS assessment, with an ARD date of 03/05/14, found Section V, the CAA summary, triggered the areas of cognitive loss/dementia, visual function, communication, urinary incontinence and indwelling catheter, falls, nutritional status, feeding tube, dehydration/fluid maintenance, dental care, pressure ulcer for additional assessment. The CAA summary identified the location and date of the CAA documentation could be found on the CAA worksheet. Review of the CAA worksheet revealed the information about the location and date of the information used to complete the CAA documentation was missing. g) Resident #61 Review of Resident #61's medical record, at 1:51 p.m. on 05/27/14, found the MDS, with an ARD of 01/02/14, triggered additional assessment for the areas of cognitive loss/dementia, visual function, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, pressure ulcer, and [MEDICAL CONDITION] drug use. In Section V, it was noted the location and dates of the information used to complete the CAA, could be found on the CAA worksheet. Review of the CAA worksheet revealed the information about the location, date and time of the CAA documentation was missing. An interview was conducted on 05/22/14 at 8:15 a.m., with Employee #71, the resident assessment coordinator. When she was asked to where the location and dates of the information used to complete the CAA was located, she confirmed the location and date should have been included on all of the CAA summaries, but was not. h) Resident #33 At 2:09 p.m. on 05/27/14, review of this resident's MDS, with an ARD of 04/24/14, found the areas of cognitive loss/dementia, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dental care, pressure ulcer, and [MEDICAL CONDITION] drug had triggered. Review of the CAA worksheet and the CAA documentation revealed the information used to complete the CAA was missing. i) Resident #66 Resident #66's medical record, reviewed at 1:37 p.m. on 05/28/14, included an MDS, with an ARD 2/12/13. The CAA summary identified the assessment triggered [MEDICAL CONDITION], cognitive loss/dementia, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being mood state, behavioral symptoms, activities, falls, nutritional status, dental care and pressure ulcer. Review of the CAA summary and the CAA worksheet revealed the information about the location, date and time of the information used to complete the CAA was missing. j) Resident #13 Resident #13's medical record, reviewed 9:01 a.m., on 05/23/14, found the MDS, with an ARD of 01/30/14, triggered the care areas of [MEDICAL CONDITION], communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, and [MEDICAL CONDITION] drug use. The dates and location of the information used to complete the CAAs could not be found in Section V or the CAA. k) Resident #9 On 05/22/14 at 8:52 a.m., review of Resident #9's medical record found the MDS with an ARD of 12/20/13 triggered for cognitive loss/dementia, visual function, communication, ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer and [MEDICAL CONDITION] drug use. [MEDICAL CONDITION],communication, ADL (activity of daily living) functional/rehabilitation potential, urinary incontinence and indwelling catheter, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, and [MEDICAL CONDITION] drug use. The dates and location of the information used to complete the CAAs could not be found in Section V or the CAA. l) Resident #10 At 9:50 a.m. on 05/28/14, review of this resident's medical record found the MDS, with an ARD of 03/27/14 triggered for [MEDICAL CONDITION],cognitive loss/dementia, ADL functional/rehabilitation potential, falls, nutritional status, dental care, pressure ulcer, and pain. Review of the CAA worksheet revealed the information was missing the location, date and time of the information used to complete the CAA. m) Resident #31 Review of the this resident's MDS with an ARD of 03/26/14, on 05/28/14 at 3:56 p.m., found the assessment had triggered the areas of ADL functional/rehabilitation potential, urinary incontinence and indwelling catheter, psychosocial well-being, falls, nutritional status, dehydration/fluid maintenance, dental care, pressure ulcer, [MEDICAL CONDITION] drug use and pain. The CAA summary, nor the CAA, identified the location and dates of the information used to complete the CAA. n) Resident #17 On 05/27/14 at 9:57 a.m., review of Resident #17's medical record found the MDS, with an ARD 08/01/13, triggered for further assessment of falls. The column in Section V for the location and date of CAA documentation was blank. The CAA worksheet for falls was reviewed and no documentation was found to indicate the source, location and date of the information utilized to complete the CAA. o) Resident #3 Review of the Resident #3's medical record on 05/21/14 at 5:00 p.m., found an MDS, with an ARD of 01/16/14. The MDS triggered for further assessment of falls. The column in Section V for the location and date of CAA documentation was blank. The CAA worksheet for falls was reviewed and no documentation was found to indicate the source, location and date of the information utilized to complete the CAA. p) Resident #12 Resident #12's medical record, reviewed on 05/22/14 at 11:45 a.m., found the MDS, with an ARD of 11/11/13 triggered for the area of falls. The location and date of the information used to complete the CAA was not located in either Section V or in the CAA. q) Resident #5 Review of Resident #5's medical record, on 05/30/14 at 9:52 a.m., found the MDS with an ARD of 02/12/14, triggered for falls. The location and date of the information used to complete the CAA was not located in either Section V or in the CAA. r) Resident #60 On 05/30/14 at 9:11 a.m., review of the resident's MDS with an ARD of 12/06/13, noted it triggered for falls. The location and date of the information used to complete the CAA was not located in either Section V or in the CAA. s) Resident #18 The medical record review for Resident #18, on 05/29/14 at 12:50 p.m., revealed Resident #18 had a comprehensive MDS assessment dated [DATE]. The CAA worksheet for falls, dated 01/017/14, discussed the nature of Resident #18's problem with falls; however, it did not give the date and location of the information used to complete the additional assessment. t) Resident #51 On 05/29/14 at 12:55 p.m., review of Resident #51's comprehensive MDS assessment dated [DATE], found the CAA worksheet, dated 11/21/13, discussed the nature of Resident #51's problem with falls; however, the CAA worksheet did not give the date and location of the information used to complete the additional assessment. u) Resident #28 Resident #28's medical record, review on 05/29/14 at 1:10 p.m., revealed Resident #28 had a comprehensive MDS assessment completed on 03/05/14. The CAA summary worksheets did not contain the location and date of the information used to assess the problem. v) Resident #27 Review of this resident's medical record, on 05/29/14 at 1:20 p.m., the comprehensive MDS, with an ARD of 03/12/14, triggered for falls. The CAA worksheet, dated 03/18/14, discussed the nature of Resident #18's problem with falls, but did not identify the date and location of the documentation used to further assess the problem. w) Resident #40 Resident #40's medical record, reviewed on 05/29/14 at 1:30 p.m., revealed the resident had a comprehensive MDS, with an ARD of 11/14/13. The CAA worksheet for falls discussed the nature of Resident #40's problem with falls, but did not identify the date and location of the documentation used to complete the CAA. According to the MDS 3.0 manual, Chapter 1, Resident Assessment Instrument (RAI), CAA summary, Section V of the MDS 3.0 provides a location for documentation of the care area(s) that have triggered from the MDS. The manual stated to use the Location and Date of CAA Documentation column on the CAA Summary (Section V of the MDS 3.0) to note where the CAA information and decision-making documentation could be located in the resident's medical record. x) Staff interviews In an interview with Employee #52, registered nurse (RN) - unit charge nurse (UCN), on 05/21/14 at 2:32 p.m., confirmed the CAA worksheet did not contain the source, location and date of the information utilized to complete the CAAs. An interview was conducted on 05/22/14 at 8:15 a.m., with Employee #71, the MDS Coordinator. When asked, Where can we find the source, location and date of the information used to complete the MDS assessment, she stated, The information should be located in Section V (CAA Summary), but since the facility started using this new system, I have not been able to put the information on Section V (CAA Summary). She also stated, With the old system I was able to put in the source, dates and location of the information used to complete the MDS, but with this system it will not let me do it. She also confirmed Section V or the CAAs did not contain the location and dates of the information used to complete the CAA.",2018-04-01
6366,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,279,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to develop comprehensive care plans, including measurable goals and timetables, to assist four (4) of forty-nine (49) residents in attaining the highest level of well-being. Oral needs were not addressed for Resident #33. The risk for falls was not addressed for Resident #25. There was no care plan for Resident #78 regarding the amount of assistance needed in transfers. A care plan was not developed for Resident #26, regarding the risk for injuries during transfers. Resident identifiers: #33, #25, #78, and #26. Facility census: 61. Findings include: a) Resident #33 Employee #73, clinical care services (CCS), a registered nurse (RN), was observed evaluating Resident #33's mouth on 05/22/14 at 11:00 a.m. Observation revealed the resident had white patches on the left side of her mouth and gum line. A review of a progress note, written by Employee #52, a registered nurse (RN),, on 05/21/14 at 9:42 a.m., revealed the resident voiced complaints of pain in her jaw and mouth on 05/16/14 at 10:54 a.m. A sore was noted under her tongue and and a white patchy area was noted on the inside of her cheek. Employee #52 noted a message was left for the physician to return a call made to him/her. The record revealed Resident #33 was given [MEDICATION NAME] and [MEDICATION NAME] as ordered for pain. On 05/21/14 at 10:00 a.m., further review of the resident's medical record revealed [REDACTED]. The noted indicated the physician was in the facility and was aware of the complaint. According to the medical record, the physician ordered [MEDICATION NAME] (an antifungal agent used to treat yeast infection), one (1) tablet five (5) times a day for fourteen (14) days related to the [DIAGNOSES REDACTED]. Review of Resident #33's care plan, on 05/21/14 at 4:42 p.m., revealed there was no care plan, with measurable goals and interventions, regarding the care needed for the resident's oral condition. An interview was conducted with Employee #73, on 05/22/14 at 11:12 a.m. When asked if Resident #33 should have a care plan related to Candidiasis, she reviewed the resident's care plan and stated, Yes, there should be a care plan, but there is no care plan. She stated she would make sure there was a care plan put in place for this problem. b) Resident #25 Medical record review, on 05/28/14, at approximately 2:00 p.m., revealed this [AGE] year old female was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The history and physical noted the resident had experienced a fall prior to her admission to the hospital, and was at high risk for falls. On the day of Resident #25's admission, on 02/03/14, a Nursing Assessment form was completed. Under the N section, Factors Influencing Fall Risk, the assessor failed to indicate the resident had a history of [REDACTED]. These medications are known to increase the risk of falls. The episodic care plan, dated 02/03/14, contained no focus, goals, or interventions related to the risk of falls. Record review revealed the resident had a fall on 02/08/14, five (5) days after admission. The incident/accident report, dated 02/08/14 at 4:47 p.m., was reviewed. It indicated the resident was found sitting on her buttocks in the doorway of her bathroom with her feet facing out of the bathroom. The resident stated, I had to use the bathroom and crawled to the bathroom to use it and couldn't get up on the toilet. The resident was noted to be wearing improper footwear. An episodic care plan was not developed until 02/08/14, after the resident fell . It indicated the resident was at risk for falls. A goal was written: Patient will be free of falls during review period. The interventions included: (1) Educate patient and family members about safety reminders and what to do if a fall occurs. (2) Ensure the patient wears non-skid socks or shoes when ambulating or when up in wheelchair. (3) Provide frequent orientation to the use of the call light. Ask the patient to demonstrate operation of the call light after providing instruction. Encourage patient to use it to call for assistance as needed. Respond promptly to all requests for assistance. On 05/27/14 at 10:00 a.m., in an interview with Employee #72, the director of nursing, she confirmed Resident #25 was at high risk for falls on admission due to recent falls, impaired mobility due to a recent toe amputation, and confusion. She further confirmed no episodic care plan was initiated until 02/08/14, which was after the resident experienced an actual fall. c) Resident #26 Review of the medical records, on 05/21/14 at 2:30 p.m., revealed Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. During an interview with the resident, at 10:51 a.m. on 05/19/14, she stated, The staff says my pressure ulcer is from a blood blister caused by being pinched by a lift pad during a transfer; although I don't know because I have no feeling from the waist down. A telephone interview was conducted, on 05/28/14 at 11:30 a.m., with Employee #42, the licensed practical nurse (LPN) who completed the occurrence documentation regarding an incident on 12/01/13. When asked what happened to Resident #26 on 12/01/13, she answered, Two nursing assistants, (Employees #20 and #32) had used the full body lift to transfer (Resident #26) from the chair to the bed, and they noted a purple bruise with blistering present to left outer thigh area and then they notified me of the area. When asked about the statement on the occurrence form which read, The resident reported she thinks the metal bar in the lift pad could have caused it during transfer by pinching the skin, she stated, Resident #26 does not have any feeling below her waist, she did not know how it happened. The two NAs and I looked at the lift pad and there is a metal bar located at the bottom of the pad, and it would hit her body in the bruised blistered area during the transfers, and we felt the resident's skin probably got pinched by the lift pad. Employee #42 was asked if the bruised, blistered area was noted prior to that time. She said, No, not to my knowledge. Review of the resident's current comprehensive care plan revealed no interventions regarding the safe use of the lift and/or lift pad with Resident #26. Interview with the Director of Nursing, Employee #72, on 05/27/14 at 2:00 p.m., confirmed the care plan did not contain precautions during transfers, to prevent further injury involving the full body lift pad. d) Resident #78 Record review, at 3:42 p.m. on 05/27/14, revealed this resident was admitted on [DATE] and was discharged on [DATE]. Her interim care plan, which was completed upon admission, indicated she was to be transferred with physical assistance of two (2) persons. The resident's minimum data set (MDS) admission assessment, with an assessment reference date (ARD) of 06/19/13, was reviewed. It indicated the resident required the assistance of two (2) persons for transfers. Review of the resident's comprehensive care plans, completed after the interim care plan, revealed the resident's transfer status was not addressed. There was nothing in the resident's care plans which indicated she required the assistance of two (2) for transfers. The care plans only addressed the resident's weight bearing status. On 09/06/13, Employee #85 transferred the resident, without assistance, from her wheelchair to the toilet. At that time, the resident received a 9 centimeter (cm) skin tear to her right outer calf. The CCS, a registered nurse, was interviewed at 4:00 p.m. on 05/28/14. She confirmed the only place this resident's transfer status was addressed was on her interim care plan upon admission.",2018-04-01
6367,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,280,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plans for four (4) of forty-nine (49) residents reviewed for accidents. The care plans were not revised to address fall prevention and/or changes in planned interventions to prevent falls. Resident identifiers: #33, #66, #13, and #3. Facility census: 61. Findings include: a) Resident #33 Record review, on 05/27/14 at 2:04 p.m., revealed Resident #33 had accidents resulting in injury on 02/04/14, 02/05/14, and 03/08/14. The resident's care plan was not revised after the accidents. -- On 02/04/14 at 5:00 a.m., the resident was found on the floor mat beside her bed. She complained of pain in her left hand and forearm. A hematoma was noted on her left hand, and small abrasions were noted on the middle of her back. Review of the progress notes related to the fall, on 05/27/14 at 9:30 a.m., revealed the bed alarm was in place and turned on; however, it did not activate. A new bed alarm pad was placed and was noted as working properly. The resident's care plan was not revised to address the prevention of another fall. -- On 02/05/14, the resident was found with an open area on her left shin. The progress note for this incident stated the resident was known to self-ambulate in her wheelchair. The care plan was not revised to reflect interventions to assist the resident in the prevention of accidents. -- On 03/08/14 at 9:08 a.m., the resident was sitting in the hallway waiting for her medications. She leaned forward to fix her shoe and fell straight out of her wheelchair. A raised area was noted to top of her head. A progress note, written by Employee #52, a registered nurse (RN), included: Patient is being transferred for Resident had a fall and vital signs unstable at this time. Review of the neurological evaluation completed after the fall revealed the resident's blood pressure was 217/105, her temperature was 97.8, and her pulse was 104. On 05/27/14 at 9:40 a.m., review of the acute care hospital report, dated 03/08/14 at 11:00 a.m., revealed the physician's clinical impression was a frontal hematoma. Review of the resident's care plan, on 05/27/14 at 9:45 a.m., revealed no interventions specifically for accident prevention. There was an intervention for neurological checks, which was not relevant to accident prevention. There was also an intervention regarding the new bed alarm pad which was placed and working properly; however, there was not an intervention to check the bed alarm for continued functioning. The bed alarm intervention, which had been in place since 10/08/13 was: Alarm to bed at all times to alert staff of patient attempts to transfer unassisted. This intervention had a revision date of 01/14/14. The care plan was not revised, related to the resident's continued accidents and/or related to falling out of her wheelchair until forty (40) days after the accident. On 04/17/14, a flip tray was ordered for the wheelchair to remind the resident of safety and to prevent injury. An interview was conducted on 05/27/14 at 3:50 p.m., with Employee #74 the quality standard coordinator. When asked to provide evidence the resident's care plan was revised after the resident had accidents with injuries, she stated, I have nothing for you. She confirmed staff did not identify individual risks and revise the resident's care plan accordingly. b) Resident #66 Medical record review, on 05/28/14 at 12:00 p.m., revealed Resident #66 fell on [DATE], 01/01/14 and 01/16/14. Each of the falls was related to the resident going to the bathroom without assistance. -- On 12/26/13 the resident was found lying on the floor at her bedside. When asked what happened, the resident stated, I had to pee and No I didn't hit my head I was trying to crawl to the toilet before I have an accident. The resident's care plan was reviewed on 05/28/14 at 2:18 p.m. After the fall on 12/26/13, an intervention was developed to educate the resident on use of the call light. There was also an intervention to toilet the resident as needed. The facility was unable to provide evidence these interventions were implemented. -- On 01/01/14 at 11:16 a.m., Resident #66 was found sitting on her buttocks on the floor at the bedside. The resident stated, I went to the bathroom, and made it back to here and just fell down on my butt. Review of the care plan revealed an intervention for a bed alarm was added after the fall on 01/01/14. Medical record review revealed the resident had two (2) additional falls after this intervention was put in place. -- On 01/16/14 at 04:12 a.m., the resident's bed alarm sounded. Nursing staff found Resident #66 sitting on her buttocks at the bathroom door, facing the bathroom door. When asked what happened, Resident #66 stated: I had to use the bathroom and I was trying to crawl to get there. The bed alarm was not an effective intervention; however, the care plan after this fall was not updated. It still had the intervention to educate the resident on proper use of the call light. Review of the resident's Brief Interview of Mental Status (BIMS) revealed the resident's score was six (6) when assessed in December 2013. This score indicated the resident was not cognitively intact. At 9:07 a.m. on 05/29/14, Employee #55, the unit charge nurse, RN, was asked for evidence the resident's care plan was revised, after the falls, to reflect Resident #66 s individual needs. She confirmed there was no evidence which indicated revisions were made to the care plan as needed. On 05/29/14 at 10:10 a.m., during an interview with Employee #5, a nursing assistant (NA), she stated Resident #66 did not use her call bell. The NA also stated she found the resident in the bathroom on the toilet after lunch yesterday (05/28/14). At 3:50 p.m. on 05/29/14, Employee #49, the unit charge nurse, a licensed practical nurse, was asked if the resident understood she should use her call light to get assistance with toileting. Employee #49 stated the resident could not always follow directions given to her. The intervention to educate the resident was not an appropriate intervention for this resident, yet the facility did not revise the care plan to include interventions which were appropriate for the resident's cognitive status and/or abilities. Review of the resident's care plan, dated 01/20/14, revealed documentation that a voiding diary was initiated. The plan was to develop and implement an individualized toileting plan to avoid incontinent episodes. The facility was requested to provide information related to the resident's toileting program; however, evidence the toileting program was implemented was not provided by the end of the survey on 06/02/14. At 11:58 a.m. on 05/30/14, review of the resident's care plan revealed the use and function of the resident's bed alarm was supposed to be tested daily with a sensor device to verify both the alarm and sensor were operating properly. Employee #74, the quality standard registered nurse, was asked what evidence she had that staff were performing this intervention. She stated she had no evidence this was being done. c) Resident #13 Record review, on 05/23/14 at 9:39 a.m., revealed Resident #13 had a fall on 11/12/13 and 03/02/14. The fall on 11/12/13 at 4:50 p.m. occurred when the resident was attempting to close the door behind her. She stated she stood up, became unsteady and sat down on the floor. She was found with her back against the wall. Information regarding the fall on 03/02/14 at 3::42 p.m., noted the resident was found sitting on her buttocks on the floor with her back leaning against the door, and her feet stretched out in front of her. The resident stated she just sat down on the floor. Record review, on 05/27/14 at 11:00 a.m., revealed a care plan for falls was initiated, related to the 11/12/13 fall. The plan included a review of information on past falls and an attempt to determine the cause of the falls. The facility was going to determine possible root causes and alter or remove any potential cause if possible. Education of the patient/family/interdisciplinary team as to causes was to occur. There was also a plan to Communicate with patient and family members regarding resident's capabilities and needs. These interventions were not effective, as the resident had a similar fall on 03/02/14. There was no evidence the care plan was revised after the fall on 03/02/14. An interview was conducted, on 05/27/14 at 4:00 p.m., with Employee #74, the quality standard coordinator (QSC). She was asked what revisions were made to the resident's care plan to prevent another fall. Employee #74 stated she could find no new interventions after the fall on 03/02/14. d) Resident #3 On 05/21/14 at 5:00 p.m., medical record review revealed a nursing progress note dated 03/15/14. The note indicated the Nurse Aide (NA) reported to Employee #55, Unit Charge Nurse, Registered Nurse (RN), the resident exhibited weakness and shakiness when being transferred with the sit-to-stand mechanical lift. The progress note indicated Employee #55 observed the resident being transferred with the sit-to-stand mechanical lift. The RN noted the resident had coarse tremors to her upper extremities when grasping the handles of the lift. She indicated the resident did not attempt to put her feet into the designated foot pad area of the lift. According to the note, the resident complained of pain in her shoulders when being transferred with the lift. The outcome section of the note contained documentation that occupational therapy (OT) was consulted regarding the safety concerns of using the sit-to-stand lift with Rresident #3. OT advised they did not make recommendations concerning the use of lifts, as this was a safety issue to be determined by nursing staff. The matter was reviewed with the physician. On 03/15/14, the order to use a sit-to-stand lift, which originated on 10/28/13, was discontinued. The new lift order, dated 03/15/14, was: Resident to be transferred with amount of assistance required to ensure resident /staff safety. This order was the current order at the time of the survey, as well as at the time the resident fell while being transferred with the sit-to-stand lift. The facility determined the safest method to assist Resident #3 in transfers was a full body lift. A progress note, written by Employee #55 on 03/16/14, described when the use of a full body lift was discussed with Resident #3, she was upset about having to use the full body lift. The resident wanted to use the sit-to-stand mechanical lift. On 05/14/13, the resident sustained [REDACTED]. Documentation, dated 05/15/14, indicated the equipment involved in a fall, resulting in the bruise, was the sit-to-stand lift. The follow up to this incident, dated 05/18/14, indicated the intervention to prevent reoccurrence was, Resident to use full body lift for transfers. At the time of the fall on 05/14/14, the resident already had a physician's orders [REDACTED]. Based on this physician's orders [REDACTED]. Review of Resident #3's current care plan revealed the following intervention, which originated on 01/20/14 and was revised on 03/12/14: Transfer Self-Performance: (Residents Name) requires assist of 2. (Residents 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. The resident's care plan and Kardex (the care plan information for the NAs) was not consistent with the physician's orders [REDACTED]. The care plan was not revised to reflect the changes identified in the physician orders [REDACTED]. On 05/28/14 at 3:25 p.m., Employee #74, Quality Standard Coordinator (QSC), Registered Nurse (RN) was interviewed. She reviewed the care plan and confirmed Resident #3's care plan had not been revised to reflect manner in which the residfent should be transferred.",2018-04-01
6368,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,282,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observation, the facility failed to implement the care plans for five (5) of 49 residents whose care plans were reviewed during Stage 2 of the quality indicator survey. The care plan interventions related to transfers were not implemented for Residents #3, #30, and #66. In addition, the care interventions for a scheduled toileting program were not implemented for Residents #16 and #25. Resident Identifiers: #3, #30, #66, #16, and #25. Facility Census: 61. Findings Include: a) Resident #3 Review of the resident's medical record, on 05/21/14 at 5:00 p.m., revealed the resident had a fall from a sit-to-stand lift on 05/14/14. The resident sustained [REDACTED]. Employee #25 was the nursing assistant (NA) who was assisting the resident at the time the resident fell . Resident #3 was observed being transferred on 05/22/14 at 9:15 a.m. Employee #3, a NA, was assisting the resident using a mechanical sit-to-stand lift. Employee #3 was the only employee in the room during the transfer of Resident #3. Upon inquiry, Employee #3 indicated she transferred Resident #3 by herself all the time because the resident was able to hold on to the lift and was not likely to fall. On 05/22/14 at 10:52 a.m., Employee #25 was interviewed. When asked about the resident's fall, Employee #25 stated she was assisting the resident to bed using the sit-to- stand lift. The NA said she was the only staff member in the room. She stated 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. The NA 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. She stated the resident's arms were tangled in the lift, requiring her to raise the lift a little to get the resident's arms out of the sling. Review of Resident #3's current care plan revealed an intervention regarding the amount of assistance the resident required for transfers. It was initiated on 01/20/14 and revised on 03/12/14. The intervention was: Transfer Self-Performance: (Residents Name) requires assist of 2 . This was the current care plan intervention at the time of Resident #3's fall on 05/14/14 and at the time of the observation of Resident #3 being transferred with the assistance of only one (1) NA on 05/22/14. b) Resident #30 Employee #3, NA, was interviewed at 8:40 a.m. on 05/22/14. During this interview, she stated they could use the sit-to-stand lift with one (1) aide or two (2). She said she reviewed the Kardex (the care plans used by NAs) each morning, and this was how she knew what assistance was needed for the transfer of each resident. Employee #3 said if the resident was able to hold on to the handles and able to stand up once the lift assists them up, she did not get another staff member to help with the transfer. Resident #30 was observed being transferred at 9:08 a.m. on 05/22/14. Employee #3 was assisting the resident from the edge of her bed to her wheelchair using a sit-to-stand lift. Employee #3 was the only employee in the room during this transfer and completed the transfer by herself. Review of the resident's medical record, at 9:15 a.m. on 05/22/14, revealed a care plan intervention for assistance with transfers: Transfer Self-Performance: (resident name) requires extensive assist of 2 (two) . This intervention was initiated on 12/13/13 and revised on 01/03/14. It was the current care plan intervention at the time of the observation when Employee #3 transferred Resident #30 without the assistance of another person. Review of the Kardex revealed it also directed the resident be lifted with the assistance of two (2) persons. . c) Resident #66 1) Review of the resident's care plan, on 05/21/14 at 6:24 p.m., revealed Resident #66 required extensive assist of two (2) for transfers on and off the toilet. The NA Kardex, reviewed on 05/21/14 at 6:30 p.m., also indicated Resident #66 required extensive assist of two (2) for transfers. On 05/22/14 at 9:20 a.m., Employee #3, a NA, was asked about the amount of assistance Resident #66 needed for transfers. The NA stated she was required to check the resident every two (2) hours and assist her to the bathroom for toileting. She indicated she transferred the resident by herself, with a gait belt, from the wheelchair to the toilet. During an observation, on 05/22/14 at 9:40 a.m., with Employee #72, the director of nursing services (DNS), Employee #3 was observed transferring Resident #66 from the toilet to the wheelchair. The NA assisted Resident #66 from the toilet to the wheelchair by herself and without a gait belt. Following the observation, in the presence of the DNS, Employee #3 was asked to look at the Kiosk and to read the Kardex to see how Resident #66 was supposed to transferred. Employee #3 read out loud, Resident requires 2 to be assisted for transfers. When asked if she transferred Resident #66 with two assistants and a gait belt, Employee #3 stated, No. The DNS confirmed Employee #3 did not transfer Resident #66 as directed in the care plan and as instructed in the Kardex. The DNS commented that the NA did not even ask her (the DNS) to help with the transfer. 2) Review of the care plan, on 05/29/14 at 9:00 a.m., revealed a care plan related to a toileting plan for Resident #66. The care plan, initiated on 01/20/14, indicated the establishment of the resident's typical voiding patterns over a seventy-two (72) hour period using a voiding diary. A toileting plan to avoid incontinence episodes was noted as developed and implemented. The toileting program was to offer and assist the resident with toileting, using the prompted voiding protocol, upon rising, before and after meals, every two hours, before bedtime, and whenever necessary. This plan was intended to decrease the chance of injury and to maintain the resident's current level of continence. On 05/29/14 at 9:07 a.m., Employee #55, a registered nurse (RN) was interviewed regarding the resident's toileting plan. She was asked to provide evidence that nursing staff implemented any of the care plan interventions related to a toileting program for Resident #66. She said the facility used to have a fall prevention nurse who assessed, ensured implementation, evaluated, and modified interventions as needed for a resident who needed a toileting program. Employee #55 stated when the new change of ownership occurred, this position was eliminated. She confirmed she had no evidence to provide which indicated nursing staff was providing care in accordance with Resident #66's care plan for a toileting program. . d) Resident #25 Medical record review, on 05/28/14 at approximately 2:00 p.m., revealed Resident #25 was admitted to the facility on [DATE]. The resident's episodic care plan contained the following intervention, dated 02/12/14: Habit/Scheduled toileting program: Resident to be offered & (and) assisted w (with)/ toileting before & after meals, Q (every) 2 hrs. (Hours), & PRN (when necessary) to decrease episodes of functional incontinence. An interview was conducted on 05/29/14 at 9:07 a.m., with Employee #55, RN, who was responsible for the implementation of the restorative programs, including bowel and bladder programs. Upon inquiry, she was unable to provide evidence the facility implemented a habit/scheduled toileting program, as directed in the care plan, for Resident #25. e) Resident #16 1. The medical record review for Resident #16, completed on 05/28/14 at 12:45 p.m., revealed the resident had experienced four (4) falls. -- The first fall was on 11/18/13 at 3:30 p.m. The associated incident report stated, The housekeeping supervisor was standing behind the resident's w/c (wheelchair) attempting to redirect him. The resident turned to sit down in w/c sat on floor on buttocks. Then the resident laid down on his right side. -- A second fall occurred on 12/21/13 at 4:39 a.m. The incident report stated, Bed alarm sounding, CNA (nurse aide) responded and called this nurse to residents room. Resident noted to be sitting on buttocks beside bed. Resident denies pain/discomfort, resident noted to be wearing regular socks. Resident responded appropriately to questions, alert and oriented to location and person at this time. Hand grasps equal PERLA resident noted to be moving all extremities with ease leg extensions equal no shortening noted. No visible signs of injury at this time. Bed alarm remains in place and working properly. Bed in lowest position. Resident states when asked if he needed to go to the restroom ' I already went, I was going back to bed and fell . -- A third fall occurred on 01/22/14 at 8:00 a.m. The incident report stated, Time of incident 0800 Alarm sounding. Called to res. (resident) room by cna who reports residents lying in floor noted resident lying in floor on his left side beside bed. Over the bed table beside bed as well as with breakfast tray set up. cna reports obvious injuries noted. Clear liquid noted in floor. Resident reports 'I slipped in that slick stuff.' Unable to give an account of what he was doing when he slipped. Denies any pain or injury. Stating 'no ' I am alright. -- A fourth fall occurred on 04/06/14 at 2:07 p.m. The incident report stated, Resident bed alarm sound from room. Upon going down the hall resident was in room [ROOM NUMBER] sitting in the floor on buttock with back against a wheel chair. Resident has a skin tear to right to right upper arm measuring 11 cm (centimeters) by 1 cm. Resident states 'I was going to the bathroom.' Review of the resident's care plan, on 05/28/14 at 1:00 p.m., revealed a care plan for falls was initiated on 10/15/13. The resident had an intervention for a bedside commode to aid in prevention of unassisted ambulation. The date listed for initiation of this intervention was 04/07/14. Observations of Resident #16's room, on 05/28/14 at 1:30 p.m. and on 05/29/14 at 8:00 a.m., revealed the resident did not have a bedside commode. An interview with Employee #5 (nurse aide) revealed the resident did not have a bedside commode. The nurse aide said she did not remember the resident having a bedside commode since he had lived in the room in which he currently resided. The progress notes revealed Resident #16 moved to that room on 04/04/14. On 05/29/14 at 8:00 a.m. Employee #73 (clinical care supervisor) said someone would get the resident a bedside commode since he did not have one. 2. Resident #16's care plan also stated he would have a habit/scheduled toilet program. The program would consist of the resident being offered and assisted with toileting every two hours and prn (as needed) for safety issues r/t impaired mobility and to maintain current level of continence. The facility initiated this intervention on 01/23/14. On 05/29/14 at 9:30 a.m., Employee #55 (registered nurse) said she had helped develop the habit toilet program for residents. She said she did not develop care plans. Employee #55 said she did not have any evidence to show the facility implemented the toileting plan for the resident. .",2018-04-01
6369,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,314,G,0,1,OMIN11,"**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 entered the facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable. Resident #26 developed a suspected deep tissue injury as a result of an incident during a transfer using a full body lift. The area subsequently evolved into a Stage IV pressure ulcer which constituted actual harm. Resident identifier: #26. Facility census: 61. Findings include: a) Resident #26 A review of the resident's medical records on 05/21/14 at 2:30 p.m., revealed this [AGE] year old female resident had [DIAGNOSES REDACTED]. The resident had lived in the facility since at least mid 2010. She was discharged return not anticipated on 10/03/13 to another nursing home or swingbed, and returned to the facility on same day, on 10/03/13. As the resident was discharged with return not anticipated, the comprehensive minimum data set (MDS) assessment, with an assessment reference date (ARD) of 10/10/13, was an admission assessment although the resident had resided in the building for over three (3) years. This assessment indicated she scored 15 on the Brief Interview for Mental Status (BIMS), indicating she was cognitively intact. According to the assessment, the resident had no pressure ulcers, but was at risk of developing pressure ulcers. Further medical record review revealed a significant change in status MDS, with an ARD of 12/12/13, that identified the resident had an unhealed pressure ulcer at a Stage 1 or higher. Item M0300 F was coded as the resident having one (1) unstageable pressure ulcer present. Section S, the state specific section of the MDS indicated the resident had one (1) new in-house pressure acquired pressure ulcer, which had developed on the resident's left buttock during the last quarter. Additional review of the MDSs found in 2010, the resident had had a Stage IV pressure ulcer which had subsequently healed. Her annual MDS, with an ARD of 12/26/12, a Quarterly assessment with an ARD of 06/18/13, a significant change of status MDS with an ARD of 03/28/13, a Quarterly assessment with an ARD of 06/18/13, as well as the admission MDS of 10/10/13, all indicated the resident did not have pressure ulcers. The unstageable pressure ulcer identified on the significant change assessment with an ARD of 12/12/13,was the first time a pressure ulcer was coded for this resident in more than a year. At that time, the area was 3 cm (centimeters) long x 2 cm wide x 0.1 cm. deep, and the most severe tissue type was slough (Non-viable yellow, tan, gray, green or brown tissue), The resident was hospitalized from [DATE] to 02/27/14. On her next MDS, a Quarterly assessment with an ARD of 03/06/14, the area was coded as a Stage IV with granulation tissue and measured 4 cm x 2 cm x 2.9 cm.) Subsequent assessments, with ARDs of 03/12/14 and 03/27/14, reflected the area remained a Stage IV with granulation tissue measuring 4 cm x 2 cm x 2.9 cm. All of the assessments, with the exception of the 30-day MDS with an ARD of 03/27/14, identified the area had developed in-house. During an interview with the resident, at 10:51 a.m., on 05/19/14, she stated, The staff says my pressure ulcer is from a blood blister caused by being pinched by a lift pad during a transfer, although I don't know because I have no feeling from the waist down. Review of the nurses' notes for Resident #26 found an entry on 11/28/13 at 9:00 a.m., Skin evaluation completed. Resident has no [MEDICAL CONDITION], rash, excoriation, skin tear, bruising or skin breakdown noted. At 11:15 a.m. on 11/28/14, the resident went out of the facility with her family for Thanksgiving dinner. When she returned at 6:30 p.m., a nurse noted, No distress noted. Further review of nurses' notes revealed a note, entered on 12/01/13 at 4:07 p.m. by Employee #42, licensed practical nurse (LPN). The documentation included: -- Type of nurse's note: Occurrence. -- Type of occurrence: bruising observed to left thigh (rear). -- 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. On 12/02/13 at 10:00 a.m., Employee #39, LPN, noted, blister to back of left thigh is open. Attending physician notified and new orders received to cleanse the area with normal saline solution and 4 x 4 pad and then apply [MEDICATION NAME] powder and cover with foam dressing daily for 7 (seven) days. An initial pressure wound assessment, dated 12/08/13, completed by Employee #52, registered nurse (RN), noted, Unstageable pressure ulcer on left buttocks, the area measures 3 cm (centimeters) in length and 2 cm in width with a depth of 0.2 cm with eschar noted in wound bed and surrounding skin reddened. Additional notes were, Resident is a quadriplegic and has no sensations down there. She was out to home on Thanksgiving Day and when she came back that evening she had a fluid filled blister noted. The blister has opened and there is eschar noted in the wound bed with peri-area pink and fragile. Review of the Wound Care Center notes revealed Resident #26 had a Stage IV (four) pressure ulcer located on the left ischial tuberosity. In an interview with Employee #52, RN, on 05/21/14 at 4:00 p.m., when asked, how the pressure occurred, she said, It was a blister that I think we had been watching for a few days prior to the initial pressure ulcer assessment which was completed on 12/08/14. I think the staff said the blister had ruptured when the resident's family took her home for Thanksgiving. When asked what type of wound a blister was considered according to the facility's protocol, she stated, A blister is a pressure ulcer. The nurse was asked whether the the wound on the rear of the resident's left thigh and the wound on the left buttock were the same or different areas. She answered, It is the same area. She was asked whether the area referred to in facility documentation as being on the left buttock was the same area the Wound Care Center's notes identified as located on the left ischial tuberosity. She answered, Yes. In an interview with Employee #73, RN, the Clinical Care Supervisor on 05/22/14 at 7:00 p.m., was asked according to the occurrence report and the nurses' notes what type of wound did Resident #26 have documented on her left thigh/buttocks starting on 12/01/13. She stated, It is a suspected deep tissue injury. When asked the location of the wound, she replied, The wound is located on the resident's left ischial tuberosity. During a telephone interview on 05/28/14 at 11:30 a.m. with Employee #42, LPN, who completed the occurrence report on 12/01/13, the nurse was asked what had happened to Resident #26 on 12/01/13. She said, Two nursing assistants, (Names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area. When asked about the portion of the occurrence form noting, The resident reported she thinks the metal bar in the lift pad could have caused it during transfer by pinching the skin, she stated, Resident #26 does not have any feeling below her waist, she did not know how it happened. The two (2) NA and I looked at the lift pad and there was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised, blistered area during the transfers and we felt the resident's skin probably got pinch by the lift pad. When asked whether the bruised, blistered area was noted prior that time, she said, No, not to my knowledge. Review of the comprehensive care plan, dated 03/11/14, found no interventions in place to prevent the worsening and/or the development of further deep tissue injury/pressure ulcers.",2018-04-01
6370,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,323,K,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Based on observations, record review, resident interviews, staff interviews, review of the Centers for Medicare and Medicaid State Operations Manual, and documentation provided by the facility, the facility failed to ensure the resident environment remained as free of accident hazards as possible. The facility also failed to ensure residents received needed supervision and assistance devices for safe transfer of residents requiring assistance for that activity. The facility had an ineffective program for assessing/implementing and reassessing residents after they had a functional status change in transfer ability. The facility also failed to implement an effective educational training program related to safe transfers with mechanical lifts and staff assisted transfers. This placed all residents who needed assistance with transfers in an immediate jeopardy situation. It had the potential to affect fifty-four (54) of sixty-one (61) residents residing in the facility who required transfer assistance. Residents #3, #30, and #66 were each observed being transferred by one (1) aide, although their care plans indicated they needed assistance of two (2) persons for transfers. Resident #26 received a suspected deep tissue injury (SDTI) as a result of being pinched by the lift pad during a full body lift transfer. The SDTI eventually became a Stage IV pressure ulcer. The improper use of the mechanical lift resulted in actual harm for Resident #26. Residents #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. The immediate jeopardy situation began on 05/14/14 when Resident #3 slid out of the sit to stand mechanical lift while being transferred from her wheelchair to her bed. The resident was transferred by one (1) aide assisting the resident ,when there should have been two (2) aides assisting the resident with the transfer, as was identified in her care plan. The facility was notified of the immediate jeopardy at 10:49 a.m. on 05/22/14. A plan of correction (P(NAME)) was provided by the facility at 3:50 p.m. on 05/22/14. The P(NAME) was accepted at 4:06 p.m. on 05/22/14. The plan of correction indicated the facility would do the following: 1. The facility's policy for assessment of residents for safe transfers and use of lifts has been updated. 2. All direct caregivers on duty have received training on the following from the Maintenance Supervisor, Director of Nursing Services, and/or RN (registered nurse) assessment coordinator: a. How to identify the transfer requirements of a resident through the P(NAME) (plan of care) Care Plan Kardex. b. How to correctly use the full body lift to transfer a resident requiring full body lift. c. How to correctly use the sit to stand lift to transfer a resident requiring sit to stand lift. 3. Resident #3, #66, and #30 have all been screened for transfer requirements. Physician orders [REDACTED]. Direct caregivers have been re-educated on the transfer requirements of Resident #3, #66 and #30. 4. All other residents will be assessed for transfer requirements. Physician orders [REDACTED]. Direct caregivers will be re-educated on the transfer requirements of all other residents. This will be completed by 05/23/14. 5. The executive director will ensure immediate compliance with this abatement plan by 05/23/14. 6. Changes in the transfer status of residents will be communicated to direct care staff on duty through verbal notification by the Unit Charge Nurse at the time the change is made. Other direct care staff will be made aware of the change through review of the resident's plan of care and CNA Kardex. 7. The Clinical Care Supervisor or designee will monitor this process weekly for compliance. At 7:15 p.m. on 05/22/14, the survey team observed for compliance in the areas related to direct care givers on duty receiving training, Residents #3, #66, and #30 being reassessed for transfer ability using the new assessment tool, and the newly developed policy was reviewed. Residents #3, #66, and #30 were also observed being transferred and were transferred in accordance with their newly completed assessments and in accordance with their plan of care. The training of all direct care staff on duty was also verified at that time. The immediacy of this deficient practice was abated at 7:15 p.m. on 05/22/14; however, a deficient practice still remained, so the scope and severity was decreased from a K to a G. Resident Identifiers: #3, #30, #66, #26, #78, #12, #5, and #60. Facility Census: 61. Findings Include: a) Resident #3 Review of Resident #3's medical record, on 05/21/14 at 5:00 p.m., revealed a nursing progress note dated 03/15/14. This note indicated the nurse aide (NA) reported to Employee #55, unit charge nurse/registered nurse (RN) that Resident #3 exhibited weakness and shakiness when being transferred with the sit to stand mechanical lift. This progress note indicated the following actions were taken: This Nurse, (Employee #55) observed resident being transferred by staff with assist of sit to stand mechanical lift. Noted resident to have coarse tremors noted to upper extremities when grasping handles of lift. Resident does not attempt to put feet into designated foot pad area of lift. Staff assisted with placement of feet/legs. Resident c/o (complained of) pain in shoulders when being transferred with lift. Reports pain subsides after transfer complete. The outcome section of the note stated: Spoke with OT (occupational therapy) staff regarding safety concerns with transfer utilizing sit to stand lift. She advises that OT services do not make recommendations concerning use of lifts, that this is a matter of safety to be determined by nursing staff. Reviewed matter with physician. N.O. (new order) received to transfer resident with as much assistance as required to ensure resident and staff safety. MPOA (medical power of attorney) aware and agreeable with plan of care. Employee #55, RN, wrote another progress note concerning Resident #3 on 03/16/14. This note indicated Resident #3 was upset about having to use the full body lift and she wanted to use the sit to stand mechanical lift. Employee #55 documented she told Resident #3 the new order was for her to be transferred with the amount of assistance necessary to ensure her safety. Resident then told Employee #55, Well, I've never offered to fall in all the times I've been using that lift I'm not going to fall. Employee #55 then documented the following, Again explained to resident that it was a safety concern because of noted weakness/tremors and difficulty maintaining standing position when being transferred, and that this presented a risk for fall. Employee #55 offered the resident the possibility to be referred to Physical therapy for strengthening exercises to which the resident replied, Oh No. I can't do them exercises. My arms and legs are too weak. The (they) hurt my arms and legs. Employee #55 then reminded resident again that weakness is the reason the transfer orders were changed. The resident did not reply and propelled herself away from the nurses' station. There were no other progress notes, physician's orders [REDACTED].#3's transfer status until her fall on 05/14/14 from the sit to stand mechanical lift. The sit to stand lift was the lift identified as unsafe for transfers of this resident on 03/15/14. Resident #3 had an occurrence note dated 05/14/14. This note indicated Resident #3 had a fall on 05/14/14, sustaining a 5 cm (centimeters) X (by) 7 cm bruise to her outer right antecubital area with no swelling or open areas observed. There was an additional occurrence note dated 05/15/14, which discussed Resident #3's fall and indicated the equipment involved in the fall was the sit to stand lift. An occurrence follow-up note, dated 05/18/14, written as a follow up to the occurrence note on 05/14/14, indicated the intervention put into place to prevent reoccurrence was, Resident to use full body lift for transfers. Additional occurrence follow-up notes dated 05/19/14, 05/20/14, and 05/21/14 indicated the interventions put into place to prevent reoccurrence were to educate staff on proper transfers. Review of the incident report regarding this fall revealed the resident slid off her bed onto the floor. Employees #25, a nurse aide (NA), stated, 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. Employee #61, social services supervisor, provided additional documentation regarding Resident #3's fall on 05/14/14. She had written a note on a form titled, Daily Contacts. This note stated, Spoke with resident about fall which was reported to SW (social worker) earlier. Resident stated she was on the lift between beds and her hands slipped and she fell towards her bed. She stated it was no one's fault, 'it just happened.' She was not hurt. On the same form titled, Daily Contacts, dated 05/16/14, was an unsigned note, SW (Social Worker), CCS (Clinical Care Supervisor), and DON (Director of Nurses) met to discuss occurrence. Order for full body lift to be obtained for resident safety. The resident's medical record contained a general patient note dated 05/18/14. This note indicated the resident was upset d/t (due to) having to use a full body lift. The nurse explained to the resident that for her safety, she would have to be transferred with the full body lift. The resident was noted to be unhappy with this decision. The resident's transfer status was not reassessed as a result of her being unhappy, and there was no indication the resident's transfer status was changed back to a sit to stand lift. Additionally there was no indication this matter was discussed with Resident #3's medical power of attorney (MPOA). Review of Resident #3's care plan revealed an intervention of, Transfer Self-Performance: (Resident #3) requires assist of 2. (Resident #3) 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. Resident #3 had a physician's orders [REDACTED]. This order was discontinued on 03/15/14. Another order dated 03/15/14 was, Transfer Order: Resident to be transferred with amount of assistance required to ensure resident /staff safety. This order was the current order at the time of this review. This order was not consistent with the resident's care plan or Kardex because neither was updated to reflect the changes identified in the physician orders [REDACTED]. Resident #3 was observed being transferred on 05/22/14 at 9:15 a.m. with a mechanical sit to stand lift. Employee #3, nurse aide (NA), was assisting the resident during the transfer. Employee #3 indicated she transferred Resident #3 by herself all the time because the resident was able to hold on to the lift and was not likely to fall. She stated she would have someone assist her if the resident was unable to hold on to the lift and was at risk for falling. Review of the in-service records related to lifts for Employee #3 on 05/23/14 at 1:00 p.m., found a form signed by Employee #3 dated 05/17/01, titled Back Injury prevention program (BIPP) Resident Lifting/Transfer Policy. This form indicated the facility was a No Lift work place and had provided mechanical lifting equipment to achieve this goal. The form also indicated the following, . it will be mandatory as of January 1, 2001 that no resident be lifted or transferred without the proper situation, any situation that in your judgment makes use of the equipment inappropriate. A Check-Off List, in the in-service records, for the correct usage of lifts, dated 07/19/11, indicated Employee #3 was in-serviced on all aspects of correctly using the lifts and gave a return demonstration on using the lift correctly. This was completed for the, Hoyer Sit to stand 400 lbs. (pounds), Hoyer sit to stand 750 lbs. and Hoyer Full Body 400 lbs. Employee #3 had also attended an in-service, dated 12/27/12, for training on sling/lift proper placement. Despite receiving in-service education on the correct way to use the lift, Employee #3 still transferred Resident #3 with the sit to stand lift in a manner that was not consistent with the resident's care plan. This observation, on 05/22/14, found Employee #3 transferring residents incorrectly. The education provided to this employee was ineffective as evidenced by her continuing to transfer residents via mechanical lift with only a one (1) person assist. When interviewed, the employee acknowledged she, Did it all the time. On 05/22/14 at 10:52 a.m., Employee #25, the NA, who had transferred Resident #3 on 05/14/14, the night the resident had the fallen from the lift, was asked what had happened the night of the fall. Employee #25 stated she was assisting the resident to bed using the sit to stand lift with Resident #3. Employee #25 indicated she was the only staff member in the room at the time of the fall. She confirmed, she should have had another staff member with her when operating the lift, but did not go and 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, lifted up her feet, and began to slide to the floor. She stated the resident's arms were tangled in the lift sling and she had to raise the lift a little to get the resident's arms out of the sling. She stated she then went and got another NA and the Licensed Practical Nurse (LPN) to help her get the resident back to bed. When asked if she had ever been trained to use the lifts, Employee #25 indicated they had annual in-services, watched a slide show, and took a test regarding the use of lifts. She stated she did not recall the last time she had taken this in-service. She stated the DON or another RN would train them on the use of lifts. 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. The policy also included that as of 11/15/05, two (2) persons be in attendance with all mechanical lifting episodes. According to the in-service records, Employee #25 also attended an in-service on Full body slings, provided on 11/18/13 by Employee #53, the maintenance supervisor. At 12:45 p.m. on 05/22/14, Employee #64, NA, was asked if she was working the night of 05/14/14 when Resident #3 fell . She stated she did not know a lot about the fall, she was just told the resident had fallen by Employee #25. Employee #64 was asked if she ever worked with Resident #3. She confirmed she did. She was asked if she had ever had any problems with Resident #3 letting go of the lift or if she had any concerns about transferring Resident #3. She stated a few weeks before, Resident #3 had fallen from the lift. They had told the RN the resident was sliding, her legs were shaking, and her knees were buckling. She also indicated Resident #3 had also let go of the handles before with one hand. She stated if she would let go with both hands she would slide out of the lift. She stated when therapy reevaluated residents for the lifts, they did it in the morning when the residents were fresh, and not in the evening when they were tired. She stated she felt they needed to evaluate the residents in the evening when they were tired. She indicated they changed Resident #3 to a full body lift for about 2 (two) days, and then they switched her back to the sit to stand lift. Employee #64 was asked if she had been trained on the proper use of the mechanical lifts. She stated when she started to work at the facility, the other aides would watch the new NAs use the lift to make sure they were doing it correctly. She stated, We usually have an in-service in rotation once a year about the safety of the lifts. She stated a nurse would go over everything and would verbally discuss the lifts with the staff. When asked how many staff members need to be present when using a mechanical lift, she replied, At least two (2). When asked how she determined what type of assistance a resident needed with transfers, Employee #64 stated if it was a new resident, she would look at the Kardex. She stated if it was not a new resident, the nursing staff would give them report, and that was how they knew how to transfer their residents. She stated, If we are off a few days, the other aides try to fill us in because it is like a whole new world after you are off a few days. She also stated it was always in the Kardex. She reported she would try to look at the Kardex at least once a week to see if anything had changed. Review of in-service records for lift training found Employee #64 signed a Back Injury Prevention Program (BIPP) Resident Lifting/Transfer Policy on 04/29/13. The policy included that as of 11/15/05, two (2) persons be in attendance with all mechanical lifting episodes. The facility was unable to provide any other in-service records for this employee. Employee #32, NA, was interviewed at 1:03 p.m. on 05/22/2014. Employee #32 stated she was working the night Resident #3 had fallen from the lift. She stated the only thing she did to assist with Resident #3 after she fell was to help the other aide and the LPN get the resident back in bed. She stated they should have used the lift to transfer her from the floor to the bed but they did not. She reports they just manually lifted the resident back to bed. Employee #32 stated she always had two (2) staff members present when she used a lift. She stated there would never be a time when it would be appropriate for just one (1) person to be present. Employee #32, when asked if she had been trained on the appropriate use of the lifts, stated her CNA (certified nursing assistant) instructor had trained her when she took the CNA class. She stated when she began to work here, the other aides would watch you and make sure you knew how to use the lifts. She stated she was not sure if she has attended any training or in-services on the use of lifts since she has been employed her. She did state, I have missed a few in-services though. The facility was unable to locate any in-service records related to lifts for Employee #32. When asked how she knew how to transfer a resident, she stated she would look in the Kiosk, at the Kardex, or someone would tell you verbally if you had been off a few days. She stated she only looked at the Kardex when she needed to, such as when there was a new resident or if she would have a question about something. She stated if something changed with the current residents, the other staff would just tell you verbally. 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. She stated, Employee #25 had come and got her and told her Resident #3 had fallen. She stated when she entered the room, the resident was on her buttock beside the bed with her legs fully extended and her feet were still resting on the foot base of the sit to stand lift. Employee #56 confirmed Employee #25 was the only aide assisting the resident with her transfer. She stated the aide should have had another aide assisting her. When asked how they transferred the resident from the floor to the bed, she stated she and two (2) other NAs picked the resident up and put her in the bed. She stated they should have used the other lift to get the resident from the floor to the bed, but they did not. The facility's policy titled Subject: Lifts-Sit-To Stand, Hoyer (full body), with a revision date of 11/11/10 was reviewed. This policy included, Policy (Name of Facility) mission is to provide the safest way of transporting a resident to prevent harm to a resident and staff by way of the 2-types of lifts provided at the facility. The following procedures will be followed by the manufactures recommendations and the OSHA regulations. 1. Each resident will be evaluated upon admission by RN assessment within 24 hours of admission if resident requires a lift, by following check off list to determine which lift to use. 2. PT (Physical Therapy) will screen each resident for safety measures of using the proper lift ordered for the resident. In an interview the evening of 05/21/14, Employee #72, DON, was asked to provide a copy of the check off list mentioned in the policy and/or the assessments completed by PT regarding Resident #3. She stated there was not a check off list. She indicated nursing completed a head to toe assessment upon admission, but did not complete a check off list. She was unable to provide any documentation to suggest therapy had evaluated Resident #3 and determined it safe for her to use a sit to stand lift. b) Resident #30 During an interview with Employee #3, NA, at 8:40 a.m. on 05/22/14, she stated that they could use the lift with either one (1) aide or two (2). She indicated she reviewed the Kardex each morning and this was how she knew what assistance each resident needed for the transfers. She indicated if the resident was able to hold on to the handles and able to stand up once the lift assisted them up, she did not get another staff member to help with the transfer. She stated if the resident was not able to do this, then they have to notify the nurse. Resident #30 was observed being transferred at 9:08 a.m. on 05/22/14. Employee #3, NA transferred this resident using a sit to stand lift from the edge of her bed to her wheelchair. Employee #3 completed this transfer by herself. Review of Resident #30's medical record at 9:15 a.m. on 05/22/14, revealed a care plan intervention of, Transfer Self-Performance: (resident name) requires extensive assist of 2 (two). May use sit to stand lift as needed for transfers. (Resident Name) uses 1/2 side rails and her wheelchair for balance and is able to stand and pivot. (Resident name) may use the sit to stand lift as needed for transfers, safety. This intervention was initiated on 12/13/13, revised on 01/03/14, and was the current care plan intervention at the time of this review. This care plan intervention was also noted on Resident #30's active Kardex at the time of this review. On 05/23/14, a review of the reportable incidents for the previous 12 months revealed a reportable incident dated 09/26/13 for Resident #30. This incident indicated Resident #30 was transferred via full body lift and bumped her forehead on the lift causing a reddened area. The facility completed an investigation into this incident and found that Employee #23 and Employee #86 were transferring Resident #30 using a full body lift on 09/26/13. The resident was instructed to fold her arms, but instead, grabbed the bar and bumped her forehead on the bar of the full body lift. Review of the incident report found it indicated the nurse, Informed CNA's to be more careful during transfers and to watch placement of head during lift. This was a step taken to prevent reoccurrence. On 05/29/14 at 5:25 p.m., Employee #72, DON, was asked to provide evidence of the education provided to Employee #23 and Employee #86, but was unable to do so. She stated the education provided was verbal and was not documented anywhere. The medical record review revealed an order dated 09/16/13, which stated to use a full body lift for transfers. This order was discontinued on 09/30/13. Interview with Employee #73, Clinical Care Supervisor (CCS) Registered Nurse (RN) at 5:33 p.m. on 05/29/14, revealed the resident had to have a change in transfer orders because she had a [PR(NAME)EDURE] and was unable to use the sit to stand lift temporarily. She reported she was switched back to the sit to stand lift on 09/30/13. She stated at that time they did not have specific transfer orders and assessments, so it was just assumed when the full body lift order was discontinued, she would be transferred with the sit to stand lift when unable to tolerate the stand and pivot transfer. The facility was unable to provide an order for [REDACTED]. The next order, dated 05/22/14, and entered after the facility was notified of the immediate jeopardy situation, was for the resident to be transferred via stand and pivot with the assistance of two (2). The order indicated the resident was to be transferred via full body lift when unable to tolerate stand and pivot with assist of 2. This order was consistent with the Lift/Transfer Screening completed on 05/22/14 as a result of the immediate jeopardy. c) Resident #66 A review of the care plan, on 05/21/14 at 6:24 p.m., revealed Resident #66 required the extensive assistance of two (2) with transfers on/off the toilet. A review of the nursing assistant Kardex, on 05/21/14 at 6:30 p.m., revealed Resident #66 required the extensive assistance of two (2) for all transfers. In an interview, on 05/2214 at 9:20 a.m., with Employee #3 nursing assistant (NA), when asked what type of transfer assistance Resident #66 required, she stated she was required to check her resident every two (2) hours and assist her to the bathroom for toileting. She stated that she would transfer her with a gait belt from the wheelchair to the toilet. During an observation on 05/22/14 at 9:40 a.m., with Employee #72, the director of nursing (DON), Employee #5, nursing assistant (NA), transferred Resident #66 from the toilet to the wheelchair with the assistance of one (1) person and without a gait belt. On 05/22/14 at 9:40 a.m., Employee #3 (NA) and the DON read the Kardex on how Resident #66 was to be transferred. Employee #3 said the resident required the assistance of two (2) people for transfers. Employee #3 then admitted she did not transfer Resident #66 with two assistants and a gait belt on 05/22/14. During an interview with the DON, on 05/22/14 at 10:10 a.m., when asked whether the nursing assistant transferred this resident properly, she stated, No. The DON agreed the nursing assistant should have transferred Resident #66 in accordance with the instructions on the Kardex. The DON stated the nursing assistant did not ask her to help with the transfer. On 05/22/14 at 10:40 a.m., the revised policy, dated March 2004, that addressed moving a resident from the bed to chair/chair to bed was reviewed. The policy instructed, if a resident could not stand alone staff were to use two (2) persons (one on each side), apply the gait belt on the resident, gently stand and turn the resident and sit him or her in the chair. d) Resident #26 Medical record review, on 05/21/14 at 2:30 p.m., revealed this resident was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Her admission comprehensive assessment indicated that she had a score a 15 on the Brief Interview for Mental Status (BIMS); which indicated the resident was cognitively intact During an interview with the resident, at 10:51 a.m. on 05/19/14, she stated, The staff says my pressure ulcer is from a blood blister caused by being pinched by a lift pad during a transfer, although I don't know because I have no feeling from the waist down. A review of the nurses' notes for Resident #26, found an entry dated 11/28/13 at 9:00 a.m., that included, Skin evaluation completed. Resident has no edema, rash, excoriation, skin tear, bruising or skin breakdown noted. Further review of nurses' notes revealed an Occurrence note entered on 12/01/13 at 4:07 p.m. by Employee #42, licensed practical nurse (LPN). The entry included, bruising observed to left thigh (rear). Nursing Assessment: purple bruising to left thigh 2cm (centimeters) in length x (by) 1cm 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. A note by Employee #39, LPN, on 12/02/13 at 10:00 a.m., included, blister to back of left thigh is open. Attending physician notified and new orders received to cleanse the area with normal saline solution and 4x4 pad and then apply polysporin powder and cover with foam dressing daily for 7 (seven) days. In an initial pressure wound assessment, dated 12/08/13, Employee #52, RN, noted, Unstageable pressure ulcer on left buttocks, the area measures 3cm in length and 2cm in width with a depth of 0.2 cm with eschar noted in wound bed and surrounding skin reddened. Additional notes were, Resident is a quadriplegic and has no sensations down there. She was out to home on Thanksgiving Day and when she came back that evening she had a fluid filled blister noted. The blister has opened and there is eschar noted in the wound bed with peri-area pink and fragile. Review of the Wound Care Center notes revealed Resident #26 had a Stage IV (four) pressure ulcer located on the left ischial tuberosity. In an interview on 05/21/14 at 4:00 p.m., Employee #52, RN, was asked how the pressure ulcer occurred. She replied, It was a blister that I think we had been watching for a few days prior to the initial pressure ulcer assessment which was completed on 12/08/14. I think the staff said the blister had ruptured when the resident's family took her home for Thanksgiving. When asked, According to the facility wound protocol, what type of wound is a blister? she stated, A blister is a pressure ulcer. When asked whether the wound on the rear of the resident's left thigh and the wound on the left buttocks were the same or different areas, she said, It is the same area. When asked, whether the wound care center's notes identifying the wound as located on the left ischial tuberosity, was this the same area the facility was calling the left buttock, she answered, Yes. Employee #42, LPN, the nurse who completed the occurrence note on 12/01/13, was interviewed by telephone on 05/28/14 at 11:30 a.m. When asked what had happened to Resident #26 on 12/01/13, she said, Two nursing assistants, (names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area. She was asked about the occurrence form statement, the resident reported she thinks the metal bar in the lift pad could have caused it during transfer by pinching the skin. She stated, Resident #26 did not have any feeling below her waist, she did not know how it happened. The two (2) nurse aides and I looked at the lift pad. There was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised blistered area during the transfers. We felt the resident's skin probably got pinch by the lift pad. When asked, whether the bruised, blistered area was noted prior to that time, she said, No, not to my knowledge. A review of current comprehensive care plan revealed no interventions had been initiated since the injury on 12/01/13 involving the lift pad pinching her skin causing a suspected deep tissue injury. An interview with the director of nursing, Employee #72, on 05/27/14 at 2:00 p.m., confirmed the resident's care plan was not revised to include precautions with the use of lift pads during transfer. No actions (TRUNCATED)",2018-04-01
6371,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,371,E,0,1,OMIN11,"Based on observation and staff interview, the facility failed to ensure food was stored under sanitary conditions. Unlabeled, undated, and/or expired food Items were found in the pantry refrigerator at the nursing station. This had the potential to affect more than a limited number of residents who consumed food by oral meals. Facility Census: 61. Findings include: a) Nutrition Pantry An observation of the nutrition pantry refrigerator was conducted during the initial tour of the facility on 05/19/14 at 9:30 a.m. The following was found in the refrigerator: 1. Light tuna sandwiches with no resident's name. The date the sandwiches were to be removed from the refrigerator was 05/18/14. 2. One (1) large ketchup bottle with no name or date. It had a manufacturer's expiration date of 04/28/13. 3. One (1) container of grape jelly with no name or date. The manufacturer's expiration date was August 2013. 4. Half a loaf of Heiner's old fashioned bread with no name or date indicating when the bread was opened. 5. A Styrofoam container with a barbeque sandwich, baked beans, and potato wedges. It had no name or date regarding when the items were obtained. 6. Two (2) servings of rice pudding in a container with no name or date of opening. 7. Homemade bread wrapped in aluminum foil with Resident #49's name. The discard date was 05/11/14. 8. A plastic bag with Resident #27's name on the bag. It contained four (4) bananas, four (4) pieces of cheddar cheese pieces, and one (1) pickle. There was no date regarding when the items were placed in the refrigerator. 9. A plastic bag had a serving of watermelon in a container. It had no name or date. b) Employee #73, was present during the observation of the nutrition pantry refrigerator. She confirmed the listed items were not appropriately labeled, and/or discarded timely. c) An interview was conducted with Employee #66, the dietary supervisor, at 9:40 a.m. on 05/19/14. When informed of these findings, she stated the reason the nutrition pantry was not cleaned out was because a dietary aide called in that morning.",2018-04-01
6372,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,441,E,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to maintain an infection control program to prevent the transmission of disease and/or infection to the extent possible. Dirty oxygen concentrator filters and outdated, unchanged oxygen tubing were observed for six (6) of fourteen (14) residents receiving oxygen therapy. In addition, the facility failed to keep resident care equipment in good repair, which inhibited its ability to be cleaned for infection control purposes. Residents #32, #15, #29, #63, #41, and #19 all had dirty concentrator filters and/or outdated/unchanged oxygen tubing. A random observation noted Resident #46's wheelchair had cracks in the material on the seat which would inhibit effective cleaning. Resident Identifiers: #32, #15, #29, #63, #41, #19, and #46. Facility Census: 61 Findings Include: a) Resident #32 Resident #32's oxygen concentrator was observed at 10:40 a.m. on 05/20/14. The tubing which was currently in use for Resident #32 had a date of 04/2?/14. The date was not legible to determine if it was the 20th-29th. Resident #32's filter on her oxygen concentrator, which was supposed to be black in color was observed to be white due to the amount of dust which had collected on the filter. Employee #73, Clinical Care Supervisor (CCS), Registered Nurse (RN) was interviewed at 10:45 a.m. on 05/20/14. She indicated all residents who had orders for oxygen should have their tubing changed every two (2) weeks. She stated the tubing should not be dated 04/2?/14. She stated they can either date it for the date they change it, or they can put the date when it needs to be changed. She stated either way, the tubing was outdated and should not have been on the machine. Employee #73 also confirmed the filter was dirty and needed to be cleaned. Review of the resident's medical record, at 10:06 a.m. on 05/21/14, revealed an oxygen order dated 03/13/14, which was for oxygen at 2 liters per minute (L/m) continuously. Resident #32's treatment administration record (TAR) was reviewed for the months of April 2014 and May 2014. The TAR contained the following: Change Humidifier and tubing q week. Every night shift every 7 days. The TAR also contained a directive to Clean Filters on concentrator q week and prn (as needed). The TAR indicated the resident's tubing was changed on 04/23/14, 04/30/14, 05/07/14, 05/14/14; however, when observed on 05/20/14, the tubing still had a date of 04/2?/14. The TAR indicated the filter was also cleaned on 04/23, 04/30, 05/07, and 05/14, but based on observation, it had not been cleaned as required, as it was covered in dust. b) Resident #15 Observation of Resident #15's oxygen concentrator, on 05/20/14 at 1:21 p.m., found the oxygen concentrator was covered with dust. Employee #73, CCS, RN, was interviewed at 1:25 p.m. on 05/20/14. She confirmed the filter on Resident #15's oxygen concentrator was dirty. She removed the filter and a plume of dust went into the air. Review of Resident #15's medical record, at 10:50 a.m. on 05/20/14, revealed Resident #15 had an order dated 11/02/13 for oxygen at 2 L/min via nasal cannula at bedtime due to apnea. His TARs for the months of April 2014 and May 2014 were reviewed and contained the following orders, Change Humidifier bottle and tubing every week. The TAR indicated this was performed on 05/13/14, 05/20/14, 05/06/14, 04/08/14, 04/15/14, 04/22/14, and 04/29/14. Resident #15's TAR did not contain an order to clean the filter on the oxygen concentrator. c) Resident #29 Resident observation at 10:50 a.m. on 05/20/14 revealed the resident's oxygen tubing was dated 04/19/14. An additional observation was conducted at 10:55 a.m. At that time, Employee #41, Licensed Practical Nurse (LPN), was observed in the resident's room changing the oxygen tubing. She confirmed she had just changed the oxygen tubing. she confirmed the resident's previous tubing was dated 04/19/14, and should have been changed prior to this date. Review of the resident's TAR for the months of April 2014 and May 2014 revealed an order to Change tubing q (every) week and Clean filter Q (every) week. Neither order was placed on the TAR until 05/21/14. d) Resident #63 Resident #63's oxygen concentrator was observed 11:00 a.m. on 05/20/14. Employee #41, LPN, was present during the observation and confirmed the resident's filter on the oxygen concentrator was dirty and needed to be cleaned. Resident #63's medical record was reviewed at 11:15 a.m. on 05/21/14. It showed the resident had an order for [REDACTED]. This order had a date of 12/15/13. The resident's TAR was reviewed and contained the following order Change humidifier bottle and tubing q week every night shift on Tuesday. The TAR also indicated the filter should be cleaned every week and prn (as needed). The TAR indicated the tubing was changed and the filter was cleaned on 05/06/14, 05/13/14, 05/20/14, 04/08/14, 04/15/14, 04/22/14, and 04/29/14. e) Resident #41 Resident #41's oxygen concentrator was observed at 10:42 a.m. on 05/20/14. The oxygen concentrator filter was observed to be dusty. At 10:57 a.m. on 05/20/14, Employee #41, LPN, confirmed she had just cleaned the filter. The filter was observed to be wet to the touch at that time. Employee #41 confirmed she had just cleaned the filter because it was dusty. Resident #41's medical record was reviewed at 11:20 a.m. on 05/21/14. Her medical record did not contain any orders related to when oxygen tubing should be changed, nor did it indicate when the filter on the oxygen concentrator should be cleaned. f) Resident #19 At 11:02 a.m. on 05/20/14, Resident #19's oxygen concentrator was observed to have a dusty filter in place. Employee #73, CCS, RN, confirmed the filter was dirty and the resident was just started on oxygen that day, so it had to be set up with a dusty filter in place. Resident #19's medical record was reviewed at 10:54 a.m. on 05/21/14. Resident #19 had an order dated 05/20/14 for Oxygen at 2 liters per minute via nasal cannula. This order was given at 9:37 a.m. which was one (1) hour and 25 minutes prior to the time the dusty filter was observed. g) Resident #46 On 05/29/14 at 5:00 p.m., an observation was made of Resident #46's wheelchair. The seat in Resident #46 's wheelchair had cracks in the material, which would hinder effective cleaning of the seat. At 5:15 p.m. the administrator (Employee #70) observed the wheelchair. He said he would have someone from housekeeping look at the wheelchair. During an interview with Employee #60 (housekeeping supervisor), she indicated she would have maintenance take care of the cracks in Resident #46's wheelchair seat.",2018-04-01
6373,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,490,F,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, policy reviews, review of incident reports, review of resident council minutes, review of reportable abuse allegations, review of water temperature records, review of personal funds documentation, review of activity calendars, resident interviews, and staff interviews, the administration failed to ensure the facility was administered in an efficient and effective manner to maintain the highest practicable physical, mental and psychosocial well-being of more than a limited number of residents. In the areas of resident rights, the facility failed to ensure a resident's right to privacy, the right to be notified of changes in condition following an incident, the right to be informed of the balance of personal funds handled by the facility on a quarterly basis, the right for security of personal funds managed by the facility by ensuring the surety bond is sufficient amount, the right for prompt efforts to resolve grievances, and the right to readily accessible survey results. In the area of resident behavior and facility practices, the facility failed to report and investigate allegations of abuse and neglect, and failed to implement the facility's abuse and neglect policies. In the areas of quality of life, the facility failed to provide an ongoing program of activities in accordance with the comprehensive assessments and/or voiced interests, failed to listen and act upon the resident council's concerns regarding activities and the right to privacy, failed to provide medically-related social services to assist a resident in resolving a conflict with a roommate, and failed to provide housekeeping/maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. In the area of resident assessment, the facility failed to ensure the Care Area Assessment (CAA) summary, a part of the comprehensive assessment, was completed. The location, date, and source of the documentation used to complete the CAAs for triggered areas was not identified in Section V - the CAA Summary or in the CAA itself. In the areas of quality of care, the facility failed to provide care and services to prevent an avoidable pressure ulcer, failed to ensure the resident environment remained as free of accident hazards as possible, and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. In the area of medical records, the facility failed to ensure medical records were readily accessible to facility staff and the survey team. Staff were not knowledgeable of how to use the facility's computer program. This is where direct care staff document the actual care residents receive. The lack of knowledge resulted in an inability for staff to use and/or provide essential information which was only available in the P(NAME) computer program. In addition, ordered neurological assessments and vital sign documentation after incidents were found incomplete and/or inaccurate. These issues, which had the potential to affect all residents, were identified during the survey from [DATE] through [DATE]. Facility census: 61. Findings include: a) The facility failed to ensure Resident #24 was afforded the opportunity to exercise her rights about how she lived in the facility. Resident #24 had a private room. Recently, on two (2) occasions, she had returned to her room to find other residents in her bathroom. On another occasion, housekeeping had found her dentures on the floor. The resident said she had found her bed messed-up also. The resident said her door was supposed to be closed, but staff did not consistently close the door when exiting the room. These issues had been reported to the Social Services Supervisor and voiced in the Resident Council Meetings. There was no evidence of any evaluation of the effectiveness of any interventions that were implemented. No one had followed up with the resident to determine whether the problem was resolved. b) The facility failed to make prompt efforts to resolve grievances voiced by two (2) 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. c) The facility failed to immediately inform Resident #26 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 occurred. The incident occurred at 4:07 p.m. on [DATE], but the resident was not informed until 8:47 a.m. on [DATE]. In an interview , on [DATE] at 10:15 a.m., the resident said she did not realize the injury had occurred because she had no feeling from her waist down due to paralysis. d) 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 (#7, #21, and #22) reviewed for personal funds. It was found the nursing home administrator had received and signed the statements. 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. e) The facility failed to ensure a final accounting of Resident #79 funds, that were managed by the facility, were conveyed to the individual administering the resident's estate or probate jurisdiction within thirty (30) days of the resident's death. f) 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. The account balance exceeded the amount of the facility's surety bond on at least two (2) occasions. g) The facility failed to ensure Resident #52 was afforded privacy during personal care. In an interview of [DATE] at 8:17 a.m., Employee #29, a housekeeper, stated about three (3) or four (4) months ago he reported an incident of alleged abuse involving Resident #52. This involved the male housekeeper being present in the resident's room and able to witness the provision of personal care, during which the alleged abuse occurred, for a female resident. Employee #67, the SSS, was interviewed at 12:00 p.m. on [DATE]. 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 resident's residing in the four (4) bed ward. h) The facility failed to post a sign informing residents of where the most recent State and Federal survey results were located. i) 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. j) The facility failed to implement their written abuse/neglect/misappropriation of resident property policies 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. Facility staff also observed abuse of Residents #59 and #62, but did not immediately report the abuse to their supervisor. Policies and procedures related to these situations were contained in the facility's policy titled, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident/Reporting and Investigation. k) The facility failed to act upon grievances voiced by the resident council in areas related to resident rights and resident activities. Resident #24 had voiced concerns related to activities and resident privacy in resident council meetings. She felt the facility had not acted upon those concerns. Residents #24, expressed a concern about the lack of privacy in her room, despite having a private room. The facility had failed to implement effective measures to ensure the resident's right to privacy and failed to follow up with the resident on resolutions. Residents #56, #48, #76, #13, #9, #4, #10, #24, #15, #46, and #35 had expressed interest in out of facility activities such as going to the Senior Center, shopping, and/or fishing. The facility had not provided any out of facility activities for more than 12 months. l) The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessments and/or voiced interests for twelve (12) of thirteen (13) residents reviewed for activities during Stage 2 of the survey. The residents were not provided activities for which they were assessed and/or expressed interest. Resident #3 expressed a desire to attend Sunday school at the facility each Sunday, but was not afforded the opportunity to do so. Residents #56, #48, #41, #13, #9, #4, #10, #24, #15, #46, and #35 expressed interest in attending activities outside the facility; however, the facility had not provided out of the facility activities on an on-going basis. The comprehensive minimum data set (MDS) assessments for each of these residents indicated these residents' activity preferences for religious activities and/or for out of the facility activities. m) The facility failed to provide medically-related social services for one (1) of one (1) resident reviewed for the care area of social services during Stage 2 of the survey. The facility did not assist the resident in finding an option to meet her physical and emotional needs. There was no attempt to help resolve Resident #67's conflict with the her roommate, whose television was disturbing the resident's ability to sleep well at night. Employee #61, social services supervisor (SSS), was interviewed at 12:33 p.m. on [DATE]. 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. n) The facility failed to provide maintenance and housekeeping services to maintain a comfortable and sanitary interior in eight (8) resident rooms/bathrooms and a resident common area. Resident rooms/bathrooms were observed with walls, ceilings, and/or doors in disrepair. The 100 Hall shower room was observed with dirty exhaust fans. Oxygen concentrators for six (6) residents (#32, #15, #29, #63, #41, and #19) of 14 residents who received oxygen therapy had dirty filters and/or outdated tubing. The wheelchairs for Resident #3 and #46 were not clean. It addition, Resident #46's wheelchair had cracks in the seat, rendering it unable to be effectively cleaned and sanitized. o) The facility failed to complete the required documentation for the care area assessments and triggers for twenty-four (24) of forty-nine (49) residents whose Minimum Data Set (MDS) assessments were reviewed in Stage 2 of the Quality Indicator Survey (QIS). (Residents #26, #73, #25, #29, #53, #36, #61, #33, #66, #13, #9, #10, #31, #17, #3, #12, #5, #60, #18, #51, #28, #27, and #40.) The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. p) The facility failed to develop comprehensive care plans, including measurable goals and timetables, to assist four (4) of forty-nine (49) residents in attaining the highest level of well-being. Oral needs were not addressed for Resident #33. The risk for falls was not addressed for Resident #25. There was no care plan for Resident #78 regarding the amount of assistance needed in transfers. A care plan was not developed for Resident #26, regarding the risk for injuries during transfers. 1. Resident #33 complained of pain in her jaw and mouth on [DATE]. She had a sore under her tongue and a white patchy area was noted on the inside of her cheek. She was diagnosed with [REDACTED]. Review of her care plan, on [DATE] at 4:42 p.m., revealed there was no care plan, with measurable goals and interventions, regarding the care needed for the resident's oral condition. 2. Resident #25 had [DIAGNOSES REDACTED]. The resident had experienced a fall prior to her admission to the hospital, and was at high risk for falls. The resident was also prescribed anti-[MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) and [MEDICAL CONDITION] ([MEDICATION NAME]) medications on a daily basis, which can contribute to falls. The episodic care plan contained no focus, goals, or interventions related to the risk of falls. The resident had a fall five (5) days after admission. At that time, a care plan for falls was developed. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She developed a pressure ulcer from being pinched by a lift pad during a transfer. The resident had no feeling from the waist down, so she was unaware she was injured. It was surmised the metal bar in the lift pad could have caused the injury during the transfer. The resident's care plan had no interventions regarding the safe use of the lift and/or lift pad with Resident #26. 4. Resident #78 had an interim care plan completed upon admission. It indicated she was to be transferred with physical assistance of two (2) persons. The resident's minimum data set (MDS) admission assessment indicated the resident required the assistance of two (2) persons for transfers. T resident's comprehensive care plan contained nothing which indicated she required the assistance of two (2) for transfers. On [DATE], the resident was transferred by only one (1) nursing assistant,from her wheelchair to the toilet. At that time, the resident received a 9 centimeter (cm) skin tear to her right outer calf. q) The facility failed to revise the care plans for four (4) of forty-nine (49) residents reviewed for accidents. The care plans were not revised to address fall prevention and/or changes in planned interventions to prevent falls. 1. Resident #33 had accidents resulting in injury on [DATE], [DATE], and [DATE]. The resident's care plan was not revised after any of the accidents to address the prevention of falls, and the resident's care plan had no interventions specifically related to accident prevention. 2. Resident #66 fell on [DATE], [DATE] and [DATE]. Each of the falls was related to the resident going to the bathroom without assistance. A bed alarm was not effective and an intervention to educate the resident to use her call light was not realistic because of the resident's decreased cognitive status. The resident's care plan was not revised, after the falls, to reflect her individual needs. In addition, the resident had a care plan for an individualized toileting plan to avoid incontinent episodes which was not implemented. 3. Resident #13 had falls on [DATE] and [DATE]. A care plan for falls was initiated, related to the [DATE] fall. The plan included a review of information on past falls and an attempt to determine the cause of the falls. The facility was going to determine possible root causes and alter or remove any potential cause if possible. Education of the patient/family/interdisciplinary team as to causes was to occur. There was also a plan to Communicate with patient and family members regarding resident's capabilities and needs. These interventions were not effective, as the resident had a similar fall on [DATE]. The care plan was not revised after the fall on [DATE]. 4. Resident #3 had an order, dated [DATE], to be transferred with the amount of assistance required to ensure her safety. The facility was using a sit-to-stand lift with the resident prior to this order. The facility determined the safest method to assist Resident #3 in transfers was a full body lift. On [DATE], the resident sustained [REDACTED]. At the time of the injury, the resident's care plan still contained an intervention to use a sit-to-stand lift to assist the resident in transfers. The care plan was not revised to reflect the changes identified in the physician orders [REDACTED]. r) The facility failed to implement the care plans for five (5) of 49 residents whose care plans were reviewed during Stage 2 of the quality indicator survey. The care plan interventions related to transfers were not implemented for Residents #3, #30, and #66. In addition, the care interventions for a scheduled toileting program were not implemented for Residents #16 and #25. 1. Resident #3 had a fall from a sit-to-stand lift on [DATE], while being assisted by one (1) person. The resident sustained [REDACTED]. She was also observed being transferred, on [DATE] at 9:15 a.m., with a mechanical sit-to-stand lift and one (1) person. The resident's care plan indicated the resident required the assistance of two (2) persons for transfers. This was the care plan in place at the time of Resident #3's fall on [DATE] and at the time of the observation of Resident #3 being transferred with the assistance of only one (1) NA on [DATE]. 2. Resident #30 was observed being transferred at 9:08 a.m. on [DATE], with the assistance of one (1) person and a sit-to-stand lift. The resident's current care plan, initiated on [DATE] and revised on [DATE], indicated the resident required extensive assistance of two (2) persons in transfers. 3. Resident #66's current care plan revealed the resident required extensive assistance of two (2) for transfers on and off the toilet. On [DATE] at 9:40 a.m., the resident observed being transferred from the toilet to the wheelchair by one (1) person. This resident also had a care plan related to a toileting plan. It was initiated on [DATE] and indicated the establishment of the resident's typical voiding patterns over a seventy-two (72) hour period using a voiding diary. A toileting plan to avoid incontinence episodes was noted as developed and implemented, to decrease the chance of injury and to maintain the resident's current level of continence. The facility could provide no evidence which indicated the care plan for a toileting program was implemented for the resident. 4. Resident #25 was admitted to the facility on [DATE]. The resident's episodic care plan, dated [DATE], indicated the resident was on a scheduled toileting program. The facility was unable to provide evidence scheduled toileting program was implemented as directed in the resident's care plan., for Resident #25. 5. Resident #16 experienced falls on [DATE] at 3:30 p.m., on [DATE] at 4:39 a.m., on [DATE] at 8:00 a.m., and on [DATE] at 2:07 p.m. Each fall was associated with the resident going to the bathroom. The resident's current care plan related to falls had an intervention for a bedside commode. The date listed for initiation of this intervention was [DATE]. Observations of the resident's room, on [DATE] at 1:30 p.m. and on [DATE] at 8:00 a.m., revealed the resident did not have a bedside commode. Resident #16's care plan also stated he would have a habit/scheduled toilet program. The facility initiated this intervention on [DATE]. The facility was unable to provide evidence to show the facility implemented the toileting plan for the resident. s) The facility failed to ensure a resident who entered the facility without a pressure ulcer did not develop a pressure ulcer unless it was clinically unavoidable. Resident #26 developed a suspected deep tissue injury as a result of an incident during a transfer using a full body lift. The area subsequently evolved into a Stage IV pressure ulcer which constituted actual harm. The resident had [DIAGNOSES REDACTED]. An unstageable pressure ulcer was identified on a significant change assessment with an assessment reference date (ARD) of [DATE]. This ,was the first time a pressure ulcer was coded for this resident in more than a year. The resident was hospitalized from [DATE] to [DATE]. Her next MDS, a quarterly assessment with an ARD of [DATE], indicated the area was a Stage IV with granulation tissue and measured 4 cm x 2 cm x 2.9 cm.) Subsequent assessments, with ARDs of [DATE] and [DATE], reflected the area remained a Stage IV with granulation tissue measuring 4 cm x 2 cm x 2.9 cm. All of the assessments, with the exception of the 30-day MDS with an ARD of [DATE], identified the area had developed in-house. Review of nurses' notes revealed a note, entered on [DATE] at 4:07 p.m., which indicated bruising observed to left thigh (rear). It was assessed as purple bruising to left thigh 2 cm in length x 1 cm width with blistered area in center, skin intact. The actions taken were : Instruct staff to use caution with lift pads and report any further injuries. The noted also noted a full body lift pad was the equipment involved. An initial pressure wound assessment, dated [DATE], noted, Unstageable pressure ulcer on left buttocks, the area measures 3 cm (centimeters) in length and 2 cm in width with a depth of 0.2 cm with eschar noted in wound bed and surrounding skin reddened. Review of the Wound Care Center notes revealed Resident #26 had a Stage IV (four) pressure ulcer located on the left ischial tuberosity. Further investigation revealed two (2) nursing assistants used the full body lift to transfer the resident from the chair to the bed. They noted a purple bruise with blistering present to the left outer (rear) thigh area. The facility surmised the metal bar in the lift pad pinched the resident's skin during transfer, as the bruised, blistered area was not noted prior that time. The comprehensive care plan, dated [DATE], contained no interventions to prevent the worsening and/or the development of further deep tissue injury/pressure ulcers. t) The facility failed to ensure residents received needed supervision and assistance devices for safe transfer of residents requiring assistance for that activity. The facility had an ineffective program for assessing/implementing and reassessing residents after they had a functional status change in transfer ability. The facility also failed to implement an effective educational training program related to safe transfers with mechanical lifts and staff assisted transfers. This placed all residents who needed assistance with transfers in an immediate jeopardy situation. It had the potential to affect fifty-four (54) of sixty-one (61) residents residing in the facility who required transfer assistance. Residents #3, #30, and #66 were each observed being transferred by one (1) aide, although their care plans indicated they needed assistance of two (2) persons for transfers. Resident #26 received a suspected deep tissue injury (SDTI) as a result of being pinched by the lift pad during a full body lift transfer. The SDTI eventually became a Stage IV pressure ulcer. The improper use of the mechanical lift resulted in actual harm for Resident #26. Resident #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. 1. Resident #3 had an order, dated [DATE], to be transferred with the amount of assistance required to ensure her safety. The facility was using a sit-to-stand lift with the resident prior to this order. The facility determined the safest method to assist Resident #3 in transfers was a full body lift. On [DATE], the resident sustained [REDACTED]. At the time of the injury, the resident's care plan still contained an intervention to use a sit-to-stand lift to assist the resident in transfers. The care plan was not revised to reflect the changes identified in the physician orders [REDACTED]. 2. Resident #30 was observed being transferred at 9:08 a.m. on [DATE], with the assistance of one (1) person and a sit-to-stand lift. The resident's current care plan, initiated on [DATE] and revised on [DATE], indicated the resident required extensive assistance of two (2) persons in transfers 3) Resident #66 required the extensive assistance of two (2) with transfers on/off the toilet. This was reflected in the resident's current care plan and Kardex. An interview, on [DATE] at 9:20 a.m., with Employee #3 nursing assistant (NA), revealed she would transfer the resident with a gait belt from the wheelchair to the toilet. An observation on [DATE] at 9:40 a.m., revealed the NA transferred Resident #66 from the toilet to the wheelchair with the assistance of one (1) person and without a gait belt. 4) Resident #26 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of nurses' notes revealed on [DATE] at 4:07 p.m., bruising observed to left thigh (rear). The nursing Assessment: indicated purple bruising to left thigh 2 cm (centimeters) in length x (by) 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. The equipment involved was a full body lift pad. The nurse who completed the occurrence note on [DATE], was interviewed by telephone on [DATE] at 11:30 a.m. When asked what had happened to Resident #26 on [DATE], she said, Two nursing assistants, (names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area. The nurse stated, .The two (2) nurse aides and I looked at the lift pad. There was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised blistered area during the transfers. We felt the resident's skin probably got pinched by the lift pad. When asked whether the bruised, blistered area was noted prior to that time, the nurse said, No, not to my knowledge. The resident's current comprehensive care plan had no interventions initiated, since the injury on [DATE] involving the lift pad pinching the resident's skin and causing a suspected deep tissue injury. The care plan did not include precautions with the use of lift pads during transfers. 5) Residents #78 #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. u) The facility failed to ensure food was stored under sanitary conditions. Unlabeled, undated, and/or expired food Items were found in the pantry refrigerator at the nursing station. When informed of these findings, the dietary supervisor stated the reason the nutrition pantry was not cleaned out was because a dietary aide called in that morning. v) The facility failed to maintain an infection control program to prevent the transmission of disease and/or infection to the extent possible. Residents #32, #15, #29, #63, #41, and #19 all had dirty concentrator filters and/or outdated oxygen concentrator filters and outdated, unchanged oxygen tubing. In addition, the facility failed to keep Resident #46's wheelchair in good repair, which inhibited its ability to be adequately cleaned. w) The facility failed to provide/arrange for laboratory services for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Review of Resident #73's medical record on [DATE] at 3:00 p.m., revealed a physician's orders [REDACTED]. Further medical record review found no evidence the CBC and BMP were obtained. x) The facility failed to provide access to a part of the electronic health record where staff documented the care provided to the individual resident, either by computer or in print. As a result, neither the staff nor the survey team, had access to residents' complete medical records. Additionally, Residents #73, #25, #29, #66, #13, #53, #33 and #16 were all ordered neurological assessments and vital signs after incidents. These assessments were found incomplete/inaccurate. This had the potential to affect all residents residing in the facility.",2018-04-01
6374,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,502,D,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide/arrange for laboratory services for one (1) of five (5) Stage 2 sample residents reviewed for unnecessary medications. Resident identifier: #73. Facility census: 61. Findings include: a) Resident #73 Review of the resident's medical record, on 05/22/13 at 3:00 p.m., revealed a physician's orders [REDACTED]. Further medical record review found no evidence the CBC and BMP were obtained. An interview, on 05/22/14 at 5:15 p.m., with Employee #72, the director of nursing (DON), confirmed the ordered CBC and BMP had not been done.",2018-04-01
6375,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,514,F,0,1,OMIN11,"Based on medical record review, review of facility policy, and staff interview, the facility failed to provide access to a part of the electronic health record where staff documented the care provided to the individual resident, either by computer or in print. As a result, neither the staff nor the survey team, had access to residents' complete medical records. Additionally, Residents #73, #25, #29, #66, #13, #53, #33 and #16 were all ordered neurological assessments and vital signs after incidents. These assessments were found incomplete/inaccurate. This had the potential to affect all residents residing in the facility. Resident identifiers: #73, #25, #29, #66, #13, #53, #33, and #16. Facility census: 61. Findings include: a) Limited access to portions of the medical records During the survey, from 05/19/14 through 06/02/14, the survey team had limited access to the computer system, particularly the part of the electronic health record (EHR) utilized by direct care staff to document the actual care provided for the residents. The team was not given access to the information electronically, and the facility was not able to provide the survey team with printed copies, due to a lack of knowledge of the new computer system. The facility could not provide electronic access and could not provide printed information about resident care information such as residents' meal intakes, the documented assistance needed and/or provided for activities of daily living (ADLs) including bed mobility, transfers, baths, etc. Documentation about the residents' continence/incontinence status, toileting, and activity attendance also could not be accessed electronically by the surveyors, nor could the facility provide printed copies of this information. Staff were able to show the surveyors information for the current week, but could not show older information, such as the data for the look back periods used to complete the minimum data set (MDS) assessments. Staff stated the information was there, but they could not retrieve or print the information. An interview with Employee #72, director of nursing (DON), was conducted on 05/29/14 at 11:00 a.m. She confirmed the facility began using the new computer system on 10/01/13, and staff were still not familiar with the system. Due to the lack of knowledge of the computer system, documentation was incomplete in the computer and/or could not be retrieved. b) Resident #73 Medical record review, on 05/28/14 at 9:15 a.m., revealed Resident #73 had documented falls on 04/11/14, 04/15/14, 04/26/14, and 05/01/14 for which neuro-checks had been initiated in accordance with the facility's policy. Review of the neuro-checks found the forms were incomplete (missing dates and times) and some forms were omitted entirely. Review of the Neuro Check Policy and Procedure found it included, (typed as written): Procedure: Neuro Checks Policy: BHCC (Braxton Health Care Center) policy and procedure for Neuro-checks is to be initiated upon every fall that occurs with potential head injury or any un-witnessed fall in which a resident cannot tell you details about the fall. Monitor a resident for 24 hours for head trauma. Nurses will follow procedure for neuro-checks for all falls. 1) Begin Neurological Assessment flow sheet with the very first set of vital signs and check resident eyes to see if pupils are reactive and equal to light. 2) First one hour there should be four 15 min. (minutes) checks completed. 3) Two 30 minutes neuro checks. 4) Then four sets of 1 hour neuro checks. 5) 2 set of 2 hour neuro checks. 6) 1 set of four hours later. 7) Will do vital signs every shift for seven days. An interview with Employee # 72, director of nursing (DON) was conducted on 5/28/14 at 3:00 p.m. She acknowledged the neuro-checks and vital signs were incomplete for Resident #73. c) Resident #25 Medical record review, on 05/28/14 at 11:15 a.m., revealed Resident #25 had documented incident/accidents on 02/08/14, 02/14/14, 02/15/14, 03/20/14, 03/24/14, 03/31/14, 04/25/14, 05/01/14 and 05/22/14 in which neuro-checks were initiated in accordance with the facility's policy. Review of the neuro-checks found the forms were incomplete (missing dates and times) and some were omitted. An interview with Employee # 72, director of nursing (DON) was conducted on 5/28/14 at 3:00 p.m. She acknowledged the neuro-checks and vital signs were incomplete for Resident #25. d) Resident #29 Medical record review on 05/28/14 at 1:15 p.m. revealed Resident #29 had a documented incident/accident on 04/02/14 in which neuro-checks were initiated in accordance with the facility's policy. Review of the neuro-checks found the forms were incomplete (missing dates and times) and some were omitted. An interview with Employee # 72, director of nursing (DON) was conducted on 5/28/14 at 3:00 p.m. She acknowledged the neuro-checks and vital signs were incomplete for Resident #29. e) Resident #66 A review of the occurrence log, on 05/28/14 at 12:00 p.m., revealed Resident #66 had incident/accident reports documented related to falls which occurred on 12/26/13, 01/01/14, and 01/16/14. On 05/28/14 at 2:00 p.m., a review of the immediate actions taken for these falls revealed Resident #66 was to have neurological checks performed by the staff following each of the three (3) falls according to the facility's neurological check policy and procedure. Review of the neurological checks, on 05/28/14 at 1:05 p.m., found Resident #66's neurological checks were not completed according to the facility's neurological check policy and procedure. In an interview with Employee #74, quality standard coordinator (QSQ), on 05/28/14 at 2:18 p.m., when asked about the missing neurological checks for the falls on 12/26/13, 01/01/14 and 01/16/14, she stated she would have to look and see if she could find any of the missing neurological checks. Employee #74 returned and stated she was unable to find the missing neurological checks for Resident #66. f) Resident #13 Review of the occurrence log on 05/23/14 at 9:39 a.m., revealed Resident #13 had falls on 11/12/13 and 03/02/14. At 9:47 a.m. on 05/23/14, review of the immediate action taken for Resident #13's falls on 11/12/13 and 03/02/14 revealed the staff were to perform neurological checks after the falls according to the facility's neurological check policy and procedure. Resident #13's neurological checks were reviewed on 05/23/14 at 9:55 a.m. This review revealed the neurological checks were not completed according to the facility's neurological check policy and procedure. When asked, on 05/23/14 at 10:33 a.m., about the missing neurological checks for Resident #13's falls, the QSO stated she would have to look and see if she could find the missing neurological checks. Employee #74 returned and stated she was unable to find the missing neurological checks for these occurrences for Resident #13. g) Resident #53 Review of the occurrence log, on 05/29/14 at 1:32 p.m., revealed Resident #53 had a fall on 03/08/14. A review, completed at 3:23 p.m. on 05/29/14, of the immediate action taken for Resident #53's fall on 03/08/14 revealed staff were to perform neurological checks after the fall in accordance with the facility's neurological check policy and procedure. Review of Resident #53's neurological checks, on 05/29/14 at 3:25 p.m., revealed the neurological checks were not completed according to the facility's neurological check policy and procedure. When asked, on 05/29/14 at 3:46 p.m., about the missing neurological checks, Employee #73, stated she would have to look and see if she could find any of the missing neurological checks. Employee #73 returned and stated she was unable to find the missing neurological checks for Resident #53. h) Resident #33 Review of occurrence log on 05/29/14 at 1:32 p.m., revealed Resident #33 had falls on 02/04/14, 02/05/14, and 03/08/14. A review, completed at 1:40 p.m. on 05/29/14, of the immediate action taken for Resident #33's falls revealed staff were to perform neurological checks after the falls according to the facility's neurological check policy and procedure. On 05/29/14 at 1:50 p.m., review of Resident #33's neurological checks found the neurological checks were not completed according to the facility's neurological check policy and procedure. When Employee #73 was asked, on 05/29/14 at 2:02 p.m., about the missing neurological checks for Resident #33's falls, she stated she would have to look and see if she could find any of the missing neurological checks. Employee #73 returned and stated that she was unable to find the missing neurological checks for Resident #33. i) Resident #16 Medical record review, on 05/30/14 at 1:00 p.m., revealed Resident #16 had a neurological evaluation without a date and time to show when the evaluation occurred. On 05/30/14 at Employee #74 (corporate registered nurse) became aware of the issue of the neurological evaluation not having the date/time the assessment was completed. She had no comment.",2018-04-01
6376,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2014-06-02,520,F,0,1,OMIN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, policy reviews, review of incident reports, review of resident council minutes, review of reportable abuse allegations, review of water temperature records, review of personal funds documentation, review of activity calendars, resident interviews, and staff interviews, the quality assessment and assurance (QA & A) committee failed to identify and address quality deficiencies of which they were aware or should have been aware. These practices had the potential to affect all residents. In the areas of resident rights, the (QA & A) committee failed to identify and address the failure to provide the right to be informed of the balance of personal funds handled by the facility on a quarterly basis, the right for security of personal funds managed by the facility by ensuring the surety bond is sufficient amount, the right for prompt efforts to resolve grievances, and the right to readily accessible survey results. In the area of resident behavior and facility practices, the (QA & A) committee failed to identify and address the failure to report and investigate allegations of abuse and neglect, and failed to implement the facility's abuse and neglect policies. In the areas of quality of life, the (QA & A) committee failed to identify and address the failure to provide an ongoing program of activities in accordance with the comprehensive assessments and/or voiced interests, failed to listen and act upon the resident council's concerns regarding activities and the right to privacy, failed to provide medically-related social services to assist a resident in resolving a conflict with a roommate, and failed to provide housekeeping/maintenance services necessary to maintain an orderly, sanitary, and comfortable environment. In the area of resident assessment, the (QA & A) committee failed to identify and address the failure to complete the Care Area Assessment (CAA), a part of the comprehensive assessment, as required. The location, date, and source of the documentation used to complete the CAAs for triggered areas was not identified in Section V - the CAA Summary or in the CAA itself. In the areas of quality of care, the (QA & A) committee failed to identify and address the failure to ensure the resident environment remained as free of accident hazards as possible, and failed to ensure each resident received adequate supervision and assistance devices to prevent accidents. In the area of medical records, the (QA & A) committee failed to identify and address the failure to ensure medical records were readily accessible to facility staff and the survey team. Staff were not knowledgeable of how to use the facility's electronic health record program. The area where direct care staff documented the actual care residents received could not be accessed or printed. The lack of knowledge resulted in an inability for staff to use and/or provide essential information which was only available in the P(NAME) computer program. In addition, ordered neurological assessments and vital sign documentation after incidents were found incomplete and/or inaccurate. These issues, which had the potential to affect all residents, were identified during the survey from [DATE] through [DATE]. Facility census: 61. Findings include: a) The facility failed to make prompt efforts to resolve grievances voiced by two (2) 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. b) 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 (#7, #21, and #22) reviewed for personal funds. It was found the nursing home administrator had received and signed the statements. 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. c) The facility failed to ensure a final accounting of Resident #79 funds, that were managed by the facility, were conveyed to the individual administering the resident's estate or probate jurisdiction within thirty (30) days of the resident's death. d) 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. The account balance exceeded the amount of the facility's surety bond on at least two (2) occasions. e) The facility failed to ensure Resident #52 was afforded privacy during personal care. In an interview of [DATE] at 8:17 a.m., Employee #29, a housekeeper, stated about three (3) or four (4) months ago he reported an incident of alleged abuse involving Resident #52. This involved the male housekeeper being present in the resident's room and able to witness the provision of personal care, during which the alleged abuse occurred, for a female resident. Employee #67, the SSS, was interviewed at 12:00 p.m. on [DATE]. 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 resident's residing in the four (4) bed ward. f) The facility failed to post a sign informing residents of where the most recent State and Federal survey results were located. g) 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. h) The facility failed to implement their written abuse/neglect/misappropriation of resident property policies 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. Facility staff also observed abuse of Residents #59 and #62, but did not immediately report the abuse to their supervisor. Policies and procedures related to these situations were contained in the facility's policy titled, Abuse, Neglect and Misappropriation of Resident Property: Protection of Resident/Reporting and Investigation. i) The facility failed to act upon grievances voiced by the resident council in areas related to resident rights and resident activities. Resident #24 had voiced concerns related to activities and resident privacy in resident council meetings. She felt the facility had not acted upon those concerns. Residents #24, expressed a concern about the lack of privacy in her room, despite having a private room. The facility had failed to implement effective measures to ensure the resident's right to privacy and failed to follow up with the resident on resolutions. Residents #56, #48, #76, #13, #9, #4, #10, #24, #15, #46, and #35 had expressed interest in out of facility activities such as going to the Senior Center, shopping, and/or fishing. The facility had not provided any out of facility activities for more than 12 months. j) The facility failed to provide an ongoing program of activities in accordance with the comprehensive assessments and/or voiced interests for twelve (12) of thirteen (13) residents reviewed for activities during Stage 2 of the survey. The residents were not provided activities for which they were assessed and/or expressed interest. Resident #3 expressed a desire to attend Sunday school at the facility each Sunday, but was not afforded the opportunity to do so. Residents #56, #48, #41, #13, #9, #4, #10, #24, #15, #46, and #35 expressed interest in attending activities outside the facility; however, the facility had not provided out of the facility activities on an on-going basis. The comprehensive minimum data set (MDS) assessments for each of these residents indicated these residents' activity preferences for religious activities and/or for out of the facility activities. k) The facility failed to provide medically-related social services for one (1) of one (1) resident reviewed for the care area of social services during Stage 2 of the survey. The facility did not assist the resident in finding an option to meet her physical and emotional needs. There was no attempt to help resolve Resident #67's conflict with the her roommate, whose television was disturbing the resident's ability to sleep well at night. Employee #61, social services supervisor (SSS), was interviewed at 12:33 p.m. on [DATE]. 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. l) The facility failed to provide maintenance and housekeeping services to maintain a comfortable and sanitary interior in eight (8) resident rooms/bathrooms and a resident common area. Resident rooms/bathrooms were observed with walls, ceilings, and/or doors in disrepair. The 100 Hall shower room was observed with dirty exhaust fans. Oxygen concentrators for six (6) residents (#32, #15, #29, #63, #41, and #19) of 14 residents who received oxygen therapy had dirty filters and/or outdated tubing. The wheelchairs for Resident #3 and #46 were not clean. It addition, Resident #46's wheelchair had cracks in the seat, rendering it unable to be effectively cleaned and sanitized. m) The facility failed to complete the required documentation for the care area assessments and triggers for twenty-four (24) of forty-nine (49) residents whose Minimum Data Set (MDS) assessments were reviewed in Stage 2 of the Quality Indicator Survey (QIS). (Residents #26, #73, #25, #29, #53, #36, #61,#33, #66, #13, #9, #10, #31, #17, #3,#12, #5, #60, #18, #51, #28, #27 and #40.) The Care Area Assessment (CAA) Summary, Section V of the MDS 3.0., nor the CAA documentation, provided the location and dates for the information used to complete the additional assessment for triggered areas. n) The facility failed to develop comprehensive care plans, including measurable goals and timetables, to assist four (4) of forty-nine (49) residents in attaining the highest level of well-being. Oral needs were not addressed for Resident #33. The risk for falls was not addressed for Resident #25. There was no care plan for Resident #78 regarding the amount of assistance needed in transfers. A care plan was not developed for Resident #26, regarding the risk for injuries during transfers. 1. Resident #33 complained of pain in her jaw and mouth on [DATE]. She had a sore under her tongue and a white patchy area was noted on the inside of her cheek. She was diagnosed with [REDACTED]. Review of her care plan, on [DATE] at 4:42 p.m., revealed there was no care plan, with measurable goals and interventions, regarding the care needed for the resident's oral condition. 2. Resident #25 had [DIAGNOSES REDACTED]. The resident had experienced a fall prior to her admission to the hospital, and was at high risk for falls. The resident was also prescribed anti-[MEDICAL CONDITION] ([MEDICATION NAME] and [MEDICATION NAME]) and [MEDICAL CONDITION] ([MEDICATION NAME]) medications on a daily basis, which can contribute to falls. The episodic care plan contained no focus, goals, or interventions related to the risk of falls. The resident had a fall five (5) days after admission. At that time, a care plan for falls was developed. 3. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. She developed a pressure ulcer from being pinched by a lift pad during a transfer. The resident had no feeling from the waist down, so she was unaware she was injured. It was surmised the metal bar in the lift pad could have caused the injury during the transfer. The resident's care plan had no interventions regarding the safe use of the lift and/or lift pad with Resident #26. 4. Resident #78 had an interim care plan completed upon admission. It indicated she was to be transferred with physical assistance of two (2) persons. The resident's minimum data set (MDS) admission assessment indicated the resident required the assistance of two (2) persons for transfers. T resident's comprehensive care plan contained nothing which indicated she required the assistance of two (2) for transfers. On [DATE], the resident was transferred by only one (1) nursing assistant,from her wheelchair to the toilet. At that time, the resident received a 9 centimeter (cm) skin tear to her right outer calf. o) The facility failed to revise the care plans for four (4) of forty-nine (49) residents reviewed for accidents. The care plans were not revised to address fall prevention and/or changes in planned interventions to prevent falls. 1. Resident #33 had accidents resulting in injury on [DATE], [DATE], and [DATE]. The resident's care plan was not revised after any of the accidents to address the prevention of falls, and the resident's care plan had no interventions specifically related to accident prevention. 2. Resident #66 fell on [DATE], [DATE] and [DATE]. Each of the falls was related to the resident going to the bathroom without assistance. A bed alarm was not effective and an intervention to educate the resident to use her call light was not realistic because of the resident's decreased cognitive status. The resident's care plan was not revised, after the falls, to reflect her individual needs. In addition, the resident had a care plan for an individualized toileting plan to avoid incontinent episodes which was not implemented. 3. Resident #13 had falls on [DATE] and [DATE]. A care plan for falls was initiated, related to the [DATE] fall. The plan included a review of information on past falls and an attempt to determine the cause of the falls. The facility was going to determine possible root causes and alter or remove any potential cause if possible. Education of the patient/family/interdisciplinary team as to causes was to occur. There was also a plan to Communicate with patient and family members regarding resident's capabilities and needs. These interventions were not effective, as the resident had a similar fall on [DATE]. The care plan was not revised after the fall on [DATE]. 4. Resident #3 had an order, dated [DATE], to be transferred with the amount of assistance required to ensure her safety. The facility was using a sit-to-stand lift with the resident prior to this order. The facility determined the safest method to assist Resident #3 in transfers was a full body lift. On [DATE], the resident sustained [REDACTED]. At the time of the injury, the resident's care plan still contained an intervention to use a sit-to-stand lift to assist the resident in transfers. The care plan was not revised to reflect the changes identified in the physician orders [REDACTED]. p) The facility failed to implement the care plans for five (5) of 49 residents whose care plans were reviewed during Stage 2 of the quality indicator survey. The care plan interventions related to transfers were not implemented for Residents #3, #30, and #66. In addition, the care interventions for a scheduled toileting program were not implemented for Residents #16 and #25. 1. Resident #3 had a fall from a sit-to-stand lift on [DATE], while being assisted by one (1) person. The resident sustained [REDACTED]. She was also observed being transferred, on [DATE] at 9:15 a.m., with a mechanical sit-to-stand lift and one (1) person. The resident's care plan indicated the resident required the assistance of two (2) persons for transfers. This was the care plan in place at the time of Resident #3's fall on [DATE] and at the time of the observation of Resident #3 being transferred with the assistance of only one (1) NA on [DATE]. 2. Resident #30 was observed being transferred at 9:08 a.m. on [DATE], with the assistance of one (1) person and a sit-to-stand lift. The resident's current care plan, initiated on [DATE] and revised on [DATE], indicated the resident required extensive assistance of two (2) persons in transfers. 3. Resident #66's current care plan revealed the resident required extensive assistance of two (2) for transfers on and off the toilet. On [DATE] at 9:40 a.m., the resident observed being transferred from the toilet to the wheelchair by one (1) person. This resident also had a care plan related to a toileting plan. It was initiated on [DATE] and indicated the establishment of the resident's typical voiding patterns over a seventy-two (72) hour period using a voiding diary. A toileting plan to avoid incontinence episodes was noted as developed and implemented, to decrease the chance of injury and to maintain the resident's current level of continence. The facility could provide no evidence which indicated the care plan for a toileting program was implemented for the resident. 4. Resident #25 was admitted to the facility on [DATE]. The resident's episodic care plan, dated [DATE], indicated the resident was on a scheduled toileting program. The facility was unable to provide evidence scheduled toileting program was implemented as directed in the resident's care plan., for Resident #25. 5. Resident #16 experienced falls on [DATE] at 3:30 p.m., on [DATE] at 4:39 a.m., on [DATE] at 8:00 a.m., and on [DATE] at 2:07 p.m. Each fall was associated with the resident going to the bathroom. The resident's current care plan related to falls had an intervention for a bedside commode. The date listed for initiation of this intervention was [DATE]. Observations of the resident's room, on [DATE] at 1:30 p.m. and on [DATE] at 8:00 a.m., revealed the resident did not have a bedside commode. Resident #16's care plan also stated he would have a habit/scheduled toilet program. The facility initiated this intervention on [DATE]. The facility was unable to provide evidence to show the facility implemented the toileting plan for the resident. q) The facility failed to ensure residents received needed supervision and assistance devices for safe transfer of residents requiring assistance for that activity. The facility had an ineffective program for assessing/implementing and reassessing residents after they had a functional status change in transfer ability. The facility also failed to implement an effective educational training program related to safe transfers with mechanical lifts and staff assisted transfers. This placed all residents who needed assistance with transfers in an immediate jeopardy situation. It had the potential to affect fifty-four (54) of sixty-one (61) residents residing in the facility who required transfer assistance. Residents #3, #30, and #66 were each observed being transferred by one (1) aide, although their care plans indicated they needed assistance of two (2) persons for transfers. Resident #26 received a suspected deep tissue injury (SDTI) as a result of being pinched by the lift pad during a full body lift transfer. The SDTI eventually became a Stage IV pressure ulcer. The improper use of the mechanical lift resulted in actual harm for Resident #26. Resident #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. 1. Resident #3 had an order, dated [DATE], to be transferred with the amount of assistance required to ensure her safety. The facility was using a sit-to-stand lift with the resident prior to this order. The facility determined the safest method to assist Resident #3 in transfers was a full body lift. On [DATE], the resident sustained [REDACTED]. At the time of the injury, the resident's care plan still contained an intervention to use a sit-to-stand lift to assist the resident in transfers. The care plan was not revised to reflect the changes identified in the physician orders [REDACTED]. 2. Resident #30 was observed being transferred at 9:08 a.m. on [DATE], with the assistance of one (1) person and a sit-to-stand lift. The resident's current care plan, initiated on [DATE] and revised on [DATE], indicated the resident required extensive assistance of two (2) persons in transfers 3) Resident #66 required the extensive assistance of two (2) with transfers on/off the toilet. This was reflected in the resident's current care plan and Kardex. An interview, on [DATE] at 9:20 a.m., with Employee #3 nursing assistant (NA), revealed she would transfer the resident with a gait belt from the wheelchair to the toilet. An observation on [DATE] at 9:40 a.m., revealed the NA transferred Resident #66 from the toilet to the wheelchair with the assistance of one (1) person and without a gait belt. 4) Resident #26 was admitted to the facility on [DATE] with the [DIAGNOSES REDACTED]. Review of nurses' notes revealed on [DATE] at 4:07 p.m., bruising observed to left thigh (rear). The nursing Assessment: indicated purple bruising to left thigh 2 cm (centimeters) in length x (by) 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. The equipment involved was a full body lift pad. The nurse who completed the occurrence note on [DATE], was interviewed by telephone on [DATE] at 11:30 a.m. When asked what had happened to Resident #26 on [DATE], she said, Two nursing assistants, (names of Employees #20 and #32) had used the full body lift to transfer Resident #26 from the chair to the bed. They noted a purple bruise with blistering present to left outer (rear) thigh area and then they notified me of the area. The nurse stated, .The two (2) nurse aides and I looked at the lift pad. There was a metal bar located at the bottom of the pad and it would hit her body in the area of the bruised blistered area during the transfers. We felt the resident's skin probably got pinched by the lift pad. When asked whether the bruised, blistered area was noted prior to that time, the nurse said, No, not to my knowledge. The resident's current comprehensive care plan had no interventions initiated, since the injury on [DATE] involving the lift pad pinching the resident's skin and causing a suspected deep tissue injury. The care plan did not include precautions with the use of lift pads during transfers. 5) Residents #78 #78, #12, #5, and #60 were each identified as receiving skin tears and/or bruises during transfers using a mechanical lift. r) The facility failed to ensure food was stored under sanitary conditions. Unlabeled, undated, and/or expired food Items were found in the pantry refrigerator at the nursing station. When informed of these findings, the dietary supervisor stated the reason the nutrition pantry was not cleaned out was because a dietary aide called in that morning. s) The facility failed to maintain an infection control program to prevent the transmission of disease and/or infection to the extent possible. Residents #32, #15, #29, #63, #41, and #19 all had dirty concentrator filters and/or outdated oxygen concentrator filters and outdated, unchanged oxygen tubing. In addition, the facility failed to keep Resident #46's wheelchair in good repair, which inhibited its ability to be adequately cleaned. t) The failed to provide access to a part of the electronic health record where staff documented the care provided to the individual resident, either by computer or in print. As a result, neither the staff nor the survey team, had access to residents' complete medical records. Additionally, Residents #73, #25, #29, #66, #13, #53, #33 and #16 were all ordered neurological assessments and vital signs after incidents. These assessments were found incomplete/inaccurate. This had the potential to affect all residents residing in the facility. u) An interview on [DATE] at 3:30 p.m., with the Nursing Home Administrator, the Director of Nursing, and the Admission Director, confirmed the QA & A committee had failed to identify any of the quality concerns which were identified during the QIS survey.",2018-04-01
8016,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2013-01-23,272,E,0,1,VVRS11,"Based on observation, clinical record review, and staff interview, the facility failed to comprehensively assess defined perimeter mattresses as potential restraints for 3 residents (#'s 4, 75, 40) out of 27 residents whose comprehensive assessments were reviewed. Findings include: On 01/21/2013 at 9:55 AM, Resident #4 was observed in bed lying on a defined perimeter mattress. Review Resident #4's clinical record was silent for an assessment for the use of a defined perimeter mattress. On 01/21/2013 at 10:51 AM Resident #75 was observed in bed lying on a defined perimeter mattress. Review of Resident #75's clinical record was silent for an assessment for the use of a defined perimeter mattress. On 1/22/13 at 12:51 PM Resident #40 was observed in bed lying on a defined perimeter mattress. Review of Resident #40's clinical record was silent for an assessment for the use of a defined perimeter mattress. During an interview conducted on 1/22/13 at 2:10 PM, nurse #33 stated the he/she does not assess the use of a defined perimeter mattress as a potential restraint. During an interview on 1/22/13 at 4:12 PM, nurse #25 verified the use of the a defined perimeter mattress for Resident #4, 75, and 40 and verified the lack of an assessment for the use of the defined perimeter mattress. He/she stated they do not assess the use of a defined perimeter mattress as a potential restraint and provided a copy of the manufacturers guidelines for Geo-Mattress. Review of the manufacturers guidelines documented the new Geo-Mattress with Wings can help add an important measure of safety to your facility, especially in high risk areas. By gently urging the user away from the edge of the mattress, its tissue-friendly raised perimeter can help reduce the risk of accidental falls from the bed. On 1/23/13 at 9:00 AM, nurse #25 provided additional facility documentation for the use of a defined perimeter mattress. The documentation revealed the raised perimeter mattress have raised edges that are higher than the center. These raised edges perform several functions: Makes it more difficult for the patient roll out of the bed. Encourages the patient who should not get up unsupervised from doing just that. When evaluating these mattresses, the clinician must ask several questions: During interview at this time nurse #25 again verified the lack of an assessment for the use of the defined perimeter mattress.",2016-11-01
8017,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2013-01-23,371,D,0,1,VVRS11,"Based on observations, interviews, and review of facility documentation, the facility failed to ensure proper sanitation for the dish machine. This had the potential to affect all residents who receive nourishment from the dietary department. Findings include: On 1/21/13 at 9:00 AM the initial kitchen tour with dietary staff member #18 was conducted. At that date and time the staff person tested the dish machine with a chlorine test strip and the chlorine test strip did not register a chlorine level. Dietary staff member #18 stated the dish machine should be at 50-100 ppm (parts per million) chlorine, and immediately contacted maintenance staff member #1. At 9:15 AM, maintenance staff member #1 identified the chlorine container was not primed and stated the container was pushed too far back underneath the counter and was not allowing the Chlorine to flow into the machine. He/she quickly corrected the situation and the sanitizer reached 100 ppm. Dietary staff member #18 instructed staff to rewash all the morning dishes by running them back through the dish machine. At 1:07 PM the dish machine test strip read 100 ppm of chlorine. Review of the Sanitizer and Temperature Recording Chart was silent for chlorine level checks on 12/11/12 for lunch and dinner, 12/14/12 for dinner, 12/19/12 for dinner, 12/20/12 for dinner and 12/24/12 for dinner. Dietary staff member #18 verified the missed chlorine testing and stated it should be tested 3 times per day at breakfast, lunch and dinner.",2016-11-01
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
9725,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,225,D,0,1,U9W011,"Based on observation, a review of the facility's abuse / neglect files, policy review, and staff interview, the facility failed to thoroughly investigate and/or immediately report all allegations of abuse, neglect, mistreatment, and/or injuries of unknown origin to the appropriate State agencies, and events that may constitute mistreatment or abuse were not identified as such and were not further investigated to assure the safety and well-being of the residents. This was true for three (3) of twenty seven (27) Stage II sample residents. Resident identifiers: #78, #31, and #57. Facility census: 60. Findings include: a) Resident #78 Review of the facility's abuse / neglect files revealed an allegation reported by the wife of Resident #78 on 09/11/10, in which the wife alleged the nursing assistant washed the resident's groin, then washed his face and mouth with the same washcloth. The wife also stated the nursing assistant did not rinse all of the soap off of the resident. These allegations of neglect were reported to the WV Nurse Aide Registry on 09/11/10, and an internal investigation was conducted by the facility. However, there was no evidence these allegations of neglect had been reported to the ombudsman program or adult protective services (APS) as required by State law. The five-day follow-up report was completed by the facility on 09/13/10. This report stated the nursing assistant in question, when asked to outline the proper procedure for giving a resident a bath, was able to recite the procedure in the proper order. The nursing assistant did recall giving the resident a bath with his wife present, but she could not recall anything out of the ordinary happening. The nursing assistant was cautioned to always follow the proper procedure with any resident she bathes. According to the results of the facility's internal investigation, there will be two (2) staff members present anytime Resident #78 receives care. The social worker, when interviewed about this incident on 10/06/10 at 9:45 a.m., confirmed she viewed this as an allegation of neglect, because the family member alleged that the nursing assistant had not provided a bath correctly. The social worker confirmed that the information in the facility's report into these allegations reflected the full extent of its investigation and that the nursing assistant no longer provides care for that resident. She confirmed that she did not interview other residents about being bathed inappropriately by this nursing assistant, nor she did not interview any other staff members who worked with this nursing assistant regarding her techniques for bathing to see if anyone else had ever witnessed this worker not performing her duties properly. She also confirmed that no one, during the course of the investigation, actually observed this nursing assistant giving a bath to a resident to assure she did it properly; they just talked with her. The social worker stated, on 10/06/10 at 9:30 a.m., she was advised she did not have to report incidents to APS. The social worker was informed by this surveyor that, if a nursing assistant is suspected of neglecting a resident, the facility is required to report the allegation to the WV Nurse Aide Registry, APS, and the ombudsman program. -- b) Resident #31 Observations in the dining room, during the evening meal on 09/27/10 at 5:55 p.m., found Employee #16 mistreating Resident #31. Resident #31 was in the dining area sitting with three (3) other residents and two (2) nursing assistants. Her meal had been placed in front of her at approximately 5:15 p.m., after which she did not touch it, nor did a staff member cue her or attempt to assist her with the meal. At 5:55 p.m., Employee #16 entered the dining room and sat down to assist Resident #31 with her meal. This surveyor asked Employee #16 if he should reheat Resident #31's meal related to the fact that her food had been sitting uncovered for forty (40) minutes. Employee #16 looked at Resident #31, threw the silverware on the table, and said, I guess we'll heat it up. He then returned after heating the meal and attempted to feed Resident #31 some peas. Resident #31 said it was too hot. Employee #16 said, Well, you're not going to eat it anyway. Employee #16 then removed Resident #31 from the dining room without further assisting her with her evening meal. On 09/30/10 at 1:35 p.m., the incident was discussed with the director of nursing (DON - Employee #53) in the presence of two (2) other surveyors. Employee #53 confirmed this behavior was not acceptable and would not be tolerated. On 10/05/10 at 11:15 a.m., Employee #53 was asked what the facility did in response to the report made by the survey team of the incident that occurred on 09/27/10. Employee #53 said she had completed counseling with Employee #16. On 10/06/10 at 8:40 a.m., an interview was conducted with the social worker (Employee #65), to further investigate how the facility responded to allegations of mistreatment. After explaining the incident to Employee #65, she stated, I think it would be a dignity issue, and his attitude wasn't good. Employee #65 further stated, In hindsight, I think it should have been reported, because of his (Employee #16's) attitude and his tone of voice. Employee #65 stated if she had investigated the incident on 09/27/10, she would have talked to other staff members and residents who were alert and oriented. When Employee #65 was shown the employee counseling paper for Employee #16, she stated, I guess he was the only one that was spoken to from the looks of this counseling paper. There was no evidence to reflect the facility management had conducted a thorough investigation into this allegation of mistreatment. -- c) Resident #57 On 10/05/10, a review of the resident's nursing notes found an entry, dated 07/12/10 at 11:20 a.m., describing a dark purple hematoma to the resident's right forearm. The resident's medical power of attorney representative (MPOA) was notified. No further nursing notes or incident / accident reports were found regarding the source or cause of this injury. Nursing notes, dated 08/27/10 at 6:35 a.m., described another bruise to the resident's upper right arm. No further nursing notes or incident / accident reports were found regarding the source or cause of this injury. Nursing notes, dated 09/10/10 at 8:50 a.m., contained a skin assessment that revealed a red-purple bruise to left side of of the resident's neck and a red-purple bruise to left ear lobe. No further nursing notes or incident / accident reports were found regarding the source or cause of this injury. Nursing notes, dated 10/02/10 at 3:50 p.m., recorded the resident's wife reporting to staff that the resident had a bruise on his left arm and a rash on his left hand. A nursing assessment revealed no rash on the resident's left hand and a light grey ecchymotic area to left inner forearm measuring 10 cm x 6 cm in size. The resident's wife, MPOA, and physician were made aware of bruising. An incident / accident report was completed regarding this injury, but no evidence of further investigation or reporting of this bruising of unknown origin was found. An interview with the social services director (Employee #65) revealed that, when an unusual bruise that cannot be explained is found, we usually report it. Employee #65 further stated that, once the nursing department is aware of any bruising, it should be investigated and reported.",2015-10-01
9726,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,241,D,0,1,U9W011,"Based on observation and staff interview, the facility failed to provide care in a manner that maintains and enhances each resident's dignity. Resident #31 was not assisted with her evening meal for forty (40) minutes after it was place in front of her, and she was treated in a manner by a licensed practical nurse (LPN - Employee #16) that did not enhance her dignity. Resident identifier: #31 Facility census: 60 Findings include: a) Resident #31 Observations in the dining room, during the evening meal on 09/27/10 at 5:55 p.m., found Employee #16 mistreating Resident #31. Resident #31 was in the dining area sitting with three (3) other residents and two (2) nursing assistants. Her meal had been placed in front of her at approximately 5:15 p.m., after which she did not touch it, nor did a staff member cue her or attempt to assist her with the meal. At 5:55 p.m., Employee #16 entered the dining room and sat down to assist Resident #31 with her meal. This surveyor asked Employee #16 if he should reheat Resident #31's meal related to the fact that her food had been sitting uncovered for forty (40) minutes. Employee #16 looked at Resident #31, threw the silverware on the table, and said, I guess we'll heat it up. He then returned after heating the meal and attempted to feed Resident #31 some peas. Resident #31 said it was too hot. Employee #16 said, Well, you're not going to eat it anyway. Employee #16 then removed Resident #31 from the dining room without further assisting her with her evening meal. On 09/30/10 at 1:35 p.m., the incident was discussed with the director of nursing (DON - Employee #53) in the presence of two (2) other surveyors. Employee #53 confirmed this behavior was not acceptable and would not be tolerated. On 10/05/10 at 11:15 a.m., Employee #53 was asked what the facility did in response to the report made by the survey team of the incident that occurred on 09/27/10. Employee #53 said she had completed counseling with Employee #16. On 10/06/10 at 8:40 a.m., an interview was conducted with the social worker (Employee #65), to further investigate how the facility responded to allegations of mistreatment. After explaining the incident to Employee #65, she stated, I think it would be a dignity issue, and his attitude wasn't good. Employee #65 further stated, In hindsight, I think it should have been reported, because of his (Employee #16's) attitude and his tone of voice.",2015-10-01
9727,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,279,D,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, staff interview, and resident interview, the facility failed to develop a comprehensive care plan that described the services to be provided to assist each resident in attaining or maintaining his/her highest practicable level of well-being. One (1) resident's care plan did not include non-pharmacologic interventions for pain or behaviors to provide guidance to direct care givers, and the resident's care plan did not include interventions that were proactive in achievement of goals. Another resident's care plan contained an intervention to address the resident's skin condition that was not appropriate given the resident's mental health status. Two (2) of twenty-seven (27) Stage II sample residents were affected. Resident identifiers: #54 and #63. Facility census: 60. Findings include: a) Resident #54 1. The resident's care plan included the following goal for pain management: Resident will be comfortable with chronic pain at an acceptable level daily through to the next review. The problem statement was: Has chronic pain due to old fracture repair sites. Takes Tylenol with [MEDICATION NAME] q (every) 6 hours prn (as needed) for pain. The interventions were: Administer pain medication and observe for efficacy. Observe for side effects as listed on the trifold located in front of this care plan. Rate resident's pain and report pain that is not controlled. Try different methods of non pharmacy pain management techniques. No non-pharmacy techniques were identified to provide direct care givers with guidance on what techniques were to be employed. This information would be needed to determine what interventions were effective and when other interventions needed to be attempted. The resident complained of other types of pain. During observations and interviews with the resident throughout the Stage II portion of the survey, the resident would complain of mid-epigastric pain. In an interview with Employee #22 (a licensed practical nurse - LPN) on 10/06/10 at approximately 2:00 p.m., she said the only pain the resident had complained about to her was between her throat and her stomach. The resident was given [MEDICATION NAME] for these complaints. The nurse said the resident did not complain of pain due to her arthritis or other types of pain. The resident's complaint of stomach problems also was discussed with another LPN (Employee #16) in mid-afternoon on 10/04/10. He also said the resident had complaints of stomach problems and she had repetitive health complaints. The care plan did not address the resident's complaints of stomach pain. - 2. Resident #54 was started on [MEDICATION NAME] on 06/22/10, for anxiety and repetitive health complaints. These complaints were reported to have increased, and the dosage of the medication was increased on 07/15/10. The care plan had a goal of: Resident will have no harmful side effects and severe mood swings daily through to next review date. The care plan was established on 08/25/10 with interventions listed as: Observe for side effects as listed on the trifold located at the front of this care plan. Plan dose reductions as regulations state. Document behaviors and mood swings on nurse's notes. Observe for increased anxiety and report. Hold [MEDICATION NAME] (sic) if no signs or symptoms of anxiety or if sedated. Monitor for signs of increased anxiety, and for fear of falling. On 09/10/10, the following intervention was added: Monitor for repetitive health complaints. The interventions did not include guidance for the direct care givers to employ in an attempt to assist the resident in dealing with severe mood swings and repetitive health complaints. No non-pharmacological interventions to address the identified problems had been established. The interventions identified did not lend to correction or lessening of the stated problems. as the interventions consisted primarily of observations and monitoring. The goal did not addressed the resident's identified problem of repetitive health complaints. -- b) Resident #63 Observation found scabbed areas on Resident #63's skin where he scratches himself on his head and face. This resident, when interviewed on the morning of 10/06/10, reported his belief that his itching was caused by mites under his skin. Documentation in the resident's medical record noted that he scratched his arms and legs, and he would sometimes tell the nurses that they're back. Other documentation in the medical record noted he had [DIAGNOSES REDACTED]. He often thinks things are crawling on him, and he was receiving treatment from a psychiatrist and a psychologist for this disorder. His plan of care, dated 08/18/10, addressed the resident's skin condition and, as an approach, stated, Reassure resident that he does not have mites (sic) that he is under the delusion that he has. During an interview at 3:40 p.m. on 10/05/10, the social worker confirmed this resident thinks the mites are real. She stated, You cannot convince him that it is not real. She confirmed this was not an appropriate care plan intervention for this resident.",2015-10-01
9728,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,280,E,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, resident interview, and staff interview, the facility failed to review and revise each resident's care plan to reflect changes in condition and/or treatment. Five (5) of twenty-seven (27) Stage II sample residents. Resident identifiers: #57, #62, #72, #8, and #52. Facility census: 60. Findings include: a) Resident #57 1. Review, on 09/30/10, of the resident's current care plan regarding history of falls revealed an intervention of administer [MEDICATION NAME] to treat [MEDICAL CONDITION]. Review of the resident's physician orders [REDACTED]. - 2. Review of the resident's current care plan regarding activities of daily living revealed an intervention to apply palm protector to the resident's right hand for four (4) hours daily. Interview with the resident's wife / medical power of attorney representative (MPOA), on 10/05/10 at 5:50 p.m., revealed the resident had not used palm protectors for three (3) to four (4) months. Review of the resident's physician orders, on 10/05/10 at 6:00 p.m., found the palm protector to the resident's right hand had been discontinued. -- b) Resident #62 During an interview with this resident on 10/05/10 at 2:00 p.m., she reported her dentures did not fit her; she went to have them adjusted, and the dentist told her nothing else could be done to make them fit better. She stated they put a rubber piece under the lower dentures, because I do not have a gum there. Review of the resident's medical record found a physician's orders [REDACTED]. Brush dentures with toothbrush and toothpaste every night at bedtime due to soft reline. Review of the care plan found this resident performed most activities of daily living (ADLs) with set-up assistance (except bathing). Her goal stated she would perform the ADLs that she can do and will accept assistance from staff with bath weekly through next review date. The interventions associated with this goal were: Encourage to participate in care as much as she is able. Give wash cloth and allow her to wash face and hands. Do not soak dentures. Brush with toothbrush and toothpaste q (every) hs (hours of sleep) due to soft reline. During an interview with the resident's nursing assistant (Employee #12) at 4:40 p.m. on 10/04/2010, she stated she was taking care of Resident #62 today and has had her frequently. When asked about the resident's oral care, the nursing assistant stated the resident cleans her own teeth and she does not help do anything with the resident's teeth. When questioned about how the resident cleans her teeth, the nursing assistant stated the resident soaked her teeth in a denture cup with denture cleaner. There was no evidence in the care plan that the staff provided teaching, instruction, or assistance this resident to help her perform her oral care adequately. The facility did not assist her to understand why she should not soak her dentures and/or instruct her of the recommended method for cleaning her dentures which had recently been adjusted. -- c) Resident #72 Review of Resident #72's medical record, including her October 2010 monthly recapitulation of physician orders, found she was to receive a regular diet. Review of her current care plan, dated 08/04/10, stated she was to receive a pureed NAS (no added salt) diet and fluids according to her likes and dislikes daily. Observation of the noon meal, on 10/05/10 at 12:00 p.m., found this resident eating in the dining area for residents who required cueing and assistance. This resident received a regular diet. During an interview with the dietary manager (Employee #5) on 10/05/10 at 3:00 p.m., she presented this surveyor with a copy of an updated care plan with the correct diet order. She stated she had this care plan in her computer and had not put the updated care plan in the care plan book. She verified this revised care plan, which was in her computer, would not have been not available to the nursing assistants. -- d) Resident #8 The current care plan for Resident #8, dated as established on 09/15/10, was compared to the care plan established on 06/16/10. No changes had been made to the care plan goal regarding nutrition or to the associated interventions. - The 06/16/10 care plan included a problem statement of: Weight loss @180 days 10.1% down at risk for additional weight lost, R/T (related to) consumes less than 75% of meals. Requires a mech. (mechanical) soft diet. Requires some assist with meals (sic) requires staff to feed at times. The goal was: Resident will consume at lest 75% of 2 meals per day, will show no additional weight loss through next review. (current weight 97.2) The interventions were: Provide tray set-up. Allow resident extra time to eat. Encourage to consume at least 75% of meals. Assist as needed with meals. May crush HS (hour of sleep) meds if needed. Medpass 2.0 2 oz TID (three times a day). Resident wishes to sit in her wheelchair to eat her meals and declining a dining room chair. Assist as needed with meals may require staff to feed at times. These interventions were to be provided by nursing personnel. Additional interventions were: Provide mech. soft diet as ordered. Provide subs (substitutes) for disliked foods. Provide foods according to likes and dislikes. Provide 8 oz. water on all meal trays. These interventions were to be provided by dietary personnel. - The care plan established on 09/15/10 included the same interventions. The only changes made to the plan were the weight loss @ 180 days was changed from 10.1% to 13% in the problem statement and the current weight was changed from 97.2 to 91.8 in the goal statement. Although the resident had continued to lose weight, no changes were made to the interventions. -- e) Resident #52 Review of the facility's incident / accident reports found Resident #52 fell on [DATE] at 3:20 p.m., and Resident #52 complained of a slight headache at 5:30 p.m. The physician was notified, and Resident #52 was sent to the hospital for evaluation. Resident #52 returned to the facility at 9:21 p.m. on 09/23/10. She sustained lacerations and swelling to her forehead which required treatment. During tour of the facility in the afternoon of 09/27/10, Resident #52 was observed with purple and yellow bruising to her face and lacerations to her forehead. On 10/04/10 at 3:45 p.m., an interview was conducted with a registered nurse (RN - Employee #44) related to revisions and interventions made to the care plan. Employee #44, when asked for information related to the fall on 09/23/10, confirmed the resident's care plan had not been updated after Resident #52 fell .",2015-10-01
9729,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,281,D,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of facility policies, and review of the Criteria for Determining the Scope of Practice for the Licensed Nurses and Guidelines for Determining Acts that May be Delegated or Assigned by Licensed Nurses (Guidelines for Delegation), revised by the WV Boards of Nursing in 2009, the facility failed to ensure staff followed its policy with regards to medications given on an as needed (PRN) basis. The facility also failed to ensure physician orders [REDACTED]. Additionally, there was no evidence of assessment of a resident's weight loss relative to the use of [MEDICATION NAME], and there was no evidence the resident and / or responsible party had been made aware of potential risks associated with the use of [MEDICATION NAME]. One (1) of twenty-seven (27) residents on the Stage II sample was affected. Resident identifier: #54. Facility census: 60. Findings include: a) Resident #54 1. Review of the medication administration records (MARs) for July, August, and September 2010 found PRN medications, such as [MEDICATION NAME] and Tylenol with [MEDICATION NAME], had been administered. No reason for administration of the medications was found for all but one (1) dose of a PRN medication. Additionally, there was no evidence the effectiveness of the medication had been assessed. One (1) PRN medication was documented in the nurses' notes, but its administration had not been recorded on the MAR. The MAR for August 2010 indicated the resident had received Tylenol with [MEDICATION NAME] i (1) tsp at 14:40 (2:40 p.m.) on 08/02/10 for c/o (complaint of)pain. This was later noted to have been effective. Neither the location nor the intensity of the pain was identified on the MAR or in the nurses' notes. On 08/28/10 at 2200 (10:00 p.m.), another does of Tylenol with [MEDICATION NAME] was recorded on the MAR. There was no reason for administration of the medication, no location of pain, no assessment of pain intensity, and no discussion of the medication's effectiveness documented on the MAR or in the nurses' notes. Doses of [MEDICATION NAME] 30 ml had been administered per PRN order on 08/11/10 at 8:30 p.m. and on 08/16/10 at 7:10 p.m. with nothing charted on the back of the MAR or in the nurses' notes. The MAR for September 2010 had [MEDICATION NAME] initialed as given on 09/09/10 (no time), on 09/13/10 at 1420 (2:20 p.m.) and 1950 (7:50 p.m.), on 09/17/10 at 2000 (8:00 p.m.), on 09/18/10 at 1600 (4:00 p.m.), on 09/27/10 at 1640 (4:40 p.m.), and initialed as given on 09/29/10 (no time). No information about the reasons these doses of pain medication were given or whether each dose was effective was found on the back of the MAR, and there were no relevant entries in the nurses' notes. No PRN pain medications were documented on the MAR on 09/18/10. However, in the nurses' notes, staff recorded the resident had complained of lower back pain of a 7 on a scale of 1 to 10 and Tylenol #3 (Tylenol with [MEDICATION NAME]) was given at 1500 (3:00 p.m.). The nurse noted that, at 1530 (3:30 p.m.), the resident had been in the dining room with no complaints of pain. The director of nursing (DON) was asked for a copy of the facility's policy for PRN medications at approximately 3:10 p.m. on 10/06/10. A document entitled PRN Medications was provided. Under the heading of Procedure in part B To assure the proper utilization of 'PRN' drug orders:, Item 3 stated: A nurse should chart why a 'PRN' order was administered (subjective and/or objective symptoms). The nurse should also chart the results of the medication given (e.g., effective, ineffective, adverse reaction, etc.). A clear written description of nursing decisions about administered medications is important for two reasons: to provide a legal record of the sequence of events, and to document for the prescribed and other and other (sic) professionals the resident's response to various medications. - 2. The resident had orders for [MEDICATION NAME] 200 mg every four (4) hours for pain and Tylenol with [MEDICATION NAME] 1 tsp every six (6) hours for pain. Other than that the medications were to be administered for pain, no guidance was provided for these medications, leaving their use at the discretion of the LPNs who administered medications. Page 12 of the Guidelines for Delegation, published by the Boards of Nursing, includes: Activities appropriate for delegation to the LPN should be those that, after careful evaluation by the supervising RN, are expected to contain only one option. Activities that are NOT appropriate for delegation to an LPN are those that are likely to present decision making options, requiring in depth assessment and professional judgment in determining the next step to take as the provider proceeds through the steps of the activity. - 3. The resident had been started on [MEDICATION NAME] 0.25 mg in the morning and at night for anxiety on 06/22/10. On 07/15/10, the night time dose of [MEDICATION NAME] was increased due to an increase in repetitive health complaints. (These dosages were well within the manufacturer's recommendations for an elderly individual.) The MARs included lines for recording the nurses' observations for: Monitor resident for (a) isolation and (b) decreased appetite. There were lines for (a) and (b) for the time period from 7:00 a.m. to 7:00 p.m. and for the time period from 7:00 p.m. to 7:00 a.m. On the September 2010 MAR, all of the responses for the 7:00 p.m. to 7:00 a.m. section were filled with minus signs (-). Eighteen (18) days of the 7:00 a.m. to 7:00 p.m. section were filled with minus signs (-) for both isolation and decreased appetite. Zeros (0) had been entered for both responses on eight (8) days. On 09/20/10, a zero had been entered for isolation and a plus sign (+) had been entered for decreased appetite. On 09/28/10, a plus sign (+) had been recorded for isolation and a minus sign (-) for appetite. According to the DON in an interview of 10/06/10 at 2:55 p.m., if something was not a problem, a minus sign (-) was to be entered on the MAR, and a plus sign (+) was to be recorded if it was a problem. The resident had weights that were fairly stable. From January 2010 through June 2010, her weights ranged between 117 to 119 pounds with a high of 121 pounds in March. In June 2010, she weighed 119 pounds, and according to the July weight of 113.8 pounds, she lost 5.2 pounds in one (1) month. In August, she weighed 112 pounds, but she had lost weight again by September, when she weighed 107.2 pounds. Her weight for October 2010 was 99.4 pounds. The form utilized by the facility entitled Medication Side Effects and Adverse Effects had [MEDICATION NAME] ([MEDICATION NAME]) circled. The side effects listed included, Behavior problems, blurred vision, change in appetite, . weight gain/loss, . There was no evidence of an evaluation of the cause for the resident's weight loss. Although the [MEDICATION NAME] may not have been a contributing factor, it warranted further consideration. There was no evidence the implementation of [MEDICATION NAME] in June (after which the resident's weights began to decline) was considered as a possible causal factor.",2015-10-01
9730,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,282,D,0,1,U9W011,"Based on review of medical records, staff interviews, and observations, the facility failed to ensure services were provided in accordance with the plan of care for one (1) of twenty-seven (27) Stage II sample residents. Resident #54's care plan included provisions to offer substitutions and encourage food intake. During meal observations, the resident (who had experienced weight loss) was not provided with encouragement and was not offered a substitution as specified in her care plan. Resident identifier: #54. Facility census: 60. Findings include: a) Resident #54 The resident's care plan, established on 08/25/10, included providing substitutions and encouraging food and fluid intake. During meal observations on 10/04/10, 10/05/10, and 10/06/10, prompting and encouragement were not offered. At supper time on 10/05/10, the resident served her meal in her room. While the resident was in the bathroom, a nursing assistant went into the bathroom to check on the resident and to remind her to ask for help. The nursing assistant came out of the bathroom and removed the resident's dinner tray. She did not ask whether the resident was finished or whether she would like a substitution.",2015-10-01
9731,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,311,D,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility failed to provide services to maintain or improve the self-feeding ability of one (1) of twenty-seven (27) Stage II sample residents who was cognitively impaired. Resident identifier: #31. Facility census: 60. Findings include: a) Resident #31 Observations in the dining room, during the evening meal on 09/27/10 at 5:55 p.m., found Resident #31 was sitting with three (3) other residents and two (2) nursing assistants. Her meal had been placed in front of her at approximately 5:15 p.m., after which she did not touch it, nor did a staff member cue her or attempt to assist her with the meal. At 5:55 p.m., Employee #16 entered the dining room and sat down to assist Resident #31 with her meal. This surveyor asked Employee #16 if he should reheat Resident #31's meal related to the fact that her food had been sitting uncovered for forty (40) minutes. Employee #16 looked at Resident #31, threw the silverware on the table, and said, I guess we'll heat it up. He then returned after heating the meal and attempted to feed Resident #31 some peas. Resident #31 said it was too hot. Employee #16 said, Well, you're not going to eat it anyway. Employee #16 then removed Resident #31 from the dining room without further assisting her with her evening meal. Review of Resident #31's most recent assessment (an abbreviated assessment with an assessment reference date of 07/28/10) revealed she had problems with her short-term memory, she could not recall the current season, location of her room, or that she was in a nursing home, her cognitive skills for daily decision-making were moderately impaired, and she could eat independently with supervision. Elsewhere in her record it was noted that she had [MEDICAL CONDITION].",2015-10-01
9732,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,325,E,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to ensure each resident maintained acceptable parameters of nutrition status, such as body weight, unless the resident's clinical condition demonstrated this was not possible. Four (4) of the twenty-seven (27) Stage II sample residents were affected. Resident #8 had lost weight, but no evidence was found indicating additional dietary interventions had been implemented in an attempt to reverse or slow the weight loss. Resident #54 was observed during meal times, staff was not observed to offer substitutes for uneaten food items, nor was prompting or encouragement noted to be offered. Resident #52's dietary consult was not conducted timely. Resident #72 experienced weight loss, and there was no evidence a speech therapy consult had been completed as recommended to assure the resident was receiving the appropriate diet. Resident identifiers: #8, #54, #52, and #72. Facility census: 60. Findings include: a) Resident #8 This resident was triggered for review in Stage II of the survey, as her body mass index (BMI) had been calculated as 17.97. This was based on her weight of 92 pounds (#) and height of 60 inches. Review of the resident's weight records disclosed the following: 01/06/10 - 109.60# 02/08/10 - 106.2# 03/03/10 - 105.60# 04/06/10 - 101.60# 05/03/10 - 101.40# 06/04/10 - 97.20# 07/06/10 - 95.00# 08/04/10 - 93.00# 09/02/10 - 91.80# 10/10 - 88.00# (A specific date when this weight was obtained was not given, but this information was provided to the surveyor at approximately 2:10 p.m. on 10/05/10.) Review of the physician's orders [REDACTED]. The quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/09/10, indicated the resident was independent in eating after set-up. She was coded as having a chewing problem. At that time, she weighed 98# (although her weight record indicated she weighed 97.2# on 06/04/10), and she was coded as having had a weight loss. The assessment indicated the resident was on a planned weight change program. She was not coded as leaving 25% or more of her meals uneaten. She was on ten (10) medications, none of them were antipsychotics, antidepressants, or diuretics, according to the assessment. The quarterly assessment, with an ARD 09/08/10, was reviewed. At that time, she was coded as requiring the limited assistance of one (1) for eating. Her weight was entered as being 92#, and weight loss coded. She was again coded as having a chewing problem and as being on a planned weight change program. The assessment note, signed on 09/17/10, included, Resident contiunues (sic) to eat well or drink fluids well. Resident is stable in her current condition. Care plan goals and interventions reviewed and updtaed (sic). Review of the resident's care plans, established 09/15/10 and 06/16/10, found no changes had been made to the care plan goal or interventions. (See also citation at F280.) Review of the documentation by the dietary manager (DM - Employee #5) and the registered dietitian (RD) for 2010 found the following: - A care plan note, dated 03/24/10, noted her weight was 105.6#, up in thirty (30) days and down in ninety (90) days. It was noted at that time that she received Med Pass 2.0 - 2 oz TID and a multivitamin. - A form for food the resident did not like was dated 04/08/10, but there was nothing written on the form except for the identifying information. - An annual Nutritional Assessment Form was completed by the DM on 04/08/10 and reviewed by the RD on 04/26/10. At that time, she was noted to weigh 101.6#. Her estimated calorie needs were 1173 kcal per day, estimated fluid needs 1150 cc per day, and estimated protein needs 46 grams per day. Her BMI was recorded as 19.5. She was assessed as having a small frame. - RD note, dated 04/26/10, noted: Reviewed d/t (due to) annual assessment. Current wt. is 101.6#, (down arrow) 4# in 1 month (4%), (down arrow) 8# in 3 months (7%), (down arrow) 8# in 6 months (7.6%), (up arrow) 3.6 # since admit 5/22/01 (4%). Wt has been stable for past month /s (without) sig. (symbol for 'change'). Slightly above IBWR (ideal body weight range) (80-100#) BMI is 19.5 - WNL (within normal limits). Diet order is mech soft. Meal intake is 25-50%. Also receives Med Pass 2.0 2 oz. TID. Diet & supplement meets est. needs. Most recent labs on 03/08/10: [MEDICATION NAME] is 3.4 WNL. (Symbol for 'No') [MEDICAL CONDITION] noted. Skin intact. (Symbol for 'No') recs (recommendations) @ this time. - On 06/04/10, the DM noted that weight loss triggered, and the director of nursing (DON) and physician were notified. The DM noted the resident's weight was 97.2#. The resident's diet and supplement were noted, but no recommendations for changes were made. - On 06/07/10, the RD noted the resident was reviewed due to weight loses at ninety (90) and one hundred-eighty (180) days. She noted the resident's current weight was 97# and it had been stable for the last month. Her BMI of 19.0 was within normal limits on low end of the range. The resident's diet and supplement were noted, but no recommendations for changes were made. - On 07/06/10, the DM noted the resident again triggered for weight loss, and the DON and physician were aware. Her current weight was 95#. The resident was receiving an antidepressant. The resident's diet and supplement were noted, but no recommendations for changes were made. - On 07/08/10, the RD reviewed the resident and noted her weight was 95#. No recommendations for changes were made. - On 08/04/10, the RD notes her weight was 93# and had stabilized of the past month. She noted the resident's current BMI of 18.2 was within normal limits, but on the low end of the range. The resident's diet and supplement were again noted, but no recommendations for changes were made. - On 08/11/10, the DM noted the resident's weight was 93#, the DON and physician were aware, and [MEDICATION NAME] was ordered related to the resident's appetite. - On 09/02/10, the DM noted the resident's weight was 91.8#. The DON and physician were notified. The DM noted, Will refer to Dietitian. - On 09/08/10, the RD noted, Reviewed d/t 6 month wt. loss. Current wt is 92# . Wt has been stable for past 3 months /s sig. change. No recommendations at this time. The care plan note of 09/15/10 included the resident's weight was 91.8# and she was receiving Med Pass 2.0 TID for weight loss prevention. It was noted the resident was receiving an antidepressant medication and nursing staff was monitoring for side effects. It was noted the team would proceed to nutritional care plan. Documentation on the August 2010 Medication Administration Record [REDACTED]. On 10/05/10 at 3:30 p.m., the DM was asked for, and provided, the information used to calculate the BMI. She provided a slide rule from Ross Products Division, Abbott Laboratories with a date of May 1997. According to the DM, this was what they had used, but the computer did the calculations now. The slide rule had a chart for BMI Ranges for American Women with the following: 19.1 - 27.3 - Acceptable weight >_ (greater than or equal to) 27.3 - Overweight >_ 32.3 - Severe overweight >_ 44.8 - [MEDICAL CONDITION] It also had Signs of Nutrition Risk in Older (italicized and underlined) American Women and Suggested Interventions, which stated: BMI BMI > 27 - Screen for Type II diabetes, cardiovascular disease, and hypertension. Intervene appropriately; consider medical nutritional therapy. Unintended weight loss or gain of 10 lb in last 6 months. Nothing was found in the dietary notes regarding the possibility of providing enhanced foods or of making any other changes to her diet in order to halt or slow the resident's weight loss. This was discussed with the DM at 2:05 p.m. on 10/05/10. She was familiar with methods to enhance food to increase the amount of calories. She mentioned adding butter, powdered milk, sugar, etc. The DM said she let the RD know whenever a resident lost weight and did not know why no recommendations had been made. She said the RD talked to staff about the residents when there was an issue. It was also noted the resident usually drank the Med Pass supplement according to the medical record. The DM agreed it might be worth a try to increase the amount of supplement. On 10/05/10 at 2:08 p.m., a licensed practical nurse (LPN) familiar with the resident (Employee #9) was asked whether it might be beneficial to try to increase the amount of Med Pass, by either providing more ounces or additional times. She said could she could check with the doctor and have the amount increased. -- b) Resident #54 During observations of meal times for this resident, it was found she ate in her room. She was observed at lunch time on 10/04/10; breakfast, lunch, and dinner on 10/05/10; and breakfast and lunch on 10/06/10. Staff was not observed to go into the resident's room at meal time and offer prompting / encouragement. On 10/05/10, at breakfast, the resident would drift away from the overbed table on which her meal had been served. No staff was observed to enter the resident's room. This observer asked if she would like the table closer. When the table was repositioned, the resident ate a few more bites. On 10/05/10, at supper time, the resident was again served her evening meal in her room. The resident went into the bathroom unassisted. A nursing assistant went in and reminded the resident she was to ask for help when she went to the bathroom. The nursing assistant came out of the bathroom and removed the resident's dinner tray. She did not ask whether the resident was finished or whether she would like a substitution. (Of note, typically, only one (1) staff member was on the floor during the evening meal. That individual was observed feeding other residents, which did not allow for prompting / encouragement of less dependent residents.) This observer would visit the resident during meal times and encourage her to eat. By 10/06/10, when this observer went to the resident's room, she would return to her tray without prompting, say she was trying to eat, and consume a few more bites of food. This resident had experienced an unplanned weight loss. In March 2010, the resident had weighed 119#; in May - 118#; June - 119#; July - 113#; August - 112#; September - 107#; and October - 99.4#. The resident had been started on Med Pass 2.0 - 2 ounces once a day on 06/07/10. This was increased to three (3) times a day on 09/08/10, in an effort to halt her weight loss. The resident had also been started on [MEDICATION NAME] 0.25 mg twice a day for anxiety on 06/22/10. This had been increased to 0.25 mg in the morning and 0.5 mg at bed time on 07/15/10. The form utilized by the facility entitled Medication Side Effects and Adverse Effects had [MEDICATION NAME] ([MEDICATION NAME]) circled. The side effects listed included, Behavior problems, blurred vision, change in appetite, . weight gain/loss, . There was no evidence of an evaluation of the cause for the resident's weight loss. Although the [MEDICATION NAME] may not have been a contributing factor, it warranted further consideration. There was no evidence the implementation of [MEDICATION NAME] in June (after which the resident's weights began to decline) was considered as a possible causal factor. -- c) Resident 52 Resident #52 was admitted to the facility on [DATE] upon admission Resident #52's weight was 139.4#. Resident #52 was ordered a regular diet upon admission. Her monthly weights were as follows: - August 2010 - 134.8# - September 2010 - 129.4# - October 2010 - 121.0# On 09/11/10, Resident #52's diet consistency was changed to pureed. On 09/23/10 at 11:12 a.m., the social worker (Employee #65) documented that Resident #52 was to eat in the small dining room so she could be assisted. On 09/24/10, a diet order was changed to identify Resident #52's need for assistance with feeding. On 10/05/10 at 12:00 p.m., an interview was conducted with the DON, who stated, The dietitian only comes once a month. She further stated Resident #52 continues not to eat. We had her on [MEDICATION NAME], but she wouldn't take it, so it was discontinued, and we changed her diet to pureed. During an interview with the DM on 10/05/10 at 12:35 p.m., it was found that the DM had contacted the RD on 09/15/10. The RD did come to the facility on [DATE] but did not see Resident #52. The DM stated, The dietitian didn't have time or maybe (Resident #52) was out of the facility. Record review found Resident #52 to be present at the facility on 09/22/10. On 10/05/10, a physician's orders [REDACTED].#52 to receive intravenous (IV) fluids and a Foley indwelling urinary catheter to monitor strict fluid intake and output. -- d) Resident #72 Review of Resident #72's medical record found, in the October 2010 monthly recapitulation of physician's orders [REDACTED]. The plan of care, dated 08/04/10, stated the resident was to receive a pureed NAS (no added salt) diet and fluids according to her likes and dislikes daily. During an observation of the meal on 10/06/10 at 12:00 p.m., this resident was observed to be eating in the dining room for residents requiring cueing and assistance. She received a regular consistency diet and was eating sauerkraut and sausages. She was rolling the sausages in her mouth and exhibiting difficulty chewing them. Documentation in the medical record disclosed this resident had experienced a significant weight loss. She had been acutely ill and had been in the hospital on two (2) different occasions in the last three (3) months. Her weight, when she was admitted to the facility in May 2010, was 146#, and in October 2010, her weight was 120#. Multiple interventions had been attempted to address her weight loss, including nutritional supplements, assisted feeding, IV fluids, and medication changes. The resident had a [DIAGNOSES REDACTED]. The resident had a speech therapy consult done on 06/02/10, which noted she had difficulty with regular solids and was unable to chew. She pocketed her food and required verbal cuing to swallow. Her diet was downgraded to a pureed consistency at that time. She was then sent to the hospital and admitted on [DATE]. She remained in the hospital until 07/19/10. Her discharge summary from the hospital stated she was to have a cardiac diet, but the nursing home physician ordered a regular diet on her re-admission. A nursing assistant (Employee #39) was observed to be assisting the resident at lunch time at 12:00 p.m. on 10/06/10. When questioned about the resident's diet, Employee #39 stated the resident was on a pureed diet at one (1) time, but her diet was changed. She was not aware why. The resident was observed at this meal to be having difficulty chewing the meat, but she was consuming the mashed potatoes without difficulty. The medical record was further reviewed, and there was no evidence that speech therapy had re-evaluated this resident to assure she was receiving the appropriate diet after she returned from the hospital on [DATE]. Prior to this hospitalization , she was receiving a pureed diet, but her diet order upon readmission was for regular consistency foods. There was no further evaluation of her dietary needs, even though she exhibited signs of chewing difficulty. The DON, when interviewed on 10/06/10 at 2:45 p.m., verified this resident was not re-evaluated by speech therapy after she came back from the hospital. The DON also verified that there had been a recommendation by the nurses for speech therapy to review her last month (September 2010), but there was no evidence to reflect this had occurred. She stated they called the speech language pathologist (SLP), and she was coming in to evaluate the resident. The SLP came to the facility and evaluated this resident on 10/07/10. She recommended, at that time, changing the texture and consistency of this resident's diet to Mechanical Soft.",2015-10-01
9733,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,441,E,0,1,U9W011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and review of policies and procedures, the facility failed to establish and maintain an infection control program designed to provide a safe, sanitary, and comfortable environment and to help prevent the development and transmission of disease and infection. A nursing assistant working in the restorative dining room did nor employ appropriate handwashing technique. Additionally, the facility did not implement any measures to prevent the spread of [MEDICATION NAME] for one (1) resident who was being treated for [REDACTED]. Facility census: 60. Findings include: a) Handwashing On 10/05/10 at 11:30 a.m., observation in the restorative dining room found a nursing assistant (Employee #7) failed to use proper handwashing techniques. Employee #7 was observed, on five (5) separate occasions, to wash her hands for less than ten (10) seconds each time. On 10/06/10 at 1:00 p.m., an interview with the director of nursing (Employee #53) confirmed this was not proper handwashing technique. On 10/06/10 at 1:30 p.m., review of the facility's policy and procedure regarding Handwashing revealed that employees should scrub their hands for a minimum of ten (10) to fifteen (15) seconds before rinsing. -- b) Resident #54 On the morning of 10/06/10, record review revealed [MEDICATION NAME] had been ordered for this resident to treat shingles. Further review of the resident's medical record found a nursing entry, dated 10/05/10 at 1100 (9:00 a.m.), Contacted Dr. (name) regarding res (ident) having two patches fluid filled blisters on buttocks. Dr. (name) states they sound like shingles. New orders: [MEDICATION NAME] 1000 mg i PO (by mouth) three times daily x 5 days due to shingles. Observation of the resident's room did not find any evidence of any type of precautions having been implemented. A copy of the facility's infection control policies related to shingles was requested. At 11:00 a.m. on 10/06/10, a document entitled Infection or Conditions Requiring Airborne Precautions, which included Chickenpox ([MEDICATION NAME]); Herpes zosta (sic) ([MEDICATION NAME]-[MEDICATION NAME]), localized in immunocompromised patient, or disseminated; ., was provided. At 11:15 a.m., Employee #50 brought in another document entitled Policy and Procedure / Shingles which included: Post Shingles treatment purpose is to prevent possibilities of other residents coming in contact with the virus. Staff will follow the following procedure/protocol: 1. Upon assessment / finding clusters of raised, blistered areas resident will be confined to room. Doctor will be notified. Medical POA will be notified. 2. Resident will remain in their room for 48 hrs after antibiotics are started. 3. Wounds will be covered if draining. 4. Universal precautions will be maintained unless wounds are draining. Nursing will use contact precautions during care. This was signed by the administrator and the DON on 08/15/08. On 10/06/10 at 11:15 a.m., Employee #50 said the DON always tells staff to stay out of the room if the person is pregnant. She cited a past occurrence. On 10/06/10 at approximately 12:18 p.m., the resident complained of being cold. Employee #63 (a licensed practical nurse - LPN) was passing by and the resident's complaint was conveyed. She went into the resident's room and asked the resident if she would like a blanket around her shoulders. As she placed a blanket around the resident's shoulders, two (2) other staff members (nurses) came into the room to talk to Resident #54's roommate about an incident that had occurred earlier. The nurses sat in chairs as they spoke with the roommate. At this time, Employee #50 entered the residents' bathroom to wash her hands. She was asked whether she had ever had chickenpox. She replied she had and asked whether Resident #54 had shingles. She said she worked restorative and had not known the resident had shingles. Employee #50 exited the room and the other two (2) nurses exited the room within no more than ten (10) seconds. This would not have allowed time for them to have washed their hands at the sink, nor would it have allowed sufficient time for the use of an alcohol hand wash preparation. - WebMD notes, You can't catch shingles from someone else who has shingles. But a person with a shingles rash can spread chickenpox to another person who hasn't had chickenpox and who hasn't gotten the chickenpox vaccine. - The Centers for Disease Control (CDC) recommendations include: V.D.1. Use Airborne Precautions as recommended in Appendix A for patients known or suspected to be infected with infectious agents transmitted person-to-person by the airborne route (e.g., M [DIAGNOSES REDACTED], [DIAGNOSES REDACTED], chickenpox, disseminated herpes [MEDICATION NAME]. Category IA/IC V.D.3. Personnel restrictions Restrict susceptible healthcare personnel from entering the rooms of patients known or suspected to have [DIAGNOSES REDACTED] (rubeola), [MEDICATION NAME] (chickenpox), disseminated [MEDICATION NAME], or [DIAGNOSES REDACTED] if other immune healthcare personnel are available. Category IB - Appendix A of the CDC's 2007 guidelines for Type and Duration of Precautions Recommended for Selected Infections and Conditions includes: For Herpes [MEDICATION NAME] (shingles): Disseminated disease in any patient. Localized disease in immunocompromised patient until disseminated infection ruled out. The type of precautions are listed as airborne and contact until the lesions dry. It also notes, Susceptible HCWs (health care workers) should not enter room if immune caregivers are available; no recommendation for protection of immune HCWs; no recommendation for type of protection, i.e. surgical mask or respirator; for susceptible HCWs.",2015-10-01
9734,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-10-06,463,D,0,1,U9W011,"Based on observation and staff interview, the facility failed to ensure two (2) of approximately seventy-five (75) call lights in resident rooms and bathrooms, central bathing areas, and common restrooms functioned properly. Facility census: 60. Findings include: a) During Stage I, on 09/29/10 at approximately 3:00 p.m., observation found the call light in room 114 (bed 1) did not activate the light outside of the door. This triggered a review of the environment for Stage II of the survey process. On 10/05/10, between approximately 8:30 a.m. and 9:45 a.m., all call bells were tested with the assistance of the maintenance supervisor (Employee 51). The call bell in room 114 (bed 1) did not activate when tested again at approximately 8:35 a.m. on 10/05/10. The call bell in the bathroom in room 107 did not activate when tested at approximately 8:40 a.m. on 10/05/10.",2015-10-01
11135,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-08-06,241,D,0,1,R1DI11,"Based on observation and staff interview, the facility failed to ensure each resident was treated with dignity. A staff member made a comment about a resident's behaviors in the presence of others that would be considered embarrassing to a cognitively intact person. This affected one (1) of the twenty-seven (27) residents attending a group meeting with surveyors. Resident identifier: #7. Facility census: 58. Findings include: a) Resident #7 On 08/05/09, residents electing to attend a group meeting with surveyors were assembling in the designated meeting area. Resident #7 was assisted to the area by Employee #19. After placing the resident's wheelchair at a table in the group area, the employee turned to exit the area and loudly stated, ""If she spits on the floor, just call housekeeping."" This remark was made in front of all other residents attending the group meeting. In an interview conducted on 08/06/09, the administrator confirmed Resident #7 was a habitual floor spitter but agreed the employee's remarks should not have been made in the manner observed when escorting the resident to the group meeting. .",2014-08-01
11136,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-08-06,310,D,0,1,R1DI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and resident interviews, the facility failed to ensure residents were positioned to facilitate their abilities to feed themselves without undue effort. Three (3) residents were observed eating breakfast in their rooms. Two (2) of the residents were served meals on overbed tables that were too high, and one (1) was in bed leaning to her right, feeding herself with her right hand. Resident identifiers: #5, #46, and #44. Facility census: 58. Findings include: a) Resident #5 At 7:20 a.m. on 08/06/09, observation found this resident eating breakfast in her room. She was seated in a small wheelchair, and her meal was on an overbed table. Her plate on a warming base atop a tray. This resulted in her food being at the height of her mouth. She was noted to have some difficulty in reaching items on the back of the tray. When asked whether she could reach everything, she said it was hard. b) Resident #46 At approximately 7:25 a.m. on 08/06/09, observation found this resident eating breakfast in bed. She had slid down in the bed, so that her mid [MEDICATION NAME] region was in the bend of the bed (where the head of the bed was elevated). She also was leaning to her right and feeding herself with her right hand. This position required additional effort for the resident to feed herself. c) Resident #44 Observation of this resident, at approximately 7:30 a.m. on 08/06/09, found her meal tray was at the height of the base of her neck. Increased effort was required for the resident to lift her arms in order to reach her food. .",2014-08-01
11137,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-08-06,371,F,0,1,R1DI11,"Based on observations, the facility failed to ensure food was prepared and distributed under sanitary conditions. Food debris was noted between two (2) sheet pans. Scrambled eggs were being held at 130 degrees Fahrenheit (F). The cook dropped a thermometer on the floor but did not wash her hands or change gloves after picking it up. Plastic pitchers and bins were inverted directly on a solid cart shelf with trapped moisture. These had the potential to affect residents who were served meals from the dietary department. Facility census: 58. Findings include: a) During the initial tour of the dietary department at approximately 6:20 a.m. on 08/04/09, the following were noted: 1. Food debris was found between two (2) inverted sheet pans stored on a shelf. 2. The temperature of scrambled eggs on the steam table was 130 degrees F. The danger zone for holding foods is between 41 degrees F and 135 degrees F. 3. As the cook approached the steam table with a clean thermometer, she dropped it on the floor. She picked the thermometer up and put it in a sanitizing solution. She got another thermometer and proceeded to check the temperature of the pureed eggs without changing her gloves and washing her hands. 4. Pitchers and plastic bins were observed stored directly on the surface of a metal cart with moisture trapped inside. This has the potential to provide an environment conducive to the proliferation of microorganisms. .",2014-08-01
11138,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-08-06,252,B,0,1,R1DI11,"Based on observations, the facility failed to ensure window curtains were in good repair. Holes were observed in the curtains in five (5) rooms on the 200 hall. This had the potential to affect the residents living in those rooms. Facility census: 58. Findings include: a) During the initial tour of the facility on 08/04/09, holes were observed in the window curtains in rooms #200, #202, #206, #210, and #212. .",2014-08-01
11288,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-02-10,225,D,1,0,33YV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility did not ensure an incident of possible neglect, whereby a resident sustained [REDACTED]. Resident identifier: #59. Facility census: 58. Findings include: a) Record review revealed a nursing note, dated 10/29/08, documenting Resident #59 was being transferred by two (2) NAs and a nurse utilizing a mechanical lift, when the resident sustained [REDACTED]. An interview with the director of nursing (DON), on 02/10/09 at 10:00 a.m., revealed the facility did not submit an immediate report and 5-day follow-up report to the State nurse aide registry for the nursing assistants involved. The DON had reported the incident to only the State survey and certification agency and Adult Protective Services. .",2014-07-01
11289,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2009-02-10,309,D,1,0,33YV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility did not ensure one (1) of three (3) sampled residents received timely care and services to maintain physical well-being. Resident #59 sustained a [MEDICAL CONDITION] humerus and was not seen by an orthopedic specialist until eight (8) days later. Additionally, Resident #59 did not receive a skin assessment or skin care under an Ace wrap that was ordered by the physician to immobilize the fractured humerus, resulting in the development of an open area. Facility census: 58. Findings include: a) Resident #59 1. An interview with the director of social services, on 02/10/09 at 12:20 p.m., revealed she did not make medical appointments for the residents. She stated the admission coordinator was responsible for making these appointments. An interview with the admission coordinator, on 02/10/09 at 12:45 p.m., revealed she received a physician's telephone order from the nursing department requesting an appointment for Resident #59 to see an orthopedic specialist. The physician's orders [REDACTED]. She stated she told the specialist's office staff the resident had a fracture to her right elbow and needed to be seen as soon as possible. A nursing note, dated 10/29/08 at 3:50 p.m., revealed, ""Resident transferred from bed to wheelchair using total body lift with assist of 2 CNA's (certified nursing assistants) and this nurse. Resident transferred without difficulty. Some crying noted, but stopped crying when sitting in wheelchair. Bruise to right inner elbow with [MEDICAL CONDITION] noted. Sitting upright with good posture."" Another nursing note at 4:00 p.m. revealed, ""Spoke with daughter about the bruising and swelling of elbow. Explained we are going to obtain a x-ray and will let her know of the results."" A nursing note at 5:15 p.m. indicated, ""Imaging contacted this nurse by phone and reported right distal humerus non-displaced fracture to right elbow. MPOA stated I think it could of happened when being dressed, because she is stiff."" Nursing notes continued from 10/29/08 to 11/03/08, describing the condition of the resident's right elbow area. An order was received from the physician on 10/30/08, to apply an immobilizer Ace wrap to the right arm and to leave in place until the orthopedic appointment. There was no evidence of attempts by any staff to call to schedule an appointment with the orthopedist until 11/03/08, when a telephone order was received from the physician to order an appointment with an orthopedic specialist. An interview with the director of nursing (DON), on 02/10/09 at 1:00 p.m., revealed it was very difficult to get an appointment with an orthopedic specialist in the area. She stated the nursing staff had attempted to get an appointment and was not able to do so. (There was no documented evidence of these efforts by the nursing staff to obtain an appointment for the resident.) The resident was diagnosed with [REDACTED]. 2. A review of the resident's medical record revealed [REDACTED]. At 5:15 p.m., a report from the x-ray department indicated the resident had a [MEDICAL CONDITION] distal humerus that was non-displaced. At 7:35 p.m., a nursing note described the resident as exhibiting signs of discomfort related to the right arm. A physician's orders [REDACTED]."" An interview with the DON, on 02/10/09 at 11:00 a.m., revealed the Ace wrap was placed on the resident in accordance with the physician's orders [REDACTED]. The resident returned to the facility without the wrap, which was removed at the physician's office. She further stated they did not remove the Ace bandage during this time, frame because the order from the physician clearly indicated the Ace wrap was not to be removed. The staff washed the resident around the Ace wrap but not under the wrap. When the resident returned to the facility from the physician's office she was assessed with [REDACTED]. The resident's hand remained in this position, resting against her breast for seven (7) days. On 11/06/08 at 4:40 p.m., the resident returned from the appointment with the orthopedic specialist without the Ace wrap. The specialist's report indicated the resident was not to have the Ace wrap applied and that the area would heal without problems. Surgery would not be necessary and to not passively extend the right elbow. A sling may be used for comfort. A nursing note, dated 11/06/08 at 7:20 p.m., indicated, ""This nurse entered room for assessment. MPOA (medical power of attorney) was upset with red areas to left breast and right hand. Measurement right thumb 1.5 cm length and 2 cm width. Right hand 2nd knuckle 1 cm x 2 cm outer wrist bone on right arm 1 cm x 1 cm left breast top red area 5 cm x ? cm area below. Skin is not open."" At 9:30 p.m., a nursing note indicated, ""Red areas fading in color."" An interview with the DON, on 02/10/09 at 1:00 p.m., confirmed the resident had an open area on the left breast. She continued to state they could not remove the Ace wrap, because they had an order not to remove. She further stated the resident could be very combative, and to attempt to remove the Ace wrap may have caused problems with the resident right elbow fracture. The facility failed to ensure the resident's skin was assessed and cleaned under the Ace wrap for seven (7) days. .",2014-07-01
11290,BRAXTON HEALTH CARE CENTER,515180,859 DAYS DRIVE,SUTTON,WV,26601,2010-11-03,332,E,1,0,RE7D11,". Based on observation and staff interview, the facility failed to assure licensed practical nurses (LPNs) administered medications according to professional standards of practice which would ensure that it is free of medication error rates of five percent (5%) or greater. During the observation of preparation for medication pass, LPNs removed medications from their original packaging, placed them in medication cups, and stored the pre-poured medications in the medication cart; they also documented the administration of these pre-poured medications on the medication administration records (MARs) prior to actually giving them to the residents and performing the five (5) rights of medication administration. This practice would provide a greater potential for medication error to all residents. A total of sixty-eight (68) medications were pre-poured and placed in cups to be given to the residents. This deficient practice had the potential to affect more than an isolated number of residents currently residing in the facility. Facility census: 58. Findings include: a) On 11/02/10 at 4:45 a.m., random observation of the MARs found the LPN (that Employee #9) had already documented having administered all of 6:00 a.m. scheduled doses medications. She had also pre-poured all of the medications in cups, including narcotics. An interview with Employee #9, on 11/02/10 at 4:45 a.m., confirmed that medications scheduled to be given on the 6:00 a.m. medication pass had already been signed off and placed in cups for twenty-seven (27) residents on the 100 hall. A total of sixty-five (65) doses of medications were pre-poured in cups for administration. Employee #9 stated, ""Sometimes, we are short on nursing assistants and have to help on the floor, and pre-pouring saves time."" On 11/02/10 at 5:30 a.m., an interview with Employee #6 (another LPN) confirmed that medications for residents on the 200 hall had also been pre-poured and placed in cups without the nurse performing the five ""rights"" of medication administration (right resident, right drug, right dose, right route, and right time). This finding was discussed with the administrator (Employee #21) on 11/02/10 at 9:30 a.m., who stated, ""They think that saves them time."" On 11/03/10 at 10:00 a.m., the director of nursing (Employee #51) confirmed this was not acceptable practice and would not be tolerated by the facility.",2014-07-01
3530,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,241,D,0,1,Inf,"Based on observation and staff interview, the facility failed to ensure a resident had a dignified dining experience. This was for one randomly observed resident #48, who was not served or assisted with her meal for over an hour at lunch on 10/30/17. This was evident for one random resident. Census:51. Findings include: a) Resident.#48 was observed in the dining area at lunch on 10/30/17. She was seated in a wheelchair propelling herself around the dining room area. She was bumping into other resident's chairs and then in the hallway surrounding this area. This was observed from 12:00 p.m. until 1:15 p.m. During this interval (over an hour) the resident was not seen having any intervention by nursing staff attempting to offer her a lunch tray or assisting her to eat. The resident was finally approached by staff and she was moved in her wheelchair to a table where they did offer her food. She did not want what was offered and she requested a sandwich which staff obtained for her.",2020-09-01
3531,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,257,E,0,1,Inf,"Based on observation and staff interview, the facility failed to maintain comfortable temperature levels in the dining room area. This had the potential to affect more than a limited number of residents who eat in the main dining room. Census: 51 Findings include: a) During meal observations at lunch on 10/30/17 in the main dining area of the facility It was found the thermostat was set for 76 F but was reading 68 F as the in room temperature. Random observations of the residents in the dining room found that a table where four female residents were seated, they mentioned their food was cold. Staff did intervene and had three of the residents foods reheated but the fourth one did not wish anything done to hers. The surveyor checked the food temperatures in the kitchen and all food items were at proper temperature at the time. A review of resident council minutes at 9:15 a.m. on 10/31/17 revealed in (MONTH) (YEAR) residents expressed the temperature of the building was cold. Discussion with the corporate environmental staff and the facility maintenance worker on 11/02/17 12:20 p.m. revealed there is a thermostat near the dining area. There is also an air conditioning vent overhead near this thermostat. Even though the thermostat is set for a warm temperature the air vent is blowing cold air and making it cooler. The units were working against each other. The ambient air temperature in a facility is to be between 71-81 F but was 68 F at the time of observation.",2020-09-01
3532,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,278,D,0,1,Inf,"Based on medical record review and staff interview, the facility failed to ensure its fourteen (14) day comprehensive assessment was accurate in the area of locomotion for one of (1) of ten (10) residents whose care plans were reviewed. Resident identifier: #68. Facility census: 51. Findings include: a) Resident #68 The fourteen (14) day comprehensive assessment, with assessment reference date 05/23/17, was compared with the ninety (90) day quarterly assessment, with assessment reference date of 08/08/17. According to the assessments, the resident declined in the area of locomotion off the unit from supervision (oversight) on 05/23/17, to limited assistance on 08/08/17. An interview was conducted with minimum data set (MDS) registered nurse #32 on 11/02/17 at 10:49 a.m. She said the MDS with ARD 05/23/17 in the area of locomotion off the unit was assessed incorrectly. She said she should have assessed that he required limited assistance with locomotion off the unit, rather than supervision. She said the resident had no decline in this area. She said on the 05/23/17 look back period, he had four (4) occurrences where he needed assistance, and the rest was independent. She said on the 08/08/17 quarterly MDS, she assessed correctly that he required limited assistance with locomotion off the unit. An interview was completed with the administrator on 11/02/17 at 3:00 p.m. about the MDS assessment error. No further information was provided prior to exit.",2020-09-01
3533,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,279,D,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** individuated goals and non-pharmacological interventions to treat behaviors of Resident #48, who received psychoactive medications. The facility also failed to care plan for Resident #68's decline in urinary continence. These practices affected two (2) of ten (10) residents whose care plans were reviewed, and one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #68 and #48. Facility census: 51. Findings include: a) Resident #68 Review of the medical record on [DATE], found [DIAGNOSES REDACTED]. This resident was assessed when he first came to the facility as only occasionally incontinent of urine. The admission minimum data set (MDS,) with assessment reference date (ARD) of [DATE], assessed that he was only occasionally incontinent of urine. This amounted to less than seven (7) instances of urinary incontinence in the seven (7) day look-back period. In comparison, the quarterly MDS with ARD of [DATE], assessed him as always incontinent of urine. There were no instances of continent voiding in the seven (7) day look-back period. Review of the care plan found no focus or identification of the decline in urinary continence ability, and no interventions to try to help him improve in urinary continence. On [DATE] at 10:24 a.m. an interview was completed with the director of nursing (DON). She said the aides' Kardex noted he has episodes of bowel and bladder incontinence, uses incontinence products, and uses the urinal at the bedside. She said he had more incontinence right before his wife passed away in July, and had an acute episode right after his wife passed away. She said she was not working at the facility at that time, but that was what she was told by the minimum data set (MDS) registered nurse #32. An interview was conducted with MDS registered nurse #32 on [DATE] at 10:57 a.m. She said she thought the decline in urinary continence was situational and would return to baseline, so a care plan was not completed at the time of the [DATE] assessment. She said his wife, who was also his room-mate, expired in the time between the two (2) MDS assessments. She said they referred him to physical therapy (PT) for evaluation on [DATE], and he received PT services from [DATE] through [DATE] to help improve his strength. She said he also received occupational therapy from [DATE] through [DATE]. The MDS nurse said she also identified a problem with staff not always remembering to document each episode of voiding, and whether or not the resident was continent or incontinent with each voiding episode. She said she educated staff toward the end of (MONTH) about the importance of capturing an accurate assessment of the number of times of voiding each day, and noting if they were continent or incontinent each time. Further review of the medical record found the quarterly MDS, with ARD [DATE], assessed him as frequently incontinent of urine. When asked on [DATE] at 11:00 a.m. about his current voiding ability, MDS nurse #32 said in the past seven (7) days, he was still frequently incontinent of urine. She said she thinks he needs goals care planned related to the decline in urinary continence, and appropriate interventions to meet the goals. She said she would work on the care plan today. On [DATE] at 3:00 p.m., an interview was conducted with the administrator. It was discussed that a care plan focus and goal was not identified and developed for Resident #68 related to his decline in urinary continence. No further information was provided prior to exit. b) Resident #48 Review of the medical record on [DATE] found [DIAGNOSES REDACTED]. Her brief interview for mental status (BIMS) score on the comprehensive annual minimum data set (MDS), with assessment reference date (ARD) [DATE], assessed that her cognition was severely impaired. Behaviors identified within the medical record included yelling at staff and hitting them, removing her clothing in public places, combativeness with care at times, wandering in the hallways in her wheelchair, and cursing. Medications prescribed by her physician to treat her medical conditions and behaviors included Depakoate sprinkles 250 milligrams (mg.) twice daily for dementia with behavioral disturbance as evidenced by rejections of care, cursing, and threatening behaviors, [MEDICATION NAME] (a medication used in the treatment of [REDACTED]. daily at bedtime, and [MEDICATION NAME] (an anti-anxiety medication) one (1) mg. twice daily for anxiety. The care plan was reviewed. Although the behaviors and the medications prescribed for the behaviors were noted within the care plan, there were no individualized, measurable goals for the behaviors they were treating. There were also no non-pharmacological methods care planned to address the behaviors. An interview was conducted with the minimum data set (MDS) registered nurse, #32, on [DATE] at 3:33 p.m. She printed the resident's current care plan, and reviewed the focus of behaviors related to the Depakoate, [MEDICATION NAME], and the [MEDICATION NAME]. The goals simply stated that she would be free from discomfort or adverse reactions related to anti-[MEDICAL CONDITION] therapy and anti-anxiety therapy, and would remain free of drug related complications. After reading over the care plan a couple more times, she agreed there were no measurable or individualized goals for her behaviors, and there were no non-pharmacological interventions listed to treat those behaviors. She said the resident had no separate behavioral management care plan. An interview was completed with the administrator on [DATE] at 3:45 p.m. related to the absence of individualized and measurable goals to treat a resident's behaviors with psychoactive medications, and the absence of non-pharmacological interventions to treat the behaviors. No further information was provided prior to exit.",2020-09-01
3534,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,332,D,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews, policy review and National Institute of Health recommendations, the facility failed to ensure a medication error rate of less than five percent (5%). The nurse failed to observe the complete medication administration process for Resident #44 and #78. The nurse also failed to use proper technique to ensure eye drops were administered correctly to Resident #44. Medication errors were identified for two (2) of three (3) residents observed for medication pass. There were three (3) medication errors in thirty (33) opportunities for error, resulting in a medication error rate of 9.09%(percent). This practice has the potential to affect more than a limited number of residents. Resident identifiers: #44 and #78. Facility census: 51 Findings include: a) Resident #44 On 11/01/17 at 9:45 a.m., observation of LPN #58 administering morning medication to Resident #44, revealed the nurse mixed seventeen (17) grams (gm) of [MEDICATION NAME] (Polyethylene [MEDICATION NAME]) in eight (8) ounce (oz) of water and gave the glass to the resident to use to swallow his other ordered pills. Resident #44 swallowed his pills with approximately one (1) oz. of the eight (8) oz. of [MEDICATION NAME] ordered, and left the glass with the rest of the [MEDICATION NAME] bedside. At 11:05 a.m. on 11/01/17, observations revealed the glass of left over [MEDICATION NAME] was still sitting on the bedside table. LPN #58 was asked to come to Resident #44's room. The nurse observed the glass of [MEDICATION NAME] remaining at the bedside and agreed the resident only had taken seven (7) of the eight (8) oz ordered. On 11/01/17 at 11:09 a.m., review of Resident #44's administration record (MAR) by this surveyor and LPN #58, revealed the MAR indicated [REDACTED]. The nurse agreed she should not have marked the MAR indicated [REDACTED]. During morning medication pass, LPN #58 also administered [MEDICATION NAME] Alcohol-[MEDICATION NAME] eye drops to both eyes of the resident, by asking him to look up and dropping the eye drop directly on the eye between the center and inner corner of the left eye and in the inner corner of the right eye. LPN #58 did not pull the lower center eyelid forming a pouch to drop the eye drop into as is the procedure for administering eye drops. The nurse did not make certain the eye drops made full contact with the conjunctival sac of the lower eye lid so that the eye drops washed over the eye when the resident closes his eyelid. According to the National Institute of Health (NIH.gov) the correct way to administer eye drops is to, Pull your lower lid down gently to form a pocket for the drop. Squeeze the bottle lightly to allow the drop to fall into the pocket. Position the tip of the eye drop bottle so that it does not come closer than 3/4 inch above your lower lid. Squeeze the bottle lightly to allow the drop to fall into the pocket.(Nursing staff created this information to show patients the correct way to put in eye drops). Review of the facility's policy Instillation of eye drops, under steps of procedure #7 through #9 revealed, Gently pull the lower eyelid down. Instruct the resident to look up. Drop the medication in the midlower eye lid . Instruct the resident not to blink or squeeze the eyelids shut to allow for even distribution of the drops. b) Resident #78 On 11/01/17 at 10:07 a.m., observation of LPN #58 administering morning medication to Resident #78, revealed the nurse mixed seventeen (17) grams (gm) of [MEDICATION NAME] (Polyethylene [MEDICATION NAME]) in eight (8) ounce (oz) of water and gave the glass of [MEDICATION NAME] to the resident to use to swallow the other morning pills. The nurse did not tell the resident that it was [MEDICATION NAME] but referred to it as water. Resident #78 swallowed her pills with approximately two (2) oz of the eight (8) oz of [MEDICATION NAME] ordered, and left the rest of the [MEDICATION NAME] on the overbed table. LPN #58 did not at any time encourage the resident to finish the [MEDICATION NAME] as ordered or inform her the glass had [MEDICATION NAME] in it. LPN #58 was notified by this surveyor the results of the observations made during the medication pass. At 11:04 a.m. observation revealed the remaining [MEDICATION NAME] was still sitting on the overbed table in Resident #78's room.",2020-09-01
3535,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,334,E,0,1,Inf,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, policy review, and review of Centers for Disease Control and prevention (CDC) guidelines, the facility failed to develop and implement policies and procedures related to pneumococcal vaccinations. The facility policy did not state it would offer both types of pneumonia vaccinations to residents, or assess newly admitted residents as to their history of the types of pneumonia vaccines previously received. Rather, the facility policy stated it would follow CDC guidelines. Review of CDC guidelines found it recommended routine administration of pneumococcal conjugate vaccine (PCV13 or Prevnar13, and PPSV23 or [MEDICATION NAME] 23) for all adults [AGE] years or older. Four (4) of five (5) residents who were eligible for both types of pneumonia vaccinations, were found either not to have been assessed for their previous pneumonia vaccination status for both types of vaccine, or were not offered both types of pneumonia vaccinations. Resident identifiers: #21, #68, #48, #20. Facility census: 51. Findings include: a) Resident #21 Review of the medical record on 11/01/17 found that this resident had a history of [REDACTED]. Interviews were completed with the director of nursing (DON) on 11/01/17 at 9:08 a.m. and 2:30 p.m. The DON said that after reviewing the medical record, It appeared that he was not offered, and did not receive, the second type of pneumonia vaccination. b) Resident #68 Review of the medical record on 11/01/17 found that this resident had a history of [REDACTED]. Interviews were completed with the DON on 11/01/17 at 9:08 a.m. and 2:30 p.m. The DON said that after reviewing the record, she found that he received the [MEDICATION NAME] 23 on 10/01/16. She said the Prevnar 13 could have offered on 10/01/17, but it was not offered. c) Resident #48 Review of the medical record on 11/01/17 found this resident received [MEDICATION NAME] vaccination on 03/12/15. Interviews were completed with the DON on 11/01/17 at 9:08 a.m. and 2:30 p.m. The DON said that after reviewing the medical record, this resident received the [MEDICATION NAME] based on historical information on 03/12/15. She was unable to provide evidence that the resident received, or was offered, the Prevnar 13. The DON said there was no consent in the medical record for her to agree or to decline the Prevnar pneumonia vaccination. d) Resident #20 Review of the medical record on 11/01/17 found that on 10/03/15 she refused the [MEDICATION NAME] pneumonia vaccination. There was no evidence that the facility offered her the [MEDICATION NAME] again in (YEAR) or in (YEAR). There was no evidence that the facility offered her the Prevnar 13 at any time during her stay there. Interviews were completed with the DON on 11/01/17 at 9:08 a.m. and 2:30 p.m. The DON said they offered a [MEDICATION NAME] on 09/28/15 and the resident declined. The DON was unable to provide evidence that the resident was offered the [MEDICATION NAME] again since (YEAR), or that the Prevnar 13 was ever offered. The facility policy on Pneumococcal vaccination, with effective date 05/01/16, was reviewed. It stated all residents will be offered the pneumococcal vaccines in accordance with CDC guidelines. Policy interpretation and implementation was as follows: 1. Upon admission to the facility, each resident will be evaluated for history of pneumococcal vaccinations, and offered the appropriate pneumococcal vaccine in accordance with CDC recommendations for adult immunizations. This was followed by the following five (5) steps: a. The facility will educate the resident and/or the legal representative about the risks and benefits of vaccination. b. Consent must be obtained from the resident or the resident's legal representative prior to administration of the pneumococcal vaccine. c. The current Vaccine Information Statement published by the CDC must be reviewed with the resident or the resident's representative and a copy provided. d. Administration of the vaccine will be documented by the administering nurse in the resident's clinical record. e. Declination of the vaccine will be documented in the resident's clinical record. Review of the current CDC recommendations found that the CDC recommends routine administration of pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults [AGE] years or older. CDC recommends that adults [AGE] years or older who have not previously received PCV13, should receive a dose of PCV13 first, followed one (1) year later by a dose of PPSV23 or [MEDICATION NAME] 23. If the patient already received one (1) or more doses of PPSV23 or [MEDICATION NAME] 23, the dose of PCV13 should be given at least one (1) year after they received the most recent dose of PPSV23. An interview was completed with the administrator on 11/02/17 at 3:00 p.m. She said they held an ad hoc meeting to address the issues with the pneumonia vaccination surveillance, and with residents' immunization status.",2020-09-01
3536,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,371,E,0,1,Inf,"Based on observation and staff interview, the facility failed to ensure foods are stored under sanitary conditions and equipment kept clean. Dry food item (macaroni noodles) was opened with no date of when it was opened and drip pans under the range top were lined with foil which contained food debris that was not due to recent spillage. This has the potential to affect more than a limited number of residents who may be served foods from this central location. Census: 51 Findings include: a) During the initial tour of the dietary department on 10/30/17 after entrance, it was noted the drip pan under the range top was soiled with food debris and needed cleaning, This was dried food substance and not recent spillage. b) The dry food storage area was found to have packages of elbow macaroni which was opened but no date of when it was opened. This practice does not allow the dietary staff to determine how long the item has been opened if still safe for consumption. The certified dietary manager was present during the observations and verified the issues at the time.",2020-09-01
3537,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,431,D,0,1,Inf,"Based on observation and staff interview, the facility failed, in collaboration with the pharmacist, to ensure the safe and effective use of medications. An opened and partially used insulin pen was not dated when initially opened. This had the potential to negatively impact the safety and/or potency of the medication. This was evident for one (1) of six (6) opened insulin pens stored in one (1) of two (2) medication carts. Resident identifier: #7. Facility census: 51. Findings include: a) Resident #7 Observation on 11/01/17 at 8:46 a.m. found a Tresiba insulin pen which belonged to Resident #7 was opened and partially used. This prescription was filled by the pharmacy on 10/03/17. There was no date indicating when this vial was initially opened, or the date it should be discarded. The pen had a label on it with a space to write the date of opening and the date it should be discarded. Rather, it was blank. Licensed practical nurse #58 was present at this time. She said Triseba pens may be kept up to fifty-six (56) days after initially opened for the first time. She agreed there was no date on the pen to indicate when it was first opened, or when it should be discarded. She said it would have opened sometime after the pharmacy filled the prescription on 10/03/17. An interview was completed with the director of nursing (DON) on 11/02/17 at 10:04 a.m. She said their policy is to date each insulin pen when initially opened, and then date when to discard the pen a certain number of days after initially opened based on manufacturer's recommendations.",2020-09-01
3538,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2017-11-02,441,D,0,1,Inf,"Based on a random observation and staff interviews, the facility failed to implement practices and processes designed to prevent infection and/or cross-contamination for one (1) of twenty (20) residents reviewed in stage two (2) of the Quality Indicator Survey (QIS). A nurse aid (NA) breached infection control principals while providing peri-care for Resident #20. This practice has the potential to affect more than a limited number of residents. Resident identifiers: #20. Facility census: 51 Findings include: a) Resident #20 On 11/02/17 at 10:15 a.m., observations of nurse aides (NA) #18 and NA #76 providing peri-care for Resident #20 revealed infection control principals were breached. NA#18 wiped the rectal area and the crease between the buttocks with a wipe, then proceeded to wipe the rest of the buttocks with same wipe used to wipe rectal area. Interview with NA #18 and NA #76 revealed, both nurse aids agreed it was a breech in infection control principals. NA #18 stated she should have wiped the buttocks first then the rectal area or disposed of the wipe used on the rectal area and got a clean wipe to finish wiping the buttocks.",2020-09-01
3539,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2018-11-07,655,D,0,1,YU6F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide the resident and/or their representative with a summary of the baseline care plan. This practice was found for one (1) of twenty-seven (27) care plans reviewed during the LTCSP survey. Resident identifier: #55. Facility census: 57. Findings included: a) Resident #55 Resident #55 was admitted to the facility on [DATE]. The resident was alert and oriented, but unable to make medical decisions. A baseline care plan was completed on the day of admission. There is no evidence available that the resident and/or their representative received a summary of the baseline care plan. During an interview on 11/07/18 at 08:15 AM, [NAME] #21 agreed and verified the baseline care plan summary was not given to the resident or their representative. She stated the resident representative had been unable to keep the scheduled care plan appointments due to having some family issues and illness. I have nothing to prove that the care plan was reviewed with the family or the resident. In the future would review it over the phone, have another person witness that I reviewed it over the phone and document on it on the care plan.",2020-09-01
3540,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2018-11-07,657,D,0,1,YU6F11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise the care plan for R57 to reflect a resolved urinary tract infection [MEDICAL CONDITION]. This was found to be true for one (1) of fur (4) residents reviewed for [MEDICAL CONDITION] during the survey process. Resident identifier: R57. Facility census: 57. Findings included: a) Resident #57 A review of the medical record for R57 on 11/06/18, revealed the care plan developed on 10/10/18 had not been revised to reflect this resident no longer had a UTI. Further review of the Medication Administration Record [REDACTED]. She has shown no signs or symptoms of a UTI since completing the antibiotic. During an interview with the Minimum Data Set (MDS) Coordinator on 11/07/18 at 10:00 AM verified the care plan had not been revised to reflect R57 no longer had a UTI.",2020-09-01
3541,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2018-11-07,661,D,0,1,YU6F11,"Based on medical record review and staff interview the facility failed to develop a person-centered comprehensive care plan to include discharge planning for Resident #109. This was found to be true for one (1) of 27 care plans reviewed during the survey process. Resident identifier: #109 Facility census: 57. Findings included: a) Resident #109 A medical record review for R109 on 11/06/18 revealed the comprehensive care plan failed to identify discharge goals, needs and interventions to ensure a successful discharge for R109. During an interview with E21, Minimum Data Set Coordinator on 11/06/18 at 11:35 AM, verified the comprehensive care plan for R109 failed to identify discharge goals, needs and interventions for a successful discharge for R109.",2020-09-01
3542,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2018-11-07,812,F,0,1,YU6F11,"Based on observation and staff interview the facility failed to install the ice machines properly to prevent back flow in the kitchen and the Nutrition Pantry. This had the potential to affect all receiving ice from these machines. Facility census: 57. Findings included: a) Kitchen ice machine During the kitchen tour on 11/05/18 at 11:05 AM, the ice machine was discovered to be improperly installed. The drain pipes were in direct physical contact with the floor drain cap. There was no gap between the drip lines and floor drain to prevent back flow from build up of back pressure. In an interview with the Dietary Manager on 11/05/18 at 11:15 AM, verified the drain pipes were in direct contact with the floor drain. b) Nutrition pantry ice machine During a tour of the Nutrition Pantry on 11/06/18 at 8:10 AM, the ice machine was discovered to be improperly installed. The drain pipes were in direct physical contact with the drain. There was no gap between the drip lines and the drain to prevent back flow from build up of back pressure. The Nursing Home Administrator (NHA) on 11/06/18 at 8:10 AM, verified there was no gap between the drip lines and the drain to prevent back flow",2020-09-01
3543,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2018-11-07,881,F,0,1,YU6F11,"Based on medical record review, policy review and staff interview, the facility's infection prevention control program failed to ensure staff utilized an assessment tool prior to the prescribing and administration of antibiotics. This practice has the potential to affect all residents residing in the facility. Facility census: 57. Findings included: a) Review of random medical records on 11/06/18, identified through the infection control nurse's tracking and trending log for (MONTH) and (MONTH) (YEAR), revealed no information related to the utilization of an assessment tool prior to the initiation of antibiotics. The facility policy for the Antibiotic Stewardship Program, states under section 4aii. Assessments of residents suspected of having an infection. Providers will utilize the Loeb Criteria (minimum criteria for initiation of antibiotics in long-term care residents) when considering initiation of antibiotics . During an interview at 2:15 PM on 11/06/18, the Director of Nursing (DON) acknowledged the facility's Antibiotic Stewardship Policy identifies the Loeb's criteria as the required assessment tool to utilize prior to initiating antibiotics. The DON reported not every physician is referring to the Loeb's assessment tool prior to prescribing antibiotics and confirmed the medical records lack any information related to the staff and/or physicians' use of the Loeb's assessment tool prior to prescribing and administering antibiotics.",2020-09-01
3544,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2019-11-14,695,D,0,1,3YLV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A breathing treatment was left on a resident for over an hour. This practice affected one (1) of six (6) residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident identifier: #17. Facility census: 74. Findings include: a) Resident #17 A review of the facility's policy titled Specific Medication Administration Procedures. Effective date 01/01/2017. Remain with the resident for the treatment unless the resident has been assessed and authorized to self-administer. Monitor for medication side effects, including rapid pulse, restlessness and nervousness throughout the treatment. Stop the treatment and notify the physician if the resident complains of nausea or vomits. Administer therapy until medication is gone (mist has stopped) or until the designated time of treatment has been reached. An observation of Resident #17 (R #17), on 11/13/19 at 02:19 PM, revealed the Resident was lying in bed receiving a nebulizer treatment (a drug delivery device used to administer medication in the form of a mist inhaled into the lungs.) The nebulizer medication cup was empty at this time. A review of the Resident's physician order, revealed the order for [MEDICATION NAME]-[MEDICATION NAME] Solution, an inhaled medication, one (1) dose, every eight (8) hours for congestion, at 6:00 AM, 2:00 PM and 10:00 PM. A second observation of Resident #17 on 11/13/19 at 3:15 PM, revealed the Resident continued to have the Nebulizer treatment mask on with the nebulizer machine running. During an interview with the Director of Nursing (DON), on 11/13/19 at 3:22 PM, the DON stated that nebulizer treatments usually only last 15 minutes and confirmed that one (1) hour was too long to stay on. The DON removed the nebulizer mask and turned the nebulizer machine off at this time. No other information was provided prior to the end of the survey on 11/14/19 at 11:00 AM. .",2020-09-01
4301,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,246,D,0,1,NH6O11,"Based on observation and staff interview the facility failed to ensure Resident #49's call light was placed within his reach while he was in his room. This was true for one (1) of thirty (30) Stage 1 sampled residents during the Quality Indicator Survey (QIS). Resident identifier: #49. Facility census: 42. Findings include: a) Resident #49 During observations of Resident #49 during Stage 1 of the QIS, his call light was noted to be clipped to his privacy curtain hanging at the foot of his bed. These observation took place on 11/08/16 at 9:18 a.m., 12:30 p.m., 2:30 p.m., and 3:37 p.m. Resident #49 was observed resting in his bed on each of the observations. At 3:40 p.m. on 11/08/16, observations were made with the Nursing Home Administrator. Again the resident's call light was observed clipped to the privacy curtain at the foot of his bed. The resident was resting in his bed during this observation. The Administrator confirmed the call light was not within his reach.",2020-02-01
4302,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,253,E,0,1,NH6O11,"The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for six (6) of 24 rooms observed during Stage 1 of the Quality Indicator Survey (QIS). Room identifiers: #3, #9, #16, #21, #27, and #31. Facility census: 42. Findings include: a) Observations during Stage 1 of the QIS noted the following cosmetic imperfections: --Observation of Room #3, at 11:00 a.m. on 11/08/16, found missing paint on the dresser drawers and the door frames leading into the bathroom and the main door leading into the room. The walls about one foot up from the floor was missing paint and the walls were observed to have deep scratches on them. --Observation of Room #9, at 3:17 p.m. on 11/08/16, found the over the bed table was leaning downward and was scratched and marred. --Observation of Room #16, at 2:44 p.m. on 11/08/16, found the wall behind the resident ' s recliner had deep scratches and the paint was missing exposing the dry wall. --Observation of Room #21, at 3:01 p.m. on 11/08/16, found the doors to the bathroom and the main door used to enter the room was scratched and the varnish was missing. The dresser drawers were also scratched and were missing paint. --Observation of Room #27, at 3:10 p.m. on 11/08/16, found were deep scratches on the closet door. --Observation of Room #31, at 3:04 p.m. on 11/08/16, found the door facing leading into the room and the door facing leading into the bathroom were scratched and missing paint. The closet door also had deep scratches. At 1:53 p.m. on 11/09/16, a tour was conducted with Employee #61, the corporate environmental coordinator and the Nursing Home Administrator. They confirmed the observed environmental/cosmetic imperfections were in need of repair.",2020-02-01
4303,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,256,D,0,1,NH6O11,"Based on observation, resident interview, and staff interview, the facility failed to ensure the resident's room contained adequate lighting suitable for tasks the resident chooses to perform. This was true for one (1) of twelve (12) residents interviewed during Stage 1 of the Quality Indicator Survey (QIS). Resident identifier: #21. Facility census: 42. Findings include: a) Resident #21 At 9:02 a.m. on 11/08/16, the resident was asked if she had any problems with the temperature, lighting, noise or anything else in the building that affected her comfort. The resident replied she could not see to read her Bible due to the lighting. A lamp was present on the resident's night stand as well as a light above her bed. When asked if she uses her lamp beside her bed, she replied, No, the lamp doesn't have a bulb and they won't give me one. Observation found the lamp was plugged into a socket behind the bed. The lamp did not have a light bulb. During Stage 2 of the QIS survey, at 3:30 p.m. on 11/09/16, the lamp was observed with the corporate environmental services coordinator, Employee #61. Employee #61 said she would get a light bulb for the lamp. The director of nursing (DON) was interviewed at 3:51 p.m. on 11/09/16. She had no further information to present.",2020-02-01
4304,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,272,D,0,1,NH6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to ensure Resident #27's annual Minimum Data Set (MDS) was accurate in the care area of dental services. Resident #13's admission MDS was inaccurate in the care area of behaviors. In addition, Resident #13's significant change MDS was inaccurate related to the resident's prognosis. This was true for two (2) of nineteen (19) residents whose MDS's were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #27 and #13. Facility census: 42. Findings include: a) Resident #27 Observation of the resident's oral cavity, at 3:11 p.m. on 11/08/16, found the resident had some broken, discolored and missing teeth on the lower gum. Review of the resident's last annual, minimum data set (MDS), with an assessment reference date (ARD) of 03/08/16, found the resident was coded as having no dental issues. Further review of a nursing assessment, dated 03/06/16, noted the resident did have missing, decayed and broken teeth. The Registered Nurse Assessment Coordinator (RNAC), #49 was interviewed at 11:24 a.m. on 11/10/16. RNAC #49 said she must have just missed coding the MDS correctly. She said the resident had been out to see the dentist since the assessment and the resident was care planned for her dental issues. The resident's oral cavity was observed with the clinical care supervisor (CCS) #50, at 4:30 p.m. on 11/10/16. She verified the resident had one black tooth, broken at the gum line on the right side of the resident's lower gum, and one broken, discolored sharp tooth on the right side of the lower gum. The director of nursing, (DON) was interviewed at 5:00 p.m. on 11/10/16. The DON provided no further information regarding the resident's dental status. b) Resident #13 1. Admission MDS Resident #13 was admitted to the facility on [DATE]. The admission MDS assessment with an ARD of 09/21/16 indicated Resident #13 had no behaviors. Nurse ' s notes dated 09/16/16 read, resident refused neurological assessment after experiencing a fall. Resident #13 was yelling and grabbing at staff. On 09/16/16 at 7:07 p.m., a note read, Resident is anxious turning head back and forth trying to see everything going on around her. Resident has refused neurological exams and vital signs several times this shift. Has threatened to hit staff and grabbing at them. Appears restless and tearful at times. Interview with the Director of Nursing (DON) revealed the admission MDS with an ARD of 09/21/16 was coded inaccurately. She confirmed the resident did have behaviors during the seven (7) day look back period. The MDS was immediately corrected. 2. Significant change MDS This resident was admitted on [DATE] and had orders for comfort measures only. She was placed on hospice services on 09/14/16 for end stage dementia. The significant change MDS with an ARD of 10/14/16 did not indicate the resident had a condition or terminal illness which would result in a life expectancy of less than six (6) months. Physician order [REDACTED]. the family agreed .During an interview with the Director of Nursing (DON) found the residents life expectancy of less than six (6) months had not changed. During an IDT care conference the family chose to stop Hospice services to allow therapy to assess the resident.",2020-02-01
4305,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,278,D,0,1,NH6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to accurately complete two (2) of nineteen (19) Stage 2 sampled resident minimum data sets (MDS) correctly. Resident # 18 had two assessments which were inaccurate. One was inaccurate in the area of medications and the other was inaccurate in the area of injections received. Resident #6 had an MDS which was inaccurate in the area of pressure ulcers. Resident Identifiers: #18 and #6. Facility Census: 42. Findings Include: a) Resident #18 1. MDS with an Assessment Reference Date (ARD) of 06/14/16. Review of Resident #18's medical record found an MDS with an ARD of 06/14/16, and a Medicare 5-Day assessment. Review of this assessment found Section N0410 was coded to indicate Resident #18 received an antipsychotic medication one (1) of the seven (7) days during the look back period. Also section N0410B for Antianxiety was coded to indicate Resident #18 only received this medication two (2) days during the look back period. The Medication Administration Record [REDACTED]. Upon completion of this review it was found Resident #18 had received and antipsychotic medication on two (2) days and an antianxiety medication on three (3) days during this seven (7) day period. An interview with the Registered Nurse Assessment Coordinator (RNAC), at 11:15 a.m. on 11/10/16, confirmed the MDS with an ARD of 06/14/16 was inaccurate in the area of antipsychotics and antianxiety medication use. She stated, I must have had my reference range a day off. She indicated that she would complete a modification to correct the assessment. 2. MDS with an ARD of 06/24/16. A review of Resident #18's medical record found an MDS with an ARD of 06/24/16. Review of this MDS found section N0300 for Injections was completed to indicate Resident #18 received an injection on one (1) day during the seven day look back period of 06/18/16 through 06/24/16. Review of the MAR for 06/18/16 through 06/24/16 found Resident #18 received an intramuscular injection of antibiotic on seven (7) of the seven (7) days during the look back period. An interview with the RNAC, at 11:15 a.m. on 11/10/16, confirmed this section was inaccurately completed. She indicated it should have been completed to indicate 7 days. She stated she would do a modification to correct the error on the assessment. b) Resident #6 Review of Resident #6's medical record found Resident #6 was admitted to the facility on [DATE]. Review of Resident #6's quarterly MDS assessment with an assessment reference date (ARD) of 10/04/16, found the number of pressure ulcers coded on Section M was as one (1) Stage 4 pressure ulcer. No pressure ulcers were present on admission. In Section S, the assessment had zeros (0) for the number of new or recurring pressure ulcers during last quarter and in what setting did the pressure ulcer develop. The location and status of existing wounds was also left blank in Section S. Review of admission nursing assessment revealed Resident #6 was admitted with a deep tissue injury located on the sacral area. The director of nursing (DON) confirmed the MDS with an ARD of 10/04/16 was inaccurately completed. She further confirmed the resident was admitted with the pressure ulcer located on the sacral area.",2020-02-01
4306,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,280,D,0,1,NH6O11,"Based on observation, record review, and staff interviews, the facility failed to revise the care plan for one (1) of two (2) residents reviewed for pressure ulcers during Stage 2 of the Quality Indicator Survey (QIS). A resident's care plan was not revised after his skin status changed. Resident identifier: #6. Facility Census: 42 Findings include: a) Resident #6 Review of Resident #6's care plan found a focus on the care plan related to risk of pressure ulcer development related to disease process, history of pressure ulcers, impaired mobility, and bowel and bladder incontinence. The care plan had a goal for the resident to have intact skin, free of redness, blisters, or discoloration through the review date. The care plan also contained goals for an actual pressure ulcer on the sacrum. On 11//09/16 at 10:00 a.m., Licensed Practical Nurse (LPN) #28, performed pressure ulcer care to Resident #6's sacral area. The LPN confirmed the resident did have the pressure area to the sacrum. Interview with Director of Nursing (DON) revealed the only treatment the resident was receiving was to the sacral area. She stated, The care plan was not revised when the resident ' s skin impairment changed. The facility failed to revise the care plan for Resident #6 when she experienced a change in area pressure ulcers.",2020-02-01
4307,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,282,D,0,1,NH6O11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement Resident's #5's care plan for pain management. In addition, the care plan was not implemented for Resident #9 in the care area of accidents. This was true for two (2) of nineteen (19) resident's whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #5 and #9. Facility census: 42. Findings include: a) Resident #5 During Stage 1 of the Quality Indicator Survey (QIS), at 3:56 p.m. on 11/08/16, Resident #5 said she was had pain without relief. She said she received pain medication but her back continued to hurt. She said she was in pain during the interview. Review of the current physician's orders [REDACTED]. Further review of the current Medication Administration Record [REDACTED] --11/02/16 at 10:00 p.m., pain was rated as a 4; --11/03/16 at 6:00 a.m., pain was rated as a 6 and at 10:00 p.m., pain was rated as a 4. --11/04/16 at 6:00 a.m., pain was rated as a 6; --11/07/16 at 10:00 a.m., pain was rated as a 6; --11/08/16 at 6:00 a.m., pain was rated as a 10, at 10:00 p.m. pain was rated as a 7; and --11/09/16 at 6:00 a.m., pain was rated as a 6. Review of October, (YEAR) MAR found the following pain ratings: --10/02/16 at 6:00 a.m., pain was rated as a 7; --10/03/16 at 2:00 p.m., pain was rated as a 6; --10/05/16 at 2:00 p.m., pain was rated as a 7; --10/06/16 at 2:00 p.m., pain was rated as a 6; --10/19/16 at 10:00 p.m.; pain was rated as a 5; --10/29/16 at 10:00 p.m., pain was rated as a 4; --10/30/16 at 10:00 p.m., pain was rated as a 6; and --10/31/16 at 6:00 a.m. pain was rated as a 6. At 9:49 a.m. on 11/09/16, the Director of Nursing (DON) was interviewed. She was unable to provide any evidence the resident's pain was re-evaluated after administration of the pain medication on any of the above occasions when the resident expressed pain. She provided a copy of the pain scale used by the facility for rating pain: --0 = no pain; --1-3 = mild pain; --4-5 = moderate pain; --6-9 = severe pain; --10 = excruciating pain. Review of the current care plan, revised on 05/13/16 found the following problem: 1. (Name of resident ) has chronic pain. 2. The goal associated with the problem: Will voice/display a level of comfort acceptable to the patient thorough the review date. 3. Approaches included: --Monitor/document verbal and non-verbal signs and symptoms of pain. Patient reports pain. Weight changes, protective behavior, guarding behavior, facial mask, irritability, self-focusing, restlessness, depression, atrophy of involved muscle group, changes in sleep pattern, fatigue, fear of re-injury, reduced interaction with people, altered ability to continue previous activities, sympathetic mediated responses (e.g. temperature, cold changes of body position, hypersensitivity), anorexia. --Monitor/ document anatomical location, onset, duration (e.g. continuous, intermittent) aggravating factors, relieving factors. --Monitor/document report to physician as needed signs and symptoms of anxiety, restlessness, wringing hands, tearfulness, rapid heartbeat, rapid shallow breathing, flushed face, dizziness, nausea, fear of [MEDICAL CONDITION]. --Provide [MEDICATION NAME]/pain management as ordered. Monitor for side effects and effectiveness. --Teach the patient/family/caregivers about using non-pharmacological pain management strategies. Cold applications, massage of the painful area. Heat applications, progressive relaxation, imagery, and music, distraction, acupressure, transcutaneous electrical nerve stimulation (TENS), assist the patent and family in identifying lifestyle modifications that may contribute to effective pain management. The care plan interventions were reviewed with the DON at 9:49 a.m. on 11/09/16. The DON provided a copy of the therapy notes dated 11/08/16 at 2:52 p.m. which noted the resident ' s pain was a 0 out of 10. The DON was made aware the therapist visit could not have occurred at 2:52 p.m. because the resident was observed attending a game of bingo at this time. The DON checked with the therapy department and returned to say that was the time the note was written but therapy was actually provided earlier in the morning. A physician's acute visit occurred on 10/30/16. The resident was complaining of facial pain in cheeks and congestion. The physician treated the resident with antibiotics and steroids. There was no mention of back pain during this visit. At 2:03 p.m. on 11/09/16 the occupational therapist, (OT), #59 was interviewed. She confirmed the resident was not seen at the time of the therapy note, written on 11/08/16 at 2:52 p.m. She stated the computers from the therapy department were being used for the QIS survey when the resident was actually seen around 9:30 a.m. on 11/08/16. She stated, The resident never really complained of pain because she isn't using her legs. I work on her upper body. At 5:00 p.m. on 11/10/16, the DON was unable to provide any verification the resident's pain was evaluated after the pain medication was provided. The DON was unable to provide any documentation the facility had determined the resident's acceptable level of comfort as outlined in the goal of the care plan. The DON was unable to provide any evidence the facility documented the location, onset and duration of the pain as outlined in the care plan. There was no evidence provided of non-pharmacological interventions outlined in the care plan for: Cold applications, massage of the painful area, heat applications, progressive relaxation, imagery, and music, distraction, acupressure, transcutaneous electrical nerve stimulation (TENS), and assist the patient and family in identifying lifestyle modifications that may contribute to effective pain management. The DON did provide evidence the facility applied Biofreeze (a topical pain relief product) PRN to the resident's neck after she was hit by another resident in a wheelchair on 11/03/16. However, the location of the resident's pain noted on the MAR indicated [REDACTED]. b) Resident #9 A review of Resident #9's medical record found she had seven (7) falls since 10/20/16. Of the seven (7) falls only the fall on 10/30/16 was a result of the resident sliding out of her wheelchair. Further review of Resident #9's record found a care plan with the following focus statement: (Name of Resident) has had actual fall in facility with injury. Resident continues to be at risk for falls related to poor safety awareness has dementia with behavioral disturbances, attention seeking behavior, reoccurring falls, and non compliant at risk behaviors. Residents mood and mental status varies throughout the day and makes maintaining safety difficult. It is suspected that some falls maybe related to attention seeking behaviors. Has lowered herself to the floor to reach dropped items with purpose. Receives [MEDICAL CONDITION] medications. Personal Alarm discontinued due to an increase in behaviors. This focus statement was last revised on 10/31/16 but was initiated on 11/04/15. 1. The goal associated with this focus statement read: --Will remain free from falls with major injury through next review. This goal had a target completion date of 01/30/17. 2. The interventions associated with this focus and goal included: --Non skid material to wheelchair (on top of wheelchair cushion). This was added to Resident #9's care plan on 05/05/16. Observations of Resident #9, at 3:54 p.m. on 11/10/16, found the resident lying in bed resting. Her wheelchair was sitting at her bedside. The wheelchair had a cushion however the non-skid material was noted to be under the cushion instead of on top of the cushion. At 4:18 p.m. on 11/10/16, Resident #9's was observed up in her wheelchair and was sitting in the hall the Director of Nursing (DON) was asked if Resident #9's non-skid material was on top of her wheelchair cushion. The DON asked Resident #9 to go to her room so that she could look at her wheelchair. Once in the room the resident stood up from her wheelchair and the DON stated, It is under her cushion not on top of her cushion. The DON then took the non-skid material and placed it on top of the wheelchair cushion and Resident #9 sat back down. The DON was then asked to review Resident #9's care plan and confirmed the fall intervention was for the non-skid material to be on top of the cushion not underneath it. She confirmed Resident #9's care plan related to falls had not been implemented.",2020-02-01
4308,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,323,D,0,1,NH6O11,"Based on record review, resident observation, and staff interview the facility failed to ensure Resident #9's environment, over which it had control, was as free from accident hazards. This was true for one (1) of five (5) residents reviewed for the care area of accidents during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifier: #9. Facility Census: 42. Findings Include: a) Resident #9 A review of Resident #9's medical record found she had seven (7) falls since 10/20/16. Of the seven (7) only the fall on 10/30/16 was the result of the resident sliding out of her wheelchair. Further review of Resident #9's record found a care plan with the following focus statement: (Name of Resident) has had actual fall in facility with injury. Resident continues to be at risk for falls related to poor safety awareness has dementia with behavioral disturbances, attention seeking behavior, reoccurring falls, and non compliant at risk behaviors. Residents mood and mental status varies throughout the day and makes maintaining safety difficult. It is suspected that some falls maybe related to attention seeking behaviors. Has lowered herself to the floor to reach dropped items with purpose. Receives psychotropic medications. Personal Alarm discontinued due to an increase in behaviors. This focus statement was last revised on 10/31/16 but was initiated on 11/04/15. 1. The goal associated with this focus statement read: --Will remain free from falls with major injury through next review. This goal had a target completion date of 01/30/17. 2. The interventions associated with this focus and goal included: --Non skid material to wheelchair (on top of wheelchair cushion). This was added to Resident #9's care plan on 05/05/16. Observations of Resident #9, at 3:54 p.m. on 11/10/16, found the resident lying in bed resting. Her wheelchair was sitting at her bedside. The wheelchair had a cushion however the non-skid material was noted to be under the cushion instead of on top of the cushion. At 4:18 p.m. on 11/10/16, Resident #9's was observed up in her wheelchair and was sitting in the hall the Director of Nursing (DON) was asked if Resident #9's non-skid material was on top of her wheelchair cushion. The DON asked Resident #9 to go to her room so that she could look at her wheelchair. Once in the room the resident stood up from her wheelchair and the DON stated, It is under her cushion not on top of her cushion. The DON then took the non-skid material and placed it on top of the wheelchair cushion and Resident #9 sat back down. The DON was then asked to review Resident #9's care plan and confirmed the fall intervention was for the non-skid material to be on top of the cushion not underneath it. She confirmed Resident #9's care plan related to falls had not been implemented. The DON was then asked to review Resident #9's care plan and confirmed the fall intervention was for the non-skid material to be on top of the cushion not underneath it.",2020-02-01
4309,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,428,D,0,1,NH6O11,"Based on record review and staff interview, the facility failed to ensure irregularities, reported by the pharmacist, were addressed by the attending physician. Resident #13 had a pharmacist recommendation for review of her antianxiety medication. Resident #29 had a pharmacist recommendation to review her antidepressant medication. This was true for two (2) of five (5) residents reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident identifiers: #13 and #29. Facility census: 42. Findings include: a) Resident #1 Review of the consultant pharmacist recommendation form, dated 10/05/16 found: This resident (Resident #13) is receiving Xanax 0.5 milligrams (mg) three times a day (TID). The maximum recommended dose in geriatric patients is 0.75 mg per day due to an increase risk of falls and confusion. Please evaluate and consider reducing their daily intake if you feel it is appropriate. If you feel that their anxiety will not be well controlled on the lower dose, consider decreasing the Xanax and adding Buspar. Thanks. The attending physician's response dated 10/16/16 read, Started on Haldol yesterday. The director of nursing (DON) was interviewed on 11/10/16 at 1:30 p.m., she confirmed the physician had not provided an explanation concerning the Xanax. No further information was provided. b) Resident #29 The pharmacist completed the resident's monthly drug regimen review on 07/06/16 and made the following recommendation: -- Per the guidelines for psychotropic drug review, the following antidepressant is due for evaluation for continued use: Lexapro 10 milligrams - (semi-annual review) Please review the resident ' s medication regimen and indicate your professional opinion on further use of the medication listed above. The physician responded to the request on 07/29/26 and noted the following, A dose reduction will be attempted. See new order below. The physician reduced the medication to Lexapro 5 milligrams daily. Review of the Medication Administration Record [REDACTED]. The director of nursing (DON) was interviewed at 10:34 a.m. on 11/10/2016. She stated the doctor was going to reduce the medication but he was reminded by the nurse the next day the resident was still having mood changes. The DON provided a copy of a nursing note, transcribed on 07/20/16 at 4:50 p.m. which include, . Also discussed the recent pharmacy recommendation to decrease Lexapro. (name of physician) has decided not to reduce dose at this time due to frequent mood changes. The DON confirmed the physician did not document his reasons for a denial of a dose reduction to the pharmacist by detailing why a gradual dose reduction would be clinically contraindicated.",2020-02-01
4310,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2016-11-11,463,D,0,1,NH6O11,"Based on observation and staff interview, the facility failed to ensure Resident #15 had a functioning call light system to contact caregivers. This was true for one (1) of thirty (30) residents whose call light was tested during Stage 1 of the Quality Indicator Survey. Resident identifier: #15. Facility census: 42. Findings include: a) Resident #15 At 11:14 a.m. on 11/08/16, Resident #15's call light was tested . The call light had no audio or visual signals. The facility does not have a wireless system. At 11:17 a.m. on 11/08/16, the administrator was advised the call light was not working. The administrator observed the light and said she would immediately have maintenance fix the light. At 11:30 a.m. on 11/08/16, the Corporate Environmental Services Coordinator, #61 was observed repairing the call light system.",2020-02-01
5490,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,272,D,0,1,7BNU11,"Based on record review and staff interview, the facility failed to accurately assess a resident's dental status for an annual comprehensive minimum data set (MDS) assessment. This was found for one (1) of three (3) residents whose MDSs were reviewed for the care area of dental services. Resident Identifier: #19. Facility census: 32. Findings include: a) Resident #19 A review of Resident #19's annual MDS, with an assessment reference date (ARD) of 12/23/14, on 08/25/15 at 1:08 p.m., found Item L0200. Dental, coded as None of the above were present, indicating the resident had no problems with his/her teeth, oral tissues, or pain related to dental problems. On 08/25/15 at 1:30 p.m., a review of Resident #19's annual nursing assessment for 12/23/14, found the resident assessed as having missing teeth and dental caries. On 08/25/15 at 4:15 p.m., when asked whether the MDS with an ARD of 12/23/14 was accurately coded related to Resident #19's dental status, the Minimum Data Set Coordinator (MDSC) stated, The MDS was coded inaccurately, due to it being written on the annual nursing assessment the resident had caries. The MDS should have been coded obvious or likely cavity.",2019-01-01
5491,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,329,E,0,1,7BNU11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents whose drug regimens were reviewed for unnecessary medications, was free from unnecessary medications. The facility failed to ensure non-pharmacological interventions were considered and used when indicated before the use of an as needed (PRN) hypnotic for Resident #32. Resident identifier: #32. Facility census: 32. Findings include: a) Resident #32 Record review on 08/25/15 at 1:00 p.m., found the resident was [MEDICATION NAME] milligrams (mg) every twenty-four (24) hours, as needed (PRN) for difficulty falling asleep/staying asleep related to [MEDICAL CONDITION]. According to the pharmacist's consultation report, dated 04/14/15, the resident had been receiving [MEDICATION NAME], .since readmission (MONTH) 2014. Review of the Medication Administration Record [REDACTED] 1. Review of the (MONTH) MAR found: --[MEDICATION NAME] administered on 5 (five) occasions in (MONTH) (YEAR): 08/02/15, 08/06/15, 08/10/15, 08/14/15 and 08/22/15. -- On 08/06/15, the medication was administered after non-pharmacological interventions were implemented. 2. In (MONTH) (YEAR), [MEDICATION NAME] administered on nineteen (19) occasions: 07/02/15, 07/03/15, 07/04/15, 07/05/15, 07/07/15, 07/09/15, 07/10/15, 07/11/15, 07/12/15, 07/13/15, 07/14/15, 07/15/15, 07/17/15, 07/18/15, 07/19/15, 07/23/15, 07/25/15, 07/26/15, and 07/27/15. There was no evidence any non-pharmacological interventions were implemented before [MEDICATION NAME] any of the nineteen (19) occasions the medication was administered. 3. In (MONTH) (YEAR), the medication was administered on ten (10) occasions: 06/06/15, 06/08/15, 06/09/15, 06/10/15, 06/17/15, 06/20/15, 06/23/15, 06/24/15, 06/26/15, and 06/27/15. There was no evidence any non-pharmacological interventions were implemented before giving the Ambien. b) At 3:04 p.m. on 08/25/15, these findings were discussed with the director of nursing (DON). The DON stated she had given [MEDICATION NAME] 08/06/15 and she had provided the non-pharmacological interventions. She stated she had just had a meeting with the nursing staff regarding documentation of non-pharmacological interventions. She confirmed there was no evidence non-pharmacological interventions were attempted before providing the medication on the identified dates. At 4:15 p.m. on 08/25/15, the MARs for August, July, and (MONTH) (YEAR) were reviewed with the administrator. She was asked if the facility could provide evidence of any non-pharmacological interventions implemented before administering the Ambien. At 4:30 p.m. on 08/26/15, the findings were again discussed with the DON, administrator, and Minimum Data Set Coordinator #38. No further information was provided.",2019-01-01
5492,BRIDGEPORT HEALTH CARE CENTER,515194,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,412,D,0,1,7BNU11,"Based on record review, observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of dental services received assistance to obtain routine dental services. Resident #28 had carious and missing teeth which had not be assessed. Resident identifier: #28. Facility census: 32. Findings include: a) Resident #28 Observation of the resident's oral cavity at 8:59 a.m. on 08/25/15, found the resident had missing and carious teeth. Record review on 08/25/15 at 12:30 p.m., found the last comprehensive minimum data set (MDS) assessment, an annual, with an assessment reference date (ARD) of 03/15/15, coded the resident as having no dental issues in Section L, entitled Oral/Dental Status. At 1:05 p.m. on 08/25/15 the resident's oral cavity was observed with Registered Nurse (RN), MDS Coordinator #38. The examination revealed the resident had several of her own teeth and had numerous missing teeth on both the upper and lower gums. Her teeth were covered with food particles and what appeared to be a build up of plaque. At least two (2) jaw teeth on the upper gum, one on the left side and one on the right side, were black, broken, and worn to the gum area. During the examination, when RN #38 touched her teeth and gums, the resident yelled out, Oh, Oh. When asked if her gums were hurting, she said, Yes, then she said, No, then said, Well, I thought it hurt. RN #38 stated she had completed an oral exam in (MONTH) (YEAR), before coding the annual MDS. She said the resident's teeth were not in this condition at the time of her examination. She stated the resident had just finished lunch and her teeth had not been brushed after the noon meal. RN #38 said she had no documentation of her exam, but she did make her own observation of the resident's oral status. Further review of the resident's record found Registered Dietitian (RD) #60 had completed an annual nutrition risk review on 03/15/15. Under the section, entitled Oral/Dental Status, the dietitian had checked dentures upper/lower and missing/broken teeth. At 1:27 p.m. on 08/25/2015, RD #60 was interviewed regarding the completion of her 03/15/15 assessment. RD #60 was asked where she obtained her information for the assessment. She stated she personally observed the resident eating before completion of the assessment. When asked about the coding of dentures, she stated dentures could also mean a partial. She stated she would have obtained this information from previous assessments, most likely from nursing assessments. A nutritional risk review, dated 12/07/12, indicating the resident had an upper partial at the time of admission, was reviewed with RD #60. RD #60 said she did not know if the resident had an upper partial or if it was in use at the time of her observation. At 8:13 a.m. on 08/26/15, Nurse Aide (NA) #10 was observed feeding the resident breakfast. NA #10 stated she had worked at the facility for approximately two (2) years and she had never known the resident to have an upper partial. She said she was aware the resident had some teeth that, looked bad. She said she thought the resident had some mouth pain in the past, possibly from her teeth, but she could not remember exactly when. She said the resident did not express any pain at this time. At 8:30 a.m. on 08/26/15, Medical Records Clerk #21, was asked if the resident had any dental consults while at the facility. At 8:45 a.m., Medical Record Clerk #21 stated she could find no evidence of any dental consults in the medical record. At 4:30 p.m. on 08/26/15, this information was discussed with the administrator, the director of nursing, and RN #38. RN #38 stated she was unable to find any evidence in the medical record, other than the 12/07/12 dietary assessment, indicating the resident had an upper partial. She believed this assessment was incorrect. No further information was provided. At 9:00 a.m. on 08/27/15, RN #38 stated the facility was scheduling a dental consult for Resident #28.",2019-01-01
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
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
8940,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,241,D,0,1,R8A111,"Based on observation and staff interview, it was determined the facility failed to promote care for two (2) randomly observed residents (#44 and #48) in a manner that maintained the residents, dignity and respect. During the initial tour of the facility, on 09/16/12 at 4:00 p.m., Resident #44 was observed yelling out loudly for help. Resident # 48 was observed, from the hallway, in his room wearing only an adult incontinence brief. These residents were also two (2) of thirty-three (33) sampled residents. Resident identifiers: Residents #44 and #48. Facility census: 50. Findings include: a) Resident #48 and #44 During the initial tour of the facility, on 09/16/12 at 4:25 p.m., Resident #48 was observed from the hallway in his room laying on the bed wearing only an incontinence brief. It was also observed there was a nurse in the hall passing medications and other facility staff and residents passing the room door and looking into the resident's room. When passing the resident's room door again at 4:40 p.m., the resident was still laying exposed and staff and residents continued to pass the room. Staff did not attempt to cover the resident. Further observation on this hall revealed Residents #44 and #48, who were in different rooms, were yelling for help. No staff member responded for approximately 30 minutes. During this time numerous staff walked by the residents' rooms. The staff nurse (Employee # 5) was still passing medications in the area of the residents' rooms and did not respond. At 5:00 p.m., the activity director (Employee #48) entered the rooms and covered Resident #48 and responded to Resident #44. The residents stopped yelling. During interviews conducted with the nursing home administrator and the director of nursing, on 09/26/12 at approximately 5:00 p.m., they were informed of the observations.",2016-03-01
8941,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,242,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, it was determined the facility failed to allow one (1) of three (3) residents reviewed for the care area for choices, to make choices about aspects of life in the facility that were significant to the resident. Side rails were removed from the bed of Resident #9 without the resident's approval. The resident was told it was a new corporate policy and the State had outlawed them. Resident #9 had a flaccid left arm and above knee amputation (AKA) on the left side and weighed over 250 pounds. The resident stated the side rails assisted him with movement in the bed and allowed him to assist the staff when they were providing care. Resident identifier: #9. Facility census: 50. Findings include: a) Resident #9 During the initial tour of the facility, on 09/16/12 at 4:30 p.m., and during a brief interview with this resident in his room, the resident stated he would like his side rails put back on his bed. The resident's bed was a bariatric bed with a trapeze attached. The resident was observed to be obese with a left AKA. Medical record review noted the resident weighed over 250 pounds. The resident directed attention to his bed, which had no side rails. He stated the maintenance man had removed the side rails and had told him The State outlawed them. The resident stated he had an amputation of the left leg and needed the rails in order to turn and position himself in bed and to hold himself over so staff could provide care. Review of the current physician's orders [REDACTED]. The resident's current comprehensive plan of care, identified the resident required assistance with activity of daily living (ADLs) related to immobility and left AKA. Further review of the care plan found one (1) of the interventions in the care plan was Top 2 side rails to assist with turning and repositioning. The Physical Therapy notes, dated 09/05/12, included in the comments, Patient states bed mobility has become more difficult due to loss of bed rails and also states the trapeze bar is too weak to assist with bed mobility. During an interview with the Physical Therapist (Employee #103), on 09/27/12 at 10:00 a.m., it was revealed the quarter side rails were helpful to this resident. The therapist also indicated that with the rails the resident was minimal to moderate assist and without them he was maximum assist. He also stated that without the rails it was more difficult for the resident and the staff to take care of him. In an interview with the nursing home administrator, on 09/25/12, it was revealed the the side rails had been removed in response to a new corporate policy to not use side rails due to entrapment hazards.",2016-03-01
8942,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,246,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, it was determined the facility failed to allow one (1) of three (3) residents the right to receive services in the facility with reasonable accommodations of the individual's needs and preference. Side rails were removed from the bed of Resident #9 without the resident's input or approval. The resident was told it was a new corporate policy and the State had outlawed them. Resident #9 had a flaccid left arm and above knee amputation (AKA) on the left side, weighed over 250 pounds, and stated the side rails assisted him with movement in the bed and allowed him to assist the staff when care was being provided. Resident identifier: #9. Facility census was 50. Findings include: a) Resident #9 During the initial tour of the facility, on 09/16/12 at 4:30 p.m., and during a brief interview with this resident in his room, the resident stated he would like his side rails put back on his bed. The resident stated his left leg had been amputated and needed the rails in order to turn and position himself in bed and to hold himself over so staff could provide his care. The resident's bed was observed to be a bariatric bed with a trapeze attached. The resident was observed to be obese with a left AKA. According to the resident, the maintenance man had removed the side rails. The maintenance man had told him The State outlawed them. The current physician's orders [REDACTED]. The resident's current comprehensive care plan identified the resident required assistance with activity of daily living (ADLs) related to immobility and left AKA. The plan included an intervention of Top 2 side rails to assist with turning and repositioning. The Physical Therapy notes, dated 09/05/12, included the comment, Patient states bed mobility has become more difficult due to loss of bed rails and also states the trapeze bar is too weak to assist with bed mobility. During an interview with the Physical Therapist (Employee #103), on 09/27/12, at 10:00 a.m., it was revealed the quarter side rails were helpful to this resident. The therapist also indicated that with the rails, the resident was minimal to moderate assist, and without them he was maximum assist. He also stated that without the rails it was more difficult for the resident and the staff to take care of him. In an interview with the nursing home administrator, on 09/25/12, it was revealed the removal of the side rails was done in response to a new corporate policy to not use side rails due to entrapment hazards.",2016-03-01
8943,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,253,E,0,1,R8A111,"Based on observation, including observation of posted signage, and staff interview, the facility failed to provide necessary housekeeping services to maintain a clean and sanitary environment and to maintain the cleanliness of resident care equipment. The only shower room in use in the facility had a very strong moldy smell with black debris noted around the wall tiles, floor tiles were cracked and sticking out of the floor, and blood pressure cuffs, lift slings, and otoscopes were stored in slotted plastic baskets on the dirty carpeted floor under the nursing station desk where staff placed their feet. Further, the dryer lint traps were covered with a blanket of lint and had not been cleaned in accordance with posted signage. This had the potential to affect more than a minimal number of residents residing in the facility. Facility census: 50. Findings include: a) Physical Environment 1. Observation, of the only shower room in the facility, on 09/25/12 at 2:30 p.m., found it had a very strong moldy smell. Further investigation found black debris in the grout with broken tiles around the base of the shower stall and floor tiles had been pulled up. A metal corner protector, which was partially pulled up from the corner, also had the black debris behind the corner. An interview conducted with a nursing assistant, Employee #59, who was in the shower room during the observation, stated, it always smells like this. At 2:50 p.m., the housekeeping staff were cleaning the tile in the shower room. In an interview, with the Administrator, on 09/26/12 at 3:00 p.m., it was revealed another shower room was in the process of being renovated and then this shower room would be closed for remodeling. She stated this building was old. In an interview, conducted on 09/26/12 at 4:00 p.m., the housekeeping/laundry director agreed the shower room tile needed to be cleaned and had personally assisted other housekeeping staff to clean the tile in the shower room. 2. On 9/26/12 11:00 a.m., observation, in the presence of the housekeeping/laundry director, revealed both dryer lint traps were completely covered in a blanket of lint. The housekeeping/laundry director stated, I usually clean these (lint traps) when I come in because other laundry staff leave at midnight. She agreed the lint traps had not been cleaned. Signs posted on the front of each dryer stated the lint trays were to be cleaned at the end of every shift. b) At 6:20 p.m. on 09/16/12, an observation of the nurses' station revealed that it was dirty. The carpet was worn, frayed, grimy, and stained. There was observable debris at the edges. The cloth part of the room partitions were also dirty and stained. There were three (3) slotted plastic baskets filled with resident care equipment, including lift belts, stethoscopes, otoscopes and the ear covers, as well as other items, sitting directly on the dirty floor beneath the desk. This was also where the staff placed their feet. This observation was repeated, at 10:10 a.m. on 09/17/12, and the administrator was informed. She stated that she would remedy the situation and thirty minutes later the baskets had been moved.",2016-03-01
8944,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,272,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure ongoing, accurate comprehensive assessments for three (3) of thirty-three (33) Stage II sample residents. There was a failure to accurately identify and code weight loss for one (1) resident, a failure to accurately code pressure ulcers for (1) resident, a failure to accurately code urinary incontinence for two (2) residents, and a failure to accurately code the cause of multiple falls for one (1) resident. Additionally, the documentation of the summary information regarding the assessment of one (1) resident indicated a significant change assessment had been done due to a decline in the activities of daily living, although the assessment reflected an improvement. Resident identifiers: #52, #5, and #47. Facility census: 50. Findings include: a) Resident #52 Review of medical records, on 09/26/12, revealed Resident #52 was admitted on [DATE], with an admission weight of 188 pounds. An entry in the resident's record by the registered dietitian, on 08/10/12, noted the resident's weight was 168 pounds. The dietitian noted This weight would indicate a significant weight loss of 22 pounds (11.7%) in the 90 days since admission. A Minimum Data Set (MDS) assessment, with an assessment reference date of 08/17/12, was coded 0 in Section K 0300, which indicated no weight loss of 5% or more in the last month or loss of 10% or more in last 6 months. An interview conducted with Employee #7 (MDS Coordinator), on 09/26/12 at 11:45 a.m., confirmed the MDS assessment had been coded inaccurately. b) Resident #5 1) Review of the resident's medical record, on 09/24/12, revealed this resident had been admitted on [DATE]. The admission body audit and nurses' note, dated 04/03/12, described no skin issues. The physician's admission history and physical, completed on 04/06/12, indicated the resident's skin was intact. The admission minimum data set assessment (MDS) assessment, with an assessment reference date (ARD) of 04/12/12, Sections M0300B1 and M0300 B2 were coded 1 , which indicated a Stage II pressure ulcer was present on admission. Review of physician orders [REDACTED]. The physician progress notes [REDACTED]. Interview with Employee #7 (MDS coordinator), on 09/26/12 at 9:25 a.m., confirmed the MDS assessment had been coded inaccurately. 2) According to the MDS, with an ARD of 04/12/12, the resident was continent of bladder. The MDS with an ARD of 06/15/12, indicated the resident was frequently incontinent of bladder. Review of nursing assistant documentation showed the resident had maintained the same bladder continence status. Interview with Employee #7, the MDS coordinator, on 09/26/12 at 9:25 a.m., confirmed the MDS of 06/15/12 had been inaccurately code for bladder continence, which had remained unchanged. 3) The assessment, with an ARD of 04/12/12, was coded as the resident requiring extensive assistance for activities such as bed mobility, transfers, locomotion on the unit and off of the unit, dressing, and toilet use. All of these areas were coded as limited assistance on the assessment with an ARD of 06/15/12. Nursing assistant documentation supported these improvements. The documentation for this assessment noted the resident had experienced a decline, when she had actually improved. Interview with Employee #7, the MDS coordinator, on 09/26/12 at 9:25 a.m., confirmed the significant change MDS on 06/15/12 was not a significant decline; in fact the resident had improved in several areas of ADLs. c) Resident #47 On 09/24/12 at 10:04 a.m., a review of Resident #47's minimum data sets (MDS) was conducted. This resident was admitted to the facility on [DATE]. Medical diagnosis' included: Non- Alzheimer's dementia, status [REDACTED]. The admission MDS, dated [DATE], was coded in section H, bladder and bowel continence, as always being continent. On 04/29/12, Resident #47 was discharged to an acute care facility with return anticipated. The discharge MDS coded section H as always being continent. On 04/14/12, the director of nursing (DON) conducted a urinary continence evaluation. The resident was noted as not continent at the time of admission. According to the evaluation the resident was occasionally incontinent and wore briefs at night. In an interview with the MDS coordinator, Employee #7, on 09/24/12 at 1:00 p.m., she stated she did not know why the MDS's of 04/26 and 04/29/12 were coded as continent when evidence stated Resident #47 was incontinent.",2016-03-01
8945,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,279,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and observations, the facility failed to develop measurable objectives, and/or establish interventions to meet those objectives, for six (6) of thirty-three (33) sampled residents in order for the resident to attain their highest level of functioning. Resident identifiers: #64, #60, #57, #52, #20, and 47. Facility census 50. Findings include: a) Resident #64 A review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert, oriented, and able to make care decisions, but needed assistance with most activities of daily living (ADLs), including transfer. He had a cast on his right lower leg. A review of the interim care plan, on 09/19/12, found no evidence of the needs associated with the [DIAGNOSES REDACTED]. The Nurse Aide's Information form, which was the aides' source of direction for care, contained only the days and shift of the shower schedule and to Keep pillow between legs while in bed. It did not inform the aides of the casted right leg, the possibility of convulsions, or give transfer instructions. During an interview with Employee #57 (the care plan nurse), at 3:00 p.m. on 09/24/12, she acknowledged that these needs should have been included on the interim care plan and stated that she would ensure it was done. In an interview with Employee #5 (Registered Nurse), at 2:15 p.m. on 09/25/12, she stated the admitting nurse was responsible to initiate the interim care plan and transfer the necessary actions to the nurse aide information form. b) Resident #60 A review of the medical record revealed Resident #60 was admitted on [DATE], with [DIAGNOSES REDACTED]. His admission physician's orders [REDACTED]. The [DIAGNOSES REDACTED]. No measurable goals had been formulated and there were no nursing interventions established to enable the resident to meet his optimum level of physical functioning without pain. There were no alternative interventions suggested to be attempted prior to the administration of pain medication. There was no evidence of communication to the direct caregivers (aides) of the nursing interventions. A review of the care plan revealed twenty-one (21) interventions to be provided to the resident by the CNA (certified nurse aide); but the only task on the Nurse Aide's Information sheet were the days and shift for bathing and it did not state type of bath or assistance required. During an interview with the director of nurses, at 12:15 p.m. on 09/24/12, she stated, after reviewing the care plan, that she had no information to add for the resident's use of pain medication and that she would check into this. She verified the Nurse Aide's Information sheets were used to communicate the resident status and care needs to the aides and they were kept in a binder at the nurses' desk. She stated the nurse also informed the aide verbally of needs and/or changes, but admitted that the sheets were supposed to be filled out. No additional information had been received at the time of exit. c) Resident # 57 Medical record review found this resident had weighed 191 pounds when admitted on [DATE]. On 09/18/12, the resident was noted to weigh 150 pounds - a 40 pound weight loss since being admitted to the facility. Observations during the course of the survey found the resident was sleeping most of the time in his wheelchair. During meal times, the resident would often be sleeping and the staff were unable to arouse the resident to eat. During interviews conducted with direct care staff, it was revealed the resident was up a lot at night and slept frequently throughout the day. Review of the comprehensive care plan noted the problem of weight loss had been addressed and a care plan developed and one of the interventions was to offer the resident frequent snacks. The interventions failed to indicate when the resident would be offered snacks and what the snacks would be. The care plan also failed to address the resident's night time activity and offering the resident food when up at night. During an interview with the nursing home administrator and the director of nursing, on 09/26/12 at 5:00 p.m., they were made aware of the care plan not addressing the issue of timing of snacks for this individual and the lack of interventions to prevent further weight loss. d) Resident #52 A review of the current care plan for Resident #52, on 09/26/12 (last reviewed by facility staff on 06/25/12) found no evidence of goals or interventions for identified problems. Problems identified for the resident concerned activities of daily living, urinary incontinence, impaired vision, [MEDICAL CONDITION], gastric [MEDICAL CONDITION] reflux, and hypertension. Nothing indicated what the staff had determined to be problematic about the conditions, or how they felt the problems needed to be addressed to best benefit the resident. Interview with Employee #7 (Minimum Data Set Coordinator), on 09/26/12 at 11:45 a.m., verified the care plan had been developed with problem areas listed but, no goals or interventions had been included. e) Resident #20 On 09/26/12 at 9:00 a.m., a review of the medical record for Resident #20, revealed this resident had a [DIAGNOSES REDACTED]. The care plan, dated 07/20/12, included a focus of The resident has hypertension r/t (related to) (blank). Goals included: The resident will maintain a blood pressure within the following parameters: (Specify) through review date. Interventions included: Give anti hypertensive medications as ordered. Monitor for side effects such as orthostatic [MEDICAL CONDITION] and increased heart rate ([MEDICAL CONDITION] and effectiveness. Obtain blood pressure readings (FREQ). Take blood pressure readings under the same conditions each time. For example resident is sitting, use right arm. The care plan did not provide staff members a specific guidance regarding how often the resident was to be monitored for antihypertensive medication side effects, orthostatic [MEDICAL CONDITION], increased heart rate, or blood pressure. On 09/26/12 at 10:15 a.m., an interview was conducted with Employee #7, the minimum data set (MDS) coordinator. When asked about the BLANK, (FREQ), (Specify) information not being completed in the care plan, she stated she was not familiar with the new computer system. She further stated she was unaware of the blanks and agreed the blanks should have been completed with the specific information. Although Employee #7 stated a new care plan with the specific information would be completed immediately, the revised care plan was not provided prior to exiting the facility. f) Resident #47 On 09/24/12 at 10:04 a.m., a review of Resident #47's care plan was conducted. This resident was admitted to the facility on [DATE]. The focus statement of the care plan, initiated on 05/04/12, was The resident has episodes of bowel and bladder incontinence. Potential for complications. The interventions included: Check and change as indicated. Provide incontinence care as needed. Monitor for areas of skin breakdown with each . Monitor for s/sx (signs and symptoms) UTI (urinary tract infection): pain, burning, blood tinged urine . Prior to observing incontinence care for this resident, on 09/25/12 at 11:00 a.m., an interview was conducted with a nursing assistant, Employee #56, regarding care for this resident. This employee stated the resident wore an incontinence brief continuously and could let staff know most of the time if she needed to go the bathroom. During an observation of incontinence care for this resident, on 09/25/12 at 11:15 a.m., found the resident was wearing an incontinence brief. In an interview with the DON, on 09/25/12 at 2:15 p.m., she reviewed the care plan which included check and change as indicated. Provide incontinence care as needed. She agreed the resident's ability to let staff know when she needed to go to the bathroom had not been incorporated into the plan. The plan did not address improvement or maintenance of the resident's urinary continence status.",2016-03-01
8946,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,280,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure five (5) of thirty-three (33) sampled residents and/or their representatives were given the opportunity to participate in planning care and treatment and/or to revise the care plan after changes in care or treatment. Residents #17, #20, #23, #32, and #38 and/or their representatives were not given the opportunity to participate in planning care for the resident. The care plans for residents # 17, #23, and #32 were not updated to accurately reflect needs of the resident when those needs changed. Resident identifiers: #17, #20, #23, #32, and #38. Facility census: 50. Findings include: a) Resident #38 During an interview with Resident #38, on 09/18/12 at 10:12 a.m., the resident stated he had never been involved in decisions about his daily care; they just take care of him the way they want to. According to the resident, changes in treatments and medications were never discussed with him by anyone in the facility. Review of the medical record found no evidence Resident #38 or his representatives had been invited to quarterly care plan meetings, nor did the record divulge conversations with the resident regarding his care. The last care plan conference was dated 04/5/12. The only attendees noted were Employees #3, the minimum data set (MDS) assessment nurse and #55, the dietary manager. The MDS nurse, Employee #7, confirmed the facility was not including residents and/or their representatives in the care plan meetings. Employee #7 stated I am going to be honest with you, I did not know I was supposed to invite the family to the care plan meetings. An interview with the administrator, Employee #56, on 09/26/12, confirmed the facility did not have a policy for inviting residents and/or their representatives to the care plan meetings. b) Resident #23 Review of the Medication Administration Record [REDACTED]. The resident's current care plan for pain in the left leg, knee, and ankle was initiated on 03/15/12. The goals were to control the pain with medical intervention through the next review. The interventions included observing for signs of pain and addressing them as needed, to administer pain medication as ordered, and to report unrelieved pain to the doctor for evaluation. Since that date, three (3) additions had been made to the care plan, on 08/01/12, 08/06/12, and 09/17/12. None of these addressed the possible resolution of leg pain. Staff interview, on 09/24/12 at 2:00 p.m., with an RN, Employee #6, and an LPN, Employee #11, confirmed the resident had received [MEDICATION NAME] 1000 mg every morning for the past two (2) months even though the resident's pain assessment indicated she had no pain. Employee #6 also could provide no evidence of the resident/responsible party's involvement in the care plan. The MDS coordinator, Employee #7, confirmed there was no evidence that this resident and/or her representative had been included in the planning of her daily care, or invited to attend her quarterly care plan meeting. c) Resident #20 On 09/18/12 at 3:46 p.m., Resident #20 was interviewed in the privacy of her room. When asked if she was involved in decisions about her daily care, the response was No. Further questioning found the resident had not been invited to participate in her care plan. Although this resident lacked capacity to make medical decisions, she did make decisions about when she got up or went to bed, what she wore, and about participation in activities. When asked if she would like to participate in making decisions about her care, she responded Yes. The minimum data set (MDS) coordinator was interviewed, on 09/26/12 at 10:15 a.m When asked if the resident was invited to her care plan meeting, she stated, she did not feel the resident understood what the meeting was about and the resident was participating in activities or going to participate in bingo or something. She further stated no attempt was made to inform this resident about the results of the care plan meeting or get the resident's input. d) Resident #17 A review of the medical record revealed that Resident #17 was originally admitted on [DATE]. Her [DIAGNOSES REDACTED]. A care plan conference was held on 05/03/12, following a comprehensive assessment on 04/30/12, that indicated a significant change in health status. The meeting was attended by an RN (registered nurse - Employee #3), the social worker (Employee #58), and the dietary manager (Employee #55). There was no evidence the family was invited to attend this meeting. The notes of the care plan meeting on 05/03/12, stated the resident had had an overall decline in health and was currently non-ambulatory. The care plan contained 21 focus areas and, although there were interventions added after the meeting, there were no new target date measurements added to any of the goals. The most recent target date for review was 05/11/12, making it unclear when the resident was to be reevaluated. Although the meeting notes indicate that the resident had declined to the point that she was dependent upon others for locomotion, the care plan entitled Potential for elopement was not discontinued. During an interview with Employee #7, on 09/26/12, she stated that she was new in the position and was unaware that she was to invite the resident and/or responsible parties to care plan meetings. She stated that the lack of a target date on the care plan was an oversight. e) Resident #32 Review of medical records, on 09/19/12 at 2:00 p.m., revealed a physician order [REDACTED]. The current care plan, dated 09/17/12, had an intervention for a no added salt diet and a low fat low salt diet. These interventions had not been updated to correctly reflect the current needs of the resident, who was receiving a regular diet. In an interview conducted with Employee #7, the Minimum Data Set (MDS) coordinator, on 09/19/12 at 3:00 p.m., she confirmed the interventions were inappropriate for the resident, and had not been updated when the resident's diet changed to a regular diet. During the interview, Employee #7 also stated she was not aware of the need to include the resident/responsible party in care plan conference, and had not done that.",2016-03-01
8947,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,281,C,0,1,R8A111,"Based on observation, staff interview, policy and procedure review, and review of a current fundamentals of nursing reference, the facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. Two (2) different staff members initialed medication(s) as given prior to the resident taking the medication(s). This practice was observed by two (2) surveyors during medication administration at separate times. This practice was observed for 13 of 13 residents during medication pass. Facility census: 50 Findings include: a) During the observation of a medication pass, on 09/19/12 at 8:16 a.m., a registered nurse, Employee #1, revealed this employee initialed each medication as given prior to giving the medications to four (4) different residents. Again on 09/25/12 at 8:09 a.m., a registered nurse, Employee #4, was observed initially medications as given prior to administering the medications to five (5) different residents. The director of nursing was interviewed, on 09/25/12 at 10:30 a.m., and agreed medications were not to be initialed as given prior to the resident receiving the medication(s). A review of the facility policy titled POLICY #/TITLE: 6.0 General Dose Preparation and Medication Preparation, revealed the following: 6. After medication administration, Facility staff should take all measures required by Facility policy and Applicable Law, including, but not limited to the following: 6.1 Document necessary medication administration/treatment information (e.g., when medications are opened, when medications are given, injection site . A review of professional standards for documenting the administration of medications found the following in Foundations of Basic Nursing by Lois White: Documentation of Drug Administration - Documentation is a critical element of drug administration. The standard is 'if it was not documented, it was not done.' Appropriate documentation can prevent many drug errors. The nurse administering a medication must initial the medication on the MAR for the time the drug was given . Documentation should be done after the client has received the drug.",2016-03-01
8948,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,282,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Base on review of medical records, staff interviews, review of blood pressure logs, review of the forms used to communicate the needs for the individual resident to the direct caregiver, and observations, the facility failed to implement all aspects of the care plan by not providing adequate communication of the care plan to direct caregivers to ensure all interventions were implemented in accordance with the care plan. This was found for six (6) of thirty-three (33) sampled residents. Resident identifiers: #60, #51, #64, #38, #57, and #31. Facility census: 50. Findings include: a) Resident #60 A review of the medical record revealed that Resident #60 was admitted on [DATE], with [DIAGNOSES REDACTED]. The resident's fall assessment indicated he had poor safety awareness and his care plan interventions addressed this need with instructions for the direct caregivers (aides). The resident also required assistance and/or cuing for bathing, oral care, hygiene, dressing, eating, transfers, and toileting. All these needs had been addressed on the care plan as the responsibility of the nurse aide. He was also identified as being socially isolated and needed the aides' encouragement to take part in activities and other socialization. There was no evidence of communication to the direct caregivers (aides) of the nursing interventions. A review of the care plan revealed twenty-one interventions to be provided to the resident by the CNA (certified nurse aide); but the only task on the Nurse Aide's Information sheet was the days and shift for bathing. It did not indicate the type of bath to be given or assistance the resident required. b) Resident # 51 A review of the medical record revealed Resident #51 had [DIAGNOSES REDACTED]. The care plan indicated that she had vision problems and was a wanderer. The resident's fall assessment indicated that she had poor safety awareness. The care plan addressed the poor vision, wandering, and safety needs with five interventions assigned in responsibility to the direct caregivers (aides). The care plan indicated the resident had impaired cognitive function with communication deficits and listed the following interventions delegated to the aide: -- Approach resident in calm, gentle manner -- Explain care and procedures to resident prior to beginning. -- Keep the resident's routine consistent and try to provide consistent caregivers as much as possible in order to decrease confusion. -- Wanderguard at all times to alert staff of unattended exits. Staff to check placement and function every shift. There was no evidence of communication to the direct caregivers (aides) of the nursing interventions. The only task on the Nurse Aide's Information sheet was the days and shift for bathing and it did not state the type of bath or assistance required. The sheet did indicate that the resident had a Wanderguard, but did not indicate the resident had a positive elopement potential. There were areas on the form for information about Eyesight, Hearing, Speech, and Behavior which were all identified in the comprehensive assessment as problems, but all of these areas were blank. In addition, the resident had a [DIAGNOSES REDACTED]. c) Resident #64 A review of the medical record revealed Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident was alert, oriented, and able to make care decisions, but needed assistance with most activities of daily living (ADLs), including transfer. He had a cast on his right lower leg. The Nurse Aide's Information form, which was the aides' source of direction for care, contained only the days and shift of the shower schedule and to Keep pillow between legs while in bed. It did not inform the aides of the casted right leg, the possibility of convulsions, or give transfer instructions. d) During an interview with Aides #29 and #28, at 2:30 p.m. on 09/25/12, they stated resident tasks were communicated from shift to shift by the aides on the previous shift or verbally by the nurse if there was a change. They stated the resident's needs and instructions for care were supposed to be on the Nurse Aide Information form kept in a binder at the nurses' desk, as the aides do not have access to the complete care plan. When interviewed at 2:45 p.m. on 09/25/12, the charge nurse (Employee # 5) verified the admitting nurse conveyed care needs to the assigned aide verbally and then the aides passed the information to the next shift. In addition, the nurse was to transfer the care plan interventions and changes to the Nurse Aide's Information sheet kept in a binder at the nurses' desk. During an interview with the director of nurses, at 12:15 p.m. on 09/24/12, she stated, after reviewing the care plans, that the Nurse Aide's Information sheets were used to communicate the resident status and care needs to the aide's and they were kept in a binder at the nurses' desk. She did state the nurse also informed the aide verbally of needs and/or changes, but admitted that the sheets were supposed to be filled out. e) Resident #38 Medical record review for Resident #38, on 09/26/12, identified a [DIAGNOSES REDACTED]. The care plan created on 04/03/12, and most recently updated on 07/31/12, identified the hypertension with a potential for complications. Interventions included monitoring and reporting to the physician any signs or symptoms of malignant hypertension and to monitor and record the blood pressure as ordered. The resident's physician orders did not specify guidelines for monitoring blood pressure, such as frequency, etc. When interviewed on 09/26/12 at 3:30 p.m., the Director of Nursing (DON), Employee #57, stated the facility's policy for vital sign monitoring was to take all resident's temperature, pulse, and respirations once a month and their blood pressures weekly. When a staff member was asked whether the blood pressures were recorded, the weekly blood pressure log was provided. Review of the weekly blood pressure log, for the period from 12/28/11 through 09/26/12, found the staff had failed to monitor this resident's blood pressure every week, as determined necessary in the care plan developed by facility staff. There were no results documented for the following dates: 03/21/12, 03/28/12, 04/04/12, 04/11/12, 05/16/12, 05/30/12, 06/06/12, 07/04/12, 07/25/12, 08/01/12, 08/08/12, and 08/15/12. f) Resident # 57 During the medical record review, it was discovered this resident weighed 191 pounds when admitted on [DATE]. On 09/18/12, the resident was noted to weigh 150 pounds - a 40 pound weight loss since being admitted to the facility. During observations, the resident was noted to be asleep most of the time in his wheelchair. During meals, it was observed the resident would often be sleeping and the staff were unable to arouse the resident to eat. Interviews conducted with direct care staff revealed the resident was up a lot at night and slept frequently throughout the day. During review of the comprehensive care plan it was discovered the problem of weight loss had been addressed and a care plan developed and one of the interventions was to offer the resident frequent snacks. Review of the Nurse Aide's care Kardex, used to direct the care of the resident, found the area under meals was not totally filled out. Observations during the course of the survey found the resident rarely fed himself, but instead was fed by staff or family. The instructions on the nurse aide Kardex indicated the resident fed himself. There were no instructions on when to give snacks or what to give. When direct care staff were questioned about how they knew how to care for residents they stated they used the nurse aide Kardex. The failure to provide the information on the nurse aide Kardex on how to provide this resident's meals, when to give snacks, and what type of snack had the potential to contribute to weight loss. g) Resident #31 Review of the resident's medical record, on 09/25/12 at 9:31 a.m., revealed on 09/10/12 a physician's order had been written for geri sleeves to bilateral forearms for fragile skin. When reviewed, on 09/25/12 at 9:50 a.m., the daily assignment care sheets described by facility staff as the method of communicating resident's specific needs to nursing assistants, also indicated bilateral geri sleeves were to be applied to forearms of Resident #31 daily. On 09/25/12 at 12:32 p.m. Resident #31 was observed in the dining room wearing a short sleeve t-shirt. The resident had on no geri sleeves.",2016-03-01
8949,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,309,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, and staff interview, it was determined the facility failed to provide the necessary care and services to meet the health care needs of two (2) of thirty-three (33) sampled residents. The facility failed to provide care to prevent shearing resulting in skin breakdown for Resident #57 and failed to provide a medication timely for Resident #17. Resident identifiers: #57 and #17. Facility census: 50. Findings include: a) Resident # 57 During the course of the survey, this resident was observed up in a wheelchair with a lap buddy. It was also observed the resident was sleeping in the wheelchair leaning over on the lap buddy for extended periods of time (throughout the day, not put back to bed after lunch) with his nose running onto the lap buddy. The resident was observed in this condition in the dining room during meals, in the front lobby, and also in his room. During observations of the resident's room it was observed there was a reclining lounge chair. On [DATE] at 11:30 a.m., the resident was observed in his room in the wheelchair slumped over sleeping with his head on the lap buddy. In an interview on [DATE], at 6:30 p.m., it was reported that a family member stated she had found the resident sitting in the wheelchair wet with urine at times when visiting and had to take the resident to the bathroom and clean him up. During a review of nursing notes, dated [DATE], it was discovered the resident's family member had reported to nursing staff the resident had two (2) open areas, one on each side of the buttocks. Further review of this nursing note revealed these [MEDICAL CONDITION] had been determined to be non-pressure related, but due to shearing. Observation of the [MEDICAL CONDITION], on [DATE], noted the open areas were on the inner aspect of both buttocks. During this observation, Employee #7, a registered nurse, reported the skin breakdown had been caused by shearing when the resident was up in the wheelchair and moving about the facility. b) Resident #17 Review of the closed medical record of Resident #17 revealed that on [DATE], the resident was in a severe state of decline and her family had been contacted to come to her bedside. Her temperature was elevated to 101.9, respirations were 24, and her oxygen level was poor (SPO2 = 84%). The resident was started on 2 liters of oxygen via nasal cannula and the physician was notified. Nurses' notes entered at 12:30 p.m. on [DATE], by Employee #11 (Licensed Practical Nurse) that stated she received a verbal order (via phone) for [MEDICATION NAME]. The physician's written order was timed 12:30 p.m. on [DATE], and read [MEDICATION NAME] 20 mg/ml 1 ml po (by mouth) Q4H (every 4 hours) PRN (as needed). A follow-up note at 1:30 p.m. on [DATE], stated, MPOA wants [MEDICATION NAME] started immediately. We told her it wasn't kept in the facility. She and her husband were very upset. Her husband stated 'there is no excuse for this. You need to do something now'. I told him I would do what I could immediately. (Physician name) hasn't returned call yet, so I called (Pharmacy name). The lady at (pharmacy name) said she had received a prescription for the [MEDICATION NAME]. I asked her to stat it and told her we needed it as soon as possible . The Director of Nurses was contacted via phone and an attempt was made to acquire the drug from the facility's local contract pharmacy, but they did not have the medication. The nurse (Employee #11) stated in her notes that the [MEDICATION NAME] arrived from the pharmacy at 2:45 p.m. and was administered immediately for air hunger. At 6:00 p.m. the nurse contacted the physician when the resident's respirations reached 40 per minute, and received a new order to increase [MEDICATION NAME] to 1 ml / hour PRN. A resident grievance was filed by the family and an investigation was made by the Social Worker (Employee #58) and the Administrator. Their findings were: We did not have [MEDICATION NAME] on site, but received it from pharmacy on a stat order. Staff acted appropriately and timely in ordering and receiving med. During a tour of the medication storage and preparation room, at 1:25 p.m. on [DATE], a notice of available stock items labeled Narcotics Kit & Refrigerated Items was observed. This notice included: [MEDICATION NAME] Oral Solution ([MEDICATION NAME] Concentrate) 20 mg/ml and indicated that 30 ml was to be stocked. During an interview with the Administrator at 9:50 a.m. on [DATE], she was shown the stock list and asked why there had been no [MEDICATION NAME] in-house on [DATE], when it was ordered. She had no comment and referred this to the Director of Nurses (DON). At 10:00 a.m., the entire incident was reviewed with the DON, who stated that she remembered the medication had been used and not refilled, but could not recall the details and would have to review the incident. At 10:55 a.m. on [DATE], the DON returned, stating that the pharmacy's Regional Manager had informed her that there was policy of when a stock medication was to be replaced after use. He confirmed that the stock medication had been used for another resident on [DATE], and not replaced. He told her that it was the facility's responsibility to reorder stock. A review of the facility's pharmacy manual failed to produce a policy/procedure for maintaining the stock medications. The DON was asked for a complete list of stock medications, but stated that she had searched and could find none. A review of the pharmacy audit report titled ER BOX and labeled for [MEDICATION NAME] 20 mg/ml (1 bottle 30 ml) revealed the following entries: -- [DATE] at 11:50 a.m.: there was 1 bottle that was expired and reordered. -- [DATE] at 9:00 p.m.: the 1 bottle was refilled. -- [DATE] NONE ON HAND -- [DATE] at 9:00 p.m.: 0 bottles on hand; 1 bottle received; 1 bottle given; 1 bottle remaining (There was no explanation for this obvious entry error.) During an interview with the Administrator and the DON, at 1:00 p.m. on [DATE], the above information was discussed and the administrator brought to the attention of the surveyor that she had indicated on the Grievance report dated [DATE] the following Recommendations/corrective action taken: Prior to this incident we had already set up meeting between (medical director name) and (pharmacy name) for later this month to get other meds in E box. [MEDICATION NAME] will be an option at that time. Neither had comment when reminded that [MEDICATION NAME] was already listed as a stock medication and had not been refilled since [DATE] according to the pharmacy audits.",2016-03-01
8950,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,312,D,0,1,R8A111,"**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 thirty-three (33) Stage II sample residents was provided services to maintain good personal hygiene. The resident was unable to independently clean and trim his own fingernails and received no assistance to ensure nail hygiene. Resident identifier: #52. Facility census: 50. Findings include: a) Resident #52 Observations, made on 09/25/12 at 9:00 a.m. and 2:30 p.m., found Resident #52 with fingernails which were long and jagged with a brown substance underneath the nails. When interviewed, on 09/25/12 at 2:30 p.m., nursing assistants (Employee #28, #29, and #26) stated it was their understanding fingernails were to be trimmed on shower days except for diabetic residents. Review of the medical record for Resident #52, on 09/26/12, revealed he was scheduled for showers on Tuesday and Friday each week, on evening shift. The resident's record disclosed no [DIAGNOSES REDACTED]. Review of the nursing assistant tracking form for Resident #52, on 09/26/12 at 9:00 a.m., revealed this resident had received a shower on evening shift of 09/25/12, although no fingernail hygiene had been documented. Repeated observation on 09/26/12 at 10:25 a.m., revealed the fingernails of Resident #52 remained long and jagged with a brown substance underneath the nails. When interviewed on 09/26/12 at 10:30 a.m., Employee #6, a registered nurse, confirmed the resident's fingernails were long and jagged with a brown substance underneath the nails. She also confirmed fingernails were to be trimmed on shower days and also at any time they are observed to be dirty. This nurse also confirmed Resident #52 was not diabetic.",2016-03-01
8951,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,315,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and review of facility policy and procedure, the facility failed to assess residents' urinary continence status and implement services in an attempt to maintain or improve their status when indicated. Three (3) of six (6) residents on the sample who had a potential for improvement, or prevention of further decline in their continence status were not thoroughly assessed and/or provided appropriate treatment and services to restore and/or maintain bladder function to the extent possible. Resident identifiers: #17, #52, and #47. Facility census: 50. Findings include: a) Resident #17 A review of the medical record revealed that Resident #17 was admitted to the facility initially on 01/14/10. Her [DIAGNOSES REDACTED]. Her admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/21/10 indicated she was continent of urine. An initial bladder continence assessment indicated she required assistance to get to the bedside commode. By 10/20/10 the resident's urinary status had deteriorated to continent with incontinent episodes less than seven times per week, but the MDS, with an ARD of 02/18/11 indicated that she was usually continent. The resident's urinary continence status had deteriorated and the MDS, with an ARD of 03/21/12 (Quarterly), and 04/30/12 (Significant change) indicated the resident was frequently incontinent of urine. The Plan of Care Note of 05/04/12 acknowledged an overall decline in health; increased assistance with activities of daily living (ADLs); and use of the Hoyer lift for transfer. Resident #17 had been discharged to short - term acute care on 01/22/12, 03/31/12 (for urinary tract infection) and 06/12/12. A review of her medical records failed to reveal any evidence of a bowel and bladder (B&B) assessments being completed on her readmissions to the facility or following her declines in urinary status as reflected on the MDS. The most recent MDS (04/30/12) indicated that the resident was still not totally incontinent of urine, but none of the MDSs in 2012 indicate that she was on a B&B training program. The care plan contained no nursing interventions to assist to maintain or improve her urinary continence status. The only interventions were for monitoring skin breakdown, output, and symptoms of urinary tract infection; and, to Check and change as indicated. Provide incontinence care as needed. During an interview with the director of nursing, at 2:00 p.m. on 09/25/12, she was asked when B&B assessments were to be completed and stated that they should be done on the initial admission, each re-admission, and when deemed necessary by changes in status. She was asked to provide evidence that any assessment, other than the initial one on 01/14/10, had been done. In a second interview at 9:30 a.m. on 09/26/2, she stated that she had been unable to find evidence that any urinary assessments had been done after admission and admitted that they should have been done. The absence of assessments was verified by Employee #52 (Medical Records Clerk), at 9:30 a.m. on 09/27/12, after searching the entire record. b) Resident #52 Review of the medical record for Resident #52, on 09/25/12 at 10:00 a.m., revealed the resident had been admitted to the facility on [DATE]. There was no evidence a bladder assessment or voiding pattern had been completed, nor was there evidence a toileting program had been attempted. Review of the facility's policy for a resident with bladder incontinence, found it instructed a bladder assessment and voiding pattern assessment would be initiated at the time of admission and a toileting program would be attempted. Interview with Employee #52, the medical records director, on 09/26/12 at 10:00 a.m., verified there was no evidence of a bladder assessment or voiding pattern assessment having been completed for this resident. An interview with Employee # 6, a registered nurse, on 09/26/12 at 11:45 a.m., confirmed this resident was continent of urine at times, and would have benefited from a bladder assessment and voiding pattern assessment at the time of admission. c) Resident #47 On 09/24/12 at 10:04 a.m., a review of Resident #47's medical record was conducted. On 04/14/12, a urinary continence evaluation was completed by the director of nursing (DON). This evaluation indicated the resident had a history of [REDACTED]. In the summary section of the urinary continence evaluation, the areas indicating which type of incontinence applies to this resident and based on the type of incontinence the resident is experiencing, indicate the most appropriate the type of intervention for this resident, had not been completed. A review of the minimum data set (MDS), dated [DATE], found Section H0300 had been coded to indicate the resident was always continent. A significant change MDS was completed on 05/29/12. It indicated, in section H0300, the resident was frequently incontinent. A quarterly MDS was completed on 08/24/12 and indicated in section H0300, the resident was frequently incontinent. A review of the facility policy and procedure entitled Bowel and Bladder Management Program, on 09/26/12 at 1:45 p.m., revealed the following: Policy It is the policy of this facility to assess each resident's elimination status on admission and to develop an individualized plan of care for those residents who require a bowel and/or bladder management program within fourteen (14) days of admission. Procedure 1. On admission the Licensed Nurse shall assess each resident's elimination status. 2. A bowel and bladder (B&B) assessment form shall be completed on all resident's with identified incontinence problems within 14 days of admission and prn. 3. The Bladder assessment shall be completed for at least three days on all shifts. According to the DON, when interviewed on 09/26/12 at 2:00 p.m., the urinary continence evaluation had not been completed in its entirety on admission or when the resident experienced a further decline in continence. The DON agreed facility policy and procedure had not been followed on admission or readmission when the resident experienced a decline in urinary continence status.",2016-03-01
8952,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,323,E,0,1,R8A111,"Based on medical record review, observations, and staff interview, it was determined the facility had failed to ensure the resident environment was as free of accident hazards as possible for one (1) of three (3) residents reviewed for falls (Resident #52) and supervision for fourteen (14) wanders/exit seekers. Staff failed to respond promptly when an exterior door alarm was triggered, interventions had not been established and implemented for a resident who wandered and was at risk for falls. Resident identifiers: # 52, #19, #20, #33, #40, #12, #24, #17, #4, #45, #38, #44, #58, #57, #51, and #26. Facility census: 50. Findings include: a) During the initial tour of the facility, on 09/16/12 at 4:00 p.m., a resident was observed on the East hall in a wheelchair and banging against the door. The alarms on the exit doors at the ends of the West and East halls were tested at that time. When checking the alarm on the East hall, the inner door was opened and the alarm sounded. After the alarm sounded for approximately five minutes, there was no staff visible in this hall and no response to the alarm. The outer door was then opened and the surveyor stepped outside. No alarm sounded. After approximately ten (10) minutes, a nurse (Employee #13) arrived and stated someone probably went out that door and did not lock the door and indicated the light on the outer door was red and it should have been green when the alarm was on. The nurse then reached up and turned the alarm on and it turned green which the nurse stated indicated it had locked. On 09/27/12, the social worker (Employee #58) provided a list of fourteen (14) residents who were identified as being at risk for elopement The failure to ensure all alarms on the exit doors were maintained, and the lack of supervision observed throughout the survey (when no staff immediately responded to the inner door alarm), provided a safety hazard to the fourteen (14) wanderers. b) Resident #52. Observations of this resident were made on 09/24/12 at 2:30 p.m., until 3:00 p.m. and again on 09/25/12 between 9:30 a.m. and 10:30 a.m. During all observations, the resident was going in and out of other residents' rooms, offices, and common areas. The resident was noted to be picking up water pitchers, remote controls for televisions, and other objects and attempting to drink from the pitchers and/or put items in his mouth. The resident was also observed to stumble at times, falling against beds, chairs, and door frames. Multiple staff members walked by the resident during these observations, with no intervention. Observation on 09/26/12 at 10:30 a.m., revealed the resident ambulating in the hallways with bruising, dark purple in color, on his elbows bilaterally with edema noted. Review of nurse's notes, on 09/26/12 at 10:45 a.m., found no documentation of bruising on the resident's elbows. The medical record also revealed the resident had experienced multiple falls since admission. When interviewed on 09/26/12 at 11:00 a.m., Employee #6, a registered nurse, acknowledge the resident had experienced multiple falls and the last one had occurred on 09/23/12. This nurse also confirmed there was no documentation concerning the recent bruising on both elbows. Medical record review revealed a comprehensive care plan developed on 06/25/12. The plan stated: Problem- The resident is (HIGH, Moderate, and Low) risk for falls related to . No goal or approaches were found and the problem statement was incomplete. It was also discovered were fall incident care plan-short term goals had been completed after each fall, no new interventions had been implemented. There was no evidence facility staff had instituted any interventions to keep this resident as safe as possible although he was identified as wandering into other resident's rooms, putting objects in his mouth, being unsteady of gait, and being at risk of falls. Interview with Employee #6, the MDS coordinator, confirmed the facility had not implemented interventions to prevent falls and eliminate injury to the extent possible.",2016-03-01
8953,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,325,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observation, interview with the hospice nurse, and staff interview, it was determined the facility failed to maintain acceptable parameters of nutritional status by failing to provide interventions to accommodate the resident's needs for individualized dining and snacks for one (1) of three (3) residents reviewed for weight loss. Resident identifier: Resident #57. Facility census: 50. Findings include: a) Resident #57 Medical record review found Resident #57 had weighed 191 pounds when admitted on [DATE]. On 09/18/12, his record indicated he had weighed 150 pounds. This was a 40 pound weight loss since being admitted to the facility. The resident had medical [DIAGNOSES REDACTED]. Observations in the facility, during the course of the survey, found this resident was asleep most of the time during the day in his wheelchair. During meals it was observed the resident would often be sleeping and the staff were unable to arouse the resident to eat. Interviews conducted with direct care staff revealed the resident was up a lot at night and slept frequently throughout the day. Review of the comprehensive care plan discovered the problem of weight loss had been addressed and a care plan developed. One of the interventions was to offer the resident frequent snacks. The interventions failed, however, to indicate when the resident would be offered snacks and what the snacks would be. The care plan also failed to address the resident's night time activity and offering the resident food when up at night. On 09/25/12, at 12:00 noon, the resident's hospice nurse was observed assisting the resident with eating. The resident was noted to become short of breath as he was being fed. The hospice nurse stated it was difficult for the resident to eat due to lack of oxygen and frequent small meals would be beneficial. There were no nutritional interventions developed related to the [DIAGNOSES REDACTED]. There was no indication the facility had identified the lack of oxygen during meals would be a deterrent to adequate food consumption. During an interview with the nursing home administrator and the director of nursing (Employee #57), on 09/26/12 at 5:00 p.m., they were made aware of the failure of the care plan to adequately address the resident's weight loss.",2016-03-01
8954,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,329,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medication regimens for three (3) of ten (10) Stage II sampled residents were free of unnecessary medications. One (1) resident had not received ordered lab testing to monitor medication use. One (1) resident had received pain medications with no documented pain and another resident received psychoactive medications without documented behaviors. Resident identifiers: #32, #23, and #60. Facility census: 50. Findings include: a) Resident #32 1) Review of the medical record, on 09/24/12 at 1:00 p.m., revealed this resident was readmitted to the facility following hospitalization , on 05/17/12. During her stay at the acute care facility the resident had an elevated creatinine clearance (which indicates kidney function), and needed to have a follow up chemistry-8 profile laboratory study. The discharge summary included instruction to obtain a chemistry-8 profile every three (3) months, which was not due again until 08/01/12. There was no evidence this lab study had been ordered and/or completed for this resident. An interview conducted on 09/24/12 at 2:30 p.m. with Employee #57, director of nursing (DON), verified there had been no follow up physician's orders [REDACTED]. The results of this test could have implications on medication usage as it is used to check the status of kidney function, electrolytes, acid/base balance, and blood glucose levels. 2) Review of the medical record revealed on 09/17/12 physician verbal orders were written by Employee #14, licensed practical nurse (LPN), for the medications Depo-[MEDICATION NAME], and [MEDICATION NAME]. None of these medications were accompanied by a medical [DIAGNOSES REDACTED]. Review of nurse's notes and physician progress notes [REDACTED]. An interview, conducted on 09/24/12 at 2:30 p.m., with Employee #57, Director of Nursing (DON), verified there was no evidence of the need for these medications. b) Resident #23 Review of the Medication Administration Record [REDACTED]. This order had been in effect since 07/01/12. Review of the resident's daily pain assessment for the 7-3 shift found it was marked as no every day from 09/01/12 through 09/23/12. It was marked as no every morning in July and August 2012, except for three (3) days which were left blank (07/07/12, 08/19/12, and 08/29/12). Every pain assessment that was completed for the 3-11 and 11-7 shifts, from 07/01/12 through 09/23/12, was also documented as no pain. Staff interview, on 09/24/12 at 2:00 p.m., with Employee #6 (a registered nurse) and Employee #11(a licensed practical nurse) identified the normal routine for the 7-3 shift was to ask the resident if she had any pain during the morning med pass prior to the administration of any medications. Resident #23 was then given her scheduled [MEDICATION NAME] 1000 mg as ordered. Staff reviewed the medical record and confirmed this daily [MEDICATION NAME] order was written in December 2011 and had been administered every morning for the past two (2) months even though the resident's pain assessment indicated she has no pain. c) Resident #60 Resident #60 A review of the medical record revealed Resident #60 had been admitted on [DATE], with [DIAGNOSES REDACTED]. His admission physician's orders [REDACTED]. This [DIAGNOSES REDACTED]. In addition, a review of the nurses' notes failed to reveal any evidence of the resident ever complaining of a headache or any other pain. The nurses indicated on the Medication Administration Record [REDACTED]. During an interview with the director of nurses, at 12:15 p.m. on 09/24/12, she stated, after reviewing the care plan, that she had no information to add for the resident's use of pain medication and that she would check into it. No additional information had been received at the time of exit.",2016-03-01
8955,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,332,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, staff interview, clinical record, and facility policy review, the facility failed to ensure medication were administered free of an error rate of 5% or greater for four (4) residents. Six (6) errors were observed for twelve (12) residents with a total of 96 opportunities for error. The medication error rate was 6.5%. Resident identifiers: #38, #3, #67, and #32. Facility census: 50. Findings include: a) Resident #38 On 09/19/12 at 8:28 a.m., medications were observed being given to Resident #38 by a registered nurse (RN), Employee #1. The resident's medications included [MEDICATION NAME] 2.5 mg. Employee #1 searched the medication cart and no [MEDICATION NAME] was available. This employee stated the [MEDICATION NAME] would have to be ordered from the pharmacy and a physician's orders [REDACTED]. b) Resident #3 On 09/25/12 at 8:37 a.m., medications were observed being given to Resident #3. [MEDICATION NAME] nasal spray, calcium, and iron were ordered for Resident #3. After a search of the medication cart, a registered nurse, Employee #4, could not find the iron or the [MEDICATION NAME]. Employee #4 stated these medications were not available. This resident was ordered Calcium 600 mg orally and Employee #4 poured Calcium 600 mg + D. When this was brought to the employee ' s attention, the Calcium + D was removed and replaced with Calcium 600 mg. c) Resident #67 On 09/25/12 at 10:04 a.m., medications were observed being given to Resident #67 by Employee #4 through a gastric tube (g tube). This resident was ordered a multivitamin per g tube. This medication was not available. d) Resident #32 On 09/25/12 at 9:10 a.m., medications were observed being given to Resident #32 by Employee #4. A multivitamin was ordered for Resident #32. After a search of the medication cart, by Employee #4, the multivitamin was not found. e) On 09/25/12 at 9:30 a.m., Employee #4 found an orange oblong pill lying on the top of the medication cart. Employee #4 stated she could not identify the pill or which resident did not receive the medication. According to Employee #4, at 10:00 a.m., the medication had been identified as [MEDICATION NAME]. Furthermore, this employee stated a determination could not be made as to which resident did not receive the medication.",2016-03-01
8956,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,353,F,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, review of facility scheduling documents, review of incident/accident reports, review of complaints/concerns, review of shift reports, review of medical records, resident interviews, family interviews, and staff interviews, the facility failed to maintain adequate staffing levels across all shifts to ensure residents' needs for nursing care were met in a manner and an environment which encouraged each resident's quality of life. This had the potential to affect all residents. Facility census: 50. Findings include: a) A review of the nurse staffing worksheet, filled out by the facility, and compared to the actual schedule and the Posting of Nursing Staff, indicated the facility did meet the minimum staffing requirements set by the State. However, a review of the care requirements of the resident population, especially the number of dependent residents and the many residents with the behavior of wandering, along with complaints/concerns received from both residents and/or family members and/or staff, and the observations made by the surveyors during the survey indicate that the facility lacked sufficient staff to meet the daily needs of the residents. The following were many of the observations, interviews with staff, interviews with residents, and interviews with family members, and information gleaned from facility records, arranged chronologically (I). Following that is a separate account of the needs of the wanderers which also were not being met with the present staffing (II.). I. Issues in Chronological order -- Upon entry into the facility, at 4:40 p.m. on 09/16/12, a general tour of the entire facility was made. At the far end of the men's hall two (2) residents were yelling at Resident #66, who was emerging from room [ROOM NUMBER], which was not his room. One of the resident's yelling at him was Resident #24, the resident who resided in the room. Resident #24 was also yelling, someone come and get him out of my room. The other resident of the room, Resident #58, was up in the hall jumping around and making sounds (Resident #58 was non-verbal). This activity could be heard throughout the hall, but no staff were seen in the area or responded while this was observed for 12 minutes. The nurse who responded, Employee #7, stated that Resident #66 was a wanderer and they tried to keep him out of other residents' rooms, but it was hard. She stated that most of the aides were busy assisting residents to get ready for the evening meal. She did lead the resident away to his own room and went back to calm the men down. -- During the initial tour, at 4:25 p.m. on 09/16/12, Resident #48, a male, was observed lying in bed sleeping uncovered, wearing only an adult incontinence brief and exposed to anyone passing in the hall. There were privacy curtains in his room, but they were not drawn. There was a nurse in the hall outside his room passing medications and other facility staff and residents passing the room door and looking into the resident's room. He was rechecked several times and remained in this position until 4:45 p.m., when a staff member entered the resident's room and covered him. -- At 4:45 p.m. a foul odor of stale urine and feces was detected in the hall outside of the closed door of room [ROOM NUMBER]. When the room was entered, Resident #18 was lying in bed awake. She did not speak. The odor was very bad. The odor was still present, and the door still closed, at 6:30 p.m. when the dinner trays arrived on the hall. -- At 5:50 p.m. on 09/16/12, Resident #30, located in room [ROOM NUMBER] could be heard yelling out with various requests on the center hallway. Twice the daughter of Resident #57, who was visiting across the hall, went to her room and assisted her. When she saw this surveyor in the hall she stated she tried to help because the aides were worked to death and they needed more help. When Resident #30 was asked if she had a call light, she said she did, but they (staff) would come faster if she yelled. -- When interviewed, the visitor stated that she came to the facility almost daily, because she wanted to assist with her father's (Resident #57) care. She stated that several times he was wet when she came in and she would take him into the bathroom and clean him up, because there were not enough aides to ensure he was seen every two (2) hours. Sometimes he was left in his chair several hours and would fall asleep there. During observations of this resident, on 09/16/12 and throughout the survey, he was observed in a wheelchair with a lap buddy. At 12:30 p.m. on 09/18/12, Resident #57 was observed slumped over his lap-buddy sleeping, with his nose running onto the lap buddy for over 1/2 hour. An aide and a nurse were seen passing him during that period. He was awakened by another aide bringing him a tray of food. At 9:30 a.m. on 09/19/12, this resident was observed again hanging forward over his lap-buddy asleep in the dining room. He was taken by an aide to the activities room and left there, still sleeping, instead of being put to bed. On 09/24/12 at 11:30 a.m., the resident was observed in his room in the wheelchair, slumped over and sleeping with his head on the lap buddy. When the aide (Employee #20) came in at 12:00 p.m., she said that he was not usually put back to bed until after lunch. She and a nurse then transferred him to a recliner chair in his room. -- Resident #9, who was alert and oriented and had the capacity to form his own health-care decisions, said in an interview, at 3:20 p.m. on 09/17/12, that he thought there was too little staff. When asked why he thought that, he stated, .sometimes it takes 2 - 3 hours to get a call - light answered. This resident was a large man totally dependent on staff for transfer and/or repositioning. -- At 10:15 a.m. on 09/18/12, Resident #31, who was dependent upon staff for all activities of daily living (ADLs), was observed in very poor position. The resident had scooted way down in bed and was leaning over to one side. -- At 10:30 a.m. on 09/18/12, an observation of room [ROOM NUMBER]B (Resident #38) revealed paper on the floor around the toilet which caught on the wheelchair when the resident was exiting the bathroom. The resident's urinal was on the bedside table next to his water pitcher. On a return visit to the room, at 11:00 a.m., and again at 1:30 p.m., the urinal was still in the same location. -- During an interview with Resident #59, in her room at 10:45 a.m. on 09/18/12, a wanderer (Resident #41) entered the room and looked at us and walked around touching several things before turning and leaving the room. Resident #59 had quit talking when Resident #41 entered and leaned way back into her chair. After Resident #41 left the room, Resident #59 stated that she was afraid of the other resident and that she frequently would take things, her favorite seemed to be cups and water pitchers. Resident #59 stated that no one could stop the resident from wandering. -- At 12:10 p.m. on 09/18/12, a female resident (#63) was observed sitting in her wheelchair in the hall with dirty, uncombed hair. -- In an interview with Resident #38, he stated he should shower on Tuesday and Thursday, but they don't keep up with the schedule and automatically give bed baths. He said he would like to stick to the schedule, but they don't have time. He said, last Saturday he waited over an hour to get back to bed because they told him they only had two (2) aides until 11:00 p.m. and two (2) on night shift. -- At 12:45 p.m. on 09/18/12, Resident #2 stated he was told that day he had to wait when he wanted to go to the bathroom before lunch and it was over 1/2 hour before they took him. He said that he sometimes wets himself around noon. -- During an interview with Resident #20, at 3:40 p.m. on 09/18/12, she stated she was only allowed to shower when staff said you could. She asked for another shower, but they said, No, she would have to wait for her day and sometimes she had to have a bed bath whether she wanted to or not because the nurse says there's not enough help. Resident #20 also said there were a lot of people who wandered around all the time. She stated that Resident #17 (male) had been in her room two (2) times today. -- At 4:00 p.m. on 09/18/12, Resident #44 was interviewed in his room. He stated there was not enough staff to take care of everyone. During the interview, he had a greenish drainage from his right eye and dried food on the right side of his mouth. This was prior to the evening meal. His glasses were dirty and his fingernails were long, jagged, and dirty. -- At 5:00 p.m. on 09/18/12, Resident #3 was observed in the main dining room during the evening meal with dirty, oily hair which was uncombed. -- An observation of Resident #52, at 2:30 p.m. on 09/25/12, revealed that his finger nails were long and dirty with brown substance under the nails. In an interview with three (3) aides (Employees #28, #29, and #26), at 2:30 p.m. on 09/25/12, they stated nails were to be done during showers unless the resident was diabetic. The ADL tracking form revealed that this resident received a shower on the evening shift on 09/25/12, but his nails had not been done. There was no reason given. An observation made at 10:25 a.m. on 09/26/12, accompanied by Employee #6 (RN) revealed the resident's nails were still long and dirty with brown substance underneath. II. Wanderers -- The facility had several residents with the behavior of wandering aimlessly through the halls and in and out of rooms. At 3:00 p.m. on 09/19/12, the Social Worker (Employee #58) supplied the surveyors with a list of seven: Residents #19, #20, #33, #40, #12, #24, and #17. She updated this list at 9:20 a.m. on 09/27/12, to include: #4, #45, #38, #44, #58, #57, #51, and #26. -- Another resident (#66) was not on either list, but was observed on the day of entry and daily during the survey wandering. He wandered into the room used by the surveyors on two (2) occasions and one (1) of those times was in the room for over 1/2 hour, picking things up off of desks and looking in shelves and drawers before being taken back out to the hall and directed to a nurse. He was the resident mentioned previously that was run out of another resident's room being yelled at on 9/16/12. -- Upon entry into the facility, at 4:30 p.m. on 09/16/12, only eight (8) residents and/or visitors were observed sitting in the dining room which was adjacent to the front entry. This was at a time when the dining room should have been filled with residents preparing for the evening meal. The Administrator, who was present in the facility, informed the surveyors that they were serving all residents in their rooms because of an outbreak of upper respiratory symptoms in the facility. This situation had started the day before. She was asked if the health department had been informed and the Administrator replied she had not reported it because it was the weekend and was considering reporting the following day. During the general tour and the observation of the serving of the evening meal, the small group of residents remained in the dining room. Several other residents were observed wandering in the halls. When questioned about who these residents were, Employee #13 (Licensed Practical Nurse) identified Residents #33, #66, #17, and #51 and stated that they were wanderers, who went throughout the facility. He acknowledged that they should be in their rooms, but said there's no way to keep them there. -- On each day of the survey, Resident #41 was observed walking back and forth down the halls continuously. She wandered in and out of the dining room and was seen picking up residents' silverware and drinking out of their glasses. This was as had been reported in an allegation by another resident on 05/09/12, and during a resident interview with Resident #59 on 09/18/12. Resident #4` was also observed wandering in the dining room during meals several times and did pick up glasses and/or utensils at times, which were then taken by the staff. A review of six (6) months of Incident Reports revealed that eight (8) residents were involved in resident to resident conflicts and all involved a wanderer. An investigated incident (unsubstantiated) of bruising of an unknown source of Resident #13, on 09/08/12, revealed that an aide had seen Resident #57 (a wanderer) in the vicinity of her room just prior to the discovery of her crying in her room with facial bruises. During a family interview, on 09/17/12, with the wife of Resident #57, she related she was worried there was not enough staff to watch all the wanderers. During the conversation, she said that one of the reasons her husband was in the nursing home was because he had started hitting her when she tried to care for him at home. -- Residents #58, #19, #4, #38, #17, and #51 were also observed almost daily wandering about. Attempts were made to redirect these residents, but seldom lasted very long. During an interview with the Activities Director (Employee #48) on 09/24/12, she stated that she knew who the wanderers were and tried to bring them into activities when she could, but they would not stay and she just did not have enough staff to keep them occupied. A review of the night shift report for 09/22/12, with one nurse (LPN #15) and two aides (Employees #19 and 25), the following incidents were reported for the 50 residents: Aide hit and slapped by resident Resident #40 wandered into another resident's room and spit on his feet. Resident #17 wandering halls naked Another resident sat up in hallway all night Resident #44 hollering help Resident #51 wandering Resident #12 up all night Resident #57 wandered prior to going to bed at 10:30 p.m. Resident #20 didn't go to bed till 1:30 a.m Resident #66 running up hall On night shift of 09/23/12 there were 14 of the same type reported incidents with the same census and amount of staffing. -- During confidential interviews with four (4) nursing assistants and one (1) nurse, they were questioned about these shift reports and all stated this was routine activity almost daily. All agreed these interruptions caused them to have to rush or omit routine care at times. The aides stated that they had made administration aware that more staff was needed. Two (2) of the aides, who worked a shift other than day shift, stated the nurse assisted them when possible. All of the aides said that the nurses on day and evening shifts rarely help. The nurses reportedly only come out of the nurses' station when giving medications. The nurse interviewed stated that the aides work hard and try to get everything done, but they would need more help to be able to do showers as scheduled and keep up with checking all residents every 2 hours. -- In an interview with the Social Worker, at 3:25 p.m. on 09/19/12, she acknowledged that at the present time there were several wanderers and that at times there were conflicts due to their activities. She stated that they did have Stop sign barriers available upon request to deter them from entering other rooms and tried to keep activities going that would interest them. She stated that, although there had been resident to resident conflicts, no one had been injured. She admitted , when asked, that increased activity staff would help in keeping them occupied. Her final statement was, We do the best we can. -- In an interview with the Administrator, at 1:00 p.m. on 09/18/12, she was asked if there were staffing vacancies and replied there were. She stated the facility was accepting applications and that present employees were good to work an extra four hours when needed to cover vacancies. -- During an interview with the Director of Nurses, at 8:30 a.m. on 09/26/12, she stated that she attempted to replace all call-offs. She verified the facility did not designate certain aides to do baths although they did try to do some on each shift. She acknowledged that bed baths had to be done at times when staffing was low. When asked about the staffing numbers on evenings and/or nights she admitted that it was low on nights, but that tasks had been moved to other shifts. -- During the exit interview regarding the complaints that accompanied the QIS survey, with the Administrator and the Director of Nurses, and accompanied by a second surveyor, at 4:00 p.m. on 09/27/12, the they were informed that a complaint aimed at insufficient staffing was substantiated based on the interviews, complaints, incident reports and number of allegations involving verbal abuse. They had no comment.",2016-03-01
8957,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,356,C,0,1,R8A111,"Based on observation and staff interview, the facility failed to include the required information on the daily posting of available direct care staff as required by CMS (Centers for Medicare & Medicaid Services). This had the potential to affect all residents. Facility census: 50. Findings include: Observation of the nurse staffing data posted daily by the facility found it did not include the actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care per shift. This was reviewed with the Administrator at 5:00 p.m. on 09/26/12, who acknowledged that the information was not supplied on the form in use.",2016-03-01
8958,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,371,F,0,1,R8A111,"Based on observation and staff interview, the facility failed to ensure food was stored under sanitary conditions. Hamburger was thawing in the bottom of the refrigerator with blood draining out of the box. Yellow debris with black flecks was observed on the bottom shelf of the refrigerator. These practices had the potential to affect all residents who resided in the facility. Facility census: 50. Findings include: a) During the initial observation of the kitchen, on 09/16/12 at 4:40 p.m., the following sanitation infractions were observed. -- The refrigerator contained hamburger thawing, in the package box, with blood draining out of the box. -- This same refrigerator had yellow debris with black flecks on the bottom shelf of the refrigerator. The dietary employee, Employee #40, was asked when the refrigerator was cleaned. Employee #40 stated, she usually cleaned the refrigerator weekly. Employee #40 further stated, she had been off for the last two (2) weeks and the refrigerator had not been cleaned. She stated the thawing hamburger should have been put in a pan to contain the draining blood.",2016-03-01
8959,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,425,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, policy review, and staff interview, the facility failed to provide or obtain routine and/or emergency medications in order to meet the needs of residents in a timely manner by: (a) not ensuring routine medications were requested and/or received; (b) not maintaining an adequate in-house stock medication supply; and (c) not maintaining an up to date list of available medications in-house, enabling timely access by nursing staff. This had direct effect on five (5) of fifteen (15) residents on the sample and the potential to affect all residents. Resident Identifiers: #17, #32, #3, #38, and #67. Facility census 50. Findings include: a) Resident #17 Review of the closed medical record of Resident #17 revealed that on 07/14/12, the resident was in a severe state of decline and her family had been contacted to come to her bedside. Her temperature was elevated to 101.9, respirations were 24, and her oxygen level was poor (SPO2 = 84%). The resident was started on 2 liters of oxygen via nasal cannula and the physician was notified. A nurse's note, entered at 12:30 p.m. on 07/14/12, by Employee #11 (Licensed Practical Nurse) stated she received a verbal order (via phone) for Roxanol. The physician's written order was timed 12:30 p.m. on 07/14/12, and read Roxanol 20 mg/ml 1 ml po (by mouth) Q4H (every 4 hours) PRN (as needed). (Note: Roxanol is morphine sulfate.) A follow-up note, at 1:30 p.m. on 07/14/12, stated, MPOA wants Roxanol started immediately. We told her it wasn't kept in the facility. She and her husband were very upset. Her husband stated 'there is no excuse for this. You need to do something now'. I told him I would do what I could immediately. (Physician name) hasn't returned call yet, so I called (Pharmacy name). The lady at (pharmacy name) said she had received a prescription for the Roxanol. I asked her to stat it and told her we needed it as soon as possible The Director of Nurses was contacted via phone and an attempt was made to acquire the drug from the facility's local contract pharmacy, but they did not have the medication. The nurse (Employee #11) stated in her notes that the Roxanol arrived from the pharmacy at 2:45 p.m. and was administered immediately for air hunger. A resident grievance was filed by the family and an investigation was made by the Social Worker (Employee #58) and the Administrator. Their findings were: We did not have Roxanol on site, but received it from pharmacy on a stat order. Staff acted appropriately and timely in ordering and receiving med. During a tour of the medication storage and preparation room at 1:25 p.m. on 09/24/12, a notice of available stock items labeled Narcotics Kit & Refrigerated Items was observed. This notice included: Roxanol Oral Solution (Morphine Concentrate) 20 mg/ml and indicated that 30 ml was to be stocked. During an interview with the Administrator, at 9:50 a.m. on 09/25/12, she was shown the stock list and asked why there had been no Roxanol in-house on 07/14/12, when it was ordered. She had no comment and referred this to the Director of Nurses (DON). At 10:00 a.m. the entire incident was reviewed with the DON, who stated that she remembered the medication had been used and not refilled, but could not recall the details and would have to review the incident. At 10:55 a.m. on 09/25/12, the DON returned, stating that the pharmacy's Regional Manager had informed her that there was no policy of when a stock medication was to be replaced after use. He confirmed that the stock medication had been used for another resident on 03/12/12, and not replaced. He told her that it was the facility's responsibility to reorder stock. A review of the facility's pharmacy manual failed to produce a policy/procedure for maintaining the stock medications. The DON was asked for a complete list of Stock Medications, but stated that she had searched and could find none. A review of the pharmacy audit report titled ER BOX and labeled for Morphine Sulfate 20 mg/ml (1 bottle 30 ml) revealed the following entries: -- 01/13/12 at 11:50 a.m.: there was 1 bottle that was expired and reordered. -- 01/13/12 at 9:00 p.m.: the 1 bottle was refilled. -- 03/27/12 NONE ON HAND -- 07/20/12 at 9:00 p.m.: 0 bottles on hand; 1 bottle received; 1 bottle given; 1 bottle remaining (There was no explanation for this entry error/discrepancy.) During an interview with the administrator and the DON, at 1:00 p.m. on 09/27/12, the above information was discussed and the administrator brought to the attention of the surveyor that she had indicated on the Grievance report dated 07/04/12 the following Recommendations/corrective action taken: Prior to this incident we had already set up meeting between (medical director name) and (pharmacy name) for later this month to get other meds in E box. Roxanol will be an option at that time. The administrator acknowledged that there was no evidence of a meeting having taken place or of any corrective action to a recognized problem. Neither the administrator or the DON had a comment when reminded that Roxanol was already listed as a stock medication and had not been refilled since 03/27/12 according to the pharmacy audits. b) Resident #32 On 09/25/12 at 9:10 a.m., medications were observed being given to Resident #32 by a registered nurse (RN), Employee #4. A multivitamin was ordered for Resident #32. After a search of the medication cart, by Employee #4, the multivitamin was not found and was not given as scheduled. c) Resident #3 On 09/25/12 at 8:37 a.m., medications were observed being given to Resident #3. Flonase nasal spray and iron were ordered for Resident #3. After a search of the medication cart, by an RN, (Employee #4), neither the iron nor the Flonase were found. Employee #4 stated these medications were not available. d) Resident #38 On 09/19/12 at 8:28 a.m., medications were observed being given to Resident #38 by an RN, (Employee #1). The resident's medications included Lisinopril 2.5 mg. Employee #1 searched the medication cart and no Lisinopril was available. This employee stated the Lisinopril would have to be ordered from the pharmacy and a physician's orders [REDACTED]. e) Resident #67 On 09/25/12 at 10:04 a.m., medications were observed being given to Resident #67 by an RN, (Employee #4). A multivitamin was ordered for this resident. After a search of the medication cart, by Employee #4, the multivitamin was not found and was not given as scheduled.",2016-03-01
8960,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,428,D,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's drug reference handbook, and staff interview, the facility consultant pharmacist failed to identify drug irregularities and act upon them for one (1) of ten (10) sampled residents. Resident #23 received an ongoing daily dose of Tylenol for pain while being assessed by facility staff to have no pain. In addition, the resident had an active order for the medication Hydrocodone, a pain medication, with a [DIAGNOSES REDACTED]. Resident identifier: #23. Facility census: 50 Findings include: a) Resident #23 Review of the Medication Administration Record [REDACTED]. In addition Hydrocodone 5-500 mg was prescribed on 06/02/12 every six (6) hours as needed for agitation/combativeness . Review of the resident's daily pain assessment for the 7-3 shift found it was marked as no on 09/01/12 through 09/23/12; it was marked as no every morning in July and August 2012 except for three (3) days which were left blank (07/07/12, 08/19/12, and 08/29/12). Every pain assessment that was completed for the 3-11 and 11-7 shifts between 07/01/12 through 09/23/12, had also been documented as no pain. Staff reviewed the medical record and confirmed this daily acetaminophen order was written in December 2011 and had been continued to be administered every morning for the past two (2) months even though the resident's pain assessment indicated she had no pain. In addition, Resident #23 had a physician's orders [REDACTED]. Review of the facility's drug reference guide, Nursing 2013 Drug Handbook, found Hydrocodone (Lortab) was used for moderate to moderately severe pain. The handbook made no mention use of the medication for agitation/combativeness. On 09/25/12, a review of the pharmacist's monthly Medication Regimen Review (MRR), for 01/30/12 through 09/22/12, verified the pharmacist had not identified the daily administration of acetaminophen with no assessed pain, or the order for Hydrocodone for agitation/combativeness as irregularities. The pharmacist failed to identify, report, or document any recommendations regarding these drug irregularities. During an interview, on 9/25/12 at 10:40 a.m., Employee #5 (an RN), and the DON, Employee #57, reported the pharmacist routinely reviews resident charts every thirty (30) days including all medications, and submits recommendations. These suggestions are forwarded to the physician for review and further orders. The DON kept a notebook of the recommendations and tracked these for response and completion. When asked about the order written on 06/02/12 for Hydrocodone 5-500 mg as needed for agitation/combativeness, Employee #5 stated that just doesn't make sense.",2016-03-01
8961,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,431,E,0,1,R8A111,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, review of the guidelines in Appendix PP of the State Operations Manual, and staff interview, the facility failed to ensure the consulting pharmacist maintained a formal system for safe and secure use and storage of medications. 1) There was no permanently affixed storage container in the refrigerator for the secure storage of controlled medications; 2) Discontinued medications were not disposed of in accordance with facility policy; 3) A multiple dose vial was expired; and 4) The freezer, in the medication refrigerator, needed defrosted. These practices had the potential to affect more than an isolated number of residents. Facility census: 50. Findings included: a) Observation, on [DATE] at 1:25 p.m., revealed the medication refrigerator contained a clear plastic box. The box contained six (6) individual vials of Lorazepam which had a green numbered break away lock. The box was freely moveable in the refrigerator. In addition, a box, labeled as emergency narcotic box, was found sitting on a shelf beside a box labeled emergency stock medications. The emergency narcotic box was freely moveable and not permanently affixed. b) The State Operations Manual (SOM), Appendix PP includes The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected. c) On [DATE] at 1:25 p.m., observation of the medication room found discontinued medications stored in a gray plastic box, a clear plastic file box, and a square plastic box. A review of the pharmacy form titled Medication Disposition Sheet, listed a total of 73 non-narcotic medications that had been discontinued from [DATE] through [DATE]. In an interview with the director of nursing, DON, on [DATE] at 1:40 p.m., she stated the discontinued medications were to be destroyed monthly. She stated, the pharmacy had been called on Saturday ([DATE]) to pick up the discontinued medications. A review of the pharmacy policy and procedure titled Disposal/Destruction of Expired or Discontinued Medication, revealed the following: 8. Facility should dispose of discontinued medication, out-dated medications, or medications left in Facility after a resident has been discharged within 90 days of the date the medication was discontinued by Physician/Prescriber. An additional review of the medication disposition sheet, revealed 25 non-narcotic medications had been discontinued more than 90 days. d) On [DATE] at 1:25 p.m., observation of the medication room revealed one (1) bottle of purified protein derivative (PPD) - tuberculin was dated [DATE]. The manufacturers' label on the medication box included to be destroyed within 30 days after being opened. In an interview with the administrator and director of nursing, on [DATE] at 3:30 p.m., the director of nursing confirmed the [DATE] was the date the PPD had been opened and the vial should have been discarded. e) Observation of the medication refrigerator, on [DATE] at 1:25 p.m., found the freezer compartment of the medication refrigerator, covered in frost. The door to the freezer section could not be opened due to the frost. A paper, taped to the front of the medication refrigerator and labeled, defrost freezer, found the last date the freezer had been defrosted was ,[DATE]. When discussed with the administrator and DON, on [DATE] at 3:30 p.m., they stated they doubt this was correct but would investigate and have the freezer defrosted.",2016-03-01
8962,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,441,F,0,1,R8A111,"Based on observations, staff interviews, review of the infection control data, and policy reviews, the facility failed to maintain a safe and sanitary environment to help prevent the development and transmission of disease and infection. The facility did not ensure the proper procedure for incontinence care was practiced by staff and failed to ensure proper handwashing technique was utilized after removing soiled gloves for one (1) of 40 sample II residents. The facility did not ensure infection control surveillance data was collected, and therefore could not be analyze for possible trends and patterns. Additionally, even though the facility had restricted residents movement in the facility due to a possible outbreak, wandering residents continued to move freely about. These practices had the potential to affect all residents residing in the facility. Resident identifiers: #47 Facility census: 50. Findings include: a) Resident #47 On 09/25/12 at 11:15 a.m., observation of incontinence care being provided to Resident #47, by nursing assistants (NA), Employees #35 and #59, revealed Employee #35 cleaned the resident's buttocks with a disposable wipe. Utilizing the same contaminated wipe, Employee #35 then proceeded to wipe the resident from back to front. Without removing the contaminated gloves, Employee #35 assisted the resident to put on a sweater and attach the tab alarm clip to the sweater. After Employee's #35 and #59 removed their contaminated gloves, both employees were observed washing their hands, turning off the water with paper towels and proceeding to dry their hands with the contaminated paper towels. A review of the facility policy titled Incontinence Care, on 09/25/12 at 1:30 p.m., revealed the following: Assisting a resident with incontinence If a resident has a bladder or bowel incontinence episode, follow these procedures: ? Provide for resident's privacy ? Remove soiled undergarment and dispose of it appropriately ? If clothing is soiled or wet, set aside for laundry ? Wash entire perineal area thoroughly with warm water and perineal wash if indicated. Wash area from front to back. ? If required, shower resident ? Dry area thoroughly ? Place dry incontinent garment on resident or assist with application. ? Remove gloves and wash hands. If necessary, apply clean gloves. ? Dress resident and assist them to comfortable position. In an interview with the administrator and director of nursing, on 09/25/12 at 3:30 p.m., both agreed the nursing assistants had not followed the facility policy and procedure for incontinence care or handwashing. b) During the review of the facility's infection control tracking log, on 09/27/12, it was discovered there was no infection monitoring included for the month of September 2012. Also, during the review of the infection control log, it was discovered the log did not contain the lab reports/results indicating the type of organisms identified. This information was necessary in order to maintain a record of infections and implement corrective actions related to infections when possible. During an interview with the Director of Nursing (Employee #57), on 09/27/12 at 1:30 p.m., it was confirmed the infection control tracking log was incomplete. c) Upon entry into the facility, at 4:30 p.m. on 09/16/12, only eight (8) residents and/or visitors were observed sitting in the dining room. The dining room was adjacent to the front entry and this was at a time when it should have been filled with residents preparing for the evening meal. The administrator, who was present in the facility informed the surveyors that they were serving all residents in their rooms because of an outbreak of upper respiratory symptoms in the facility. This situation had started the day before. She was asked if the health department had been informed and the administrator replied that she had not reported it because it was the weekend and was considering reporting the following day. During the general tour, and the observation of the serving of the evening meal, the small group of residents remained in the dining room and several residents were observed wandering in the halls. When questioned about who these residents were, Employee #13 (Licensed Practical Nurse) identified Residents #33, #66, #17, and #51. He stated they were residents who wandered and went throughout the facility. He acknowledged they should be in their rooms, but said there's no way to keep them there. On arrival the following day, the outbreak precautions had been discontinued and residents were eating in the dining room and sitting about in the halls and entryway. The administrator stated that they had evaluated the situation and made that decision.",2016-03-01
8963,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,490,F,0,1,R8A112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, it was determined the facility was not administered in a manner which enabled it to use its resources effectively and efficiently to ensure each resident attained or maintained his/her highest practicable well-being. There was a failure to fully implement the plan of correction for four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12. During the 11/28/12 revisit, deficiencies at F280, F281, F282, and F371 remained out of compliance. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. The failure to revise care plans was cited at F280 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. b) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A staff member initialed medications as given prior to the residents taking the medications. The failure to ensure services were provided in accordance with professional standards of practice was cited at F281 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. c) The facility failed to follow physician's orders [REDACTED].#32, and failed to follow physician's orders [REDACTED].#31. The failure to ensure services were provided in accordance with the written plan of care was cited at F282 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12. d) The facility failed to ensure a dietary employee adequately restrained her hair in the kitchen, to prevent contamination of food during preparation and service. This had the potential to affect all residents who consumed food from the kitchen. The failure to ensure foods were stored, prepared,distributed, and/or served under sanitary conditions was cited at F371 during the survey which ended on 09/27/12. The facility failed to correct the deficiency, resulting in a repeat deficiency during the revisit which ended on 11/28/12.",2016-03-01
8964,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2012-09-27,520,F,0,1,R8A112,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, and staff interviews, the facility's quality assurance program failed to develop and implement effective plans of action to correct identified quality deficiencies. Four (4) deficient practices identified during the annual Quality Indicator Survey (QIS) survey, which ended on 09/27/12, were still out of compliance during the re-visit survey which ended 11/28/12. The facility submitted a plan of correction for these deficiencies, but failed to implement the plans and/or correct the deficiencies cited at F280, F281, F282, and F371. This had the potential to affect all residents in the facility. Facility Census: 47. Findings Include: a) Staff interview with Employee #53 (QA Committee Contact Person), at 11:00 a.m. on 11/27/12, revealed the issues identified from the previous QIS survey had been addressed with the Quality assessment and assurance committee (QA Committee). Employee #53 confirmed the QA Committee had been presented with the entire plan of correction at their meeting on 11/01/12. Employee #53 confirmed the plan of correction, including those in which the QA committee was not expressly mentioned, was discussed during this meeting. The QA committee did not ensure the deficient practices cited during the survey which ended 09/27/12 were corrected. A plan of correction for these deficiencies was submitted by the facility. These plans were not implemented for the deficiencies previously cited at F280, F281, F282, and F371. They remained out of compliance when evaluated for compliance during the revisit survey which ended 11/28/12. b) The facility failed to revise a care plan for one (1) of ten (10) sample residents. The care plan for Resident #45 was not updated when she experienced a significant weight loss and began forgetting how to eat at times. c) The facility failed to comply with facility policy and procedure and professional standards of practice during medication administration. A staff member initialed medications as given prior to the residents taking the medications. d) The facility failed to follow physician's orders [REDACTED].#32, and failed to follow physician's orders [REDACTED].#31. e) The facility failed to ensure a dietary employee adequately restrained her hair in the dietary kitchen, to prevent contamination of food during preparation and service. This had the potential to affect all residents who consumed food from the kitchen.",2016-03-01
8965,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2013-10-17,257,E,1,0,F7JM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interviews, and resident interviews, the facility failed to ensure comfortable temperatures were maintained and/or extra blankets/clothing were provided to ensure comfort for four (4) of six (6) residents. Resident identifiers: #2 #6, #12, #34, and #25. Facility census: 42. Findings include: a) Resident #12 On 10/16/13 at 12:25 p.m., Resident #12 stated she gets cold and has to get in bed to get warm. The room felt cold. The thermostat in the resident's room was set on 84 degrees Fahrenheit (F). A temperature check of the room at 12:45 p.m. revealed the temperature to be 70 degrees F. The temperature of the hallway in front of the resident's room was 76 degrees F and the thermostat for the hallway was set on 73 degrees F. On 10/16/13 at 1:10 p.m., in an interview with Employee #43, the maintenance supervisor, he stated that each resident's room had a thermostat to regulate the temperature in the room. He stated the thermostats in the hallways were used for controlling the air conditioners. He checked the temperature in Resident #12's room and agreed the room was cool and stated it was because the vent in the ceiling for the air conditioner had not been closed to allow the heat to work properly. He said if the vent remained open, the air conditioner and the heat would work against each other. He also stated the boiler temperature had not been increased for the winter yet. When asked if he checked the room temperatures he stated he was checking them, but did not have any records of this. He stated he had stopped after the resident changed rooms and she no longer complained of being cold. On 10/17/13 at 9:00 a.m., a measurement of the temperatures in the hallway for rooms numbered 2 through 14 was 71 degrees F. The thermostat for this area was set on 70 degrees F. The temperature for room [ROOM NUMBER] was checked and was 73 degrees. Resident #12 stated that her room felt warmer to her. On 10/17/13 at 8:45 a.m. the Resident Council minutes for the months of June 2013, August 2013, and September 2013 were reviewed. The 08/27/13 council meeting revealed that Resident #25 was complaining it was cold at night. The response to this complaint was maintenance was to check the temperatures before leaving the facility every evening and this was to be corrected as soon as possible. The council meeting held 09/30/13 had complaints of residents being cold at night and the response to the complaint was for maintenance to check the temperatures prior to leaving the facility for the evening. The date of correction for this complaint was set for 10/15/13. On 10/17/13 at 10:25 a.m., an interview was conducted with Employee #43, the maintenance director, he stated he did not have any room temperature logs and that he had only one (1) resident that had complained about it being cold. When the resident council minutes were mentioned he stated he was aware and it was his fault that the resolution was not followed through with. He stated with the renovations he had a lot to correct that was not done correctly. He stated that he did turn the boiler up yesterday (10/16/13) to 100 degrees F. He stated that the hallway thermostats were to be set on 72 degrees F at least. He stated that night shift often turned the thermostats down and they have been told to leave them alone. He stated he was going to start keeping a log of checking the temperatures for rooms in the facility. b) Resident #2 On 10/17/13 at 11:45 a.m. an interview with Resident #2 was conducted. She stated her room was cold. An observation of the resident's thermostat revealed it was set at 72 degrees F. A spot check of the temperature of the room revealed the temperature was 72 degrees. c) Resident #6 On 10/16/13 at 3:25 p.m., an interview was conducted with this resident. When asked about the temperature of the room, this resident stated it was so cold the first two (2) days I was here, I cried for two (2) days. Resident #6 further stated the maintenance man came in and adjusted the vent (ceiling) and it (temperature) was okay. When the resident was asked if the room temperature was comfortable now, she stated, only if I wear three (3) shirts, sweat pants, two pairs of socks and slippers. Resident # 6 was observed, during this interview, to be wearing a tee shirt, sweater and sweat shirt, sweat pants, two (2) pairs of socks and slippers. This resident stated she had told the maintenance man, social services and the workers about the room being cold and nothing was done. During the interview, the thermostat, in Resident #6's room, revealed a temperature of 73 degrees Fahrenheit. When informed of the room temperature, Resident #6 stated it still feels cold to me. d) Resident #25 In an interview with Resident #25, on 10/17/13 at 9:30 a.m., this resident stated, The temperature (room) is not good. It is never warm enough. This resident stated I tell the nurses all the time, they listen but nothing is done. e) Resident #34 On 10/15/13 at 8:00 p.m., Resident #34 was observed in the TV lounge sitting in her wheelchair. This resident was wearing a short sleeved blouse and long pants. The administrator asked Resident #34 if she was cold. The resident responded Yes. My hands are cold and I want a blanket. The administrator retrieved a blanket for this resident.",2016-03-01
8966,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2013-10-17,364,D,1,0,F7JM11,"Based on resident interviews, staff interview, and measurement of test tray temperatures, the facility failed to ensure food was served at the proper temperatures and palatable. Residents complained food was cold and not edible, especially the biscuits and gravy. A test tray was completed which revealed temperatures were below acceptable ranges at the point of service (the generally accepted temperature for hot foods at the point of service is 120 degrees Fahrenheit). Three (3) of six (6) residents on the sample voiced complaints about the food. This had the potential to affect more than a limited number of residents. Resident identifiers: Resident #6, #25, and #23. Facility census: 41. Findings include: a) Resident #6 On 10/16/13 at 12:35 p.m., the registered dietitian (RD) was observed testing the food temperatures of the tray for the last resident (Resident #6) to be served. The meat registered 90 degrees Fahrenheit, the cornbread 110 degrees Fahrenheit, and the carrots were 78 degrees Fahrenheit. The RD agreed the food temperatures were not at the proper temperature and another tray was prepared for Resident #6. On 10/16/13 at 3:25 p.m., an interview was conducted with Resident #6. When asked about the temperature of the food, Resident #6 stated the toast at breakfast was black, hard and cold. He said When we have biscuits and gravy, it is cold and the gravy is set. This resident further stated the hot chocolate was lukewarm. b) Resident #25 On 10/17/13 at 9:30 a.m., an interview was conducted with Resident #25. When asked if hot foods were served hot and cold foods served cold, this resident stated Not really. The resident said the coffee and hot chocolate were warm, but never hot and added, The food is never warm enough. When asked if staff offer to warm up food, Resident #25 stated No. c) Resident #23 On 10/17/13 11:20 a.m., during an interview with Resident #23, he stated he got plenty of food to eat, but it was not always hot.",2016-03-01
8967,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2013-12-26,441,E,1,0,9S3311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, and employee interview, the facility failed to provide a safe and sanitary environment to prevent the spread of disease and infection. Bed linens, used gloves, a catheter bag, and trash were on the floors in resident rooms. Three (3) of thirty-one (31) rooms observed were affected. Affected rooms: #3, #4, and #22. This had the potential to affect more than an isolated number of residents. Facility census: 37. Findings include: a) A tour of the facility on 12/26/13 at 8:30 a.m. revealed the following areas had infection control issues: 1) room [ROOM NUMBER] In the bathroom, there were two (2) gloves that were inside out, indicating they had been used, and wet toilet paper lying on the floor. 2) room [ROOM NUMBER] The bathroom had soiled (brown stained) toilet paper on the floor and feces on the toilet seat. 3) room [ROOM NUMBER] The room had a yellow fluid on the floor by the bed. Resident #25's catheter bag was full and lying on the floor. Soiled bed linens were observed on the floor at the foot of the bed. The floor around the trash can was stained brown and there were several soiled pieces of paper towel on the floor around the can. An interview was conducted with Resident #25 on 12/26/13 at 9:30 a.m. This resident stated his catheter bag was usually full of urine and was always on the floor. The resident stated he tried to empty the bag himself, but usually got urine on the floor. An interview with Employee #50 (Director of Nursing-DON) was conducted on 12/26/13 at 9:45 a.m. in Resident #25's room. This employee stated the catheter bag, bed linens, and trash should never be on the floor. The DON stated she would ensure Resident #25's room, as well as the other affected rooms, would be cleaned immediately.",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
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
8970,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,225,F,0,1,VDMM11,"Based on review of employee personnel files and staff interview, the facility failed to make reasonable efforts to ensure a thorough investigation of the past histories of potential employees. The facility used statewide criminal background checks as a method to check suitability for service as a nursing home employee. The facility did not initiate and/or followed up on the statewide criminal background checks for five (5) of ten (10) employees whose personnel records were reviewed. Employee identifiers #7, #10, #25, #48, and #44. This had the potential to affect all residents. Facility census: 42. Findings include: a) Employee #7 Review of personnel records on 05/20/14 at 10:00 a.m., found Employee #7 was hired on 01/22/14. Prior to her hire, the facility fingerprinted the employee on 01/08/14. The facility sent those prints to Company #1 in order to obtain a statewide criminal background check in West Virginia (WV). A letter from the WV State Police, dated 01/28/14, was addressed to the employee at her home address. In this letter, the employee was notified that the West Virginia State Police (WVSP) records division or the Federal Bureau of Investigation (FBI) rejected the fingerprint submission. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the business office director (BOD) on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she had found that some rejection letters were mailed to the home of the employees rather than to the facility, as it was in this case. She said the facility was not notified by Company #1 of the fingerprint rejection. Rather, she learned of the rejection of the fingerprints by speaking with the employee. She said she believed she fingerprinted Employee #7 sometime in February, and resubmitted to Company #1. She could find no evidence to support the date of the resubmission. She produced a letter dated 04/24/14 from the WVSP which informed Employee #7 that the 01/28/14 fingerprint submission was rejected. This letter was addressed to the employee at the employee's address. The letter did not mention the second submission. An interview was conducted with Employee #7 on 05/20/14 at 11:40 a.m. She said the assistant business office director (ABOD) fingerprinted her in January. Employee #7 acknowledged that a rejection letter was mailed to her at her home. She said the BOD fingerprinted her the second time perhaps in March, but she was unsure of the exact time frame. Employee #7 said she did not receive a rejection letter at her home the second time. Rather, the BOD called her sometime in April and set up an appointment for her to have the fingerprints done at the office of Company #1. She said this was completed sometime in early May. Personnel record review found a letter addressed to the facility from the WVSP, with date of inquiry as 05/07/14, notifying the facility that the background check was successfully completed. Employee #7's criminal background check was completed three and a half (3 1/2) months after she was hired and began working at the facility. b) Employee #10 Review of personnel records on 05/20/14 at 10:00 a.m. found Employee #10 was hired on 02/19/13. A letter from the WVSP, dated 04/25/14, was addressed to the employee at her home address. In this letter, the employee was notified that WVSP records division or the FBI rejected the fingerprint submission from 02/28/13. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she caught this background check omission during an audit of all employees conducted between the end of March 2014 through the first week in April 2014. She said this employee was one (1) of four (4) employees the facility found during the audit that needed attention with their background checks. She produced a fax from Company #1, dated 04/28/14, which indicated that a 03/28/14 the background check submission was in process. This allegedly resulted in the 04/25/14 letter from the WVSP that a fingerprint submission from 02/28/13 was rejected. The letter did not mention the 03/28/14 submission. The BOD produced a WV Easy Path Network that confirmed the employee was fingerprinted through Company #1 on 05/08/14. She said they were awaiting the results. Employee #10 has been employed at the facility for fifteen (15) months while having no statewide criminal background check completed. c) Employee #38 Review of personnel records, on 05/20/14 at 10:30 a.m., found Employee #38 was hired on 04/06/12. A letter from the WVSP was addressed to the facility, with date of inquiry as 03/31/14. The letter notified the facility of the results of the employee's completed criminal background check. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she caught this criminal background check omission during an audit of all employees conducted between the end of March 2014 and the first week in April 2014. She said four (4) employees needed attention with these. The facility fingerprinted Employee #38 and got the results back, so he was no longer on the radar as were the other four (4) employees. d) Employee #44 Review of personnel records on 05/20/14 at 11:00 a.m. found Employee #44 was hired on 06/27/11, and worked through 10/24/12. A criminal background check was completed on 07/07/11. She left the facility for less than four (4) months, and returned to work on 03/19/13. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of March 2014 and the first week in April 2014. She said she did not know if this employee required a second criminal background check after having had a three (3) month interruption in employment. She needed a three (3) year background check in July, so she scheduled an appointment for her on 05/13/14. They were awaiting the results. She said this employee was one (1) of the four (4) employees flagged during the audit who needed attention with the criminal background checks. e) Employee #25 Review of personnel records on 05/20/14 at 11:00 a.m. found Employee #25 was hired on 03/19/13. There was no evidence of a criminal background check on file. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of March 2014 and the first week in April 2014. This employee was one (1) of four (4) identified during the audit who needed attention with the background checks. She submitted fingerprints to Company #1 on 03/31/14. She received a letter dated 04/24/14 informing the facility that the prints were rejected. Employee #25 had an appointment on 05/22/14 with Company #1 for another resubmission of her fingerprints. Employee #25 has been employed by the facility for fourteen (14) months while having no criminal background check completed. f) An interview was conducted with the BOD and the administrator on 05/20/14 at 12:00 p.m. They acknowledged their corporate office was notified in March of the results of the criminal background check audits, and ongoing progress since then. The administrator said all fingerprinting since March had been done, and would continue to be done, digitally at the office of Company #1 rather than having them completed by the facility. She spoke her belief that communications would now improve with Company #1 sending e-mail confirmations. The BOD said that Company #1 had not always sent e-mail confirmations since switching to the method of digital fingerprinting at Company #1's office. The BOD has added criminal background checks to a spreadsheet for tracking new employees, and employees who needed the every three (3) year repeats.",2016-03-01
8971,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,279,E,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to develop care plans to ensure the residents' individual care needs were met. This was found for four (4) of twenty-three (23) residents who were reviewed for care plans during Stage 2 of the survey. Residents #52, #9, and #22 had pressure ulcers for which there were no care plans. In addition, there was no care plan for Resident #64 regarding diabetes mellitus (DM). Resident identifiers: #52, #9, #22, and #64. Facility census: 42. Findings include: a) Resident #52 On [DATE] at 10:53 a.m., a review of the medical record for Resident #52 found it contained no evidence of a care plan for pressure ulcers for this resident. A review of the nursing notes, at 10:55 a.m. on [DATE], revealed a note dated [DATE] at 14:56 (1:56 p.m.), which stated, DTI (deep tissue injury) to Left Heel, Right 5th digit, and right inner ankle have no significant change in status. Skin remains intact. Skin Prep to continue as ordered. Stage III to coccyx is Dark red in color w/(with) some yellow slough, and small necrotic area. it is 3.8 cm x 3.9 cm x 0.3 in size. Stage II's Left Buttock a) is 2.2 cm x 1.8 cm x 0.3 cm b) 2.3 cm x 2.3 cm x 0.3 cm in size. Both have beefy red wound bed with moderate amt (amount) of serosangeuinous drainage. [MEDICATION NAME] to continue for both Stage II's and Santyl to continue to Stage III. On [DATE] at 1:00 p.m., the minimum data set (MDS) nurse, Employee #30, provided a copy of the resident's current care plan. Review of the care plan revealed no focus, no goals, and no interventions related to the pressure ulcers. On [DATE] at 2:30 p.m., Employee #30 provided an additional copy of the care plan which contained a focus, goals and interventions for Stage III pressure ulcer to buttocks and coccyx r/t (related to) severely diminished mobility [MEDICAL CONDITIONS]. This employee stated she had developed the pressure ulcer care plan on [DATE]. The employee agreed there was no care plan for the pressure ulcers until [DATE]. b) Resident #9 Medical record review, on [DATE] at 10:25 a.m., found this resident was admitted on [DATE] and died at the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The medical record revealed no evidence of an interim care plan for this resident. On [DATE] 11:00 a.m., an interview with the director of nursing (DON) revealed this resident did not have an interim care plan. The DON stated there should have been an interim care plan completed for Resident #9 within 24 hours of admission to the facility. The facility's policy Preliminary or Interim Care Plans, provided by the DON, included, in the Policy section, A preliminary or interim plan of care to meet the residents immediate needs shall be developed for each resident within twenty-four (24) hours of admission. c) Resident #22 Resident #22 was admitted with one (1) pressure ulcer and additional skin wounds. The physician ordered care for the ulcer and wounds. The wound nurse (Employee #2) completed care on the ulcer and wounds, but the care plan did not identify a problem or interventions for the ulcer and wounds. On [DATE] at 4:00 p.m., a registered nurse, Employee #30, stated she was responsible for completing care plans, but was under the impression she was not to complete the pressure ulcer/wound care portion of the care plan. On [DATE], at the direction of the director of nursing (DON), Employee #30 entered specific problems, goals and interventions concerning wound care. At 4:25 p.m. on [DATE], the DON stated It just wasn't done when referring to Resident #22's care plan for problems, goals and interventions for pressure ulcer and wound care. The DON stated Employee #30 was the facility's care plan coordinator and Employee #2 was the nurse responsible for wound care. The DON stated the required weekly skin assessments were completed by floor nurses, who informed the wound care nurse of issues with wounds/pressure ulcers. The information was then communicated to the care plan coordinator by the wound care nurse. The DON agreed the pressure ulcer and wounds should have been included on Resident #22's care plan beginning at admission and before [DATE]. d) Resident #64 The medical record was reviewed on [DATE] at 12:00 p.m. Resident #64 was a resident with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Medications at the time of admission included an oral anti-diabetic agent that was taken daily, and injectable insulin that was taken twice daily. On [DATE] at 12:45 p.m., the MDS nurse provided a copy of the resident's current interim care plan. The interim care plan was reviewed at that time. No focus, goals, or interventions related to diabetes were found in the care plan. Employee #30 agreed there was no mention in the interim care plan of the resident's diabetes, or that he took both oral and injectable medications for diabetes. On [DATE] at 5:00 p.m., an interview was conducted with the DON. She said that interim care plans, according to policy, were to be completed within twenty-four (24) hours of admission to the facility. When asked if she thought Resident #64 should have had an interim care plan developed for his diabetes, she replied Absolutely. The DON agreed that signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] should have been included in the interim care plan, and were not. She said dietary needs, medications, and treatments, for example, were to be reviewed and implemented into an interim nursing care plan to meet the resident's care needs. The DON said the interim care plan was used until staff completed the full comprehensive assessment.",2016-03-01
8972,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,280,D,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for the use of a Foley catheter for one (1) of twenty-three (23) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey (QIS). The care plan was not revised for the resident after she developed a new [DIAGNOSES REDACTED]. The care plan did not reflect the newly discovered medical problem. Resident identifier: #6. Facility census: 42. Findings include: a) Resident #6 On 04/24/14 at 2:45 p.m., the resident's Significant Change Minimum Data Set (MDS), with an Assessment Reference Date (ARD) of 01/19/14, was reviewed. It revealed Resident #42 was incontinent of urine at all times. The MDS noted she did not have an indwelling urinary catheter, and had no [MEDICAL CONDITION]. The medical record, reviewed on 04/24/14 at 3:00 p.m., revealed on 01/28/14 Resident #6 returned to the facility following a five (5) day hospitalization . The assessment by nurses for the bowel and bladder functionality at that time found she was never continent of urine, had been incontinent of urine for greater than a year, and was not aware of the need to toilet. She was assessed to be a large wetter, meaning she was incontinent of large amounts of urine. On 02/23/14, a hospital contacted the facility to report the findings of a recent urine culture. The urine culture was positive for [MEDICATION NAME] Resistant [MEDICATION NAME] (VRE), which is a multiple drug resistant organism. Review of the medical director's progress note, dated 02/23/14, revealed he had spoken with an epidemiologist from the reporting hospital. A Foley catheter was inserted into the bladder of Resident #6 to contain the urine. She was moved to a private room with a private bathroom. A Computerized Tomography (CT) scan of the abdomen, dated 02/28/14, showed bilateral hydro[DIAGNOSES REDACTED] (kidney swelling) and hydroureter (abnormal distension of the ureter) most likely secondary to a mass effect. There was probable scarring of the left kidney, and possible bladder wall thickening. The care plan was reviewed. On 03/03/14, the care plan contained a focus for the use of an indwelling Foley catheter related to VRE in the urine. A urine culture report, dated 03/10/14, showed no evidence of VRE. The medical director wrote on the lab slip that the resident was on an antibiotic, [MEDICATION NAME], and should continue. He also noted she had completed a course of another antibiotic (intramuscularly delivered [MEDICATION NAME]), on 03/05/14. He added that he was waiting for a urology appointment. An interview was conducted with the director of nursing (DON) on 04/24/14 at 4:30 p.m. She said she was at the nurses' station in March when staff reportedly discussed this resident with the medical director. She said staff questioned whether they could remove the Foley catheter since the infection had resolved. The medical director reportedly told staff the resident had some type of obstruction, and he wanted to leave the catheter in until she had her urology appointment in June 2014. Upon inquiry, the DON confirmed the care plan was not revised to indicate the reason for the use of the Foley catheter was obstruction, rather than due to VRE.",2016-03-01
8973,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,281,D,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a Centers for Medicare and Medicaid Services (CMS) memorandum, staff interview, and policy review, the facility failed to provide services according to accepted standards of practice as determined by the facility and included in the facility's policy on medication administration via gastrostomy tube. The facility failed to ensure the placement of the gastrostomy tube was checked for patency, in accordance with the facility's policy, prior to the administration of medications for for two (2) of two (2) residents observed for gastrostomy tube medication administration. In addition, a licensed nurse also administered all of a resident's medications and water flushes by pushing them in with a syringe, rather than allowing them to flow per gravity as the facility policy directed. Resident identifiers: #30 and #52. Facility census: 42. Findings include: a) Resident #30 On 04/17/14 at 7:23 a.m., a medication administration per gastrostomy tube was observed. Licensed nurse, Employee #26, flushed the gastrostomy tube with an ounce of water. She then administered four (4) medications, and administered an ounce of water after each of the four (4) medications. Upon inquiry as to how often they checked for residual and placement, she said she did not see an order for [REDACTED]. b) Resident #52 Medication administration per gastrostomy tube was observed on 04/17/14 at 8:15 a.m. Licensed nurse, Employee #16, placed twelve (12) medications in twelve (12) medication cups to administer via the gastrostomy tube. She pushed an ounce of water by using the plunger in the syringe. Still using the plunger in the barrel of the syringe. she pushed each of the twelve (12) medications into the gastrostomy tube, rather than letting them flow in by gravity. She used the plunger in the barrel of the syringe to push in an ounce of water after each one of the twelve (12) individual medications were instilled. This amounted to 390 cubic centimeters (ccs) of water, plus the medications. Upon inquiry as to when the gastrostomy tube was last checked for placement and residual, she replied that it most likely was checked that morning at 6:00 a.m. when the resident received her morning medications on the night shift. She then stated she forgot to check for placement and residual before giving the medications she had just given. On 04/17/14 at 10:00 a.m., an interview was conducted with the director of nursing (DON). She said she did not believe the facility had a policy related to gastrostomy tube medication administration, but she would look. According to a Centers for Medicare and Medicaid Services (CMS) memorandum dated 11/02/12, the facility, in consultation with the pharmacist, must provide procedures for the accurate administration of all medications. The procedures must reflect current standards of practice including, but not limited to, techniques to monitor and verify that a feeding tube is in the right location before administering medications. On 04/28/14 at 5:04 p.m., the DON provided a policy/procedure on administration of medications via tubes, which included gastrostomy tubes. The revision date of this form was 06/2013. Upon inquiry as to whether the insignia on the top of the form was that of their consultant pharmacy, she replied in the affirmative. The facility's procedure on administration of the medications via tubes was reviewed on 04/28/14 at 5:05 p.m. It stated to first shut off or suspend the tube feeding and cover the tip of the tube. Next, the tube must be checked for placement by a) instilling air and listening to the abdomen with a stethoscope, and b) aspirating gently for stomach content, then gently pushing the stomach contents back in. Step c directed to remove the plunger and place the barrel of the syringe in the stomach tube. In addition, Step f directed to allow each medication to flow into the tube by gravity, as well as the water flushes. The DON agreed the nurse should have instilled each medication by gravity in accordance with the facility's policy, rather than pushing it in with a syringe. She spoke her awareness that the physician had ordered a thirty (30) cc water flush after each medication for Resident #52. Also, she agreed that both nurses should have checked placement per policy prior to administration of the medications. This would have included instilling air into the abdomen and auscultating with a stethoscope, as well as aspirating gently for stomach contents.",2016-03-01
8974,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,282,D,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to implement the care plan for one (1) of twenty-three (23) residents whose care plans were reviewed during Stage 2 of the survey. The facility did not implement the pressure ulcer care plan interventions for weekly body audits or ensure the resident's eyeglasses had padded ear pieces. Resident Identifier: #35. Facility Census: 42 Findings include: a) Resident #35 On 04/28/14 at 2:20 p.m., an observation of a full body audit of Resident #35, by Employee #2, a licensed practical nurse (LPN), the facility's designated wound nurse, was conducted. The observation revealed a previously undetected Stage II pressure ulcer on the resident's coccyx. The LPN acknowledged the facility had not identified this area and should have prior to this full body audit. During the same observation, a previously undetected Stage I pressure ulcer was found on the resident's right ear under his oxygen tubing. The LPN confirmed both areas were not reported or identified until this observation. She said the resident had pressure ulcers in the past on the coccyx and the right ear; however, both pressure ulcers had resolved. At 3:00 p.m. on 04/28/14, during an interview with the director of nursing (DON), she had no comments regarding the pressure ulcers that were found on Resident #35's coccyx and ear. Review of the resident's current care plan, at 8:45 a.m. on 04/29/14, revealed an intervention to ensure the resident's eyeglasses had padded ear pieces and an intervention for weekly audits. These interventions were not implemented. A review of the nurse aide (NA) Kardex (the tool used by NAs to provide individual resident care) on 04/29/14 at 9:15 a.m., found it included, earpieces on eyeglasses to be padded. The Kardex also indicated to monitor the resident for skin breakdown during daily care, and to observe skin every shift during care. Resident #35 was observed in the activities room on 04/29/14 at 9:45 a.m. He was sitting in his wheelchair. He was wearing his glasses. There was no padding to the earpieces of his glasses at that time. During an interview with Employee #10, a NA, on 04/29/14 at 9:50 a.m., she said she did not know if Resident #35 currently had padding on the earpieces of his glasses. She said he should have padding on the earpieces. When brought to her attention there was no padding on the eyeglass earpieces, the NA stated, The nurse has those on her cart. When asked if the NAs used the Kardex information to provide care for residents, Employee #10 replied, Yes. She agreed since the NA Kardex stated the eyeglasses earpieces were to be padded, she should notify the nurse that padding was needed. When the NA was asked if she was aware the resident had a pressure ulcer to his coccyx she said, No but I saw he had a bandage there. On 04/29/14 at 1:20 p.m., during an observation of incontinence care provided by Employee #10 (NA), the area on Resident #35's coccyx was observed red and non-blanching, with a vertical split in the skin. The tissue in the area of the split was pink in color. There was also another small round open area below and to the left of the open split area. Review of the nurse's weekly assessment records, at 1:30 p.m. on 04/29/14, revealed the following: - No record of a weekly assessment for 02/13/14. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the sacrum, with a note that stated, Wound to sacrum area receiving [MEDICATION NAME]. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the coccyx, with a note that stated, Open area, received treatment daily. - There were no weekly assessments for five (5) consecutive weeks, beginning 03/20/14 through 04/17/14. - The weekly assessment dated [DATE], was marked, skin intact no problems. At 1:40 p.m. on 04/29/14, the director of nursing (DON) was asked to provide the missing nurses' weekly assessments for Resident #35. She stated, You're not going to get them, because they are not there. I looked and they were not done.",2016-03-01
8975,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,314,G,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to provide care and services necessary to prevent the development of avoidable pressure ulcers for one (1) of eight (8) residents who had a history of [REDACTED]. In addition, the facility did not implement the pressure ulcer care plan for weekly body audits. The resident developed two (2) pressure ulcers, a Stage II pressure ulcer to the coccyx and a Stage I pressure ulcer to the right ear. Resident Identifier: #35. Facility Census: 42. Findings include: a) Resident #35 On 04/28/14 at 2:20 p.m., an observation of a full body audit of Resident #35, by Employee #2, a licensed practical nurse (LPN), the facility's designated wound nurse, was conducted. The observation revealed a previously undetected Stage II pressure ulcer on the resident's coccyx. The LPN acknowledged the facility had not identified this area and should have prior to this full body audit. During the same observation, a previously undetected Stage I pressure ulcer was found on the resident's right ear under his oxygen tubing. The LPN confirmed both areas were not reported or identified until this observation. She said the resident had pressure ulcers in the past on the coccyx and the right ear; however, both pressure ulcers had resolved. At 3:00 p.m. on 04/28/14, during an interview with the director of nursing (DON), she had no comments regarding the pressure ulcers that were found on Resident #35's coccyx and ear. Review of the resident's current care plan at 8:45 a.m. on 04/29/14, identified the facility had care planned the resident for a potential for skin breakdown due to bowel and bladder incontinence, [MEDICAL CONDITION], use of aspirin daily, fragile skin, assistance with bed mobility, use of eyeglasses. The interventions for this particular focus area were: -Ear cushion to nasal cannula -Earpieces to eyeglasses to be padded -Observe visible skin every shift during care -Body audit weekly -Assess for increased [MEDICAL CONDITION] -Assist to turn and reposition during rounds and as needed -Check and change during rounds and as needed. Provide incontinence care as needed -Cushion to chair for comfort and reduction of pressure A review of the physician's orders [REDACTED]. There was also an order [REDACTED]. A review of the nurse aide (NA) Kardex (the tool used by NAs to provide individual resident care) on 04/29/14 at 9:15 a.m., stated earpieces on eyeglasses to be padded. The Kardex also indicated to monitor the resident for skin breakdown during daily care, and to observe skin every shift during care. Resident #35 was observed in the activities room on 04/29/14 at 9:45 a.m. He was sitting in his wheelchair. He was wearing his glasses. There was no padding to the earpieces of his glasses at that time. During an interview with Employee #10, a NA, on 04/29/14 at 9:50 a.m., she said she did not know if Resident #35 currently had padding on the earpieces of his glasses. She said he should have padding on the earpieces. When brought to her attention there was no padding on the eyeglass earpieces, the NA stated, The nurse has those on her cart. When asked if the NAs used the Kardex information to provide care for residents, Employee #10 replied, Yes. She agreed since the NA Kardex stated the eyeglasses earpieces were to be padded, she should notify the nurse that padding was needed. When the NA was asked if she was aware the resident had a pressure ulcer to his coccyx she said No but I saw he had a bandage there. On 04/29/14 at 1:20 p.m., during an observation of incontinence care provided by Employee #10 (NA), the area on Resident #35's coccyx was observed red and non-blanching, with a vertical split in the skin. The tissue in the area of the split was pink in color. There was also another small round open area below and to the left of the open split area. Review of the nurses' weekly assessment records, at 1:30 p.m. on 04/29/14, revealed the following: - No record of a weekly assessment for 02/13/14. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the sacrum, with a note that stated, Wound to sacrum area receiving [MEDICATION NAME]. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the coccyx, with a note that stated, Open area, received treatment daily. - There were no weekly assessments for five (5) consecutive weeks, beginning 03/20/14 through 04/17/14. - The weekly assessment dated [DATE], was marked, skin intact no problems. At 1:40 p.m. on 04/29/14, the director of nursing (DON) was asked to provide the missing nurse's weekly assessments for Resident #35. She stated, You're not going to get them, because they are not there. I looked and they were not done. Review of the minimum data set (MDS) assessment at 2:00 p.m. on 04/29/14, identified the resident had a past history of pressure ulcers to his coccyx and right ear. The resident's most recent annual MDS, with an assessment reference date (ARD) of 05/12/13, identified the resident had two (2) Stage II pressure ulcers. The date of the oldest Stage II pressure ulcer was 04/03/13. MDS assessments with an ARD of 11/10/13 and 02/09/14 also identified the resident was at risk for the development of pressure ulcers. According to the most recent care area assessment (CAA) worksheet, with an ARD of 05/12/13, the Stage II pressure ulcers were located on the 2nd digit of the left great toe and behind the right ear. The CAA also stated, Potential for development of pressure ulcers related to requires extensive assistance for bed mobility, bowel and bladder incontinence. On 04/29/14 at 3:00 p.m. a review of the wound tracking logs revealed Resident #35 had a history of [REDACTED]. The logs revealed the following: - 03/05/14 and 03/06/14 identified a Stage II pressure ulcer to his coccyx, measuring 4.3 X 2.2 X 0 , with no onset date indicated. The resident was also noted to have a Stage II pressure ulcer to his right ear, measuring 0.5 X 0.3 X 0, with no onset date identified. - 03/13/14 identified the resident had a healing Stage II pressure ulcer to his coccyx, with an onset date of 03/05/14. The ulcer was noted as, skin is pink and intact. Also the resident had a Stage II pressure ulcer to his right ear, measuring 0.2 Centimeters (cm) X 0.5 cm X 0.1 cm, with an onset date of 03/05/14. - 03/20/14 identified a resolved Stage II pressure ulcer to the resident's coccyx. There was no mention of the Stage II pressure ulcer to the resident's right ear. - 03/27/14 the Stage II pressure ulcer to the resident's right ear was noted as resolved. A review of the Treatment Administration Record (TAR), at 3:15 p.m. on 04/29/14, revealed the resident had treatment orders related to pressure ulcers which included: - Treatment orders for both day and night shifts, written separately, were started on 03/07/14 for night shift, and 03/08/14 for day shift. The order was for,Calmaseptine ointment 0.44-20.625% (Menthol-Zinc Oxide), apply to coccyx topically for open area for ten (10) days. - There was a treatment initiated on 03/11/14 for A & D Zinc Oxide cream to be applied to the right ear, topically every day shift for wound healing for ten (10) days. - On 04/29/14 at 8:04 a.m., after identification of pressure ulcers during the survey, an order was written to, Apply to coccyx topically every night shift for Stage II Cleanse open area w/NSS (normal saline solution), pat dry, apply Hydrogel and cover w/dry (with/dry) dressing.",2016-03-01
8976,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,322,D,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of a Centers for Medicare and Medicaid Services (CMS) memorandum,staff interview, and policy review, the facility failed to provide services to minimize complications for two (2) of two (2) residents observed during medication pass who had gastrostomy tubes. The facility failed to check for placement of the gastrostomy tube prior to the administration of medications. A licensed nurse also administered all of a resident's medications and water flushes by manually pushing them into the tube with a syringe, rather than allowing them to flow by gravity. Resident identifiers: #30 and #52. Facility census: 42 Findings include: a) Resident #30 On 04/17/14 at 7:23 a.m., medication administration was observed for this resident who had a gastrostomy tube. Employee #26, a nurse, stopped the tube feeding that was in progress. She flushed the gastrostomy tube with an ounce of water. She administered four (4) medications, and administered an ounce of water after each of the four (4) medications. Upon inquiry, regarding checking for residual and placement, she said she did not see an order for [REDACTED]. b) Resident #52 On 04/17/14 at 8:15 a.m., medication administration was observed for this resident who had a gastrostomy tube. Employee #16, a nurse, placed twelve (12) medications in twelve (12) medication cups for administration. She disconnected the tube feeding that was in progress, then pushed an ounce of water to flush the tube by using the plunger in the barrel of the syringe. Still using the plunger in the barrel of the syringe, she pushed each of the twelve (12) medications into the gastrostomy tube, rather than letting them flow in by gravity. She used the plunger in the barrel of the syringe to push in an ounce of water after each of the twelve (12) individual medications was instilled. An inquiry was made regarding when the gastrostomy tube was last checked for placement and residual. She replied it most likely checked that morning at 6:00 a.m. when the resident received her morning medications on the night shift. The nurse said she forgot to check for placement and residual before giving the medications today. On 04/17/14 at 10:00 a.m., an interview was conducted with the director of nursing (DON). She was asked for the facility's policy related to gastrostomy tube medication administration. At 5:04 p.m. on 04/28/14, the DON provided a policy/procedure on administration of medications via tubes, which included gastrostomy tubes. The revision date of this policy was 06/13. Upon inquiry, the DON said the form was from their consultant pharmacy. According to a Centers for Medicare and Medicaid Services (CMS) memorandum, dated 11/02/12, the facility, in consultation with the pharmacist, must provide procedures for the accurate administration of all medications. The procedures must reflect current standards of practice including, but not limited to, techniques to monitor and verify that a feeding tube is in the right location before administering medications. The facility's procedure on administration of the medications via tubes was reviewed on 04/28/14 at 5:05 p.m. The policy stated to first shut off or suspend the tube feeding and cover the tip of the tube. Next, the tube must be checked for placement by a) instilling air and listening to the abdomen with a stethoscope, and b) aspirating gently for stomach content, then gently pushing the stomach contents back in. Step c directed to remove the plunger and place the barrel of the syringe in the stomach tube. Step f directed to allow each medication to flow into the tube by gravity, as well as the water flushes. The DON on 04/28/14 at 5:05 p.m., agreed the nurse should have allowed each medication and the water to flow into the tube by gravity in accordance with the policy developed in conjunction with the facility's pharmacy. The DON agreed both nurses should have checked placement of the gastrostomy tube prior to administration of the medications.",2016-03-01
8977,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,323,E,0,1,VDMM11,"Based on observation and staff interview, the facility failed to ensure the resident environment remained as free as possible from accident hazards over which it had control. The door of the resident shower/Jacuzzi room was open and contained potentially hazardous chemicals. This practice had the potential to affect all mobile residents. Facility census: 42. Findings include: a) During the initial tour of the facility, at 10:30 a.m. on 04/16/14, the shower/Jacuzzi room doorway was observed open. The room was observed to have a bottle of Turbo Clean, an environmental cleanser, on a table next to the wall. It was not stored out of the reach of residents. Again, at 11:45 a.m. on 04/16/14, the shower/Jacuzzi room door was observed open. The Turbo Clean remained on the table. At 11:45 a.m., the charge nurse, Employee #20 was shown the Turbo Clean on the table within the reach of any mobile resident. Observation of the cleanser revealed it was marked to keep out of reach of children. Employee #20 provided the Turbo Clean material safety data sheet (MSDS). The MSDS health hazards included acute mild irritation of sensitive skin and mucus membranes, eye irritation, chest discomfort, and coughing with inhalation.",2016-03-01
8978,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,371,E,0,1,VDMM11,"Based on observation and staff interview, the facility failed to serve food under conditions which prevented the transmission of infectious organisms. A dietary employee wore contaminated gloves while serving a meal and making sandwiches. This practice had the potential to affect all residents who received nutrition from the dietary kitchen. Facility census: 42. Findings include: a) On 04/28/14 at 11:15 a.m., a dietary employee (Employee #53) took meal tickets from a table, where residents were seated, to another table where residents were seated. Dietary Employee #1 retrieved the tickets and brought them to the kitchen. While wearing gloves, Employee #1 placed the tickets in the ticket holder above the food. Employee #1 was observed serving lunch. While wearing the contaminated gloves, the employee put food on each resident's plate, retrieved the ticket and passed the plate of food to another employee. The food was then served to the residents. On three (3) separate occasions, Employee #1, was observed preparing sandwiches for residents. She wore the same gloves she had worn to handle the meal tickets. The employee cut the bread, placed meat on the bread with tongs, then covered the meat with another slice of bread using her gloved hands. At no time during the preparation of the sandwiches and serving of the meal did this employee change gloves. On 04/28/14 at 12:15 p.m., during an interview with the registered dietitian (RD), the RD agreed the cook should have changed gloves each time after handling of the meal tickets. In a separate interview with the dietary manager (DM), the DM agreed Employee #1 should have changed gloves. The DM also stated the normal dining process did not involve meal tickets being placed on residents' tables.",2016-03-01
8979,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,431,E,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, review of recommendations from the Centers for Disease Control (CDC), manufacturer's guidelines, staff interview, and policy review, the facility failed to ensure that multi-dose vials of Aplisol tuberculin testing serum and insulin were stored in a safe and orderly manner. This had the potential to affect the potency of the insulin for two (2) residents and/or any resident who received a tuberculin test from the vial of Aplisol. The practice had the potential to affect more than an isolated number of residents. Resident identifiers: #23 and #64. Facility census: 42. Findings include: a) Resident #23 Inspection of the B medication cart, on 04/17/14 at 8:00 a.m., revealed an opened, partially used vial of Lantus insulin for Resident #23. There was no date on the vial to indicate when staff had opened it. Licensed nurse Employee #26 said all insulin vials were supposed to be dated when opened, and this vial was not. b) Resident #64 On 04/17/14 at 8:05 a.m., the A medication cart was inspected with licensed nurse Employee #16 in attendance. A vial of Levemir insulin had been opened and partially used for Resident #64. There was no date on the vial to indicate when it had been opened. Employee #16 said when insulin vials were first opened for use, the vials were supposed to be dated. c) During an interview with the Director of Nursing (DON), on 04/17/14 at 2:00 p.m., she provided a 2013 pharmacy policy/procedure related to general dose preparation and medication administration. Section 3:11 of the pharmacy policy/procedure stated Facility staff should enter the date opened on the label of medications with shortened expiration dates (e.g., insulin, irrigation solutions, etc.). The DON agreed all multi-dose vials should be dated when initially opened. As the vials contained no dates to indicate when they were first opened, there was an inability for staff to know when the vials were initially opened. This prohibited staff from knowing when to discard the vials. d) Medication storage room The medication storage room was inspected on 04/28/14 at 7:30 a.m. A ten (10) dose vial of Aplisol Purified Protein Derivative (PPD - test for [DIAGNOSES REDACTED]) was opened, partially used, and not dated to indicate when it was initially opened. Licensed nurse Employee #2 said she opened the vial and used it for the first time three (3) days ago. She said she forgot to date it when it was first opened. According to the CDC (Centers for Disease Control), once a multi-dose vial has been opened or accessed (e.g., needle-punctured) the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for that opened vial. Without dates to indicate when they were first opened, staff members could not know when these vials should be discarded.",2016-03-01
8980,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,441,E,0,1,VDMM11,"Based on observation, staff interview, and policy review, the facility failed to maintain a safe and sanitary environment to prevent the development and transmission of disease and infection. Three (3) dietary employees failed to utilize proper hand washing technique. A resident's lap tray had cuts and tears which prevented effective cleaning and disinfecting. A nurse who administered medications to residents failed to disinfect, or dispose of the cap of a liquid medication that fell to the floor in the hallway. These practices had the potential to affect more than a limited number of residents. Employee identifiers: #16, #53, #45, and #51. Resident identifier: #43. Facility census: 42. Findings include: a) Employee 16 On 04/17/14 at 8:12 a.m., an observation of Employee #16 (licensed nurse) during medication pass revealed the nurse dropped the cap from a bottle of liquid iron preparation as she tried to re-cap the bottle after pouring a dose for a resident. The cap fell to the corridor floor, and bounced on the floor numerous times. Employee #16 retrieved the cap, placed it onto the bottle of liquid iron, and returned the bottle to the stock medication drawer. She was asked if she thought she should dispose of the bottle, since the cap had been on the floor and had not been cleaned prior to placing it back on the bottle. The nurse said she did not know. She disposed of the bottle of liquid iron only after surveyor intervention. An interview was conducted with the director of nursing (DON) on 04/29/14 at 3:35 p.m. She said she would have expected a nurse to dispose of the bottle of liquid iron after a she had put a contaminated cap on it. b) Employee #53 On 04/28/14 at 11:15 a.m., a cook (Employee #53) was observed washing her hands at the sink in the kitchen. After washing her hands, she turned the sink faucet off with her clean hands, then dried her hands with clean paper towels. When asked if proper handwashing procedure was followed, she agreed it was not. Employee #53 stated she should have used a dry paper towel to turn off the faucet, not her clean hands. She promptly rewashed her hands and followed the correct procedure by turning off the faucet with a dry paper towel. c) Employee #45 On 04/28/14 at 11:27 a.m., a cook (Employee #1) was observed washing her hands at the sink in the kitchen. After washing her hands, she turned the sink faucet off with her clean hands, then dried her hands with clean paper towels. When asked if proper handwashing procedure was followed, she agreed it was not. Employee #1 stated she should have used a dry paper towel to turn off the faucet, not her clean hands. She promptly rewashed her hands and followed the correct procedure by turning off the faucet with a dry paper towel. d) Employee #51 On 04/28/14 at 11:32 a.m., the dietary manager (DM ), Employee #51, was observed washing his hands at the sink in the kitchen. The DM did not follow proper handwashing techniques. After washing his hands, he turned off the sink faucet with his clean hands, then dried his hands with clean paper towels. When asked if proper handwashing procedure was followed, the DM agreed it was not. He stated a dry paper towel should have been used to turn off the faucet, not his clean hands. He promptly rewashed his hands and followed the correct procedure by turning off the faucet with a dry paper towel. On 04/30/14 at 6:00 p.m., the DM provided a copy of the Handwashing Flow Chart. Section 6 (six) of the flow chart stated Use clean, disposable paper towels to turn off faucet valves. The DM stated the facility would do an in-service for all employees regarding the proper procedure for handwashing. e) Resident #43 During the initial tour of the facility, at 10:30 a.m. on 04/16/14, Resident #43 was sitting in a wheelchair with a cushioned lap tray. The cushion was torn on both corners and the foam under the washable exterior was exposed. The resident was again observed sitting in a wheelchair with the same lap tray on 04/17/14, 04/18/14, and 04/19/14. On 04/24/14 at 11:25 a.m., Employee #13 (housekeeping), stated the wheelchair with the torn lap tray cover belonged to Resident #43. At 11:30 a.m. on 04/24/14, a licensed practical nurse, Employee #2, observed the frayed and torn area on the lap tray. The nurse agreed the condition of the lap tray was such it could not be effectively cleaned to prevent the potential transmission of disease.",2016-03-01
8981,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,490,G,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and record review, the facility was not administered in a manner to use its resources effectively to maintain the highest practicable physical, mental, and psychosocial well being of each resident. The survey, from [DATE] to [DATE], identified the facility had quality deficits related to a failure to identify pressure ulcer development, a failure to provide care and services to prevent the development of avoidable pressure ulcers, a failure to provide care planning for residents who had or developed pressure ulcers, and a failure to provide preliminary/interim care planning for residents within twenty-four hours according to facility policy. The facility had previously identified these problems regarding pressure ulcers and care planning. These practices affected five (5) of twenty-three (23) Stage 2 sample residents, but had the potential to affect all residents, including any new admission who required interim care planning for readily identifiable needs, prior to the completion of the comprehensive assessment, to address an identified health condition. Resident identifiers: #35, #52, #22, #9, and #64. During the survey, from [DATE] to [DATE], and during the extended survey from [DATE] to [DATE], it was also identified the facility allowed employees to provide care for residents without first having had a criminal investigation background (CIB) check completed prior to their hire. This was evident for five (5) of twelve (12) employees reviewed. The practice had the potential to affect all residents. Employee identifiers: #7, #10, #25, #38, and #44. Facility census: 42. Findings include: a) Resident #35 Observation, record review, and staff interview, revealed the facility failed to provide care and services necessary to prevent the development of avoidable pressure ulcers for one (1) of eight (8) residents who had a history of [REDACTED]. In addition, the facility did not implement the pressure ulcer care plan for weekly body audits. The resident developed two (2) pressure ulcers, a Stage II pressure ulcer to the coccyx and a Stage I pressure ulcer to the right ear. On [DATE] at 2:20 p.m., an observation of a full body audit of Resident #35, by Employee #2, a licensed practical nurse (LPN), the facility's designated wound nurse, was conducted. The observation revealed a previously undetected Stage II pressure ulcer on the resident's coccyx. The LPN acknowledged the facility had not identified this area and should have prior to this full body audit. During the same observation, a previously undetected Stage I pressure ulcer was found on the resident's right ear under his oxygen tubing. The LPN confirmed both areas were not reported or identified until this observation. She said the resident had pressure ulcers in the past on the coccyx and the right ear; however, both pressure ulcers had resolved. At 3:00 p.m. on [DATE], during an interview with the director of nursing (DON), she had no comments regarding the pressure ulcers that were found on Resident #35's coccyx and ear. Review of the resident's current care plan at 8:45 a.m. on [DATE], identified the facility had care planned the resident for a potential for skin breakdown due to bowel and bladder incontinence, [MEDICAL CONDITION], use of aspirin daily, fragile skin, assistance with bed mobility, use of eyeglasses. The interventions for this particular focus area were: -Ear cushion to nasal cannula -Earpieces to eyeglasses to be padded -Observe visible skin every shift during care -Body audit weekly -Assess for increased [MEDICAL CONDITION] -Assist to turn and reposition during rounds and as needed -Check and change during rounds and as needed. Provide incontinence care as needed -Cushion to chair for comfort and reduction of pressure A review of the physician orders [REDACTED]. There was also an order [REDACTED]. A review of the nurse aide (NA) Kardex (the tool used by NAs to provide individual resident care) on [DATE] at 9:15 a.m., stated earpieces on eyeglasses to be padded. The Kardex also indicated to monitor the resident for skin breakdown during daily care, and to observe skin every shift during care. Resident #35 was observed in the activities room on [DATE] at 9:45 a.m. He was sitting in his wheelchair. He was wearing his glasses. There was no padding to the earpieces of his glasses at that time. During an interview with Employee #10, a NA, on [DATE] at 9:50 a.m., she said she did not know if Resident #35 currently had padding on the earpieces of his glasses. She said he should have padding on the earpieces. When brought to her attention there was no padding on the eyeglass earpieces, the NA stated, The nurse has those on her cart. When asked if the NAs used the Kardex information to provide care for residents, Employee #10 replied, Yes. She agreed since the NA Kardex stated the eyeglasses earpieces were to be padded, she should notify the nurse that padding was needed. When the NA was asked if she was aware the resident had a pressure ulcer to his coccyx she said, No, but I saw he had a bandage there. On [DATE] at 1:20 p.m., during an observation of incontinence care provided by Employee #10 (NA), the area on Resident #35's coccyx was observed red and non-blanching, with a vertical split in the skin. The tissue in the area of the split was pink in color. There was also another small round open area below and to the left of the open split area. Review of the nurse's weekly assessment records, at 1:30 p.m. on [DATE], revealed the following: - No record of a weekly assessment for [DATE]. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the sacrum, with a note that stated, Wound to sacrum area receiving [MEDICATION NAME]. -The weekly assessment dated [DATE]: skin intact no problems. -The weekly assessment dated [DATE] indicated an open area to the coccyx, with a note that stated, Open area, received treatment daily. -There were no weekly assessments for five (5) consecutive weeks, beginning [DATE] through [DATE]. -The weekly assessment dated [DATE], was marked, skin intact no problems. At 1:40 p.m. on [DATE], the director of nursing (DON) was asked to provide the missing nurses' weekly assessments for Resident #35. She stated, You're not going to get them, because they are not there. I looked and they were not done. Review of the minimum data set (MDS) assessment at 2:00 p.m. on [DATE], identified the resident had a past history of pressure ulcers to his coccyx and right ear. The resident's most recent annual MDS, with an assessment reference date (ARD) of [DATE], identified the resident had two (2) Stage II pressure ulcers. The date of the oldest Stage II pressure ulcer was [DATE]. MDS assessments with an ARD of [DATE] and [DATE] also identified the resident was at risk for the development of pressure ulcers. According to the most recent care area assessment (CAA) worksheet, with an ARD of [DATE], the Stage II pressure ulcers were located on the 2nd digit of the left great toe and behind the right ear. The CAA also stated, Potential for development of pressure ulcers related to requires extensive assistance for bed mobility, bowel and bladder incontinence. On [DATE] at 3:00 p.m. a review of the wound tracking logs revealed Resident #35 had a history of [REDACTED]. The logs revealed the following: -[DATE] and [DATE] identified a Stage II pressure ulcer to his coccyx, measuring 4.3 X 2.2 X 0 , with no onset date indicated. The resident was also noted to have a Stage II pressure ulcer to his right ear, measuring 0.5 X 0.3 X 0 , with no onset date identified. b) Record review, policy review, and staff interview revealed the facility failed to develop care plans, to ensure the residents' individual care needs were met, for four (4) of twenty-three (23) residents who were reviewed for care plans during Stage 2 of the survey. Residents #52, #9, and #22 had pressure ulcers for which there were no care plans. In addition, there was no care plan for Resident #64 regarding diabetes mellitus (DM). 1. Resident #52 On [DATE] at 10:53 a.m., a review of the medical record for Resident #52 found it contained no evidence of a care plan for pressure ulcers for this resident. A review of the nursing notes, at 10:55 a.m. on [DATE], revealed a note dated [DATE] at 14:56 (1:56 p.m.), which stated, DTI (deep tissue injury) to Left Heel, Right 5th digit, and right inner ankle have no significant change in status. Skin remains intact. Skin Prep to continue as ordered. Stage III to coccyx is Dark red in color w/(with) some yellow slough, and small necrotic area. it is 3.8 cm x 3.9 cm x 0.3 in size. Stage II's Left Buttock a) is 2.2 cm x 1.8 cm x 0.3 cm b) 2.3 cm x 2.3 cm x 0.3 cm in size. Both have beefy red wound bed with moderate amt (amount) of serosangeuinous drainage. [MEDICATION NAME] to continue for both Stage II's and Santyl to continue to Stage III. On [DATE] at 1:00 p.m., the minimum data set (MDS) nurse, Employee #30, provided a copy of the resident's current care plan. Review of the care plan revealed no focus, no goals, and no interventions related to the pressure ulcers. On [DATE] at 2:30 p.m., Employee #30 provided an additional copy of the care plan which contained a focus, goals and interventions for Stage III pressure ulcer to buttocks and coccyx r/t (related to) severely diminished mobility [MEDICAL CONDITIONS]. This employee stated she had developed the pressure ulcer care plan on [DATE]. The employee agreed there was no care plan for the pressure ulcers until [DATE]. 2. Resident #9 Medical record review, on [DATE] at 10:25 a.m., found this resident was admitted on [DATE] and died at the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The medical record revealed no evidence of an interim care plan for this resident. On [DATE] 11:00 a.m., an interview with the director of nursing (DON) revealed this resident did not have an interim care plan. The DON stated there should have been an interim care plan completed for Resident #9 within 24 hours of admission to the facility. The facility's policy Preliminary or Interim Care Plans, provided by the DON, included, in the Policy section, A preliminary or interim plan of care to meet the residents immediate needs shall be developed for each resident within twenty-four (24) hours of admission. ressure 3. Resident #22 Resident #22 was admitted with one (1) pressure ulcer and additional skin wounds. The physician ordered care for the ulcer and wounds. The wound nurse (Employee #2) completed care on the ulcer and wounds, but the care plan did not identify a problem or interventions for the ulcer and wounds. On [DATE] at 4:00 p.m., a registered nurse, Employee #30, stated she was responsible for completing care plans, but was under the impression she was not to complete the pressure ulcer/wound care portion of the care plan. On [DATE], at the direction of the director of nursing (DON), Employee #30 entered specific problems, goals and interventions concerning wound care. At 4:25 p.m. on [DATE], the DON stated It just wasn't done when referring to Resident #22's care plan for problems, goals and interventions for pressure ulcer and wound care. The DON stated Employee #30 was the facility's care plan coordinator and Employee #2 was the nurse responsible for wound care. The DON stated the required weekly skin assessments were completed by floor nurses, who informed the wound care nurse of issues with wounds/pressure ulcers. The information was then communicated to the care plan coordinator by the wound care nurse. The DON agreed the pressure ulcer and wounds should have been included on Resident #22's care plan beginning at admission and before [DATE]. 4. Resident #64 The medical record was reviewed on [DATE] at 12:00 p.m. Resident #64 was a resident with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Medications at the time of admission included an oral anti-diabetic agent that was taken daily, and injectable insulin that was taken twice daily. On [DATE] at 12:45 p.m., the MDS nurse provided a copy of the resident's current interim care plan. The interim care plan was reviewed at that time. No focus, goals, or interventions related to diabetes was found in the care plan. Employee #30 agreed there was no mention in the interim care plan of the resident's diabetes, or that he took both oral and injectable medications for diabetes. On [DATE] at 5:00 p.m., an interview was conducted with the DON. She said that interim care plans, according to policy, were to be completed within twenty-four (24) hours of admission to the facility. When asked if she thought Resident #64 should have had an interim care plan developed for his diabetes, she replied Absolutely. The DON agreed that signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] should also have been included in the interim care plan, and were not included. She said dietary needs, medications, and treatments, for example, were to be reviewed and implemented into an interim nursing care plan to meet the resident's care needs. The DON said the interim care plan was used until staff completed the full comprehensive assessment. c) Criminal Background Investigations (CIB) 1. Employee #7 Review of personnel records on [DATE] at 10:00 a.m. found Employee #7 was hired on [DATE]. Prior to her hire, the facility fingerprinted the employee on [DATE]. The facility sent those prints to Company #1 in order to obtain a statewide criminal background check in West Virginia (WV). A letter from the WV State Police, dated [DATE], was addressed to the employee at her home address. In this letter, the employee was notified that the West Virginia State Police (WVSP) records division or the Federal Bureau of Investigation (FBI) rejected the fingerprint submission. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the business office director (BOD) on [DATE] between 10:00 a.m. and 11:30 a.m. She said she had found that some rejection letters were mailed to the home of the employees rather than to the facility, as it was in this case. She said the facility was not notified by Company #1 of the fingerprint rejection. Rather, she learned of the rejection of the fingerprints by speaking with the employee. She said she believes she fingerprinted Employee #7 sometime in February, and resubmitted to Company #1. She could find no evidence to support the date of the resubmission. She produced a letter dated [DATE] from the WVSP which informed Employee #7 that the [DATE] fingerprint submission was rejected. This letter was addressed to the employee at the employee's address. The letter did not mention the second submission. An interview was conducted with Employee #7 on [DATE] at 11:40 a.m. She said the assistant business office director (ABOD) fingerprinted her in January. Employee #7 acknowledged that a rejection letter was mailed to her at her home. She said the BOD fingerprinted her the second time perhaps in March, but she was unsure of the exact time frame. Employee #7 said she did not receive a rejection letter at her home the second time. Rather, the BOD called her sometime in April and set up an appointment for her to have the fingerprints done at the office of Company #1. She said this was completed sometime in early May. Personnel record review found a letter addressed to the facility from the WVSP, with date of inquiry as [DATE], notified the facility that the CIB was successfully completed. Employee #7's CIB was completed three and a half (3 ,[DATE]) months after she was hired and began working at the facility. 2. Employee #10 Review of personnel records on [DATE] at 10:00 a.m. found Employee #10 was hired on [DATE]. A letter from the WVSP, dated [DATE], was addressed to the employee at her home address. In this letter, the employee was notified that WVSP records division or the FBI rejected the fingerprint submission from [DATE]. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the BOD on [DATE] between 10:00 a.m. and 11:30 a.m. She said she caught this CIB omission during an audit of all employees conducted between the end of [DATE] through the first week in [DATE]. She said this employee was one (1) of four (4) employees the facility found during the audit that needed attention with their CIBs. She produced a fax from Company #1 dated [DATE] which indicated that a [DATE] CIB submission was in process. This allegedly resulted in the [DATE] letter from the WVSP that a fingerprint submission from [DATE] was rejected. The letter did not mention the [DATE] submission. The BOD produced a WV Easy Path Network that confirmed the employee was fingerprinted through Company #1 on [DATE]. She said they are awaiting the results. Employee #10 has been employed at the facility for fifteen (15) months while having no CIB completed. 3. Employee #38 Review of personnel records on [DATE] at 10:30 a.m. found Employee #38 was hired on [DATE]. A letter from the WVSP was addressed to the facility, with date of inquiry as [DATE]. The letter notified the facility of the results of the employee's completed CIB. An interview was conducted with the BOD on [DATE] between 10:00 a.m. and 11:30 a.m. She said she caught this CIB omission during an audit of all employees conducted between the end of [DATE] and the first week in [DATE]. She said four (4) employees needed attention with the CIBs. The facility fingerprinted Employee #38 and got the results back, so he was no longer on the radar as was the other four (4) employees. 4. Employee #44 Review of personnel records on [DATE] at 11:00 a.m. found Employee #44 was hired on [DATE], and worked through [DATE]. A CIB was completed on [DATE]. She left the facility for less than four (4) months, and returned to work on [DATE]. An interview was conducted with the BOD on [DATE] between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of [DATE] and the first week in [DATE]. She said she did not know if this employee required a second CIB after having had a three (3) month interruption in employment. She needs a three (3) year CIB in July, so she scheduled an appointment for her on [DATE]. They are awaiting the results. She said this employee was one (1) of the four (4) employees flagged during the audit who needed attention with the CIBs. 5. Employee #25 Review of personnel records on [DATE] at 11:00 a.m. found Employee #25 was hired on [DATE]. There was no evidence of a CIB on file. An interview was conducted with the BOD on [DATE] between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of [DATE] and the first week in [DATE]. This employee was one (1) of four (4) identified during the audit who needed attention with the CIBs. She submitted fingerprints to Company #1 on [DATE]. She received a letter dated [DATE] informing the facility that the prints were rejected. Employee #25 has an appointment on [DATE] with Company #1 for another resubmission of her fingerprints. Employee #25 has been employed by the facility for fourteen (14) months while having no CIB completed. An interview was conducted with the BOD and the administrator on [DATE] at 12:00 p.m. They acknowledged that the corporate office had been notified in March of the results of the CIB audits, and ongoing progress since then. The administrator said that all fingerprinting since March has been done, and will continue to be done, digitally at the office of Company #1 rather than having them completed by the facility. She spoke her belief that communications will now improve with Company #1 sending e-mail confirmations. The BOD said that Company #1 has not always sent e-mail confirmations since switching to the method of digital fingerprinting at Company #1's office. The BOD has added CIB to a spreadsheet for tracking new employees, and employees who need the every three (3) year repeats. To ensure the facility has not employed an individual who has been found guilty in a court of law of abusing, neglecting, or mistreating residents, West Virginia requires submission of fingerprints from 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 (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 [DATE]. 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 (three) 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 [DATE], 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 [DATE].",2016-03-01
8982,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,492,G,0,1,VDMM11,"Based on personnel record review and staff interview, review of the West Virginia (WV) requirements for criminal background checks, review of the Bureau for Medical Services manual and memorandum, and staff interview, the facility failed to operate in compliance with applicable State laws, regulations, and/or codes. The facility did not make an attempt to uncover information about any past criminal prosecutions by use of fingerprinting, a required procedure to ensure a statewide criminal background check in WV, for five (5) of twelve (12) employees whose files were reviewed. This had the potential to affect all residents. Employee identifiers: #7, #10, #25, #38, #44. Facility census: 42. Findings include: a) Employee #7 Review of personnel records on 05/20/14 at 10:00 a.m. found Employee #7 was hired on 01/22/14. Prior to her hire, the facility fingerprinted the employee on 01/08/14. The facility sent those prints to Company #1 in order to obtain a statewide criminal background check in West Virginia (WV). A letter from the WV State Police, dated 01/28/14, was addressed to the employee at her home address. In this letter, the employee was notified that the West Virginia State Police (WVSP) records division or the Federal Bureau of Investigation (FBI) rejected the fingerprint submission. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the business office director (BOD) on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she had found that some rejection letters were mailed to the home of the employees rather than to the facility, as it was in this case. She said the facility was not notified by Company #1 of the fingerprint rejection. Rather, she learned of the rejection of the fingerprints by speaking with the employee. She said she believes she fingerprinted Employee #7 sometime in February, and resubmitted to Company #1. She could find no evidence to support the date of the resubmission. She produced a letter dated 04/24/14 from the WVSP which informed Employee #7 that the 01/28/14 fingerprint submission was rejected. This letter was addressed to the employee at the employee's address. The letter did not mention the second submission. An interview was conducted with Employee #7 on 05/20/14 at 11:40 a.m. She said the assistant business office director (ABOD) fingerprinted her in January. Employee #7 acknowledged that a rejection letter was mailed to her at her home. She said the BOD fingerprinted her the second time perhaps in March, but she was unsure of the exact time frame. Employee #7 said she did not receive a rejection letter at her home the second time. Rather, the BOD called her sometime in April and set up an appointment for her to have the fingerprints done at the office of Company #1. She said this was completed sometime in early May. Personnel record review found a letter addressed to the facility from the WVSP, with date of inquiry as 05/07/14, notified the facility that the CIB was successfully completed. Employee #7's CIB was completed three and a half (3 1/2) months after she was hired and began working at the facility. b) Employee #10 Review of personnel records on 05/20/14 at 10:00 a.m. found Employee #10 was hired on 02/19/13. A letter from the WVSP, dated 04/25/14, was addressed to the employee at her home address. In this letter, the employee was notified that WVSP records division or the FBI rejected the fingerprint submission from 02/28/13. The letter informed the employee In order to complete your background screening, you must be fingerprinted again. If the employee had any questions, she was instructed to contact her employing agency, or Company #1's customer service telephone number. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she caught this CIB omission during an audit of all employees conducted between the end of March 2014 through the first week in April 2014. She said this employee was one (1) of four (4) employees the facility found during the audit that needed attention with their CIBs. She produced a fax from Company #1 dated 04/28/14 which indicated that a 03/28/14 CIB submission was in process. This allegedly resulted in the 04/25/14 letter from the WVSP that a fingerprint submission from 02/28/13 was rejected. The letter did not mention the 03/28/14 submission. The BOD produced a WV Easy Path Network that confirmed the employee was fingerprinted through Company #1 on 05/08/14. She said they are awaiting the results. Employee #10 has been employed at the facility for fifteen (15) months while having no CIB completed. c) Employee #38 Review of personnel records on 05/20/14 at 10:30 a.m. found Employee #38 was hired on 04/06/12. A letter from the WVSP was addressed to the facility, with date of inquiry as 03/31/14. The letter notified the facility of the results of the employee's completed CIB. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she caught this CIB omission during an audit of all employees conducted between the end of March 2014 and the first week in April 2014. She said four (4) employees needed attention with the CIBs. The facility fingerprinted Employee #38 and got the results back, so he was no longer on the radar as was the other four (4) employees. d) Employee #44 Review of personnel records on 05/20/14 at 11:00 a.m. found Employee #44 was hired on 06/27/11, and worked through 10/24/12. A CIB was completed on 07/07/11. She left the facility for less than four (4) months, and returned to work on 03/19/13. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of March 2014 and the first week in April 2014. She said she did not know if this employee required a second CIB after having had a three (3) month interruption in employment. She needs a three (3) year CIB in July, so she scheduled an appointment for her on 05/13/14. They are awaiting the results. She said this employee was one (1) of the four (4) employees flagged during the audit who needed attention with the CIBs. e) Employee #25 Review of personnel records on 05/20/14 at 11:00 a.m. found Employee #25 was hired on 03/19/13. There was no evidence of a CIB on file. An interview was conducted with the BOD on 05/20/14 between 10:00 a.m. and 11:30 a.m. She said she reviewed this employee's personnel file during an audit conducted between the end of March 2014 and the first week in April 2014. This employee was one (1) of four (4) identified during the audit who needed attention with the CIBs. She submitted fingerprints to Company #1 on 03/31/14. She received a letter dated 04/24/14 informing the facility that the prints were rejected. Employee #25 has an appointment on 05/22/14 with Company #1 for another resubmission of her fingerprints. Employee #25 has been employed by the facility for fourteen (14) months while having no CIB completed. An interview was conducted with the BOD and the administrator on 05/20/14 at 12:00 p.m. They acknowledged that the corporate office had been notified in March of the CIB audit results, and ongoing progress since then. The administrator said that all fingerprinting since March has been done, and will continue to be done, digitally at the office of Company #1 rather than having them completed by the facility. She spoke her belief that communications will now improve with Company #1 sending e-mail confirmations. The BOD said that Company #1 has not always sent e-mail confirmations since switching to the method of digital fingerprinting at Company #1's office. The BOD has added CIB to a spreadsheet for tracking new employees, and employees who need the every three (3) year repeats. To ensure the facility has not employed an individual who has been found guilty in a court of law of abusing, neglecting, or mistreating residents, West Virginia requires submission of fingerprints from the agency contracted by the West Virginia State Police. f) 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 (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 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 3 (three) 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 01/01/13.",2016-03-01
8983,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,500,C,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the provision of professional services which the facility did not provide. There was no current agreement/contract for (3) of nine (9) outside agencies whom the facility believed they had agreements/contracts to provide services. This practice had the potential to affect all residents. Facility census: 41 Findings include: a) Professional contracts Professional contracts were reviewed on 05/21/14 at 3:00 p.m. This review revealed three (3) contracts were made with the previous owner of the facility. These contracts were not updated and/or renegotiated by the current owner when they assumed ownership. Review of the certificate of registration of the trade name revealed the facility was authorized to transact business under their assumed name as of July 30, 2013. 1) The outpatient [MEDICAL TREATMENT] services agreement, policy -C-FDS-002, was noted as effective 07/01/00. Page seven (7) of the agreement, dated 04/01/05, read as follows: The authorized representatives of the parties have signed this Agreement on April 1, 2005. The agreement was between the previous owner and the [MEDICAL TREATMENT] unit. 2) The agreement with the hospital was effective January 1, 1990. The agreement was made between the hospital and a former owner. No evidence was present to indicate there was an agreement between the hospital and the current owner. 3) The ambulance service contract was dated 04/30/01. Review of the agreement revealed it was made between a former owner and the ambulance service. No evidence was present to indicate there was a contract between the ambulance service and the current owner. An interview with the administrator, on 05/22/14 at 11:00 a.m., confirmed the contracts were not updated since acquisition of the facility by the current owner.",2016-03-01
8984,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,503,C,0,1,VDMM11,"Based on record review and staff interview, the facility failed to ensure a current agreement to obtain laboratory testing for its residents. After the facility had a change in ownership, the agreement with an off-site laboratory to provide laboratory services to residents was not updated and/or renegotiated with the new ownership. This had the potential to affect all residents in the facility. Facility census: 42. Findings include: a) The director of nursing (DON) and the administrator provided a copy of the facility's written agreement with an off-site laboratory on 05/21/14 at 2:00 p.m. They said this was the laboratory the facility utilized for all of their routine laboratory testing. Review of the written agreement found it originated on 10/01/02. It was signed by a former facility administrator on 11/07/02. It was signed by a laboratory representative on 11/18/02. On 05/22/14 at 11:00 a.m. the administrator provided a copy of a nursing home license dated 07/23/10. She said the nursing home was purchased and re-licensed on 07/23/10 by new owners. Review of this document found a license was granted to the new owners to operate a 51 (fifty-one) bed nursing home under the provisions of Chapter 16, Article 5C, Section 6, Code of West Virginia, 1931. This license was signed by the director of the Office of Health Facility Licensure and Certification. Upon inquiry, the administrator said there had been no known revisions to the laboratories service agreement since 2002.",2016-03-01
8985,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,509,C,0,1,VDMM11,"Based on record review and staff interview, the facility failed to ensure a current agreement to obtain diagnostic radiology services for its residents. After the facility had a change in ownership, the agreement with an off-site mobile diagnostic company to provide diagnostic radiology services to residents was not updated and/or renegotiated with the new ownership. This had the potential to affect all residents in the facility. Facility census: 42. Findings include: a) The director of nursing (DON) and the administrator provided a copy of the facility's written agreement with an off-site diagnostic provider on 05/21/14 at 2:00 p.m. They said this was the provider the facility utilized for all of their diagnostic radiology services. Review of this written agreement found it originated in June 2010. It was signed by the president of the diagnostics provider. A space for the signature of the nursing home representative, his/her printed name, and his/her title, was left blank and unsigned. On 05/22/14 at 11:00 a.m. the administrator provided a copy of the nursing home license dated 07/23/10. She said the nursing home was purchased and re-licensed on 07/23/10 by new owners. Review of this document found a license was granted to the new owners to operate a 51 (fifty-one) bed nursing home under the provisions of Chapter 16, Article 5C, Section 6, Code of West Virginia, 1931. This license was signed by the director of the Office of Health Facility Licensure and Certification. Upon inquiry, the administrator said there have been no known revisions to the diagnostic service agreement since June 2010.",2016-03-01
8986,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,514,B,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain accurate clinical records for one (1) of twenty-three (23) residents reviewed in Stage 2 of the survey. The medical record for a resident, who had a gastrostomy tube ([DEVICE]) and a physician's orders [REDACTED]. Resident identifier: #52. Facility census: 42. Findings include: a) Resident #52 On 04/30/14 8:05 a.m., a review of the medical record for Resident #52 revealed the form titled CNA (certified nursing assistant) - ADL (activities of daily living) tracking form. The director of nursing (DON) stated the form was only used for contract nursing assistant (NA) documentation. This form was dated 04/2014. It contained a section titled Eating Fluids Offered - Indicate Number Offered and ml's. The form showed Resident #52 received oral fluids on 04/03/14, 04/04/14, 04/06/14, 04/07/14, 04/09/14, 04/11/14, 04/13/14, 04/16/14, and 04/17/14. According to the medical record, Resident #52 was NPO and received nourishment via a [DEVICE]. This resident was evaluated by a speech therapist (ST) on 03/17/14. The ST gave the resident only small amounts of ice chips and pureed food. In an interview, with the DON on 04/29/14 at 2:30 p.m., the DON reviewed the documentation. She stated the documentation related to oral fluids was not accurate because the resident was NPO. The DON stated this documentation was habitual documentation. An interview was conducted at this time, with the NA (Employee #56) who documented she gave fluids to Resident #52. When the DON asked what type of diet and fluids Resident #52 received, the NA stated the resident was NPO and did not receive fluids or foods. Employee #56 offered no explanation as to why she documented she had given Resident #52 fluids when she had not.",2016-03-01
8987,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,517,E,0,1,VDMM11,"Based on record review and staff interview, the facility did not have a written emergency plan and associated procedures for missing residents. This practice had the potential to affect more than a limited number of residents. Facility census: 41. Findings include: a) The disaster manual, located at the nurses' station, was reviewed on 05/21/14 at 10:30 a.m. The table of contents contained no indication the facility had a plan and procedure for missing residents. Review of the manual revealed no evidence the facility had a plan and procedure for missing residents. Upon inquiry of the maintenance director, Employee #30, he reviewed the manual and confirmed it did not contain a plan and procedure for missing residents. Employee #30 reviewed his manual and confirmed it also did not contain anything relative to missing residents. Employee #12, a nursing assistant (NA), was interviewed on 05/21/14 at 2:40 p.m. Upon inquiry regarding a protocol for a missing resident, she said the term code yellow would alert staff of a missing resident. An interview with Employee #48, housekeeping, on 05/21/14 at 2:55 p.m., revealed an alert would be announced. She did not know the alert. Upon further inquiry, she was asked where she could find the information. She said it was likely at the nurses station, but she did not know the color of the binder. Observation on 05/21/14 at 10:30 a.m. revealed the binder was red. During an interview with Employee #49 (NA), at 3:08 p.m. on 05/21/14, the NA said there was a code for a missing resident. Employee #49 said it was like John you have a phone call. An interview with Employee #2, a licensed practical nurse (LPN), on 05/21/14 at 3:55 p.m., revealed she was unable to find a plan/procedure related to a missing resident. She reviewed a white binder for emergency preparedness, which was located at the nurses station. Upon inquiry of which book was utilized, Employee #27, a medical records clerk, responded the red one. Upon further inquiry, the director of nursing indicated the facility had four (4) residents who were known wanderers and required the use of wander guards. These residents attempted, or were likely to attempt, to exit the facility without staff assistance. During an interview with the administrator, on 05/22/14 at 8:45 a.m., she confirmed staff did not have immediate access and/or were unaware of access to a missing persons policy. She confirmed staff did not exhibit knowledge and competency in handling an emergency of a missing resident.",2016-03-01
8988,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-05-22,520,E,0,1,VDMM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, and staff interviews, the facility quality assurance and assessment (QA&A) committee failed to identify quality deficiencies, of which they were aware or should have been aware, and failed to develop and implement a plan of action to correct these quality deficiencies. The survey, from [DATE] to [DATE], identified the facility had quality deficits related to a failure to identify pressure ulcer development, a failure to provide care and services to prevent the development of avoidable pressure ulcers, a failure to provide care planning for residents who had or developed pressure ulcers, and a failure to provide preliminary/interim care planning for residents within twenty-four hours according to facility policy. This was found for five (5) of twenty-three (23) Stage 2 sample residents. The facility had previously identified these same problems regarding pressure ulcers and a failure to care plan for health conditions. The QA&A committee had not developed and implemented an action plan to address the identified problems. These practices affected five (5) residents, but had the potential to affect all residents, including any new admission who required interim care planning, prior to the completion of the comprehensive assessment, to address an identified health condition. Resident identifiers: Residents #35, #52, #22, #9, and #64 Facility census: 42. Findings include: a) Resident #35 Observation, record review, and staff interview, revealed the facility failed to provide care and services necessary to prevent the development of avoidable pressure ulcers for one (1) of eight (8) residents who had a history of [REDACTED]. In addition, the facility did not implement the pressure ulcer care plan for weekly body audits. The resident developed two (2) pressure ulcers, a Stage II pressure ulcer to the coccyx and a Stage I pressure ulcer to the right ear. On [DATE] at 2:20 p.m., an observation of a full body audit of Resident #35, by Employee #2, a licensed practical nurse (LPN), the facility's designated wound nurse, was conducted. The observation revealed a previously undetected Stage II pressure ulcer on the resident's coccyx. The LPN acknowledged the facility had not identified this area and should have prior to this full body audit. During the same observation, a previously undetected Stage I pressure ulcer was found on the resident's right ear under his oxygen tubing. The LPN confirmed both areas were not reported or identified until this observation. She said the resident had pressure ulcers in the past on the coccyx and the right ear; however, both pressure ulcers had resolved. At 3:00 p.m. on [DATE], during an interview with the director of nursing (DON), she had no comments regarding the pressure ulcers that were found on Resident #35's coccyx and ear. Review of the resident's current care plan at 8:45 a.m. on [DATE], identified the facility had care planned the resident for a potential for skin breakdown due to bowel and bladder incontinence, [MEDICAL CONDITION], use of aspirin daily, fragile skin, assistance with bed mobility, use of eyeglasses. The interventions for this particular focus area were: -Ear cushion to nasal cannula -Earpieces to eyeglasses to be padded -Observe visible skin every shift during care -Body audit weekly -Assess for increased [MEDICAL CONDITION] -Assist to turn and reposition during rounds and as needed -Check and change during rounds and as needed. Provide incontinence care as needed -Cushion to chair for comfort and reduction of pressure A review of the physician orders [REDACTED]. There was also an order [REDACTED]. A review of the nurse aide (NA) Kardex (the tool used by NAs to provide individual resident care) on [DATE] at 9:15 a.m., stated earpieces on eyeglasses to be padded. The Kardex also indicated to monitor the resident for skin breakdown during daily care, and to observe skin every shift during care. Resident #35 was observed in the activities room on [DATE] at 9:45 a.m. He was sitting in his wheelchair. He was wearing his glasses. There was no padding to the earpieces of his glasses at that time. During an interview with Employee #10, a NA, on [DATE] at 9:50 a.m., she said she did not know if Resident #35 currently had padding on the earpieces of his glasses. She said he should have padding on the earpieces. When brought to her attention there was no padding on the eyeglass earpieces, the NA stated, The nurse has those on her cart. When asked if the NAs used the Kardex information to provide care for residents, Employee #10 replied, yes. She agreed since the NA Kardex stated the eyeglasses earpieces were to be padded, she should notify the nurse that padding was needed. When the NA was asked if she was aware the resident had a pressure ulcer to his coccyx she said No but I saw he had a bandage there. On [DATE] at 1:20 p.m., during an observation of incontinence care provided by Employee #10 (NA), the area on Resident #35's coccyx was observed red and non-blanching, with a vertical split in the skin. The tissue in the area of the split was pink in color. There was also another small round open area below and to the left of the open split area. Review of the nurse's weekly assessment records, at 1:30 p.m. on [DATE], revealed the following: - No record of a weekly assessment for [DATE]. - The weekly assessment dated [DATE]: skin intact no problems. - The weekly assessment dated [DATE] indicated an open area to the sacrum, with a note that stated, Wound to sacrum area receiving [MEDICATION NAME]. -The weekly assessment dated [DATE]: skin intact no problems. -The weekly assessment dated [DATE] indicated an open area to the coccyx, with a note that stated, Open area, received treatment daily. -There were no weekly assessments for five (5) consecutive weeks, beginning [DATE] through [DATE]. -The weekly assessment dated [DATE], was marked, skin intact no problems. At 1:40 p.m. on [DATE], the director of nursing (DON) was asked to provide the missing nurse's weekly assessments for Resident #35. She stated, You're not going to get them, because they are not there. I looked and they were not done. Review of the minimum data set (MDS) assessment at 2:00 p.m. on [DATE], identified the resident had a past history of pressure ulcers to his coccyx and right ear. The resident's most recent annual MDS, with an assessment reference date (ARD) of [DATE], identified the resident had two (2) Stage II pressure ulcers. The date of the oldest Stage II pressure ulcer was [DATE]. MDS assessments with an ARD of [DATE] and [DATE] also identified the resident was at risk for the development of pressure ulcers. According to the most recent care area assessment (CAA) worksheet, with an ARD of [DATE], the Stage II pressure ulcers were located on the 2nd digit of the left great toe and behind the right ear. The CAA also stated, Potential for development of pressure ulcers related to requires extensive assistance for bed mobility, bowel and bladder incontinence. On [DATE] at 3:00 p.m. a review of the wound tracking logs revealed Resident #35 had a history of [REDACTED]. The logs revealed the following: -[DATE] and [DATE] identified a Stage II pressure ulcer to his coccyx, measuring 4.3 X 2.2 X 0 , with no onset date indicated. The resident was also noted to have a Stage II pressure ulcer to his right ear, measuring 0.5 X 0.3 X 0 , with no onset date identified. b) Record review, policy review, and staff interview revealed the facility failed to develop care plans, to ensure the residents' individual care needs were met, for three (3) of twenty-three (23) residents who were reviewed for care plans for pressure ulcers during Stage 2 of the survey. Residents #52, #9, and #22, had pressure ulcers for which there were no care plans. 1. Resident #52 On [DATE] at 10:53 a.m., a review of the medical record for Resident #52 found it contained no evidence of a care plan for pressure ulcers for this resident. A review of the nursing notes, at 10:55 a.m. on [DATE], revealed a note dated [DATE] at 14:56 (1:56 p.m.), which stated, DTI (deep tissue injury) to Left Heel, Right 5th digit, and right inner ankle have no significant change in status. Skin remains intact. Skin Prep to continue as ordered. Stage III to coccyx is Dark red in color w/(with) some yellow slough, and small necrotic area. it is 3.8 cm x 3.9 cm x 0.3 in size. Stage II's Left Buttock a) is 2.2 cm x 1.8 cm x 0.3 cm b) 2.3 cm x 2.3 cm x 0.3 cm in size. Both have beefy red wound bed with moderate amt (amount) of serosangeuinous drainage. [MEDICATION NAME] to continue for both Stage II's and Santyl to continue to Stage III. On [DATE] at 1:00 p.m., the minimum data set (MDS) nurse, Employee #30, provided a copy of the resident's current care plan. Review of the care plan revealed no focus, no goals, and no interventions related to the pressure ulcers. On [DATE] at 2:30 p.m., Employee #30 provided an additional copy of the care plan which contained a focus, goals and interventions for Stage III pressure ulcer to buttocks and coccyx r/t (related to) severely diminished mobility [MEDICAL CONDITIONS]. This employee stated she had developed the pressure ulcer care plan on [DATE]. The employee agreed there was no care plan for the pressure ulcers until [DATE]. 2. Resident #9 Medical record review, on [DATE] at 10:25 a.m., found this resident was admitted on [DATE] and died at the facility on [DATE]. The admitting [DIAGNOSES REDACTED]. The medical record revealed no evidence of an interim care plan for this resident. On [DATE] 11:00 a.m., an interview with the director of nursing (DON) revealed this resident did not have an interim care plan. The DON stated there should have been an interim care plan completed for Resident #9 within 24 hours of admission to the facility. The facility's policy Preliminary or Interim Care Plans, provided by the DON, included, in the Policy section, A preliminary or interim plan of care to meet the residents immediate needs shall be developed for each resident within twenty-four (24) hours of admission. 3. Resident #22 Resident #22 was admitted with one (1) pressure ulcer and additional skin wounds. The physician ordered care for the ulcer and wounds. The wound nurse (Employee #2) completed care on the ulcer and wounds, but the care plan did not identify a problem or interventions for the ulcer and wounds. On [DATE] at 4:00 p.m., a registered nurse, Employee #30, stated she was responsible for completing care plans, but was under the impression she was not to complete the pressure ulcer/wound care portion of the care plan. On [DATE], at the direction of the director of nursing (DON), Employee #30 entered specific problems, goals and interventions concerning wound care. At 4:25 p.m. on [DATE], the DON stated It just wasn't done when referring to Resident #22's care plan for problems, goals and interventions for pressure ulcer and wound care. The DON stated Employee #30 was the facility's care plan coordinator and Employee #2 was the nurse responsible for wound care. The DON stated the required weekly skin assessments were completed by floor nurses, who informed the wound care nurse of issues with wounds/pressure ulcers. The information was then communicated to the care plan coordinator by the wound care nurse. The DON agreed the pressure ulcer and wounds should have been included on Resident #22's care plan beginning at admission and before [DATE]. 4. Resident #64 The medical record was reviewed on [DATE] at 12:00 p.m. Resident #64 was a resident with [DIAGNOSES REDACTED]. He was admitted to the facility on [DATE]. Medications at the time of admission included an oral anti-diabetic agent that was taken daily, and injectable insulin that was taken twice daily. On [DATE] at 12:45 p.m., the MDS nurse provided a copy of the resident's current interim care plan. The interim care plan was reviewed at that time. No focus, goals, or interventions related to diabetes was found in the care plan. Employee #30 agreed there was no mention in the interim care plan of the resident's diabetes, or that he took both oral and injectable medications for diabetes. On [DATE] at 5:00 p.m., an interview was conducted with the DON. She said that interim care plans, according to policy, were to be completed within twenty-four (24) hours of admission to the facility. When asked if she thought Resident #64 should have had an interim care plan developed for his diabetes, she replied Absolutely. The DON agreed that signs and symptoms of [DIAGNOSES REDACTED] and [MEDICAL CONDITION] should also have been included in the interim care plan, and were not included. She said dietary needs, medications, and treatments, for example, were to be reviewed and implemented into an interim nursing care plan to meet the resident's care needs. The DON said the interim care plan was used until staff completed the full comprehensive assessment. c) In an interview, on [DATE] at 2:38 p.m., the nursing home administrator (NHA), who chaired the QA&A committee, stated the committee met monthly. According to the NHA, issues with residents' skin, including pressure ulcers, were brought to the committee. She stated, I thought we had resolved the issues with pressure ulcers but evidently not. Concerning the care planning issues with preliminary/interim care plans not completed and no care planning for residents with pressure ulcers, the NHA stated stated she thought the care plan issue had previously been taken care of.",2016-03-01
8989,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-06-19,309,G,1,0,33W511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based upon record review, staff interview, and family interview, the facility failed to ensure each resident received care and services to assist the resident in attaining or maintaining his or her highest practicable level of well-being. Resident #41 was identified as having a decline in condition, but the facility failed to ensure all staff were aware of changes in the resident's care needs. This was found for one (1) of three (3) sampled residents. Resident identifier: #41. Facility census:40 Findings include: a) Resident #41 On [DATE] at 10:00 a.m., a report of an unusual occurrence was reviewed. The report, submitted to the appropriate State agencies by the facility on [DATE], included, (typed as written): On [DATE] at 1:10 p.m., (Resident #41) had a fall in the hallway outside of his room. His roommate's wife came to notify the charge nurses that she was worried he might fall out of his wheelchair. The nurse went to (Resident #41's) room to check on him. Upon entering the room, (Resident #41) was leaning forward in his wheelchair. The charge nurse repositioned him and asked him to sit up straight. The nurse was behind (Resident #41) pushing him in his chair. Suddenly, (Resident #41) planted his feet on the floor. This caused him to fall forward from his chair. He landed head first on the ground. He received a laceration to his forehead. The nurses immediately called 911 and started first aid. (Local) EMS (emergency medical services) arrived. They stabilized the resident and transported him to (name of local hospital). The resident returned to the facility with a cervical collar and a [DIAGNOSES REDACTED]. (Note: there are 7 cervical vertebrae - C1 and C2 are highly specialized and provide mobility to the skull.) When the nurse notified (the wife of Resident #41) of the fall she (his wife) asked if he had planted his feet on the floor. She also stated that he had done the same thing to her the day before while she was visiting him. b) Review of Resident #41's medical record on [DATE] at 10:20 a.m., found this [AGE] year-old man was admitted to the facility on [DATE]. c) An interview was conducted with the widow of Resident #41 on [DATE] at 12:00 p.m. She was very upset because they were pushing him in his wheelchair at a high rate of speed through the hallway and he planted his feet on the floor. This caused him to be thrown forward and he landed on his head causing a laceration to the head, and 3 fractures in the neck. When asked why she felt staff may have been pushing him too fast up the hallway, she said they must have been because lately, he was unable to hold his feet more than two (2) inches off the floor, and if they were not going fast, he would not have been thrown from the chair when his feet touched the ground. She was asked if she knew of any witnesses to the accident. She said she did not know for sure, but following his death, both the housekeeping supervisor and the activities director had offered condolences and said they had been working that day. She said she had received a letter from the facility for a conference on [DATE] which said he had significant changes in condition that needed to be discussed. She commented she knew he was leaning in his chair and he could no longer hold his feet up for very long, but when she asked about the significant changes, staff told her there was nothing to worry about. d) Following the interview with the resident's widow, the activities director was interviewed on [DATE] at 2:10 p.m. She stated she had not witnessed Resident #41 fall. She said a nursing assistant, whose name she could not remember, told her that Resident #41 had put his feet on the floor when he was being transported by another person. She also commented he could be very stubborn at times because of his disease process. She also said he was using a pillow on his right side when in the wheelchair to assist with positioning because he leaned over in his chair. e) The housekeeping supervisor, also mentioned by the resident's widow, was interviewed on [DATE] at 2:30 p.m. She said she remembered the day of the accident. She was on another hall, but she heard Resident #41 strike the floor, and heard the nurse call out for help, but did not witness the accident. f) In an attempt to determine whether there were any witnesses to the accident, the facility's incident report of [DATE] was requested at 3:00 p.m. on [DATE]. The facility initially refused to provide the report, citing quality assurance privileges. Following intervention by the State office, the report was presented at 4:15 p.m. The report stated (typed as written): Resident was being pushed in his wheelchair by the charge nurse. He suddenly put his feet down on the floor and fell forward hitting the front of his head. He sustained two small lacerations to the forehead. He went to ER (emergency room ) and X-rays revealed that he had a fracture of C1 and C2. first aide was provided to the laceration on his forehead, ice was applied. Neuro checks were initiated. 911 was called and was on site within 15 minutes. A cervical collar was attempted by first responders and they were unable to apply. He was assisted to a gurney by emergency staff. The report identified the nurse who was pushing the wheelchair as Licensed Practical Nurse (LPN) #24. During an interview on [DATE] at 10:40 a.m., when asked if there had been any staff who had witnessed the accident, or if the roommate's wife had witnessed the accident, she said she did not think there had been any other witnesses, there was no other staff on the hall. She said the roommate's wife had called out that he was going to fall out of his wheelchair because he was leaning forward. She was the nurse that responded and found him leaning forward. She asked him to sit back in his chair and he did, so she took him out of the room so the roommate's wife could visit with her husband. She said there were no footrests on his wheelchair because at that time, He could still move his feet a little bit. She said he planted his feet on the floor, and fell face first from the wheelchair as she was pushing him down the hall. g) In an interview on [DATE] at 10:45 a.m., Nurse Aide (NA) #20, said she was one of the regular care givers for Resident #41. She said he planted his feet all the time. He had recently declined and was leaning forward in the chair and you would have to tell him to sit back. If you pushed him you would have to tell him to raise his feet. She said If you were going to push him an a wheelchair, you had better be careful. everybody knew it. She said he had a slipover pillow on his right arm of the wheelchair. She was asked if the recent change in his condition was on the KARDEX (the document that provides the nursing assistants with specific instructions to guide them in each individual residents' care needs). She said she was not sure if those declines had been noted on the KARDEX or not. h) An interview was conducted with Employee #58, the therapy program manager at 9:20 a.m. on [DATE]. She said Resident #41 was screened in late April or early May prior to a fall. His wife did not give therapy consent to treat him because of having been sent a large bill last year and this was very upsetting to her. She was in the process of getting him on case load when he went out to the hospital again on the 9th. She had telephoned the (local hospital) emergency room regarding recommendations for treating the resident after his fall and fractures. The emergency room would not give recommendations so she contacted Dr. (name), who had recommended the collar from his x-ray. He would not give any treatment recommendations until he saw the resident and they were in the process of making an appointment when Resident #41 was sent back to the hospital and expired. i) During another interview on [DATE] at 3:20 p.m., the widow of Resident #41 said therapy had wanted to treat him, but there was a huge problem with an outstanding bill for therapy, and she was afraid to tell them to do it. She said she did not want him to go without something that might help him, but she was terrified about this huge bill which she said was all their fault in the first place. j) On [DATE] at 11:00 a.m., Therapy Program Manager #58 provided copies of a rehabilitation referral, and some pertinent therapy progress notes. The rehabilitation referral had been made by the nursing department on [DATE] due to changes in Resident #41. (This was before the fall on [DATE].) Sections of the referral were as follows (typed as written): The section Comments stated Leaning forward and to right side of wheelchair. The section Reason/Date was dated [DATE] and listed: Mobility - walking or wheelchair/Power scooter was checked Yes for Current problem, change in status, or potential risk identified. Balance/postural stability was checked Yes for Current problem, change in status, or potential risk identified. Bed/chair positioning was checked Yes for Current problem, change in status, or potential risk identified. The therapist comments section included, Patient is being screened due to nursing referral for wheelchair positioning. Patient would benefit from PT or OT services at the time, upon approval of the POA. During an interview on [DATE] at 11:00 a.m., the therapy program director said the therapy department and nursing department meet daily to discuss such changes in condition in a morning meeting. She said nursing had identified this as a new safety concern, and they were aware that therapy would not be picking him up. i) The assessment and care planning coordinator, Registered Nurse #31, was interviewed on [DATE] at 8:30 a.m. She confirmed Resident #41 had been experiencing an overall physical decline, which ultimately resulted in the significant change comprehensive assessment (MDS) of [DATE]. She said there had been no revisions or new interventions to the care plan, and therefore to the KARDEX following the identification of the new concern regarding wheelchair safety. Review of both those documents found no mention of anything since [DATE] which were to do fall assessments per protocol and remind him to use his call light. j) During the interview of [DATE] at 10:40 a.m., Licensed Practical Nurse (LPN) #24, who was pushing Resident #41 in his wheelchair when the accident occurred, said she was not aware he frequently leaned over forward or to the right in his wheelchair. She told him to sit back, and he did, so she began wheeling him out of the room. She said he planted his feet and that propelled him out of the chair with his face hitting the floor. She was not aware of the therapy referral, the fact they did not pick him up for services, or that any new concern had been identified regarding his positioning problem in the chair. She said there was no communication with the nursing staff regarding his decline and no new interventions considered such as lap buddy, seat belt, wedge cushion, foot rests, or anything else. k) The facility documented Resident #41 had been experiencing an overall physical decline, which ultimately resulted in the significant change comprehensive assessment (MDS) of [DATE]. They had made the referral for therapy. They were aware therapy would not be picking him up for services. They had identified the risk, but did nothing about it as far as considering assistive devices or communicating new safety concerns to the entire nursing department through changes in the care plan or KARDEX. Although some of the direct caregivers knew from their experience caring for him he had changed and they had to be more careful, especially when pushing him in a wheelchair, the licensed practical nurse who happened to intervene that afternoon did not, and as a result, he sustained grave injuries.",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
8991,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2014-09-25,284,D,1,0,UPSW11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on family interview, medical record review, and staff interview, the facility failed to develop a discharge plan of care, with the participation of the resident and his or her family, which would assist the resident to adjust to his or her new living environment for three (3) of three (3) residents who were given thirty (30) day discharge notices. Resident identifiers: #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 a 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 impaired. -Review of the electronic census indicated the resident received West Virginia Medicaid 11/15/12, 02/14/13, was private pay on 07/01/13, and again received Medicaid 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 -Review of the care plan revealed no evidence of discharge planning 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 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, and said, 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, and was 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 did not develop a discharge plan of care, and had made no referrals for placement to other facilities. b) Resident #12 A confidential interview on 09/25/14, revealed Resident #12 had receive 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 her father-in-law three days ago, 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, told 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 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. 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 in 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 minimum data sets(MDS), with assessment reference dates of 02/09/14, and 05/09/14, which 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 telephone. 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. 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 that the family/responsible party was made part of the discharge process. She confirmed the facility had not developed discharge plans and had made no referrals to assist the resident/family with relocation. The facility provided no evidence: - a discharge assessment which identified the residents' needs was used to develop a discharge plan - of discharge planning in the records of discharged residents who had an anticipated discharge or those residents to be discharged shortly - the facility aided the resident and his/her family in locating and coordinating post-discharge services - of pre-discharge preparation and education the facility had provided the resident and his/her family - the resident triggered the care area assessment (CAA) for return to community referral.",2016-03-01
8992,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,272,D,0,1,1LWH11,"Based on record review and staff interview, the facility failed to accurately assess a resident's dental status for an annual comprehensive minimum data set (MDS) assessment. This was found for one (1) of three (3) residents whose MDSs were reviewed for the care area of dental services. Resident Identifier: #19. Facility census: 32. Findings include: a) Resident #19 A review of Resident #19's annual MDS, with an assessment reference date (ARD) of 12/23/14, on 08/25/15 at 1:08 p.m., found Item L0200. Dental, coded as None of the above were present, indicating the resident had no problems with his/her teeth, oral tissues, or pain related to dental problems. On 08/25/15 at 1:30 p.m., a review of Resident #19's annual nursing assessment for 12/23/14, found the resident assessed as having missing teeth and dental caries. On 08/25/15 at 4:15 p.m., when asked whether the MDS with an ARD of 12/23/14 was accurately coded related to Resident #19's dental status, the Minimum Data Set Coordinator (MDSC) stated, The MDS was coded inaccurately, due to it being written on the annual nursing assessment the resident had caries. The MDS should have been coded obvious or likely cavity.",2016-03-01
8993,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,329,E,0,1,1LWH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents whose drug regimens were reviewed for unnecessary medications, was free from unnecessary medications. The facility failed to ensure non-pharmacological interventions were considered and used when indicated before the use of an as needed (PRN) hypnotic for Resident #32. Resident identifier: #32. Facility census: 32. Findings include: a) Resident #32 Record review on 08/25/15 at 1:00 p.m., found the resident was [MEDICATION NAME] milligrams (mg) every twenty-four (24) hours, as needed (PRN) for difficulty falling asleep/staying asleep related to [MEDICAL CONDITION]. According to the pharmacist's consultation report, dated 04/14/15, the resident had been receiving [MEDICATION NAME], .since readmission October 2014. Review of the Medication Administration Record [REDACTED] 1. Review of the August MAR found: --[MEDICATION NAME] administered on 5 (five) occasions in August 2015: 08/02/15, 08/06/15, 08/10/15, 08/14/15 and 08/22/15. -- On 08/06/15, the medication was administered after non-pharmacological interventions were implemented. 2. In July 2015, [MEDICATION NAME] administered on nineteen (19) occasions: 07/02/15, 07/03/15, 07/04/15, 07/05/15, 07/07/15, 07/09/15, 07/10/15, 07/11/15, 07/12/15, 07/13/15, 07/14/15, 07/15/15, 07/17/15, 07/18/15, 07/19/15, 07/23/15, 07/25/15, 07/26/15, and 07/27/15. There was no evidence any non-pharmacological interventions were implemented before [MEDICATION NAME] any of the nineteen (19) occasions the medication was administered. 3. In June 2015, the medication was administered on ten (10) occasions: 06/06/15, 06/08/15, 06/09/15, 06/10/15, 06/17/15, 06/20/15, 06/23/15, 06/24/15, 06/26/15, and 06/27/15. There was no evidence any non-pharmacological interventions were implemented before giving the Ambien. b) At 3:04 p.m. on 08/25/15, these findings were discussed with the director of nursing (DON). The DON stated she had given [MEDICATION NAME] 08/06/15 and she had provided the non-pharmacological interventions. She stated she had just had a meeting with the nursing staff regarding documentation of non-pharmacological interventions. She confirmed there was no evidence non-pharmacological interventions were attempted before providing the medication on the identified dates. At 4:15 p.m. on 08/25/15, the MARs for August, July, and June 2015 were reviewed with the administrator. She was asked if the facility could provide evidence of any non-pharmacological interventions implemented before administering the Ambien. At 4:30 p.m. on 08/26/15, the findings were again discussed with the DON, administrator, and Minimum Data Set Coordinator #38. No further information was provided.",2016-03-01
8994,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-08-27,412,D,0,1,1LWH11,"Based on record review, observation, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of dental services received assistance to obtain routine dental services. Resident #28 had carious and missing teeth which had not be assessed. Resident identifier: #28. Facility census: 32. Findings include: a) Resident #28 Observation of the resident's oral cavity at 8:59 a.m. on 08/25/15, found the resident had missing and carious teeth. Record review on 08/25/15 at 12:30 p.m., found the last comprehensive minimum data set (MDS) assessment, an annual, with an assessment reference date (ARD) of 03/15/15, coded the resident as having no dental issues in Section L, entitled Oral/Dental Status. At 1:05 p.m. on 08/25/15 the resident's oral cavity was observed with Registered Nurse (RN), MDS Coordinator #38. The examination revealed the resident had several of her own teeth and had numerous missing teeth on both the upper and lower gums. Her teeth were covered with food particles and what appeared to be a build up of plaque. At least two (2) jaw teeth on the upper gum, one on the left side and one on the right side, were black, broken, and worn to the gum area. During the examination, when RN #38 touched her teeth and gums, the resident yelled out, Oh, Oh. When asked if her gums were hurting, she said, Yes, then she said, No, then said, Well, I thought it hurt. RN #38 stated she had completed an oral exam in March 2015, before coding the annual MDS. She said the resident's teeth were not in this condition at the time of her examination. She stated the resident had just finished lunch and her teeth had not been brushed after the noon meal. RN #38 said she had no documentation of her exam, but she did make her own observation of the resident's oral status. Further review of the resident's record found Registered Dietitian (RD) #60 had completed an annual nutrition risk review on 03/15/15. Under the section, entitled Oral/Dental Status, the dietitian had checked dentures upper/lower and missing/broken teeth. At 1:27 p.m. on 08/25/2015, RD #60 was interviewed regarding the completion of her 03/15/15 assessment. RD #60 was asked where she obtained her information for the assessment. She stated she personally observed the resident eating before completion of the assessment. When asked about the coding of dentures, she stated dentures could also mean a partial. She stated she would have obtained this information from previous assessments, most likely from nursing assessments. A nutritional risk review, dated 12/07/12, indicating the resident had an upper partial at the time of admission, was reviewed with RD #60. RD #60 said she did not know if the resident had an upper partial or if it was in use at the time of her observation. At 8:13 a.m. on 08/26/15, Nurse Aide (NA) #10 was observed feeding the resident breakfast. NA #10 stated she had worked at the facility for approximately two (2) years and she had never known the resident to have an upper partial. She said she was aware the resident had some teeth that, looked bad. She said she thought the resident had some mouth pain in the past, possibly from her teeth, but she could not remember exactly when. She said the resident did not express any pain at this time. At 8:30 a.m. on 08/26/15, Medical Records Clerk #21, was asked if the resident had any dental consults while at the facility. At 8:45 a.m., Medical Record Clerk #21 stated she could find no evidence of any dental consults in the medical record. At 4:30 p.m. on 08/26/15, this information was discussed with the administrator, the director of nursing, and RN #38. RN #38 stated she was unable to find any evidence in the medical record, other than the 12/07/12 dietary assessment, indicating the resident had an upper partial. She believed this assessment was incorrect. No further information was provided. At 9:00 a.m. on 08/27/15, RN #38 stated the facility was scheduling a dental consult for Resident #28.",2016-03-01
8995,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-12-11,253,E,1,0,OIJR11,"Based on observation, staff interview, policy/procedure review and monthly preventative maintenance inspection record, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary and comfortable interior. The attic exhaust fans and air return vents located in the North and East hallway ceilings had a large visible accumulation of dust and grime. This practice has the potential to affect more than an isolated number of residents. Facility census: 31. Findings include: a) Observation during initial tour, on 12/07/15 at 12:15 p.m., found the attic exhaust fan and the return air fan located in the North hallway ceiling, coated with a heavy accumulation of dust and grime on the louvers of the vent covers and fans. At 8:45 a.m. on 12/08/15, observed the attic exhaust fan and the return air fan located in the East hallway ceiling, to have a heavy accumulation of dust and grime on the louvers of the vent covers and fans. Resident rooms are located on either side of the North and East hallways and a high traffic area used by residents, visitors and staff. During a tour the return air vent was viewed with the Clinical Services Environmental Consultant #56, on 12/08/15 at 8:50 a.m. After viewing the East hallway return air vent, she stated, that has certainly not been cleaned in the last month. After touring the North hallway, she commented, the vents will be cleaned immediately on both hallways. The return air vent and attic exhaust fan on the North hallway were cleaned and vacuumed by a maintenance employee on 12/08/15 at 9:00 a.m. a large accumulation of dust and dirt were observed to be on the carpeted floor in the hallway while the employee was using the vacuum cleaner on the vents. At 10:00 a.m. on 12/08/15, copies of the Environmental Services Policy and Procedure for Monthly Preventative Maintenance Inspections; and Monthly Preventative Maintenance Inspection Record were provided by the Clinical Services Environmental Consultant #56. She commented the Monthly Preventative Maintenance Inspection Record started in November 2015 when our new company bought the facility. She stated, I am not going to lie, as you can see from the inspection record, the air handlers and vents were not cleaned in November as they should have been. The Clinical Services Environmental Consultant #56 further stated, this will not happen again in the future. A review of the Environmental Services Policy and Procedure for Monthly Preventative Maintenance Inspections revealed monthly preventative maintenance for: HVAC-Main system .Replace air filters in attic air handlers. Ventilation Systems .Check and clean exhaust fan cover and vacuum fan housing or shaft . .",2016-03-01
8996,BRIDGEPORT HEALTH CARE CENTER,5.1e+153,1081 MAPLEWOOD DRIVE,BRIDGEPORT,WV,26330,2015-12-11,258,D,1,0,OIJR11,"Based on observation, family interview and resident interview, the facility failed to provide for the maintenance of comfortable sound levels for residents. The attic exhaust fan in the ceiling on the North hallway was not maintained in a manner to prevent a loud offensive noise level. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #2, #3, and #12. Facility census: 31 Findings include: a) During the initial tour on 12/07/15 at 12:10 p.m., the North hallway was discovered to have a very loud fan noise from the attic exhaust fan located in the ceiling. The louvers on the ceiling vent cover were wide open revealing the entire shaft and belt area. Resident #2 stated in an interview on 12/07/15 at 12:15 p.m., The hallway is really noisy, so I have to turn my television up really loud to hear over that noise. Everyone can hear that fan but nobody does anything about it. During an interview with Resident #3 on 12/07/15 at 12:30 p.m., he stated, that noise is so loud in the hallway that I have to keep my door shut all the time. Resident #3's daughter stated, on 12/07/15 at 12:35 p.m., the fan in the hallway is a little loud. I have not mentioned it to anyone, but everyone can hear it if you come down the hall. The attic exhaust fan noise was audible in the North hallway during the tour on 12/08/15 at 8:50 a.m., accompanied by the Clinical Services Environmental Consultant #56, the Housekeeping/Maintenance Supervisor #7 and the Administrator. They did agree the fan was noisy. During the interview, this surveyor explained that two (2) residents had found the noise level in the hallway to be uncomfortable. The Administrator and the Housekeeping/Maintenance Supervisor #7 commented that none of the residents had complained about the noise. Resident #12 was wheeling herself up the hallway during the interview and stated, it is noisy and I have to keep my door closed. I have said it is too noisy. An observation of the hallway exhaust fan was made on 12/08/15 at 9:30 a.m., after the fan was cleaned by maintenance. The louvers on the ceiling vent cover were only open half (1/2) way and the noise level was decreased in the hallway. .",2016-03-01
10051,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,371,F,0,1,EVU911,"Based on observation and staff interview, the facility store and prepare milk and food under sanitary conditions. The temperature of milk was measured at 45 degrees Fahrenheit (F), and a dietary employee closed the lid to the trash can and then went back to food preparation without washing her hands. This had the potential to affect all residents. Facility census: 89. Findings include: a) Observation, with the certified dietary manager on 10/13/09 at 4:55 p.m., found the temperature of the milk carton, stored on ice in a bin in the food preparation area, to be 45 degrees F. This was just prior to the evening meal service. The temperature of another carton of milk taken from the milk cooler was found it to be 40 to 42 degrees F. The temperature on the milk cooler registered at 40 degrees F. The dietary manager indicated the temperature of the milk cooler should have been about 38 degrees F and that a repair person would be called. b) During preparation of the evening meal on 10/13/09 at 4:45 p.m., a dietary staff person (Employee #45) washed and dried her hands with a paper towel. After using a second paper towel to turn off the faucet, the employee threw the paper towel into the trash can. The lid on the trash can did not close, and the employee used her hand to close the trash can lid. She then went back to the food prep area and began touching food items. .",2015-07-01
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
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
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
10055,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,309,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, staff interview, and observations, the facility failed to ensure each resident received the necessary care and services to attain or maintain his or her highest practicable level of well being in accordance with the plan of care. One (1) resident, who was observed at random, had support stockings on both legs while up in her wheelchair. The hose had wrinkled on the legs above the ankles. Another resident, who was on the sample of fourteen (14) current residents, had a physician's orders [REDACTED]. Resident identifiers: #82 and #42. Facility census: 89. Findings include: a) Resident #82 On 10/15/09 from 3:30 p.m. to 4:00 p.m., Resident #82 was observed sitting in the hall way in her wheelchair. She wore flesh colored support stockings that had wrinkled around her lower legs, causing significant indentations in her legs. At 4:00 p.m., Employee #41 was shown the condition of the stockings. She pulled the resident's stockings up, so they were wrinkle free. Indentations were apparent where the stockings had been wrinkled. These indentations persisted for at least one-half hour, when observations were ended for the day. Review of the resident's medical record found an order for [REDACTED]."" The order had been received on 07/22/08. Her [DIAGNOSES REDACTED]."" On 10/16/09 at 8:55 a.m., the resident was observed seated in her wheelchair in her room with her feet resting on the floor. The stockings were again wrinkled around the resident's lower legs. The resident was observed intermittently from 8:55 a.m. until 10:35 a.m., and the stockings remained wrinkled. At 10:35 a.m., Employee #41 was again informed of the wrinkled stockings. She said someone had [MEDICATION NAME] them earlier that morning, but the stockings would not stay [MEDICATION NAME]. b) Resident #42 Review of medical records found an order for [REDACTED]. Review of the resident's medical record found some vital signs had been recorded on the medication administration record (MAR), but many were missing. On 10/16/09 at 8:40 a.m., Employee #8 was asked where the vital signs should be documented. She said they should be on the MAR or the Skilled Nurse's Note pages. Review of the skilled nurses' notes found only one (1) set of vital signs recorded on a daily basis. These were recorded at the top of the page and were thought to be the vital signs for day shift. However, they did not always correlate with the vital signs recorded on the MAR. Review of the MAR for 10/01/09 through 10/15/09, found the vital signs had been recorded only fourteen (14) of the forty-five (45) times they should have been documented. The 6:00 a.m. vital signs were documented three (3) of fifteen (15) times; the 2:00 p.m. vital signs were documented four (4) times, plus one (1) blood pressure and respiration, of of fifteen (15) times; and 10:00 p.m. vital signs six (6) of of fifteen (15) times. .",2015-07-01
10056,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,441,D,0,1,EVU911,"Based on observations and review of posted hand washing signs, the facility's infection control program failed to ensure staff practiced appropriate hand washing to prevent the spread of infection. Additionally, staff had not labeled a bottle of saline when opened to ensure it was not used more than forty-eight (48) hours after it was opened. Three (3) residents observed at random were affected. Facility census: 89. Findings include: a) Residents #89 and #14 1. Resident #89 On 10/14/09 at approximately 8:30 a.m., a nurse (Employee #8) washed her hands after administering the resident's medications. She washed her hands for approximately three (3) seconds and turned the water off with her bare hands, recontaminating them on the faucet handles. 2. Resident #14 On 10/14/09 at approximately 8:40 a.m., Employee #8 was observed administering medications to Resident #14. The nurse only washed her hands for approximately three (3) seconds, then turned the water off with her bare hands, thus recontaminating her hands. 3. Signage posted in the staff and public restrooms indicated the hands should be washed for at least ten (10) seconds and directed staff to use a dry paper towel to turn off the water. -- b) Resident #6 After lunch on 10/14/09, a nurse (Employee #88) was observed providing a treatment to the resident. Observation found a bottle saline for irrigation sitting on a cabinet in the resident's room. The bottle was open, but it had not been dated to indicate when it should be discarded. .",2015-07-01
10057,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2009-10-16,514,D,0,1,EVU911,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records, the facility failed to ensure medical records were accurate and complete. One (1) resident had expired, but there were no nursing entries regarding the resident's final hours or that there had been a cessation of vital signs. There was no documentation regarding the reason one (1) resident did not take her [MEDICATION NAME], nor was the effectiveness of her pain medication noted. Two (2) of seventeen (17) residents on the sample were affected. Resident identifiers: #91 and #42. Facility census: 89. Findings include: a) Resident #91 1. This resident was selected for closed record review as she had expired in the facility. Review of her medical record found a form entitled ""Nursing Transfer / Discharge Note"". The form noted the resident had died at 8:35 a.m. on [DATE]. There was information regarding the release of the body to the mortuary, but other sections were blank or marked as ""N/A"" (not applicable). Review of the nursing entries found an entry for [DATE] at 6:00 a.m., noting the resident had required suctioning three (3) times. The next entry was [DATE] at 1:00 p.m., which noted the physician had been in to see the resident and there were no new orders. From [DATE] at 1:00 p.m. through the time of death on [DATE] at 8:35 a.m., there were no further notes. The findings at the time of death (i.e., there was no heart beat, respirations were absent, etc.) were not identified. It was not noted whether the resident's family had been notified or whether the physician had been made aware of the resident's death. 2. During review of the resident's close medical record, a copy of a CMS-802 with the names of seven (7) other residents was found in Resident #91's file. This document included confidential information such as continence status, whether the individual was cognitively impaired, whether the resident had a [DIAGNOSES REDACTED]. Another document, including the names of thirty-one (31) other residents along with confidential information was also found in Resident #91's closed record. b) Resident #42 1. Review of the resident's medical record noted almost every dose of [MEDICATION NAME] had been circled on the Medication Administration Record [REDACTED]. The reason the [MEDICATION NAME] had been circled was not noted on the designated space on the back of the MAR, nor was it noted in the nurses' notes. According to Employee #11, the resident said she did not need the stool softener. 2. The September ""PRN (as needed) Pain Medication Flow Sheet"" indicated the resident had been given Tylenol 650 mg five (5) times for generalized pain. The form prompted the nurse to note the effectiveness of the pain medication at intervals of 30 minutes, 1 hour, and 2 hours. Only one (1) of the five (5) had any further entries, and this may have been the nurse's initials. One (1) notation indicated the pain had been an ""8"" on the pain scale when the medication was given. The nurse had written ""9"" in the blank for the effectiveness at 30 minutes and the remainder was blank. The ""9"" would have indicated the pain was worse after 30 minutes and further monitoring / action would have been indicated. .",2015-07-01
10795,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2011-08-16,244,E,1,0,79LL11,". Based on review of the facility's resident council meeting minutes and staff interview, the facility failed to assure the actions taken on recommendations and/or concerns by the resident council were communicated to the group. There was no evidence facility responses and/or decisions were communicated to the resident council members once their concerns were addressed by facility staff. This practice had the potential to affect all resident council members, which was more than an isolated number of residents. Facility census: 82. Findings include: a) Review of the facility's resident council meeting minutes for 03/23/11, 04/20/11, 05/25/11, and 06/21/11 revealed no evidence residents were informed of the facility's decisions regarding their previous complaints, recommendations, and or concerns. Interview with the activity director (AD - Employee #48), at 2:30 p.m. on 08/16/11, revealed the facility had not routinely provided this information to the group. The AD described the group was asked if everything was ""OK"" with each department, and the AD thought this was all that was needed. The specific actions and/or responses from staff, regarding the residents' previous concerns, were not discussed with the group. In addition, these actions were not included in the resident council meeting minutes under the ""old business"" section, or in any part of the minutes. .",2014-12-01
10796,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2011-08-16,371,F,1,0,79LL11,". Based on food temperature measurement and staff interview, the facility failed to assure cold foods were held for service at temperatures which reduced the rapid and progressive growth of pathogens that may cause food borne illness. Pureed and ground dairy and meat products and sandwiches were held for service in the danger zone temperatures. Cold foods must be held for service at 41 degrees Fahrenheit (F) or below to assure food safety. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 82. Findings include: a) At 11:35 a.m. on 08/16/11, temperatures of cold foods being held for service were measured by the dietary manager (DM), with the following results: - Pureed cheese was 58 degrees F - Pureed bologna was 50 degrees F - Ground bologna was 48 degrees F - Bologna and cheese sandwiches were 54 degrees F. At that time, the DM confirmed these food items were being held at temperatures which were too high to assure food safety.",2014-12-01
10797,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2011-08-16,364,E,1,0,79LL11,". Based on observation and staff interview, the facility failed to assure foods were prepared by methods that conserved nutritive value, flavor, and appearance. The regular consistency broccoli-cauliflower combination was overcooked on 08/16/11 at the noon meal. Overcooking of vegetables results in a loss of nutritive value, flavor, and appearance. This practice had the potential to affect all residents who received regular consistency foods at meals from the facility's dietary department; this included more than a limited number of residents. Facility census: 82 Findings include: a) At 11:35 a.m. on 08/16/11, observations were made of foods being held on the steam table for the noon meal. The broccoli in the broccoli-cauliflower combination was very pale, indicative of overcooking. Additionally, the entire product was beginning to become mushy, which was also indicative of overcooking. At the time of the observation, this was brought to the attention of the dietary manager (DM). The DM confirmed the vegetables were overcooked and stated she had already brought it to the attention of the cook. .",2014-12-01
11533,"BRIER, THE",515144,601 ROCKY HILL ROAD,RONCEVERTE,WV,24970,2010-09-28,441,D,,,QQ4P11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to maintain an infection control program designed to prevent the spread of infection within the resident environment to the greatest extent possible. One (1) of four (4) sampled residents with an open portal of entry (an indwelling urinary catheter) was cohorted in a room with a resident with a wound that cultured positive for an infectious organism. Resident identifier: #27. Facility census: 89. Findings include: a) Resident #27 Medical record review for Resident #27, conducted on 09/27/10 and 09/28/10, revealed Resident #27, who was being treated by a urologist, had an indwelling Foley urinary catheter inserted from 07/26/10 through 07/30/10. On 07/26/10, the physician ordered: ""1. [MEDICATION NAME] plus 1 tablet po (by mouth) bid (twice a day) x 5 days dx (diagnosis) pain. 2. If pain continues may resume Tylenol #3 1 tablet po four times a day PRN (as needed). 3. Stop Keflex. 4. [MEDICATION NAME] mg 1 tablet po bid x 2 weeks. F/C (indwelling Foley urinary catheter) care q (every) shift until Friday 07/30/10."" Review of the resident's nursing notes revealed the following entries: - On 07/26/10 - ""F/C patent to leg ..."" - On 07/27/10 - ""F/C patent to leg drainage bag. Orange urine noted ..."" - On 07/28/10 - ""F/C patent to drainage on leg bag. Some leakage noticed but good flow ..."" - On 07/30/10 - ""Cath was removed yesterday R/T (related to) burning and leaking ..."" During this time, Resident #27 shared a room with Resident #90, who was in contact isolation from 07/21/10 through 08/26/10. - b) Resident #90 Medical record review for Resident #90 revealed lab results, dated 07/14/10, showing positive growth of Methicillin-resistant Staphylococcus aureus (MRSA) in wounds on his right foot. On 07/21/10, Resident #90 was placed in contact isolation due to this MRSA infection, for which he was treated with several courses of antibiotics. A follow-up wound culture, dated 08/03/10, found no growth of MRSA at that time, although the culture was positive for Morganella morganii. On 08/26/10, the physician ordered, ""Discontinue Isolation."" - c) In an interview at approximately 3:00 p.m. on 09/28/10, Employee #2 (the registered nurse who has responsibility for the infection control program at the facility) identified that Resident #27 should not have resided in the room with Resident #90 after the indwelling urinary catheter was inserted into Resident #27 (as this created an open portal for entry by infectious organisms). Employee #2 presented a copy of a reference she used in her facility for MRSA. The reference material came from the following Internet site: . The reference material stated the following: ""Contact precautions must be used when a resident is colonized or infected with MRSA in any site other than the nares .... Nasal colonization of a resident with MRSA does not warrant precautions other than standard precautions unless that resident is considered to be epidemiologically linked, either as a source or as a spread case, to an outbreak of MRSA in the facility. ""Contact precautions consist of the following components: ""Contact precautions must be used when a resident is colonized or infected with MRSA IN ANY SITE OTHER THAN THE NARES ... Contact precautions consist of the following components. ""1. Room placement and Activities ""- A resident who is colonized or infected with MRSA at any body site other than the nares should be placed according to the following scheme: ""-- Most Desirable: A private room or cohorting with another resident who is colonized / infected with MRSA. ""-- Less Desirable: A room with another resident who has intact skin and no 'tubes' (invasive feeding tubes, tracheotomy tubes, any type of intravascular line, any type of indwelling urinary drainage tube, or any other tube or device that breaks the skin or enters into a normal body orifice).""",2014-01-01
2018,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2020-01-09,641,D,0,1,7NBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to complete accurate assessments in the areas of dental and pressure ulcer prevention devices. This was found for two (2) of 33 residents reviewed. Resident identifiers: #30 and #74. Facility census: 111. Findings include: a) Resident (R) #30 An observation on 01/07/20 at 9:00 AM, found R #30's teeth in disrepair. Teeth were missing, broken and decayed. Review of the medical record on 01/07/20, revealed a progress note written by Nurse Practitioner #201 on 11/20/18. The oral exam notes numerous decayed and missing teeth. The significant change Minimum Data Set (MDS) assessment with and assessment reference date (ARD) of 08/07/19 is coded incorrectly as No for section L0200D indicating R #30 does not have any obvious or likely cavity or broken natural teeth. During an interview at 3:00 PM on 01/07/20, the Center Nurse Executive (CNE) presented a dental summary dated 09/25/19 stating all of R #30's residing teeth are decayed and in poor repair. The CNE acknowledged the MDS assessment was incorrect and does not accurately reflect R #30's decaying teeth. b) Resident #74 A record review, on 01/08/20 at 3:22 PM, revealed a physician order [REDACTED]. Additional record review, on 01/08/20 at 3:22 PM, revealed a Medicare five (5) day Minimum Data Set ((MDS) dated [DATE] stated, No for pressure reducing device for chair. An interview with Coordinator of Clinical Reimbursement (CCR) #4, on 01/09/20 at 9:00 AM, revealed the MDS should have been marked Yes for pressure reducing devices for chair was missed and will be revised immediately.",2020-09-01
2019,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2020-01-09,657,D,0,1,7NBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and interview, the facility failed to revise a person-centered comprehensive care plan. The facility failed to revise care plans for therapy services and hospice care. This practice affected two (2) of thirty-three (33) resident's care plans reviewed during the Long-Term Care Survey Process (LTCSP). The failure to ensure the comprehensive care plan was reviewed and revised for the resident's highest practicable well-being placed the residents at risk of not receiving services that would meet their desires or wants and a decreased quality of life. Resident identifier: #53 and #30. Facility census: 111. Findings included: a) Resident (R) #53 On 01/07/20 at 9:05 AM a review of R #53's medical records revealed, a physician's orders [REDACTED]. A review of the current care plan, dated 12/15/19, revealed a care plan addressed the ADL's (activities of daily living), with interventions for Occupational Therapy (OT) for self-care training, therapeutic activities and exercise, neuro re-education, group therapy, W/C (wheel chair) management, five (5) times a week for three (3) weeks. The care plan did not reflect the resident's current status. An interview with the Director of Nursing (DON), on 01/09/20 at 9:19 AM, verified the resident's Occasional therapy was not extended after 12/13/19 and the Residents care plan should have been revised to reflect the current status. b) Resident (R) #30 Review of the medical record on 01/07/20, revealed Resident (R) #30 began Hospice services on 07/26/19. The Hospice Certification Plan of Treatment form for the period of 10/24/19 to 01/21/20, notes an increase in Nurse Aide visits to five times a week beginning 10/28/19. The Hospice Nurse Aide (NA) visit forms confirm visits were completed four times a week. The current care plan with a revision date of 11/19/19 identifies Hospice as a focus. The interventions include Hospice visits and state: .Hospice Nursing Assistant 2X/week (two times a week) to compliment ADL (activities of daily living) care . **The care plan was not updated to reflect the increase in Hospice NA visits and/or staff were not provided a schedule of the planned visits. On 01/08/19 at 10:00 AM, and interview with Licensed Practical Nurse (LPN) #23 and Nurse Aide (NA) #15 confirmed staff was unaware of how often or when the Hospice NA was scheduled to provide services to R #30. On 01/07/19 at 10:40 AM, Coordinator of Clinical Reimbursement (CCR) Nurse #34, confirmed R #30's care plan is not up dated to reflect the increase in Hospice NA visits.",2020-09-01
2020,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2020-01-09,695,D,0,1,7NBT11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's orders [REDACTED]. This practice affected two (2) of three (3) residents reviewed for respiratory care. Resident Identifiers: #21, #22. Facility Census: 111. Findings included: a) Resident #21 An observation of Resident #21, on 01/06/20 at 11:17 AM, revealed this resident was receiving oxygen at two and a half (2.5) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the physician order, revealed Oxygen two (2) Liters Per Minute (LPM), via Nasal Cannula continuously, with an order date of 10/25/19. A second observation of Resident #21, on 01/06/20 at 2:50 PM, revealed the Resident #21 was receiving oxygen at two and a half (2.5) Liters via nasal cannula from an oxygen concentrator. An interview with Registered Nurse (RN) #4 on 01/06/20 at 2:55 PM, verified the Resident was receiving oxygen at two and a half (2.5) Liter Per Minute. RN #4 confirmed Resident #21 was ordered oxygen at two (2) Liters via nasal cannula. RN #4 verified the oxygen level was wrong. (RN) #4 changed Resident #21's oxygen to two (2) LPM on the concentrator. B) Resident #22 An observation of Resident #22, on 01/06/20 at 11:26 AM, revealed this resident was receiving oxygen at two and a half (2.5) Liters via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the physician order, revealed the order stated Oxygen three (3) Liters Per Minute (LPM), via Nasal Cannula continuously, with an revision date of 09/17/19. A second observation of Resident #22, on 01/06/20 at 2:50 PM, revealed the resident was receiving oxygen at two and a half (2.5) Liters via nasal cannula from an oxygen concentrator. An interview with Registered Nurse (RN) #4 on 01/06/20 at 2:55 PM, verified the Resident was receiving oxygen at two and a half (2.5) Liter Per Minute. RN #4 confirmed Resident #22 was ordered oxygen at three (3) Liters via nasal cannula. RN #4 verified the oxygen level was wrong and changed Resident #22's oxygen to three (3) LPM on the concentrator.",2020-09-01
2021,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2020-01-09,730,E,0,1,7NBT11,"Based on Employee Performance Appraisal (EPA) records review, education training records review and staff interview the facility failed to provide performance review requirements and specific in-service education for three (3) of five (5) Nurse Aides (NA). The facility failed to provide two (2) of five (5) NAs' EPAs. The facility failed to provide one (1) of five (5) NA's in-service training in dementia. The failed practice had the potential to affect more than a limited number of residents. Employee identifiers: #1, #65 and #43. Facility census: 111. Findings included: a) Policy and Procedure A policy review of HR 616 Performance Appraisal Program: Employee with revision date of 11/28/16 was conducted on 01/09/20 at 10:00 AM. The policy revealed, Managers will meet with their regular full-time, regular part-time, and regular casual employees at least annually to conduct a performance appraisal. A policy review of HR 224 In-Service Training with revision date of 11/01/19 was conducted on 01/09/20 at 10:15 AM. The policy revealed, (facility name) will provide in-service training for all personnel on a regularly scheduled basis. All mandatory service requirements must be completed annually as a condition of continued employment. In addition, there are requirements regarding in -service training for nurses aides; Dementia management and resident abuse prevention. b) Employee Performance Appraisal (EPA) A review of the facility's NA EPA's, on 01/08/20 at 5:00 PM, revealed NA #1 and NA #65 was not provided annual EPA's within the required 12 month period. NA #1 was to be provided an EPA within the time period of 02/06/18 to 02/06/19. EPA and was not completed until 10/28/19. NA #65 was to be provided an EPA within the time period of 08/01/18 to 08/01/19. EPA was not completed until 10/28/19. An interview with Administrator and Nurse Practitioner Educator #8, on 01/09/20 at 8:10 AM, revealed the annual EPAs for NA #1 and NA #65 were provided late and not within the required time period of 12 months. c) In-Service Training A review of the facility's NA in-service education training, on 01/08/20 at 5:30 PM, revealed NA #43 did not complete dementia training within a 12 month time period. An interview with Administrator and Nurse Practitioner Educator #8, on 01/09/20 at 8:10 AM, revealed no documented records of NA #43's completion in dementia training in the last 12 months. Administrator stated that NA #43 had been pulled off the floor until dementia training was completed.",2020-09-01
2022,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2020-01-09,812,E,0,1,7NBT11,"Based on observations and staff interview, the facility failed to ensure proper sanitation techniques had been followed. Equipment was not clean, personal items were stored in dish cleaning area and equipment was not operational. This had the potential to affect more than a limited number of residents served from the kitchen. Facility census: 111. Findings included: a) During the initial tour of the dietary department on 01/06/20 at 11:03 AM, the following issues were found: --Drip pans under the range top of the oven were found to contain an accumulation of food debris and needed cleaned. --The oven and stove needed cleaned inside and out. There was a grease like substance on the interior shelves and racks and on the outside glass doors. --A personal cell phone and wallet was found on the shelves of the dish room where clean dish items were stored. --The faucet above the three (3) compartment sink in the dish area was found to be unattached and hanging loose. This rendered the unit inoperable. These issues were identified and verified in the presence of the Dietary Manager who accompanied the surveyor on the kitchen tour.",2020-09-01
2023,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,550,D,0,1,3TSK11,"Based on observation and staff interview, the facility failed to treat residents with dignity and respect. When providing care to Resident #108, nursing staff failed to acknowledge and inform the resident of the process of urinary incontinence care and transfer using a mechanical lift. A hospice aide in the doorway of Resident #564's room discussed the residents bowel movements with a facility nurse within hearing distance of other staff, residents and visitors. This was true for two (2) of 23 residents reviewed for dignity and respect. Resident identifiers: #108 and #564. Facility census: 114. Findings include: a) Resident #108 Observation on 02/01/17 at 9:00 AM, found nurse aides (NA) placing Resident #108 on a mechanical lift pad. NA #30 and #18 were preparing the resident for the transfer. At no time during this preparation and transfer did NA #30 or #18 acknowledge the resident or explain what they were doing. Resident #108 was rolled from side to side, lifted from the bed to the Geri chair. When the Geri chair was tilted back, Resident #108 yelled out. A review of the care plan on 02/02/18 at 10:00 AM revealed an intervention initiated on 11/06/17 and revised on 01/23/18 of Explain care, including procedures (one step at a time), and reasons for performing the care before initiating. On 02/06/18 at 11:23 AM, an additional observation made with NA #30 and #45 who were in the process of providing incontinence care for Resident #108. Again, there was no conversation or explanation as to what NA #30 and #45 were doing with and to the resident. The NA's were asked if they tell the resident what they are going to do. NA #30's immediate response was that was what we were told (explaining procedure prior to completing) in NA class. Both NA's began calling the resident by name, told the resident they were going to turn her and clean her up. Resident #108 responded by cooperating with turning and did not resist care. Resident #108 was positioned comfortably and immediately fell asleep. In an interview with the Nursing Home Administrator (NHA), on 02/06/18 at 10:50 AM, she agreed the NAs were to talk with the residents when providing care. b) Resident # 564 On 02/01/18 at 09:00 AM, a random observation of a conversation in hallway of [NAME] Hall. A Hospice Aide (HA) #224 was heard describing the bowel movement of Resident #564 to a Licensed Practical Nurse (LPN #16) from the doorway of the room. LPN #16 was two (2) doors down the hallway. The conversation could be heard by other nearby residents, staff and visitors. An interview with LPN #16 at 9:10 AM on this same day found she was in agreement the conversation was not appropriate and anyone could hear the resident information. At 10:07 AM on 02/01/18, an interview with HA #224 revealed she was in agreement the conversation she had with LPN #16 was not the appropriate way to communicate about any resident. She further agreed the conversation could be heard by anyone. She apologized and stated this will never happen again, and said I am not even sure why I even did this.",2020-09-01
2024,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,578,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure an accurate physician order [REDACTED]. Resident identifier: #102. Facility census: 114. Findings include: a) Resident #102 Review of medical records found two separate POST forms with different directives on each form for Resident #102. A POST form signed by both, Resident #102 and licensed nurse (LPN) #77, on 11/30/17 reveals a direction of No IV fluids. This form is signed by a physician on 01/12/18. An additional POST form signed by both, Resident #102 (with no signature date) and registered nurse (RN) #69, reveals a direction of IV fluids for a trial period of no longer than Per Dr Discretion. This form contains a signature of the person preparing the form with a date of 01/11/18. This form does not have a physician signature. Observation while reviewing the chart revealed a direction of sign here for the physician attached to the form prepared on 01/11/18. The form with a prepared date of 11/30/17 was signed by the physician on 01/12/18. On 02/01/18 at 6:30 PM, the facility administrator agreed the medical records should have one POST form.",2020-09-01
2025,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,583,D,0,1,3TSK11,"Based on a random observation and staff interview, the facility failed to protect resident confidentiality. A hospice aide in the doorway of Resident #564's room discussed the residents bowel movements with a facility nurse within hearing distance of other staff, residents and visitors. This was true for one (1) of 23 residents reviewed for confidentiality. Resident identifier: #564. Facility census: 114. Findings include: a) Resident #564 On 02/01/18 at 09:00 AM a random conversation was heard in the hallway of [NAME] Hall. A Hospice Aide (HA #224) was heard describing the bowel movement of Resident #564 to a Licensed Practical Nurse (LPN #16) from the doorway of the room. LPN #16 was two (2) doors down the hallway. The conversation could be heard by other nearby residents, staff and visitors. An interview with LPN #16 at 9:10 AM on this same day found she was in agreement the conversation was not appropriate and anyone could hear the resident information. At 10:07 AM on 02/01/18, an interview with HA #224 revealed she was in agreement the conversation she had with LPN #16 was not the appropriate way to communicate about any resident. She further agreed the conversation could be heard by anyone. She apologized and stated this will never happen again, and she said, I am not even sure why I even did this.",2020-09-01
2026,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,584,E,0,1,3TSK11,"Based on resident interview, staff interview, and review of the grievances, the facility failed to provide a safe, comfortable and homelike environment by exercising reasonable care for the protection of one (1) of twenty-three (23) sampled residents' personnel belongings from loss or theft. Resident identifier: #45. Facility census: 114. Findings include: a) Resident #45 During an interview with Resident #45 on 01/29/18, at 12:35 PM, it was stated there are a couple of old men that come in the room and steal my pop and candy. Resident #45 stated he had addressed the issue with administrative staff but that did not take care of the problem. An additional interview with Resident #45 on 01/30/18 at 9:11 AM, confirmed that the drinks and snacks had not been replaced nor resolution to enable him to keep snacks in his room safely. A review of the grievances on 02/01/18 revealed Resident #45 had reported another resident came in his room and took pop and snacks. There was no indication the facility made any accommodations to protect the resident's personal belongings from loss of theft . On 02/01/18 at 9:50 AM, an interview with the Administrator revealed items such as snacks and money had been replaced based on the resident's complaints, however, the pop and snacks had not been replaced for Resident #45 and no mechanism was put in place to prevent the loss and theft of items Resident #45 is currently keeping in his room.",2020-09-01
2027,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,610,D,0,1,3TSK12,"Based on review of the grievance file, medical record review, staff interview, and policy review, the facility failed to ensure all allegations of abuse, neglect, or mistreatment were thoroughly investigated for one of three sampled residents. Resident identifier: #3. Facility census: 113. The findings includes: a) Resident #3 A review of the grievance file, on 04/10/18, revealed a grievance/concern dated 04/03/18, from Resident #3 noting he does not want (name of nurse aide) to provide care to him. He said this nurse aide is, reckless, mouthy, argumentative, defiant, and has no courtesy. The investigation area of the grievance form was noted to be resolved on 04/05/18 with the notation (name of nurse aide) no longer to provide care. No other documentation was noted of any investigative process of the allegation on the complaint or in the resident's medical record. A review of the Abuse Prohibition policy, under Section 6.8, reviewed 04/10/18, revealed The investigation will be thoroughly documented within RMS. Ensure that documentation of witnessed interviews is included. An interview with the Administrator on 04/11/18, at 07:50 AM, revealed Social Services had not included documentation with the grievance and did not realize she had to attach verbal conversations. The Administrator, at this time, verified all conversations were to be documented and all information attached with any grievance investigation.",2020-09-01
2028,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,641,D,1,0,3TSK12,Deficiency Text Not Available,2020-09-01
2029,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,656,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and observation, the facility failed to develop and/or implement individualized care plan goals and/or interventions for three (3) of twenty-three (23)sampled residents. The care plan for [MEDICAL TREATMENT] Resident #5 lacked individualized goals and interventions specific to his needs as related to [MEDICAL TREATMENT]. Staff failed to implement the care plan for Resident #108 related to addressing the resident during care. Staff failed to implement the care planned use of Resident #73's baby doll for her comfort. Resident identifiers: #5, #108, #73. Facility census: 114. Findings include: a) Resident #5 The medical record and care plan were reviewed on 02/02/18. The physician ordered nursing staff to monitor every shift for bleeding and to ensure the dressing was intact (to the right upper chest) for the resident's Tessio [MEDICAL TREATMENT] catheter. The physician ordered [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday at (name of [MEDICAL TREATMENT] center). Medical record review also found that the resident had Doppler studies for mapping in mid-January in preparation for insertion of a permanent arteriovenous (AV) fistula for [MEDICAL TREATMENT]. Until the AV fistula is surgically created, the [MEDICAL TREATMENT] center will use the Tessio [MEDICAL TREATMENT] catheter to perform [MEDICAL TREATMENT] three (3) times weekly. The care plan directed staff to monitor the [MEDICAL TREATMENT] access for bruit and thrill every shift and as needed. However, the resident has no AV fistula in which to monitor for bruit and thrill. The care plan directed staff to transfer him to the [MEDICAL TREATMENT] unit on Mondays and Fridays. However, the physician ordered [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday. The care plan was not developed to include the interventions for communications between the [MEDICAL TREATMENT] unit and the facility. The care plan did not have individualized, specific goals related to expected or desired laboratory monitoring results as related to a [MEDICAL TREATMENT] patient, beyond maintaining electrolyte balance. The care plan was silent related to which facility would be responsible for administering [MEDICATION NAME] and under what criteria. The care plan was silent related to which facility was responsible for obtaining which laboratory tests. On 02/02/18 at 1:30 PM, during an interview with the director of nursing (DON), she said the care planned intervention to check the bruit and thrill was not applicable to this resident because he had a Tessio catheter rather than an AV fistula. She said the care planned intervention for [MEDICAL TREATMENT] on Mondays and Fridays was also inaccurate, because he was scheduled for [MEDICAL TREATMENT] treatments every Monday, Wednesday, and Friday. The DON showed the communication book that they send with him to [MEDICAL TREATMENT]. In the book were the pre-and post-weights and the vital signs that were obtained at the [MEDICAL TREATMENT] center on [MEDICAL TREATMENT] treatment days. Review of the communication book found that pre- and post-weights and vital signs from the [MEDICAL TREATMENT] unit were omitted on 01/17/18, 01/19/18, 01/22/18, and 01/26/18. The only communication note found from the [MEDICAL TREATMENT] unit was on 02/02/18 which was related to the [MEDICATION NAME] order changed to one (1) milligram prior to [MEDICAL TREATMENT]. On 02/06/18 at 1:45 PM, the DON provided a copy of their NSG253 [MEDICAL TREATMENT] Communication and Documentation policy, with effective date 05/01/16. Per this policy, the facility was to communicate with the [MEDICAL TREATMENT] center prior to sending a patient for [MEDICAL TREATMENT] by completing the [MEDICAL TREATMENT] Communication Record and send it with the patient. The form would also be completed upon return of the patient from the [MEDICAL TREATMENT]. The purpose was To obtain highest continuum of care for patients receiving outpatient [MEDICAL TREATMENT] services. The facility practice standards stated a licensed nurse would complete the top portion of the [MEDICAL TREATMENT] Communication Record and send it with the patient to the [MEDICAL TREATMENT] center visit. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the nursing home with the patient. Step 4 directed to notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the center. Step 4.1 stated to document notification of [MEDICAL TREATMENT] center regarding return of the form or other communication. On 02/06/18 at 1:45 PM, licensed practical nurse (LPN) #36 said the forms always come back blank from this particular [MEDICAL TREATMENT] center. She showed, for example, the form the facility sent with the resident to the [MEDICAL TREATMENT] center on 02/05/18. Review of the form found it contained the resident's name and the date of 02/05/18. The space for pre- and post-weight and vital signs was blank. LPN #36 said the [MEDICAL TREATMENT] center instead provided that information in the communication book. Upon inquiry as to what information the nursing home sends to the [MEDICAL TREATMENT] on each [MEDICAL TREATMENT] treatment day, LPN #36 said they send a copy of the face sheet, and they send the notebook (communication book). Review of the communication book found no entries from the nursing home. Further review of this form, dated 02/05/18, included space for the following information that were all left blank: --Nausea, vomiting, diarrhea --[DIAGNOSES REDACTED] --Fluid bolus given --Level of consciousness change --Bleeding --Listing of medications given --Listing of behavior concerns --Additional concerns --Signature of the [MEDICAL TREATMENT] center nurse --Attach Lab Sheets for each visit b) Resident #108 Observation on 02/01/17 at 9:00 AM, found nurse aides (NA) placing Resident #108 on a mechanical lift pad. NA #30 and #18 were preparing the resident for the transfer. At no time during this preparation and transfer did NA #30 or #18 acknowledge the resident or explain what they were doing. Resident #108 was rolled from side to side, lifted from the bed to the Geri chair. When the Geri chair was tilted back, Resident #108 yelled out. A review of the care plan on 02/02/18 at 10:00 AM, revealed an intervention initiated on 11/06/17 and revised on 01/23/18 by of Explain care, including procedures (one step at a time), and reasons for performing the care before initiating. A concurrent review of the Kardex provided no instructions for the intervention. The Kardex was dated 01/31/18. The Kardex provides the interventions for the various facility disciplines to follow when providing care. c) Resident #73 A review of the care plan on 02/06/18 at 12:16 PM revealed an intervention provide doll to calm and comfort. The intervention was created/initiated on 09/21/16 and revised by social worker (SW) #65 on 01/11/18. The Kardex print date of 01/30/18 stated under the behavior section to divert resident by giving alternative objects/activity. There was no individual explanation as to what the alternative objects/activity were. Random observations found the Resident #73 sitting in the hallway without her doll, as well as in an activity program on 02/01/18 at 10:45 AM. The activity staff asked her where is your baby? Resident shook her head in the negative. During the random observations, the resident was either sleeping or restless as if looking for something or someone. When attempting a conversation with the resident she would just shake her head in the negative. Additional random observations found when the resident had the doll in her arms, she would converse with the staff and survey team members. She stated He is a good boy referring to the doll. She was smiling. On 02/06/18 at 09:39 AM, an interview with SW #65 stated she was not aware interventions were not transferring to Kardex. SW #65 confirmed the review of the Kardex during care plan meetings. An interview with the two (2) Minimum Data Set (MDS) coordinators (#35 and #60) on 02/06/18 at 12:13 PM stated each discipline must check the interventions to assure their inclusion with the Kardex. Both were in agreement there was a computer issue and the interventions would need to be entered manually to be included on the Kardex. When asked if the interventions from all disciplines should be included on the Kardex neither Coordinator responded except to say the Kardex is reviewed and each discipline reviews their own section.",2020-09-01
2030,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,684,J,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure laboratory values were obtained in a timely manner for Resident #461, failed to obtain a PT/INR test was completed as ordered by the physician for Resident #110, failed to provide care and services upon admission to the facility for Resident #39, failed to follow-up on results of a PT/INR laboratory value for Resident #16, and failed to complete neurological checks after unwitnessed falls for Residents #462 and #1. Seven (7) of twenty-three (23) residents reviewed during the facility's annual survey were affected. Resident identifiers: #66, #461, #110, #39, #16, #462, and #1. Facility census: 114. Findings include: a) Resident #66 Observations on 01/29/18 at 4:13 PM, noted Resident #66 had a large bruise covering approximately one-third (1/3) of the skin surface on the top of her left hand. Review of the resident's medical record found she had [DIAGNOSES REDACTED]. Resident #66 was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) recorded on the minimum data set (MDS) with an assessment reference date (ARD) of 01/03/18 revealed Resident #66 was cognitively intact. A progress note on 01/15/18 described a change in condition of wheezes and coughing. The physician prescribed a one-time dose of [MEDICATION NAME] (a macrolide antibiotic) 500 milligrams (mg) given on 01/19/18 at 9:00 AM, then [MEDICATION NAME] 250 mg daily for four (4) consecutive days for an upper respiratory infection. Resident #66 received all doses of the [MEDICATION NAME] as ordered. While receiving the [MEDICATION NAME], Resident #66 also received [MEDICATION NAME] 5.0 mg on 01/19/18, [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg on 01/20/18, [MEDICATION NAME] 5.0 mg on 01/21/18, [MEDICATION NAME] 7.5 mg on 01/22/18 and [MEDICATION NAME] 5.0 mg on 01/23/18. A progress note, written on 01/24/18 by Licensed Practical Nurse (LPN) #77, noted Resident #66 was experiencing a mental status change and had a critical PT of 88.8 and a critical INR of 9.1. (The generally accepted normal range for INR in a resident receiving a blood thinner is 2 to 3.) A progress note on 01/24/18 at 12:53 PM by the APRN (Advance Practice Registered Nurse) revealed Resident #66, was assessed for evaluation and management of subtherapeutic INR of 9.1 with altered mental status. The nurse also noted the resident's altered mental status was not normal for the resident and that there was dried blood noted to several nail beds on her hands. At that time, Resident #66 was administered a dose of Vitamin K 10 mg (milligrams) by mouth and sent the emergency room for evaluation. An additional note by the APRN on 01/26/18 at 2:01 PM included, The patient was seen for follow up s/p (status [REDACTED]. In addition to vitamin K 10mg po (by mouth) given here prior to her transport to the ER, she was given an additional dose of 10mg in the ER as well. During her hospitalization she did have a severe nose bleed which lasted 4-5 hours which was managed by packing and transfusion of 2 units FFP (Fresh Frozen Plasma). Her [MEDICATION NAME] has been on hold; repeat INR this am (morning) was 1.4. At 10:54 AM on 02/02/18, a telephone interview with the general manager of the pharmacy used by the facility explained, [MEDICATION NAME] was filled for Resident #66 on 01/19/18. He went on to state that [MEDICATION NAME] was considered a level two (2) drug. A level two drug interaction refers to the risk of drug interaction with other drugs. The levels range from 1 to 5, with one being the most severe potential for drug to drug interaction. Upon delivery, the pharmacy included with the [MEDICATION NAME], a severity level 2 warning for selected anticoagulants/selected macrolide antibiotics with a patient management notification to closely monitor INR values in patients maintained on anticoagulants in whom macrolide antibiotics were initiated or discontinued. Review of Resident #66's medical records found no evidence the facility monitored or attempted to monitor the resident's PT/INR more closely than every seven (7) days, during the time she received [MEDICATION NAME] and [MEDICATION NAME] at the same time. On 02/02/18 at 2:45 PM, the Director of Nursing (DON) explained during stand-down on the evening of 01/19/18, the APRN voiced there was no concern related to drug interactions when giving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) together. At 2:52 PM on 02/02/18, the APRN explained Resident #66 had refused to allow a PT/INR value to be monitored more than one time per week. When asked, if there was a consideration to monitor the PT/INR more closely while Resident #66 was receiving [MEDICATION NAME] the APRN she explained she did ask the physician for more frequent PTINR value blood draws, the physician 'saw' Resident #66's PT/INR values, knew of the prescribed [MEDICATION NAME] and still ordered the [MEDICATION NAME]. The APRN went on to state, I think it was appropriately monitored and addressed. On 02/02/18 at 3:15 PM, Resident #66 explained that she did complain about having to have her blood drawn so often and it was decided a PT/INR value would be drawn one (1) time per week. Resident #66 went on to explain she voiced concerns about being allergic to [MEDICATION NAME] and was told this medication was not on her allergy list. She went on to state she did not remember staff explaining to her the potential [MEDICATION NAME]/[MEDICATION NAME] drug interaction or asking her for permission to obtain a blood draw more often to monitor her PT/INR while taking [MEDICATION NAME]. During an interview on 02/02/18 at 3:43 PM, LPN #77 said she had not read the pharmacy warning sent with the [MEDICATION NAME]. When asked to find a warning in the resident's medical record about the potential problem of giving [MEDICATION NAME] due to a critical drug interaction with [MEDICATION NAME], LPN #77 could not. On 02/02/18 at 3:50 PM, a request to the medical director to find a notification placed in the medical records since the incident of [MEDICATION NAME] and [MEDICATION NAME] causing a severe drug interaction with Resident #66. The medical director stated there was no evidence in the medical records that [MEDICATION NAME] should not be given to Resident #66. A review of the facility's Nursing Drug Handbook (YEAR), provided by the DON on 02/02/18 at 3:55 PM, found it included a drug-drug interaction between [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) with a warning the INR might increase and should be monitored carefully. The facility's failure to heed the pharmacist's warning and monitor the resident's PT/INR was determined to constitute and immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor Resident #66, and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to health and well-being of residents. On 02/02/18 at 6:45 PM the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. The P[NAME] included: an assessment of the resident, education of the licensed nurse receiving the macrolide antibiotic, education of the advanced practice registered nurse (APRN) to consider drug interactions and to comply with professional standards. Education to all nurses regarding the potential for [MEDICATION NAME] and antibiotic drug interaction and reporting the potential to the prescribing physician. Adding a warning alert to the medical records of a resident receiving [MEDICATION NAME] and prescribed an antibiotic. A scheduled review of all new physician orders, nursing notes for antibiotics including lab results for residents who receive [MEDICATION NAME] and any drug interaction received from pharmacy to ensure the physician and APRN has been notified prior to administer the medication and to identify trends and report to the Quality Improvement Committee (QIC) for additional follow up until the issue is resolved. After removal of the immediate jeopardy deficient practices remained at a level of E. The facility failed to ensure laboratory values were obtained in a timely manner for Resident #461, failed to obtain a PT/INR test was completed as ordered by the physician for Resident #110, failed to provide care and services upon admission to the facility for Resident #39, failed to follow-up on results of a PT/INR laboratory value for Resident #16, and failed to complete neurological checks after unwitnessed falls for Residents #462 and #1. b) Resident #461 On 01/20/18, the resident's PT/INR was 1.0. A recheck of the lab test was ordered to be done on Tuesday 01/23/18. Review of the resident's medical record did not find the results test ordered for 01/23/18. On 02/02/18 at 7:00 PM, the DON provided a laboratory report dated 01/22/18 with an INR result of 1.2. The DON stated the facility did not have the results in the medical records until requested on 02/02/18. While discussing the quality assessment (QA) content on 02/06/18 at 1:45 PM, the DON explained laboratory audits were monitored for several months and discontinued 12/31/17. The DON explained one staff member assured laboratory results were received in a timely manner and reported as needed, but no education occurred in which each staff member was made aware of how to ensure laboratory values were obtained in a timely manner. c) Resident #110 A review of Resident #110's medical record on 02/02/18 revealed the physician ordered a PT/INR be obtained on 01/18/18. There was documentation the lab specimen was collected; however, no test results were found in the resident's medical record for that date. On 02/02/18 at 3:35 PM, the Assistant Director of Nursing (ADON) was interviewed and asked to provide the result for the lab test ordered to be done on 01/18/18. The ADON stated there was no information in the resident's medical record. She said she had called and requested the lab result faxed from the laboratory. At that time, the lab informed the ADON that the specimen had clotted and the lab value was not obtained. During an interview on 02/06/18 at 10:40 AM, the Director of Nursing (DON) revealed that the blood was drawn on 01/18/18, but the specimen had clotted and no notification or results had been received by the facility. A review of the laboratory result sent to the facility on [DATE] at 18:26 (6:26 PM) stated [MEDICATION NAME]- request credited, specimen clotted. There was no notation that the facility had been notified the blood sample had clotted and test ordered for 01/18/18 could not be completed. An interview with the DON on 02/06/18 at 10:40 AM, revealed that the facility failed to follow-up when the lab result was not returned to the facility in a timely manner. d) Resident #39 A review of the resident's medical record revealed [REDACTED]. Coli bacteremia, and pneumonia. A review of the Physician order [REDACTED]. Further review of the medical record revealed the medication was not given every eight (8) hours as ordered. The administration of the antibiotic was not started until 02/15/18. Through an interview with the Director of Nursing (DON) on 02/06/18 at 10:15 AM, it was revealed the medication was not started as ordered when Resident #39 returned from the hospital because Nurse #69 failed to document the orders on the correct sheet, and failed to transcribe the orders correctly onto the Medication Administration Record [REDACTED]. A review of the facility's follow-up on this medication error dated 01/17/18, revealed that Employee #6 failed to review the orders for Resident #39 to ensure the orders were correctly transcribed. It was stated that Employee #6 worked on two other admissions and did not review Resident #39's orders. Further information obtained during the interview with the DON on 02/06/18 at 10:15 AM, revealed the error should have been identified to prevent Resident #39 from missing seven (7) doses of the antibiotic ordered upon return from the hospital. It was further stated that in addition to Employee #69 and Employee #6 failing to complete or review the record, Employees #34 and #61 had also been responsible for ensuring the order was correctly documented and implemented. Review of facility's follow-up dated 01/19/18, found Employee #69 received training on the five rights of medication administration. This included right patient, right medication, right dosage, right route, right time. The education did not address the issues leading to the error and was not signed by the employee as indicated by the facility form and the date on the form provided was 09/05/17. Additionally, not all staff involved in this incident were re-educated. A review of the Medication Administration Record [REDACTED]. An interview with the DON at 10:15 AM confirmed that due to the transcription errors when the resident returned, medication orders were not transcribed and implemented. Resident #39 did not receive ordered doses of: -- [MEDICATION NAME] (used to treat [MEDICAL CONDITION], neuropathic pain, hot flashes, and [DIAGNOSES REDACTED]) 750 mg three times per day, -- [MEDICATION NAME] (a blood thinner) 5000 units injectable every eight (8) hours, -- [MEDICATION NAME] (an antidepressant, has anxiolytic, sedative, antiemetic, and appetite stimulant effects) 15 mg at bedtime, -- [MEDICATION NAME] (used to treat certain stomach and esophagus problems, such as acid reflux) 40 mg every day, -- [MEDICATION NAME] (used to treat nerve pain, depression, generalized anxiety disorder, panic disorder, and social anxiety disorder) 50 mg three times per day, -- [MEDICATION NAME] (a mouthwash) 15 milliliters (ml) twice a day, and -- [NAME]sevelam (to reduce cholesterol) 650 mg, 3 tabs twice a day with meals on 01/13/18. e) Resident #16 Medical record review on 02/02/18 found this resident's [DIAGNOSES REDACTED]. Her physician ordered a blood thinner, [MEDICATION NAME], daily in varying dosages to prevent blood clots. The physician ordered a PT/INR ([MEDICATION NAME] Time/International Normalized Ratio), a test to help the physician determine the dosage of [MEDICATION NAME] to maintain a therapeutic level. An INR range of 2.0 - 3.0 is generally an effective therapeutic range for people who take [MEDICATION NAME] for disorders such as [MEDICAL CONDITION] or a blood clot in the leg or lung. If a [MEDICATION NAME] dose is too high, the patient may bleed too easily, and if too low, the patient's blood may clot too easily. On 01/02/18, the physician ordered [MEDICATION NAME] five (5) milligrams (mg) every Sunday, Tuesday, Thursday, and Saturday. The physician ordered [MEDICATION NAME] 3.5 mg. every Monday, Wednesday, and Friday. This dosage was based on the 01/02/18 INR of 2.2. The physician ordered a repeat of the PT/INR in two (2) weeks. Review of the medical record on 02/02/18 found no evidence of PT/INR results on or near 01/16/18. During an interview with the director of nursing on 02/02/18 at 7:00 p.m., she was unable to provide evidence of a PT/INR test on or near 01/16/18. The DON contacted the lab at that time, and found that a PT/INR was completed on 01/13/18 (rather than on 01/16/18). The INR result on 01/13/18 was 3.6. According to the laboratory's reference range, an INR of 3.0 to 4.0 was considered high intensity [MEDICATION NAME] therapy, whereas in comparison, an INR of 2.0 to 3.0 was considered Moderate intensity [MEDICATION NAME] therapy. When asked whether the physician was notified of this elevated INR result, the DON replied in the negative. She said the 01/13/18 PT/INR result was not recorded on the facility's Flow Sheet for monitoring residents taking [MEDICATION NAME], as directed by the facility's [MEDICATION NAME] monitoring policy. She said she did not know if the lab test (PT/INR) may not have made it to the nursing home, or if it came, but was misfiled. The last recorded information on this resident's Flow Sheet was 12/16/17. The DON said the Flow Sheet for this resident was resumed on the day before, on 02/05/18. Upon inquiry, she confirmed again that she could find no evidence that the physician was notified of the 01/13/18 elevated INR result. She said she could find no evidence that staff used the [MEDICATION NAME] monitoring flow sheets between 12/16/17 and 02/05/18. Further review of the resident's medical record found evidence the resident showed signs of a change in condition from 01/13/18 when the INR was elevated at 3.6, until the date of the next PT/INR which occurred on 01/23/18 with a critical INR value of 8.9, as follows: - 01/19/18 nurse progress note 5:00 p.m. said the resident stated she was not feeling well, like she was going to throw up - 01/19/18 nurse progress note 5:05 p.m. said a nursing assistant came to this nurse and stated the resident was not looking good. When approached by the nurse, the resident seemed very confused and shaky and could hear mucous in throat. The nurse called the hospice to come look at the resident. - 01/19/18 at 8:00 p.m. nurse progress note said hospice came in to see the resident. New orders were received to start [MEDICATION NAME] four (4) drops every four (4) hours as needed (prn) sublingually for secretions; start [MEDICATION NAME] treatments via nebulizer every four (4) hours prn for wheezing; increase Roxinal (for pain) to five (5) mg. sublingually every one (1) hour prn (as needed). - 01/20/18 nurse progress note at 4:39 a.m. said the family was at the bedside, due to declining condition. - 01/20/18 nurse progress note at 3:19 p.m. assessed her skin color as pale, lethargic at times, apical pulse [MEDICAL CONDITION] (rapid) at 119 beats per minutes, no food intake this shift. - 01/21/18 nurse progress note at 12:45 p.m. assessed a heart rate ranging from 88 - 157 beats per minute. The resident had increased alertness today yet remains to have a poor oral intake. - 01/23/18 1:36 p.m. nurse progress note assessed her left and right sides, back and buttocks have purplish, red rashy areas, notified (name of doctor), received new orders--PT/INR now--give [MEDICATION NAME] TID (three times daily) for two (2) days. - 01/23/18 3:36 p.m. nurse progress note addressed they received new orders for Vitamin K five (5) milligrams (MD) once, hold [MEDICATION NAME], and repeat INR Thursday 01/25/18. (Vitamin K is given to counteract the blood thinning effects of [MEDICATION NAME].) - 01/23/2018 2:42 p.m. General Note - Resident has had an overall decline in health recently. Critical lab values were addressed with the physician with new orders. Poor oral intake. - 01/25/2018 9:05 p.m. Care Plan Evaluation Note - new orders for [MEDICATION NAME] 0.5 mg orally prn every four (4) hours as needed for agitation. Review of the medical record found the PT/INR on 01/23/18 was PT 86.4 and INR 8.9. The INR on 01/25/18 was back to the therapeutic level of 2.2. The physician at that time ordered to resume the previous [MEDICATION NAME] dose on Monday 01/29/18. The INR on 01/29/18 was 1.5, and the physician gave orders for daily [MEDICATION NAME] doses until the next PT/INR in one (1) week. Observation of the resident on 02/02/18 at 7:00 p.m. found that she had a small, green- colored bruise to the top of each hand. The one is circular about one inch in diameter. The other is about two inches long and narrow. On 02/06/18 at 11:30 a.m., the DON provided a copy of the facility's policy and procedure on [MEDICATION NAME] monitoring. This was most recently revised on 01/02/14. According to their policy under section 2.2, the facility must use the [MEDICATION NAME] flow sheet and Update with each PT/INR result and with every new [MEDICATION NAME] ([MEDICATION NAME]) order. Steps three (3) and four (4) direct staff to Schedule the lab draws for PT/INR values per physician/mid-level provider order. and Notify physician/mid-level provider for dosage adjustments and for results outside of the patient's therapeutic range. Step 6.1 directs nursing staff to document PT/INR test results on the [MEDICATION NAME] therapy flow sheet. The DON acknowledged that these policy steps were not followed related to the 01/13/18 PT/INR blood test, nor was it followed when the [MEDICATION NAME] monitoring flow sheet was not used between the dates of 12/16/17 and 02/05/18. f) Resident #462 1. Medical record review for Resident #462 revealed the resident had an unwitnessed fall on 01/04/18 at 11:30 a.m. The accident report stated, (typed as written) Resident was assisted in bed. bed alarm sounded and run toward him found him sitting on the floor. Resident had a abrasion to right upper forehead. Bruising to left knee and left shin. Vitals initiated and neuros initiated. A review of the neurological assessment revealed the assessments began at 11:30 a.m. They continued at 12:00 p.m., 12:30 p.m., 1:00 p.m., 2:00 p.m., 3:00 p.m., 4:00 p.m., 8:00 p.m., on 01/05/18 at 1:00 a.m., 4:00 a.m., 8:00 a.m. and 12:00 p.m. The facility's neurological assessment policy, revised on 10/01/12, directed neurological assessments would be performed when a patient sustained an injury to the head and/or had an unwitnessed fall. The purpose of the neurological assessment was to monitor the resident for neurological compromise. The policy indicated the assessments would be completed every (30) minutes for two (2) hours then every hour for four (4) hours then every four (4) hours for 24 hours. According to the facility's policy, these assessments should have been completed at 11:30 a.m., 12:00 p.m., 12:30 p.m., 1:00 p.m., 1:30 p.m., 2:30 p.m., 3:30 p.m., 4:30 p.m., 5:30 p.m. 9:30 p.m. 1:30 a.m., 5:30 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m., and 9:30 p.m. 2. Medical record review also revealed Resident #462 experienced a fall on 12/13/17 at 5:30 a.m. The accident report stated, Resident had been up most of the night in wheelchair. CNA (nurse aide) had put him to bed this morning and about 15 mins later the alarm was sounding and resident was found sitting on the floor next to bed on the right side of bed with legs facing to door. Neurological checks were completed starting on 12/13/17 at 5:30 a.m., 6:00 a.m., 6:30 a.m., 7:30 a.m., 8:30 a.m., 9:30 a.m., 1:30 p.m., 5:30 p.m., 9:30 p.m., and on 12/14/17 at 1:30 a.m., and 5:30 a.m. According to the facility's policy, neurological checks should have been completed at 5:30 a.m., 6:00 a.m., 6:30 a.m., 7:00 a.m., 7:30 a.m., 8:30 a.m., 9:30 a.m., 10:30 a.m., 11:30 a.m., 3:30 p.m., 7:30 p.m., 11:30 p.m., 3:30 a.m., 7:30 a.m., 11:30 a.m. 3:30 p.m. 7:30 p.m., 11:30 p.m., and 3:30 p.m. On 02/01/18 at 1:06 p.m., the director of nursing agreed the neurological assessments were not completed in accordance with the facility's neurological assessment policy. g) Resident #1 Medical record review revealed Resident #1 experienced a fall on 12/31/17 at 3:00 a.m. The incident/accident report stated, (typed as written) CNA (nurse aide) found sitting on the floor next to the bed on her buttocks, Resident stated she fell , asked how, she said, well I dunno, I slid off the side of the bed, I asked her what she was doing, she said, 'well I told you, I dunno, I just slid off the side of the bed' Vitals obtained, She denies pain, skin assessment completed, Found red area to back of head, started neuro checks, resident had regular socks on. So nonskid socks were added to help prevent slipping. The neurological assessment flow sheet revealed Resident #1's neurological checks were completed on 12/31/17 at 3:00 a.m., 3:30 a.m., 4:00 a.m., 5:00 a.m., 6:00 a.m., 7:00 a.m., 11:00 a.m., 3:00 p.m., 7:00 p.m., 11:00 p.m., and on 01/01/18 at 3:00 a.m., 7:00 a.m., 11:00 a.m., and at 3:00 p.m. According to the facility's policy for neurological assessment the neuro checks should have been completed at 3:00 a.m., 3:30 a.m., 4:00 a.m., 4:30 a.m., 5:00 a.m., 6:00 a.m., 7:00 a.m., 8:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., 9:00 p.m., 1:00 a.m., 5:00 a.m., 9:00 a.m., 1:00 p.m., 5:00 p.m., and 9:00 p.m., and 1:00 a.m., 5:00 a.m., 9:00 a.m., and 1:00 p.m. On 02/02/18 at 12:19 p.m., the director of nursing was interviewed regarding the lack of neurological assessments following a fall for Resident #1. No further information was provided. .",2020-09-01
2031,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,689,L,1,1,3TSK11,"> Based on observations, medical record review, staff interview, resident interview, and policy review, the facility failed to provide an environment free from accident hazards over which the facility had control. The facility allowed two (2) residents to keep cigarettes and lighters in their room. Resident #9 and #98 both kept their smoking materials in their room. The facility also had a courtyard in which residents could freely access during winter weather and other weather conditions without any type of monitoring by the facility. The doors going into the courtyard did not alarm to alert staff that residents had entered the courtyard area. Residents were observed entering the court yard freely with no alert to the facility. These deficient practices had the potential to affect all residents and had the potential to cause serious harm or death. After consultation with the State office a determination of immediate jeopardy was made based on the facility's failure to ensure each resident received adequate supervision to prevent accidents when out in the courtyard and/or allowing residents to maintain unsecured possession of lighters. The facility administrator was notified of the immediate jeopardies on 01/30/18 at 9:25 p.m. Acceptable plans of correction and their implementation was verified and the immediate jeopardies were abated on 01/31/18 at 12:24 a.m. Resident identifiers: #9 and #98. Facility census: 114. Findings include: a) Resident #9 An interview with Resident #9 on 01/30/18 at 4:20 p.m. revealed the resident was a smoker. She said she kept her cigarettes and lighter in her nightstand. The nightstand was not equipped with a lock to ensure others could not access the lighter. b) Resident #98 An observation of Resident #98 at 7:00 p.m. on 01/30/18 revealed this resident was sitting out in the courtyard with Resident #9. Both were smoking cigarettes. Resident #98 also said she kept her cigarettes and lighter with her and could go out and smoke whenever she wanted. c) On 01/30/18 at 7:29 p.m., an interview with Licensed Practical Nurse (LPN) #43 the LPN verified Resident #9 and Resident #98 both kept their smoking materials with them. LPN #43 said they were both safe smokers and that was why they were allowed to keep the materials with them. On 01/30/18 at 9:15 p.m., an observation made with Registered Nurse (RN) #90 also confirmed Resident #9 and Resident #98 kept their lighters in their room. Neither resident had a secure place to store the lighters to ensure others did not have access to them. RN #90 asked the residents to give her their lighters so they could be kept secured at the nursing station. Both residents gave RN #90 their lighters. The facility's smoking policy revised on 06/01/17 stated, Patients will not be allowed to maintain their own lighter, lighter fluid or matches. c) Doors Based on observations and staff interviews, the facility failed to ensure the facility provided an environment free from accident hazards over which the facility had control and provided adequate supervision. The enclosed courtyard had no locks/alarms to warn staff when any resident went into the enclosed courtyard. Temperatures were below freezing and wind chills were in the negative range. On 01/30/17 at 8:50 PM, it was noted that the door on the D hall leading to the enclosed courtyard was not locked, nor did it have an alarm. This allowed any mobile resident to exit the building without staff awareness. In addition, there were two (2) other doors on either side of the Dining Room which exited to the enclosed courtyard without locks or alarms. In an interview conducted on 01/30/18 at 9:12 PM, Licensed Practical Nurse (LPN #6) confirmed that the door on the D Hall was not locked and was not aware it could be locked. When asked if the door was locked when the outdoor temperatures were below freezing, she stated when it was really cold earlier that month, barrier tape was put across the door(s) so that the residents could not go outside. Observations at that time revealed no barrier tape was on any of the doors exiting into the enclosed courtyard. The outdoor temperature at that time was 16 degrees Fahrenheit (F) with a wind chill of 6 degrees F. Additional information provided by the facility included five (5) residents smoked in the enclosed courtyard at their discretion and nine (9) residents had WanderGuards resided on the A Hall. In an interview with the Nursing Home Administrator (NHA), when asked what security measures were on the doors exiting into the enclosed courtyard. the NHA stated, There are no locks because it is an enclosed area. During an observation at 9:15 PM with the NHA present, the NHA stated, This door should be locked and have caution barrier tape across the door, but it doesn't. The NHA stated, I will take care of this immediately. d) On 01/30/18 at 9:25 PM, the NHA was informed in writing that an immediate jeopardy was being called due to the lack of safety precautions for the enclosed courtyard during inclement weather. The administrator was also informed that an immediate jeopardy existed due to two (2) residents possessing unsecured lighters. e) P[NAME] for the Doors At 11:56 PM on 01/30/18, the facility presented a plan of correction that included placement of alarms on the three (3) exit doors. Rounds were made to ensure all residents were in the building and staff education was provided regarding the alarms. The plan of correction will be monitored by the Director of Nursing (DON)/designee and trends reported to the Quality Assurance Committee on a monthly basis. The IJ was abated on 01/31/18 at 12:24 AM. Rounds were made by two (2) survey team members and confirmed the three (3) courtyard exit doors had alarms and were working. f) P[NAME] for the issue regarding the lighters 1. The Administrator/designee removed smoking supplies, including lighters, from Resident #9 and Resident #98 rooms after reeducation of the residents regarding the smoking policy and procedure including need to secure all smoking materials at 10:00 p.m. on 1/30/2018. 2. All residents of the facility who smoke have the potential to be affected. The Administrator/designee conducted rounds of facility's rooms, including other smokers' rooms on 1/30/2018 at 10:00 p.m. NO additional smoking supplies, including lighters were found at that time. No residents of the facility have experienced any negative outcome. 3. The Administrator/designee will reeducate smoking residents regarding the facility's smoking policy on 1/30/2018 and upon admission and readmission. The Administrator/designee will reeducate all center staff to ensure that resident smoking supplies are secured at all times, including lighters with a posttest to validate understanding. Staff not available during this timeframe will be provided reeducation including posttest by the Nurse Practice Educator/designee upon return to work. New staff during orientation will be provided education including posttest by the NPE/designee. 4. Resident smoking materials will be monitored in the medication room and signed out by the resident and signed back in with the nurse at the completion of smoke breaks across all shifts, 7 days per week. Audits will be conducted by Director of Nurses/designee daily across all shifts x 2 weeks then 3 x per week x 2 weeks then randomly thereafter to ensure that smoking materials are secured. 5. Trends identified will be reported by the Director of Nurses/designee monthly at the Quality Improvement Committee (QIC) for any additional follow up and/or in servicing until the issue is resolved and randomly thereafter as determined by the QIC committee.",2020-09-01
2032,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,692,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, the facility failed to ensure a resident received double protein portions as indicated on her tray card, and per her physician's orders [REDACTED].#98. Facility census: 114. Findings include: a) Resident #98 On 01/31/18 at 5:34 PM, an observation of Resident #98 revealed she was eating dinner in the facility's dining area. Further observation of Resident #98's tray ticket revealed she was supposed to receive double portions of protein. The physician's orders [REDACTED]. (MONTH) cursh medications with food as appropriate//double protein portions at all meals. Sip a mug and gray weighted utensils (knife, fork and spoon). The medical record revealed Resident #98 had a [DIAGNOSES REDACTED]. During an interview, with Director of Dining Services (DDS) #131, on 01/31/18 at 5:40 PM, she was asked if the resident had received a double portion of the beef stew which was the protein served for the meal. DDS #131 said she was not sure. She had Dietary Aide #108 measure out what she served and she showed DDS #131 a serving of one (1) scoop (4 ounces) of beef stew. DDS #131 said a regular serving would consist of two (2) four (4) ounce scoops. She told Dietary Aide #108 that Resident #98 should have received two (2) bowls of the beef stew rather just the one (1) bowl that she was served.",2020-09-01
2033,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,695,E,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to ensure resident's respiratory care needs are met and consistent with professional standards of practice. This failed practice had the potential to affect five out of five residents reviewed for respiratory care. Resident identifiers: #561, #108, #5, #36. Facility census: 114. Findings include: a) Resident # 561 Observation on 01/30/18 at 2:54 PM with Licensed Practical Nurse (LPN #25) found Resident #561 who has a tracheotomy (breathing tube) had no Ambu bag (emergency breathing bag) at the bedside as ordered. LPN #25 stated it was here before I had days off but is not here now. LPN #25 immediately found an Ambu bag and placed it on the residents bedside table. b) Resident #108 On 01/30/18 at 10:19 AM, observed Resident #108's uncovered nebulizer mask with connected tubing laying on top of nebulizer machine. No date was found to indicate when the nebulizer mask was placed into service and/or was due to be change. At 2:43 PM on 01/30/18. Licensed Practical Nurse (LPN #25) confirmed the nebulizer mask was not dated and not covered. On 01/30/18 at 3:06 PM, A review of the policy and procedure titled, Nebulizer: Small Volume stated in section 20.1, Place in treatment bag labeled with patient name and date. c) Resident #5 Observation on 01/29/18 at 1:32 PM, found Resident #5 lying in bed and wearing his oxygen via nasal cannula. Beside the bed was a nebulizer machine. The oxygen tubing, and the nebulizer tubing and mask, were dated 01/18/18. On 01/30/18 at 2:10 PM, the assistant director of nursing (ADON) #10 checked the tubings for dates. She agreed the oxygen tubing and the nebulizer tubing were dated 01/18/18. Upon inquiry, the ADON said she thought they were supposed to change the tubings weekly, but she needed to check the policy to be certain. She said she thought they changed the oxygen and nebulizer tubings every Thursday. She said she would ensure the replacement of both tubings and the nebulizer mask immediately. Review of the medical record on 02/02/18 found [DIAGNOSES REDACTED]. Review on 02/02/18 of the facility's policy on respiratory equipment found the schedule for supply changes for oxygen delivery devices and nebulizers were every seven (7) days. The revision date of this policy was 11/28/17. d) Resident #36 Resident #36 pertinent [DIAGNOSES REDACTED]. During initial tour of the facility on 01/29/18 at 2:15 PM, Resident #36's oxygen concentrator had a maximum capacity of five (5) liters of oxygen. Review of physician order [REDACTED]. On 02/01/18 at 12:53 PM, maintenance director, #31 explained the facility had one concentrator which would deliver up to ten (10) liters of oxygen, not being used at this time. At 3:35 PM on 02/01/18, licensed nurse (LPN) #27 explained a concentrator capable of meeting the [MEDICAL CONDITION] physician order [REDACTED].#36.",2020-09-01
2034,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,698,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy review the facility failed to ensure consistent communication between the [MEDICAL TREATMENT] unit and the facility. This was evident for one (1) of one (1) [MEDICAL TREATMENT] residents reviewed. Resident identifier: #5. Facility census: 114. Findings include: a) Resident #5 On 02/02/18 at 1:30 PM, the director of nursing (DON), showed the communication book they send with this resident to [MEDICAL TREATMENT]. In the book were the pre-and post- [MEDICAL TREATMENT] treatment weights, weights and the pre- and post-[MEDICAL TREATMENT] vital signs from the [MEDICAL TREATMENT] center. That was all that was in the communication book. When asked to provide evidence of pertinent labs for [MEDICAL TREATMENT] residents (e.g. potassium, sodium, PTH, serum alkaline [MEDICATION NAME], calcium, phosphorus, [MEDICATION NAME], magnesium, creatinine, urea nitrogen, URR, KTN, total protein, ALT, glucose, iron, ferritin, TIBC, etc.) she said they had none. Within fifteen (15) minutes the DON obtained a fax from the [MEDICAL TREATMENT] center with lab results for this resident for (MONTH) and (MONTH) (YEAR), and (MONTH) (YEAR). On 02/06/18 at 1:45 PM, the DON provided a copy of their NSG253 [MEDICAL TREATMENT] Communication and Documentation policy, with effective date 05/01/16. Per this policy, the facility was to communicate with the [MEDICAL TREATMENT] center prior to sending a patient for [MEDICAL TREATMENT] by completed the [MEDICAL TREATMENT] Communication Record and send it with the patient. The form would also be completed upon return of the patient from the [MEDICAL TREATMENT]. The purpose was To obtain highest continuum of care for patients receiving outpatient [MEDICAL TREATMENT] services. The facility practice standards stated a licensed nurse would complete the top portion of the [MEDICAL TREATMENT] Communication Record and send it with the patient to the [MEDICAL TREATMENT] center visit. Following completion of the out-patient [MEDICAL TREATMENT] treatment, the [MEDICAL TREATMENT] nurse should complete the form and return it or other communication to the nursing home with the patient. Step 4 directed to notify the [MEDICAL TREATMENT] center if the form is not returned with the patient and ask that it be faxed to the center. Step 4.1 stated to document notification of [MEDICAL TREATMENT] center regarding return of the form or other communication. On 02/06/18 at 1:45 PM, licensed practical nurse (LPN) supervisor #36 said the forms always come back blank from this [MEDICAL TREATMENT] center. She showed the form the facility sent with this resident to the [MEDICAL TREATMENT] center on 02/05/18. Review of the form found it contained the resident's name and the date of 02/15/18. The space for pre- and post- weight and vital signs was blank. LPN #36 said the [MEDICAL TREATMENT] center instead provided pre- and post-weights and vital signs in the communication book. Further review of this form, dated 02/05/18, included spaces for the following information, and that were all left blank: --Nausea, vomiting, diarrhea --[DIAGNOSES REDACTED] --Fluid bolus given --Level of consciousness change --Bleeding --Listing of medications given --Listing of behavior concerns --Additional concerns --Signature of the [MEDICAL TREATMENT] center nurse --Attach Lab Sheets for each visit About an hour prior to exit, the DON said she found one (1) summary by the [MEDICAL TREATMENT] unit's nurse practitioner. This summary was dated 02/01/18. The DON said it had not yet been filed in the medical record.",2020-09-01
2035,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,730,D,0,1,3TSK11,"Based on employee personnel file review and staff interview, the facility failed to ensure a performance review was conducted at least once every 12 months for one (1) of five (5) nurse aides reviewed. Employee identifier #26. Facility census: 114. Findings include: Review of employee personnel files on 02/01/18 at 11:10 AM revealed there was no performance appraisal review for (YEAR) for Employee #26. An interview with the Assistant Director of Nursing (ADON) on 02/01/18 at 6:00 PM confirmed no performance appraisal was in the employee file. At this time, the ADON provided a copy of a CNA Performance Appraisal ' dated 11/27/17, but was not signed by the supervisor or employee as being completed.",2020-09-01
2036,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,760,J,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, resident interview, pharmacist interview, laboratory policy review, and review of the facility's nursing drug handbook, the facility failed to monitor Resident #66 for an adverse drug interaction of which the pharmacy had made the facility aware of the potential to develop. The pharmacy had informed the facility of the need to monitor the [MEDICATION NAME] time/partial [MEDICAL CONDITION] time (PT/INR) levels for a resident receiving a macrolide antibiotic while receiving [MEDICATION NAME] (blood thinner). Taking these two (2) medications at the same time can increase the risk of the individual's blood becoming too thin. While taking the combination of these two drugs, Resident #66's PT/INR value reached a critical value requiring implementation of interventions that included sending the resident to the emergency room . The facility's failure to heed the pharmacist's warning was determined to constitute an immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to the health and well-being of residents. On 02/02/18 at 6:45 PM, the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. After removal of the immediate jeopardy, deficient practices remained at a level of E. The facility failed to ensure Resident #39 received ordered medications when readmitted from the hospital. Doses of an antibiotic and a blood thinner were omitted. Two (2) of twenty-three (23) residents reviewed during the facility's annual survey were affected. Resident identifiers: #66 and #39. Facility census: 114. Findings include: a) Resident #66 Observations on 01/29/18 at 4:13 PM, noted Resident #66 had a large bruise covering approximately one-third (1/3) of the skin surface on the top of her left hand. Review of the resident's medical record found she had [DIAGNOSES REDACTED]. Resident #66 was admitted to the facility on [DATE]. Her Brief Interview for Mental Status (BIMS) recorded on the minimum data set (MDS) with an assessment reference date (ARD) of 01/03/18 revealed Resident #66 was cognitively intact. A progress note on 01/15/18 described a change in condition of wheezes and coughing. The physician prescribed a one-time dose of [MEDICATION NAME] (a macrolide antibiotic) 500 milligrams (mg) given on 01/19/18 at 9:00 AM, then [MEDICATION NAME] 250 mg daily for four (4) consecutive days for an upper respiratory infection. Resident #66 received all doses of the [MEDICATION NAME] as ordered. While receiving the [MEDICATION NAME], Resident #66 also received [MEDICATION NAME] 5.0 mg on 01/19/18, [MEDICATION NAME] ([MEDICATION NAME]) 7.5 mg on 01/20/18, [MEDICATION NAME] 5.0 mg on 01/21/18, [MEDICATION NAME] 7.5 mg on 01/22/18 and [MEDICATION NAME] 5.0 mg on 01/23/18. A progress note, written on 01/24/18 by Licensed Practical Nurse (LPN) #77, noted Resident #66 was experiencing a mental status change and had a critical PT of 88.8 and a critical INR of 9.1. (The generally accepted normal range for INR in a resident receiving a blood thinner is 2 to 3.) A progress note on 01/24/18 at 12:53 PM by the APRN (Advance Practice Registered Nurse) revealed Resident #66, was assessed for evaluation and management of subtherapeutic INR of 9.1 with altered mental status. The nurse also noted the resident's altered mental status was not normal for the resident and that there was dried blood noted to several nail beds on her hands. At that time, Resident #66 was administered a dose of Vitamin K 10 mg (milligrams) by mouth and sent the emergency room for evaluation. An additional note by the APRN on 01/26/18 at 2:01 PM included, The patient was seen for follow up s/p (status [REDACTED]. In addition to vitamin K 10mg po (by mouth) given here prior to her transport to the ER, she was given an additional dose of 10mg in the ER as well. During her hospitalization she did have a severe nose bleed which lasted 4-5 hours which was managed by packing and transfusion of 2 units FFP (Fresh Frozen Plasma). Her [MEDICATION NAME] has been on hold; repeat INR this am (morning) was 1.4. At 10:54 AM on 02/02/18, a telephone interview with the general manager of the pharmacy used by the facility explained, [MEDICATION NAME] was filled for Resident #66 on 01/19/18. He went on to state that [MEDICATION NAME] was considered a level two (2) drug. A level two drug interaction refers to the risk of drug interaction with other drugs. The levels range from 1 to 5, with one being the most severe potential for drug to drug interaction. Upon delivery, the pharmacy included with the [MEDICATION NAME], a severity level 2 warning for selected anticoagulants/selected macrolide antibiotics with a patient management notification to closely monitor INR values in patients maintained on anticoagulants in whom macrolide antibiotics were initiated or discontinued. Review of Resident #66's medical records found no evidence the facility monitored or attempted to monitor the resident's PT/INR more closely than every seven (7) days, during the time she received [MEDICATION NAME] and [MEDICATION NAME] at the same time. On 02/02/18 at 2:45 PM, the Director of Nursing (DON) explained during stand-down on the evening of 01/19/18, the APRN voiced there was no concern related to drug interactions when giving [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) together. At 2:52 PM on 02/02/18, the APRN explained Resident #66 had refused to allow a PT/INR value to be monitored more than one time per week. When asked, if there was a consideration to monitor the PT/INR more closely while Resident #66 was receiving [MEDICATION NAME] the APRN she explained she did ask the physician for more frequent PTINR value blood draws, the physician 'saw' Resident #66's PT/INR values, knew of the prescribed [MEDICATION NAME] and still ordered the [MEDICATION NAME]. The APRN went on to state, I think it was appropriately monitored and addressed. On 02/02/18 at 3:15 PM, Resident #66 explained that she did complain about having to have her blood drawn so often and it was decided a PT/INR value would be drawn one (1) time per week. Resident #66 went on to explain she voiced concerns about being allergic to [MEDICATION NAME] and was told this medication was not on her allergy list. She went on to state she did not remember staff explaining to her the potential [MEDICATION NAME]/[MEDICATION NAME] drug interaction or asking her for permission to obtain a blood draw more often to monitor her PT/INR while taking [MEDICATION NAME]. During an interview on 02/02/18 at 3:43 PM, LPN #77 said she had not read the pharmacy warning sent with the [MEDICATION NAME]. When asked to find a warning in the resident's medical record about the potential problem of giving [MEDICATION NAME] due to a critical drug interaction with [MEDICATION NAME], LPN #77 could not. On 02/02/18 at 3:50 PM, a request to the medical director to find a notification placed in the medical records since the incident of [MEDICATION NAME] and [MEDICATION NAME] causing a severe drug interaction with Resident #66. The medical director stated there was no evidence in the medical records that [MEDICATION NAME] should not be given to Resident #66. A review of the facility's Nursing Drug Handbook (YEAR), provided by the DON on 02/02/18 at 3:55 PM, found it included a drug-drug interaction between [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) with a warning the INR might increase and should be monitored carefully. The facility's failure to heed the pharmacist's warning and monitor the resident's PT/INR was determined to constitute and immediate jeopardy to the health and well-being of residents. On 02/02/18 at 2:34 PM, the facility's administrator was notified that the facility's failure to monitor Resident #66, and identify the adverse drug interaction for which the pharmacist had alerted the facility of the potential to occur, constituted an Immediate Jeopardy (IJ) to health and well-being of residents. On 02/02/18 at 6:45 PM the facility provided an acceptable plan of correction (P[NAME]) and the IJ was abated after verifying implementation of the P[NAME]. The P[NAME] included: an assessment of the resident, education of the licensed nurse receiving the macrolide antibiotic, education of the advanced practice registered nurse (APRN) to consider drug interactions and to comply with professional standards. Education to all nurses regarding the potential for [MEDICATION NAME] and antibiotic drug interaction and reporting the potential to the prescribing physician. Adding a warning alert to the medical records of a resident receiving [MEDICATION NAME] and prescribed an antibiotic. A scheduled review of all new physician orders, nursing notes for antibiotics including lab results for residents who receive [MEDICATION NAME] and any drug interaction received from pharmacy to ensure the physician and APRN has been notified prior to administer the medication and to identify trends and report to the Quality Improvement Committee (QIC) for additional follow up until the issue is resolved. After removal of the immediate jeopardy deficient practices remained at a level of E. The facility failed to ensure Resident #39 received medications as ordered when the resident returned from a hospital stay. The omitted medications included [MEDICATION NAME] (a blood thinner) 5000 units every 8 hours. b) Resident #39 A review of the resident's medical record revealed [REDACTED]. Coli bacteremia, and pneumonia. A review of the Physician order [REDACTED]. Further review of the medical record revealed the medication was not given every eight (8) hours as ordered. The administration of the antibiotic was not started until 02/15/18. Through an interview with the Director of Nursing (DON) on 02/06/18 at 10:15 AM, it was revealed the medication was not started as ordered when Resident #39 returned from the hospital because Nurse #69 failed to document the orders on the correct sheet, and failed to transcribe the orders correctly onto the Medication Administration Record [REDACTED]. A review of the Medication Administration Record [REDACTED]. An interview with the DON at 10:15 AM confirmed that due to the transcription errors when the resident returned, medication orders were not transcribed and implemented.",2020-09-01
2037,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,770,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and review of facility agreements for laboratory services, the facility failed to provide or obtain quality and timely laboratory services to meet the needs of one (1) of twenty-three (23) sampled residents. Resident identifier #110. Facility census: 114. Findings include: a) Resident #110 A review of the medical record for Resident #110 on 02/02/18, revealed a physician's orders [REDACTED]. There was documentation that the lab specimen was collected, however, no results were found in the medical record for this date. On 02/02/18 at 3:35 PM, the Assistant Director of Nursing (ADON) was interviewed and asked to provide the lab result for the lab ordered to be done on 01/18/18. The ADON stated there was no information on the medical record and she had called and requested the lab result to be faxed from the laboratory. The ADON was informed at this time, the specimen had clotted and the lab value was not obtained. On 02/06/18 at 10:40 AM, the Director of Nursing (DON) was interviewed which revealed that the blood was drawn on 01/18/18 but the specimen had clotted and no notification or results had been received by the facility. A review of the laboratory result sent to the facility on [DATE] at 18:26 stated [MEDICATION NAME]- request credited, specimen clotted. There was no notation that the facility had been notified of the error occurring or that the lab result ordered by the physician for 01/18/18 could not be obtained. A review of the laboratory agreement on 02/02/18 stated that all critical results will be called to Brightwood Center. Lab reports will be faxed daily to Brightwood Center and Hard Copies will be delivered the next morning either by phlebotomist or courier. Further interview with the DON on 02/06/18 at 10:40 AM, revealed that the facility failed to follow-up when the lab result was not returned to the facility in a timely manner.",2020-09-01
2038,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,775,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure laboratory reports were obtained and/or filed in the residents medical records for one (1) of twenty-three (23) sampled residents. Resident identifier: #16. Facility census: 114. Findings include: a) Resident #16 Medical record review on 02/02/18 found this resident with [DIAGNOSES REDACTED]. Her physician ordered a blood thinner, [MEDICATION NAME], daily in varying dosages to prevent blood clots. The physician ordered a laboratory test, PT/INR ([MEDICATION NAME] Time/International Normalized Ratio), periodically as a basis in which to determine the daily dosage of [MEDICATION NAME]. PT is a measure of how quickly blood clots. The results of the PT test is converted into standard units known as INR. INR is a calculation based on a PT that is used to monitor treatment with blood-thinning medications (i.e. [MEDICATION NAME]). An INR range of 2.0 - 3.0 is generally an effective therapeutic range for people who take [MEDICATION NAME] for disorders such as [MEDICAL CONDITION] or a blood clot in the leg or lung. If a [MEDICATION NAME] dose is too high, the patient may bleed too easily. If the dose is too low, the patient's blood may clot too easily. On 01/02/18, the physician ordered [MEDICATION NAME] five (5) milligrams (mg) every Sunday, Tuesday, Thursday, and Saturday. The physician ordered [MEDICATION NAME] 3.5 mg. every Monday, Wednesday, and Friday. This dosage was based on the 01/02/18 INR of 2.2. The physician ordered a repeat of the PT/INR in two (2) weeks. Review of the medical record on 02/02/18 found no evidence of PT/INR results on or near 01/16/18. An interview was completed with the director of nursing on 02/02/18 at 7:00 p.m. She was unable to provide evidence of a PT/INR test on or near 01/16/18. The DON contacted the lab at this time, and found via a fax from the lab at this time, that a PT/INR was completed on 01/13/18 (rather than on 01/16/18). The INR result on 01/13/18 was 3.6. According to the (name of hospital's) reference range, an INR of 3.0 to 4.0 was considered high intensity [MEDICATION NAME] therapy. Whereas in comparison, an INR of 2.0 to 3.0 was considered Moderate intensity [MEDICATION NAME] therapy. Upon inquiry as to whether the physician was notified of this elevated INR result, the DON replied in the negative. She said the 01/13/18 PT/INR result was not recorded on the facility's Flow Sheet for monitoring residents taking [MEDICATION NAME], so she assumed either the lab test may not have made it to the nursing home, or it was misfiled. The last recorded information on this resident's Flow Sheet was 12/16/17. The DON said the Flow Sheet for this resident was resumed yesterday on 02/05/18. Upon inquiry, she confirmed again that she could find no evidence that the physician was notified of the 01/13/18 elevated INR result. Further review of the medical record revealed evidence that the resident showed signs of a change in condition from 01/13/18 when the INR was elevated at 3.6, until the date of the next PT/INR which occurred on 01/23/18 with a critical INR value of 8.9 , as follows: --01/19/18 nurse progress note 5:00 p.m. said the resident stated she was not feeling well, like she was going to thrown up --01/19/18 nurse progress note 5:05 p.m. said a nursing assistant came to this nurse and stated the resident was not looking good. When approached by the nurse, the resident seemed very confused and shaky and could hear mucous in throat. The nurse called the hospice to come look at the resident. --01/19/18 at 8:00 p.m. nurse progress note said hospice came in to see the resident. New orders were received to start [MEDICATION NAME] four (4) drops every four (4) hours as needed (prn) sublingually for secretions; start [MEDICATION NAME] treatments via nebulizer every four (4) hours prn for wheezing; increase Roxinal to five (5) mg. sublingually every one (1) hour prn. --01/20/18 nurse progress note at 4:39 a.m. said the family was at the bedside at this time due to declining condition. --01/20/18 nurse progress note at 3:19 p.m. assessed her skin color as pale, lethargic at times, apical pulse [MEDICAL CONDITION] at 119 beats per minutes, no food intake this shift. --01/21/18 nurse progress note at 12:45 p.m. assessed a heart rate ranging from 88 - 157 beats per minute. The resident had increased alertness today yet remains to have a poor oral intake. --01/23/18 1:36 p.m. nurse progress note assessed her left and right sides, back and buttocks have purplish, red rashy areas, notified (name of doctor), received new orders--PT/INR now--give [MEDICATION NAME] TID (three times daily) for two (2) days. --01/23/18 3:36 p.m. nurse progress note addressed they received new orders for Vitamin K five (5) milligrams (MD) once, hold [MEDICATION NAME], and repeat INR Thursday 01/25/18. --01/23/18 2:42 p.m. General Note - Resident has had an overall decline in health recently. Critical lab values were addressed with the physician with new orders. Poor oral intake. --01/25/18 9:05 p.m. Care Plan Evaluation Note - new orders for [MEDICATION NAME] 0.5 mg orally prn every four (4) hours as needed for agitation. Review of the medical record found the PT/INR on 01/23/18 was PT 86.4 and INR 8.9. The INR on 01/25/18 was back to the therapeutic level of 2.2. The physician at that time ordered to resume the previous [MEDICATION NAME] dose on Monday 01/29/18. The INR on 01/29/18 was 1.5, and the physician gave orders for daily [MEDICATION NAME] doses until the next PT/INR in one (1) week. Observation of the resident on 02/02/18 at 7:00 p.m. found that she had a small, green- colored bruise to the top of each hand. The one is circular about one inch in diameter. The other is about two inches long and narrow.",2020-09-01
2039,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,804,E,0,1,3TSK12,"Based on observation, staff interview and resident interview, the facility failed to ensure that food was served at a safe and appetizing temperature for randomly tested resident meal trays served on the unit. This practice has the potential to effect more than a limited number of residents. Facility Census: 113. Findings included: Observations of breakfast meal delivery, on 04/10/18. Food temperatures obtained by Dietary Staff #101, at 08:10 AM, revealed that hot foods were served at a temperature below the accepted temperature of 120 degrees Fahrenheit (F) as evidenced by the cream of wheat was 117 degrees F and the scrambled eggs were 107 degrees F. An interview, on 04/10/18 at 07:40 AM, Dietary Staff #101 revealed trays are sitting over an hour; I don't know how temperatures can be good. An interview with the Administrator, on 04/10/18 at 10:15 AM, revealed the facility did not realize they had a problem in that area. A confidential resident interview revealed food is sometimes cold when you eat in your room.",2020-09-01
2040,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,812,E,0,1,3TSK11,"Based on observation and staff interview, the facility failed to ensure food was stored and served food under sanitary conditions. Observations revealed a kitchen staff member with long artificial nails preparing food with ungloved hands. Another kitchen staff member wore multiple rings while serving food on the tray line. An observation in the nutrition room on the B-C hall found food not dated and/or labeled and the microwave had a rusting interior. An additional observation found uncovered cake being served to residents. These practices had the potential to affect more than a limited number of residents. Facility census: 114. Findings include: a) Kitchen On 01/29/18 at 12:25 PM, Cook #109 observed making hamburger patties. She had long artificial nails. She was not wearing gloves. She used a scoop to pick up meat, placed it on sheet pan. Pressed down hamburger pattie with plastic covered plate. Cook #109 stated, I didn't know I had to wear gloves unless I was actually touching the food. Cook #109 put gloves on. At 12:28 PM on 01/29/18, Cook #105 observed serving food on the tray line with right hand not gloved. She had a three (3) band stone ring on ring finger hand. The left hand gloved with a studded ring on the ring finger. Cook #105 stated, I didn't know I couldn't wear rings in the kitchen. Cook #105 removed the rings. In an interview on 01/29/18 at 12:32 PM Dietary Manager (DM) stated, I was not aware that staff could not wear rings in the kitchen or have uncovered artificial nails. b) B-C Hall Nutrition Room On 02/01/18 at 4:46 PM, tour with the DM found food found not labeled and dated as to when the was placed in the refrigerator. The DM opened the container and stated, It was from yesterdays meal. The DM disposed of the food. The cranberry juice had no label on the pitcher. The DM agreed the cranberry juice should have been labeled and dated. The interior of the microwave contained splatters of food and there was rust around the swivel plate and around the interior back of the microwave. The microwave was shown to the NHA on 02/01/18 at 5:03 PM and she removed the microwave from the nourishment room. A label on the inside of the microwave noted the unit was made in 2002. c) During evening meal observations on 01/31/18 at 6:24 PM, staff were observed delivering meal trays to residents who ate in their rooms. The tray contained pieces of iced cake served on a plate that was not covered to prevent the physical contamination of the uncovered food items as the tray was being carried down the unit hallway. An interview with the Director of Dining Services on 02/01/18 revealed that the facility did not have a policy ensuring the safe and sanitary practices of distributing food iitems to residents who ate their meals in their rooms.",2020-09-01
2041,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,842,E,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, and staff interview the facility failed to ensure they maintained accurate and complete medical records for two (2) of 23 residents. Resident #111's medical record did not contain accurate and complete information regarding the resident's death. Resident t#69's medical record did not contain documentation of the self ham the resident inflicted. Resident identifiers: #111 and #69. Facility census: 114. Findings include: a) Resident #111 A review of Resident #111's medical record revealed the resident was deceased . The progress note dated [DATE] stated the resident had passed away at the hospital. There were no prior progress notes reflecting when the resident was discharged to the hospital. A progress note dated [DATE] stated, Received a call from the [MEDICAL TREATMENT] social worker this morning and updated her on current condition and POA (power of attorney) requests. Hospice in this morning and spoke with family. Resident continues to be confused, restless, constantly picking at her tessio dressing, removing her o2 (oxygen), and removing her gown. She has eaten very little and unable to take her medicine. SpO2 (oxygen saturation) 67% while constantly removing the n/c (nasal cannula). She was incontinent of bowel and bladder and had her hands in it and smearing it on her body and bed. Orders were given to discontinue the fluid restriction, labwork and Kaexylate (medication used to treat high potassium levels in the blood). She will attend the scheduled testing at (local hospital) on the first and the third. During an interview with the administrator on [DATE] at 9:36 AM, the administrator said the resident actually expired on [DATE] while at an appointment at a local hospital. The administrator agreed that the medical record was incomplete and inaccurate regarding Resident #111 and the events surrounding the time/date she expired. b) Resident #69 A review of the medical record for Resident #69 from [DATE] through [DATE] revealed a change of condition note by Licensed Practical Nurse (LPN #25). The note stated on [DATE] at 1800 (6:00 PM) resident attempt to self harm in the afternoon. Although the physician was notified and Resident #69 was transferred to an acute care hospital within thirty (30) minutes, the medical record failed to show any evidence of or explain what self harm the resident attempted. On [DATE] at 2:07 PM, the NHA was asked to assist in finding any evidence in the medical record that provided information regarding what self harm occurred and/or did not occur. The NHA responded to the request on [DATE] at 2:55 PM with multiple copies of the nursing notes and stated No information could be found as to what self harm occurred or did not occur. In addition, she stated she had called the LPN who wrote the note and requested her to come to the facility the following day to clarify what self harm meant. On [DATE] at 12:10 PM, an interview was conducted with LPN #25. She stated staff came and said the resident had broken off a little piece of a plastic star and was trying to cut herself on the wrist. Resident #69 further stated the men were coming that night and to protect her roommate and she would have to to kill herself. LPN #25 agreed she forgot to document a description of what had happened in the change of condition note and did not post a late entry note to fully describe the incident. This resulted in an inaccurate and incomplete medical record.",2020-09-01
2042,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,867,F,0,1,3TSK12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, staff interview, resident interview, facility documentation review, and policy review, the facility failed, through the quality assessment and assurance, to develop and implement appropriate plans to correct identified and cited deficiencies. This practice had the potential to affect all resident residing in the facility. Facility census 113. Findings included: a) Quality of care 1) Resident #22 An observation of Resident #22, on 04/10/18 at 1:35 PM, revealed the Resident was receiving oxygen, via nasal cannula, at six liters. An interview with Licensed Practical Nurse (LPN) #120, on 04/10/18 at 1:40 PM, revealed the LPN was the nurse caring for Resident #22. The LPN stated, I do not think he gets any oxygen but I am not sure. Another interview with LPN #120, on 04/10/18 at 1:50 PM, revealed she could not find any orders for oxygen for the Resident. The LPN stated if the Resident is receiving oxygen it should be documented on the Treatment Administration Record (TAR) or the Medication Administration Record [REDACTED]. The LPN stated she did not put the oxygen on the Resident. An interview with Resident #22, on 04/10/18 at 1:55 PM, revealed the Resident stated a nurse put my oxygen on. The resident stated I usually have oxygen on. An interview with the Director of Nursing (DON), on 04/10/18 at 2:00 PM, revealed the Resident should be receiving oxygen at three liters via nasal cannula continuously, not six liters. The DON stated the resident had been receiving oxygen since he was admitted in (MONTH) of (YEAR). The DON stated she could not find an order for [REDACTED]. A review of Resident #22's physician's orders [REDACTED]. The Resident had an order, dated 12/01/17, for Pulse Oximeter Checks Every Shift-Titrate To Keep Stats Above 90%. A review of the MARs and TARs revealed there were no oxygen orders on either documents. A review of the Care Plan was conducted on 04/10/18 at 2:45 PM. The Care Plan, with a creation date of 06/08/17, contained the focus the [MEDICAL CONDITION] with the intervention Administer oxygen as ordered. An interview with the DON, on 04/11/18 at 8:45 AM, revealed Resident #22 did not have an order for [REDACTED]. b) Free of accident hazards 1) Shower Room A random observation of the facility's [NAME] Hall Shower Room, on 04/10/18 at 7:00 AM, revealed the shower room was not locked. The shower room contained the following items: -Three (3) uncapped shaving razors lying on top of a bucket -Two (2) containers of Medline Shampoo and Body Wash with the warning Keep out of reach of children-For external use only-Avoid contact with eyes were on the floor. -A sign to staff members that stated DO NOT leave personal items, razors, linens, or briefs in the shower room. An interview with Licensed Practical Nurse (LPN) Supervisor #130, on 04/10/18 at 7:15 AM, revealed the razors and body wash should have never been left unattended in the shower room. The LPN Supervisor stated she would ensure the items would be put away immediately. 2) Nutrition Room An observation of the A-Side Nutrition Room, on 04/11/18 at 9:00 AM, revealed a glass vase sitting on top of the cabinets in the room. An interview with LPN #140, at 04/11/18 at 9:05 AM, revealed the vase should have never been placed on top of the cabinets. The LPN stated the vase could have easily fallen off and caused it to break. The LPN removed the vase. c) Respiratory care 1) Resident #22 An observation of Resident #22, on 04/10/18 at 1:35 PM, revealed the Resident was receiving oxygen, via nasal cannula, at six liters. An interview with Licensed Practical Nurse (LPN) #120, on 04/10/18 at 1:40 PM, revealed the LPN was the nurse caring for Resident #22. The LPN stated I do not think he gets any oxygen but I am not sure. Another interview with LPN #120, on 04/10/18 at 1:50 PM, revealed she could not find any orders for oxygen for the Resident. The LPN stated if the Resident is receiving oxygen it should be documented on the Treatment Administration Record (TAR) or the Medication Administration Record [REDACTED]. The LPN stated she did not put the oxygen on the Resident. An interview with Resident #22, on 04/10/18 at 1:55 PM, revealed the Resident stated a nurse put my oxygen on. The resident stated I usually have oxygen on. An interview with the Director of Nursing (DON), on 04/10/18 at 2:00 PM, revealed the Resident should be receiving oxygen at three liters via nasal cannula continuously, not six liters. The DON stated the resident had been receiving oxygen since he was admitted in (MONTH) of (YEAR). The DON stated she could not find an order for [REDACTED]. A review of Resident #22's physician's orders [REDACTED]. The Resident had an order, dated 12/01/17, for Pulse Oximeter Checks Every Shift-Titrate To Keep Stats Above 90%. A review of the MARs and TARs revealed there were no oxygen orders on either documents. A review of the Care Plan was conducted on 04/10/18 at 2:45 PM. The Care Plan, with a creation date of 06/08/17, contained the focus the [MEDICAL CONDITION] with the intervention Administer oxygen as ordered. An interview with the DON, on 04/11/18 at 8:45 AM, revealed Resident #22 did not have an order for [REDACTED]. d) Food storage and labeling 1) Observations of the B side nourishment station, on 04/11/18, at 09:35 AM, revealed sliced bread in the dry storage cabinet that was unsealed and not dated or labeled. Additionally, a package of Thick and Easy powder was open and in a drawer with the contents spilled out. An interview with Staff #1 confirmed the presence of the items and stated that she did not know what or who the bread was for and stated further she would throw it away. 2) Observations of the A side nourishment station on 04/11/18, at 09:40 AM, revealed several slices of yellow cheese that was not sealed with no label or date visible. Additionally, a Lean Crusine frozen meal was observed in the freeze with an expiration date of (MONTH) (YEAR). Interview with Staff #2, on 04/11/18 at 09:40 AM, revealed that the cheese had not been there yesterday and confirmed the expiration date on the Lean Crusine frozen meal to be (MONTH) (YEAR). Staff #2 stated all resident snacks are to be sealed and labeled. e) Medical records 1) Resident #22 An observation of Resident #22, on 04/10/18 at 1:35 PM, revealed the Resident was receiving oxygen, via nasal cannula, at six liters. An interview with Licensed Practical Nurse (LPN) #120, on 04/10/18 at 1:40 PM, revealed the LPN was the nurse caring for Resident #22. The LPN stated I do not think he gets any oxygen but I am not sure. Another interview with LPN #120, on 04/10/18 at 1:50 PM, revealed she could not find any orders for oxygen for the Resident. The LPN stated if the Resident is receiving oxygen it should be documented on the Treatment Administration Record (TAR) or the Medication Administration Record [REDACTED]. The LPN stated she did not put the oxygen on the Resident. An interview with Resident #22, on 04/10/18 at 1:55 PM, revealed the Resident stated a nurse put my oxygen on. The resident stated I usually have oxygen on. An interview with the Director of Nursing (DON), on 04/10/18 at 2:00 PM, revealed the Resident should be receiving oxygen at three liters via nasal cannula continuously, not six liters. The DON stated the resident had been receiving oxygen since he was admitted in (MONTH) of (YEAR). The DON stated she could not find an order for [REDACTED]. A review of Resident #22's physician's orders [REDACTED]. The Resident had an order, dated 12/01/17, for Pulse Oximeter Checks Every Shift-Titrate To Keep Stats Above 90%. A review of the MARs and TARs revealed there were no oxygen orders on either documents. A review of the Care Plan was conducted on 04/10/18 at 2:45 PM. The Care Plan, with a creation date of 06/08/17, contained the focus the [MEDICAL CONDITION] with the intervention Administer oxygen as ordered. An interview with the DON, on 04/11/18 at 8:45 AM, revealed Resident #22 did not have an order for [REDACTED]. f) Infection control 1) E-Hall Shower Room A random observation of the facility's [NAME] Hall Shower Room, on 04/10/18 at 7:00 AM, revealed the shower room was not locked. The shower room contained the following items: -Three (3) buckets of water sitting under the shower chairs -Five (5) latex gloves on the floor An interview with Licensed Practical Nurse (LPN) Supervisor #130, on 04/10/18 at 7:15 AM, revealed the gloves should have never been thrown onto the floor. The LPN stated she was not sure why the buckets of water were there. The LPN Supervisor stated she would ensure the items would be discarded immediately. 2) A-Side Shower Room A random observation of the facility's A-Side Shower Room, on 04/10/18 at 7:30 AM, revealed the shower room was not locked. The shower room contained the following items: -Three (3) latex gloves on the floor -Two (2) buckets of water sitting under the shower chairs An interview with LPN #150, on 04/10/18 at 7:35 AM, revealed the gloves should have been placed in the trash, not the floor. The LPN stated sometimes the staff places the buckets underneath the shower chairs during showers. The LPN stated she would ensure the gloves would be thrown away and the buckets emptied.",2020-09-01
2043,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,880,F,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, review of infection control surveillance records, review of manufacturer's guidelines for the facility's glucometers and staff interview, the facility failed to maintain an effective infection prevention and control program to the fullest extent possible over which it had control. Review of the facility's infection control monthly surveillance records found instances where the results of cultures were not identified, and a multi-drug resistant organism (MDRO) was not listed on the facility's MDRO surveillance line listing. The facility could provide no evidence that it conducted an annual review of its infection prevention and control program annually. Resident #107's nebulizer mouthpiece was not stored properly to prevent potential contamination. Resident #512's intravenous catheter site was potentially contaminated by a nurse when she touched it inappropriately. A nurse failed to wash and/or sanitize her hands following a fingerstick blood glucose test on a resident. The same nurse then completed a fingerstick blood glucose test on another resident (Resident #511) with her unwashed and unsanitized hands. A nurse failed to disinfect a resident-shared glucometer after completing a fingerstick blood glucose test on Resident #63. A nursing staff employee contaminated her gloves by picking up and moving a floor mat with her gloved hands, then proceeded to provide pericare to Resident #108 with the same contaminated gloves. The nursing staff employee obtained one (1) wet washcloth and provided pericare to Resident #108. She wiped the resident with the washcloth, and used the same wash cloth folded over to wipe the resident two (2) more times. She also wiped over an open wound with the same contaminated wash cloth. These practices had the potential to affect all residents in the facility. Resident identifiers: #76, #2, #105, #612, #57, #39, #61, #69, #462, #46, #107, #512, #511, #63, #108, #16, and #84. Facility census: 114. Findings include: a) Infection control surveillance records On 02/01/18 at 9:00 AM, the facility's infection control surveillance records were reviewed with infection control registered nurse (RN) #87. Numerous instances were identified where the organisms from a culture were not identified as follows: 1. Resident #76 had a left leg wound culture on 11/05/17. The culture results were documented as positive on the infection control (IC) monthly line listing, and he was ordered an antibiotic (Keflex) orally for seven (7) days. The organism was not identified on the monthly line listing. 2. Resident #2 was treated in an emergency room where antibiotic therapy was initiated on 11/24/17 ([MEDICATION NAME]). The IC monthly line listing noted the culture site was urine. The organism was not identified on the monthly line listing. 3. Resident #105 was prescribed an antibiotic beginning on 11/25/18 ([MEDICATION NAME]). The monthly line listing under the heading culture/chest x-ray said only the word urine, with no date inscribed. The organism was not identified on the monthly line listing. 4. Resident #612 had a urine culture result greater than 100,000 colony count, and was prescribed an antibiotic ([MEDICATION NAME]). The date of the onset and the date of the urine culture were not reported on the monthly line listing. The name of the organism was not identified on the monthly line listing. 5. Resident #57 on 12/05/17 had a urine culture greater than 100,000 colony count, and was prescribed an antibiotic (Bactrim). The organism was not identified on the monthly line listing. 6. Resident #16 on 12/12/17 was positive for ESBL in the urine according to the monthly line listing. She was prescribed antibiotic therapy. Review of the (MONTH) (YEAR) multi-drug resistant organism (MDRO) line listing did not include the ESBL. 7. Resident #39 on 12/22/17 had a positive blood culture according to the IC monthly line listing. She was prescribed antibiotic therapy ([MEDICATION NAME]). The organism was not identified on the monthly line listing. 8. Resident #61 came to the facility from the hospital on [DATE] with antibiotic therapy ([MEDICATION NAME]). Under the section on the monthly line listing titled Culture/chest x-ray, was written urinary tract infection from hospital. There was no organism identified on the monthly line listing. 9. Resident #69 had a positive urine culture on 12/29/17 with a colony count greater than 100,000. She was prescribed antibiotic therapy (Keflex). The organism was not identified on the monthly line listing. During an interview with RN #87 on 02/01/18 at 10:00 AM she said the hospital did not always send the culture results with the resident, and in some instances that was why the results of the culture did not contain the organisms. She said that going forward, she would contact the hospital and obtain all culture results if not sent with the resident, to ensure that she knows the organisms located on each of the facility's halls. She said she failed to record on the (MONTH) MDRO Line Listing the identified ESBL in the urine of Resident #16. She stated that was the exception rather than the rule, as she always has MDRO surveillance up to date. She said she would include that ESBL immediately on the MDRO Line Listing. 11. Per the (MONTH) (YEAR) infection control monthly line listing, two (2) residents were treated with antibiotics and/or antibiotic eye drops for symptoms of eye infection. According to the monthly line listing, Resident #462 on 12/04/17 had green drainage from both eyes. Beneath the heading of symptoms/[DIAGNOSES REDACTED].#46 on 12/15/17 under the heading of symptoms/[DIAGNOSES REDACTED]. This resident was prescribed antibiotic eye drops for two (2) weeks. The former was listed on the monthly infection control report for C hall. The latter was not included on the monthly infection control report. During an interview with RN #87 on 02/01/18 at 10:00 AM, he said Resident #462 met criteria for a true infection, while Resident #46 did not meet the criteria. She said she ensures that besides meeting the constitutional criteria, that they also meet one or more other criteria. We discussed tracking and trending and the ability to detect any patterns on the hall to enable investigates for potential causes of symptoms and/or infections within the facility. Upon inquiry as to whether the facility had any maps or floor plans to denote which residents in which rooms had various types of symptoms and/or infections to enable them to better track and trend for pockets within the building, she replied in the negative. She said that going forward, she planned to utilize a floor plan to show at a glance the various types of illness (e.g. gastroenteritis, wound, urinary, eye, etc.) and their locations (room numbers) within the facility. An interview was attempted on 02/01/18 with the administrator at 1:00 PM. She said to relay the information about infection control to the director of nursing (DON). An interview was completed with the DON on 02/01/18 at 1:30 PM. She said she spoke with the infection control nurse. The DON said that going forward they will utilize a map of the facility to denote the locations of the various types of infections and/or symptoms to better enable them to track and identify trends in the various units. She said the infection control nurse tallies the infections per hall per month based on their meeting McGreer's criteria. The DON said that going forward, the infection control nurse will obtain and include on the monthly line listings the names of organisms cultured, including accessing hospital records when needed to obtain that information. Another interview was completed with the DON on 02/02/18 at 9:30 AM. She said she was unable to find evidence that their infection control policies and procedures (ICPP) are reviewed annually. She said the thought they were reviewed annually, but was unable to provide proof to that effect. The DON said they used to have a nurse practice educator (NPE) who took care of that sort of thing, but she no longer works at the facility. She said they looked into the former NPE's files going back through (MONTH) (YEAR), and could find no evidence to show the policies were reviewed annually. b) Resident # 107 Observation during initial tour of the facility on 01/29/18 at 2:00 PM, found Resident #107's nebulizer mouth piece laying on the beside stand without a clean barrier between it and other items on the beside stand. On 01/30/18 at 1:50 PM observation found the nebulizer mouthpiece, again, laying on the beside stand without a clan barrier between it and other items on the bedside stand. At 2:00 PM on 01/30/18 the DON observed the nebulizer mouthpiece laying on the beside stand without a clean barrier between it and other items on the beside stand. The DON stated the nebulizer mouthpiece should be in a bag to prevent the potential for contamination. c) Resident #512 On 01/29/18 at 1:45 PM Resident #512 expressed concern about the quality of infection control practiced by registered nurse (RN) #69. Observation of Resident #512 found an intravenous (IV) site to the right arm, used to administer [MEDICATION NAME] (antibiotic). The IV site bandage was pulling loose from all sides and had no documented date, time or initial. Again observation of the IV site on 01/30/18 at 11:14 AM, found the bandage to be pulling loose from all sides of the bandage and less intact than the previous observation. Registered nurse #69 entered the room to flush the IV site. While completing the care RN #69 tapped the bandage, several times, with an ungloved hand and stated she would change the bandage later in the day. Registered Nurse (RN) #69 then left the room without washing her hands. On 01/30/18 at 4:00 PM, the DON changed the IV site bandage using correct nursing practice. At 10:45 AM on 02/06/18, the DON agreed RN #69 should not have touched the bandage covering the IV site without a gloved hand. d.) Resident #84 and #511 During dining observations on 1/30/18 at 12:15 PM, RN #69 was observed doing an Accu check blood glucose monitoring test on Resident #84 while he was seated at the dining room table. Nurse #69 removed the gloves after completing the blood test, put used supplies in the glove and proceeded to where Resident #511 was seated. Employee #69 put on another pair of gloves and performed an Accu check blood glucose monitoring test on Resident #511, without washing or sanitizing her hands in between residents. During an interview on 1/30/18 at 3:23 PM, RN #69 stated she did not wash or sanitize her hands after completing care for one resident before going on to the next resident. Employee #69 further stated that she did not know if she could wash her hands in the dining room since it was meal time. Review on 1/30/18, of the facility policy for Hand Hygiene, Revision Date: 11/28/17, verified that staff should perform hand hygiene after any contact with blood or other body fluids, even if gloves are worn; and after patient care. e) Resident #63 On 02/01/18 at 08:16 AM, Licensed Practical Nurse (LPN #77) was observed cleaning a glucometer with a 70% alcohol pad and did not disinfect the glucometer. LPN #77 preceded to take the glucometer and meter test strips and place them on the bed of Resident #63. The glucometer was again cleaned with a 70% alcohol pad with no disinfection and the meter test strips were placed back in the medication cart. A review of the manufacturer's instructions on 02/01/18 at 9:08 AM, revealed the manufacturer recommended four (4) EPA (Environmental Protection Agency) approved disinfecting wipes with no mention of alcohol being approved as a disinfecting agent. At 9:40 AM on this same day, the Nursing Home Administrator (NHA) was informed of the meter testing strips and glucometer being place on the residents bed.; no disinfection of the glucometer; and the contaminated equipment being placed back in the medication cart. The NHA stated we will have to discard the meter test strips and disinfect the medication cart immediately. This is not right. In an interview with the NHA and LPN #77 at 9:46 AM on 02/01/18, LPN #77 was requested by the NHA to immediately meet with the Nurse Educator regarding retraining on how to prevent contamination of multi-use resident equipment and disinfection of equipment prior to using with a resident and placing back in the medication cart. The NHA stated the medication cart required cleaning and disinfection immediately and the meter testing strips discarded. f) Resident #108 On 02/06/18 at 11:57 AM, an observation of incontinence care with Nursing Assistant (NA #30) found with gloved hands, NA #30 picked up the fall mat and then preceded to remove Resident #108's clothing and incontinence brief with the contaminated gloves. When interviewed prior to completing the incontinence care, NA #30 agreed she should have changed her gloves. She immediately changed her gloves without washing her hands or using hand sanitizer. During the incontinence care, Resident #108 had a bowel movement and NA #30 proceeded to clean stool from the resident by folding the washcloth over several times as it became soiled. During this cleaning process, she also clean open macerated skin on the resident's coccyx and sacrum (tail bones) area with the contaminated gloves and wash cloth. When asked about using the same contaminated wash cloth, NA #30 stated but I folded the wash cloth over. NA #30 changed her gloves again without washing her hands or using hand sanitizer. In an interview with the NHA, on 02/06/18 at 1:07 PM, she agreed the NA had not followed followed the steps to provide incontinence care for Resident #108.",2020-09-01
2044,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-02-06,883,D,0,1,3TSK11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure all eligible residents received and/or were offered pneumococcal vaccinations. This was evident for two (2) of five (5) residents reviewed for immunization status. Resident identifiers: #70, #20. Facility census: 114. Findings include: a) Resident #70 On 02/01/18 at 9:00 AM, the immunization status for this resident was reviewed with infection control registered nurse (RN) #87. This resident first came to the facility in 2014. She had evidence of a 10/11/13 [MEDICATION NAME] 23 vaccination. There was no evidence this resident received or was offered the Prevnar 13 vaccination. RN #87 agreed that they were not following their policy and the Center for Disease Prevention and Control (CDC) guidelines when they failed to obtain pneumococcal vaccination history for both types of pneumonia vaccines, and failed to ensure that all residents are offered both types of pneumonia vaccines if they have not had both types. b) Resident #20 On 02/01/18 at 9:00 AM, the immunization status for this resident was reviewed with infection control RN #87. This resident first came to the facility in 2011. She had evidence of a 03/29/12 [MEDICATION NAME] 23 vaccination There was no evidence this resident received or was offered the Prevnar 13 vaccination. RN #87 agreed that they were not following their policy and the Center for Disease Prevention and Control (CDC) guidelines when they failed to obtain pneumococcal vaccination history for both types of pneumonia vaccines, and failed to ensure that all residents are offered both types of pneumonia vaccines if they have not had both types. Review of the current CDC recommendations found that the CDC recommends routine administration of pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults [AGE] years or older. CDC recommends that adults [AGE] years or older who have not previously received PCV13, should receive a dose of PCV13 first, followed one (1) year later by a dose of PPSV23 or [MEDICATION NAME] 23. If the patient already received one (1) or more doses of PPSV23 or [MEDICATION NAME] 23, the dose of PCV13 should be given at least one (1) year after they received the most recent dose of PPSV23. On 02/01/18 at 1:30 PM, the DON provided a copy of the facility's IC604 Pneumococcal Vaccination policy, with revision date 11/28/16. According to this policy, the facility would obtain the pneumococcal vaccination history of all patients/residents. Based on the patients' pneumococcal vaccination histories, the appropriate vaccination of [MEDICATION NAME] (PPSV23) or Prevnar (PCV13) would be offered following the recommended schedule as determined by the facility's Algorithm for Pneumococcal Vaccination. The DON said this algorithm was based on CDC recommendations. The DON said they plan to review all of the current residents' pneumococcal vaccination histories, and offer the appropriate pneumococcal vaccinations as indicated to ensure all residents are current in their pneumococcal immunizations.",2020-09-01
2045,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-11-15,655,D,0,1,EJZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to complete the baseline care plan within 48 hours of a resident's admission for one (Resident #27) of three residents and ensure the resident and representative are informed of the initial plan for the delivery of care and services by receiving a written summary of the baseline care plan for two (Residents #27 and #95) of three residents reviewed for baseline care plans. Findings included: a) Resident #27 Review of the face sheet for Resident #27 revealed [DIAGNOSES REDACTED]. The resident was admitted on [DATE]. Review of the quarterly Minimum Data Set (MDS) assessment, dated 09/06/18, revealed the resident had intact cognition with a Brief Interview for Mental Status (BIMS) score of 14 of 15. The comprehensive care plan was reviewed on 11/13/18 at 2:50 PM with the initial date of 06/04/18 (three days after admission). Review of the POS [REDACTED]. This baseline, person-centered care plan is developed within 48 hours and is reviewed at the Post Admission Patient/Family Conference and updated as indicated. Comments: copy given to resident and/or resident representative- not checked (seven days after admission). Review of the Person-Centered Care Plan on 11/13/18, revised 03/01/18, revealed, The center must develop and implement a baseline person-centered care plan within 48 hours for each patient that includes the instructions needed to provide effective and person-centered care that meet professional standards of quality .The center must provide the patient and his/her resident representative with a summary of the baseline care plan. The director of nurses (DON) was interviewed on 11/13/18 at 2:54 PM. She confirmed the baseline care plan was not initiated until 3 days after the resident's admission and the resident was not involved in the care plan until one week after admission. She stated they started the baseline care plan and then built the comprehensive care plan into the baseline. b) Resident #95 According to the clinical record, reviewed 11/13/18 at 11:48 AM, Resident #95 was admitted to the facility on [DATE]. Resident #95 had a [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 10/25/18, Resident #95 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. She required limited assistance with all Activities of Daily Living (ADLs). Resident #95's care plans were reviewed on 11/13/18 at 11:48 AM. The overall care plan was initiated on 10/18/18. Resident #95's assessments and progress notes were reviewed on 11/13/18 at 1:19 PM. According to the assessment, titled Post Admission Resident-Family Conference, a resident meeting did not occur until 10/24/18, which was seven days after admission. The assessment documented, Objective: To review and communicate the person-centered baseline care plan and identify further patient and family expectations. Process: It is recommended that the interdisciplinary team (IDT) meets with patient/family representative within 72 hours. This baseline, person-centered care plan is developed within 48 hours and is reviewed at the post admission patient/family conference. There were no progress notes indicating a resident meeting occurred within 48 hours of admission, indicating the resident was not involved in developing her baseline care plan. The Director of Nursing (DON) was interviewed on 11/13/18 at 2:55 PM. She said that they do not have a separate care plan for the baseline care plan. The nurse starts the care plan on admission and puts in their diagnosis, ADLs, and other pertinent information. Then they build on that care plan throughout the resident's stay. They then have a 72-hour meeting with the resident and family and discuss their care and go over the baseline care plan. She agreed the 72-hour meeting occurred on 10/24/18, which was not within 48 hours. She said even if the 72-hour conference would have occurred, they would still be out of compliance because it needed to be within 48 hours. Their process was to have the nurse initiate the care plan and then have the 72-hour meeting. The Nursing Home Administrator (NHA) said the baseline care plan process was something they could improve.",2020-09-01
2046,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-11-15,677,D,0,1,EJZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review, and resident and staff interviews, the facility failed to provide adequate nail care for one resident (Resident #37) who was unable to carry out Activities of Daily Living (ADLs) out of four sampled residents reviewed for ADLs. Findings include: a) Resident #37 According to the clinical record, reviewed 11/13/18, Resident #37 was readmitted to the facility on [DATE]. Resident #37 had [DIAGNOSES REDACTED]. According to the quarterly Minimum Data Set (MDS) assessment, dated 09/12/18, Resident #37 was rarely or never understood according to the Brief Interview of Mental Status (BIMS). A staff interview was completed. The interview indicated she did not have a memory problem and she was independent in her daily decision making skills. She required total dependence with personal hygiene. Resident #37 was interviewed on 11/13/18 at 9:00 AM. She said the staff didn't cut her fingernails like they should. She asks to have them cut and the aides tell her that they don't have fingernail clippers to use. She said her fingernails were too long and when they were long, they dug into her skin. Resident #37 had severe contractures to both of her hands and fingers. Her fingers touched her palms. Her nails were observed to go beyond the tip of her finger approximately three millimeters. She said she asked to have them cut the day before but it never got done. Resident #37 was interviewed on 11/14/18 at 1:00 PM. She said her nails still needed cut. She thought the last time they were cut was a couple weeks ago. She asked if she could get her nails cut today. Her nails were observed to look the same as they did the day prior. Certified Nurse Aide (CNA) #33 was interviewed on 11/14/18 at 3:03 PM. She had worked at the facility for three months and was not very familiar with the resident. She did not know how often residents were supposed to have their nails cut. She had not cut any resident's nails since she started because no one's had been long. If she noticed a resident with long fingernails, then she would ask the nurse for the nail clippers. The clippers were stored in the medication cart. She had not seen the resident yet, so she did not know if her nails were long. CNA #66 was interviewed on 11/14/18 at 3:23 PM. She wasn't currently working with the resident, but she was very familiar with her. She had worked with the resident prior to her seven month leave. She said she checked resident's nails every day to see if they needed cut. She said it was especially important to keep nails short for residents with contractures. The nails could dig into the skin and would be painful. She said the nail clippers had to be obtained from the nurse, as they were kept in the medication cart. At 3:32 PM, CNA #66 went into Resident #37's room. She looked at the resident's nails. She verified Resident #37's nails were long. They were much longer than when she used to work with the resident. She then proceeded to cut her nails. She removed most of the white part of the nail. Resident #37 said that was the length she liked her nails to be. Licensed Practical Nurse (LPN) #3 was interviewed on 11/14/18 at 3:50 PM. She said the CNAs should be looking at resident's nails daily. They should look at their nails and cut them if they're long, dirty, rough or jagged. It was especially important to keep nails short for those residents with hand contractures. The nails could cut into the skin. The Director of Nursing (DON) was interviewed on 11/15/18 at 10:44 AM. The CNA should provide nail care during ADL care and as needed. If they were long or jagged, then they should cut their nails. It was the expectation that if a resident's nails were long or if a resident asks for their nails to be cut, then they needed to be cut. The ADL: Fingernail Care policy, dated 12/2006, was provided by the DON on 11/15/18 at 11:20 AM. The policy documented, in pertinent part, Resident's fingernails will be cleaned and trimmed as needed or requested .",2020-09-01
2047,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-11-15,684,D,0,1,EJZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident and staff interviews, observations, and record review, the facility failed to ensure residents receive treatment and care in accordance with professional standards of practice, and the comprehensive person-centered care plan. Specifically, the facility failed to follow physician's orders [REDACTED].#95's Peripherally Inserted Central Catheter (PICC) line. This effected one of two residents who's PICC lines were observed. Findings include: a) Resident #95 According to the clinical record, reviewed 11/13/18 at 11:48 AM, Resident #95 was admitted to the facility on [DATE]. Resident #95 had a [DIAGNOSES REDACTED]. According to the admission Minimum Data Set (MDS) assessment, dated 10/25/18, Resident #95 was cognitively intact with a Brief Interview of Mental Status (BIMS) score of 15 out of 15. She required limited assistance with all Activities of Daily Living (ADLs). Resident #95 was interviewed on 11/12/18 at 2:33 PM. She was concerned that her bandage covering her PICC line hadn't been changed. She didn't think it had been changed since she admitted to the facility. The bandage was observed to be a transparent bandage. It was unstuck on all sides and curling up. Resident #95's care plans were reviewed on 11/13/18 at 11:48 AM. A care plan initiated 10/19/18 identified the resident as having a PICC line due to antibiotic therapy. Interventions included sterile dressing changes per policy and as needed. Licensed Practical Nurse (LPN) #57 was interviewed on 11/14/18 at 9:37 AM. She knew the resident had a PICC line. She said the dressing should have a date on it, indicating when it was changed. She looked in the Medication Administration Record (MAR) and the Central Vascular Access Device ([MEDICAL CONDITION]) Treatment Record and said there was an order for [REDACTED]. There was nothing on the (MONTH) [MEDICAL CONDITION] Treatment Record indicating the dressing had been changed. The Assistant Director of Nursing (ADON) looked at the [MEDICAL CONDITION] Treatment Record at 9:43 AM. She said the nurses were to sign off on the treatment when they changed the dressing. It looked like the dressing hadn't been changed all month. At 9:44 AM, Registered Nurse (RN) #14, who was also the unit manager, went into Resident #95's room. She looked at the dressing covering the PICC line. She verified the dressing was unstuck on all sides, was curling up and had lifted. She had to uncurl the bandage to see the date. It was dated 10/26/18. After looking at the date, Resident #95 said she thought it had been awhile since it was changed. RN #14 said the site looked good underneath the dressing. There were no signs of infection. She said the bandage should be completely sealed. She thought the dressing change was missed because there was nothing marked on the [MEDICAL CONDITION] Treatment Record. Normally there was a box on what day the dressing change needed to occur throughout the month, but it was not marked. The ADON was interviewed on 11/14/18 at 9:51 AM. She said the nursing staff weren't paying attention to when the bandage needed changed. They observe the site daily and they should have noticed that the bandage was coming off and needed to be changed. It was missed. The [MEDICAL CONDITION] Treatment Records were reviewed in greater detail on 11/14/18 at 10:15 AM. There was an order to Change catheter site dressing: 24 hours post PICC insertion; On admission; Q (every) week with transparent dressing. For the month of (MONTH) (YEAR), there was a box around the date 10/25. There were initials in the box, indicating the dressing change had been completed on 10/25. For the month of November, there were no boxes on the dates the dressing needed changed. It was blank, indicating the dressing change was not completed. The Central Vascular Access Device ([MEDICAL CONDITION]) Dressing Change policy, revised 05/2016, was provided by the ADON on 11/14/18 at 12:00 PM. The policy documented, in pertinent part, Guidance: 1. Sterile dressing change using transparent dressings is performed: 1.1 24 hours post-insertion or upon admission. 1.2 At least weekly. 1.3 If the integrity of the dressing has been compromised (wet, loose, or soiled). The Director of Nursing (DON) was interviewed on 11/15/18 at 10:44 AM. She said the nurses were supposed to follow physician's orders [REDACTED]. Since the nurses observe the site every couple of hours, they should have noticed the dressing was peeling up and changed it. They should also pay attention to the date when they're observing the site. The nurse who works on the overnight shift on the first day of the month is in charge of making sure the orders were transcribed properly from month to month on the MAR and [MEDICAL CONDITION] Treatment Record.",2020-09-01
2048,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-11-15,812,F,0,1,EJZP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, policy review and interviews, the facility failed to store, prepare and serve food in accordance with professional standards for food service safety. Specifically, the facility failed to ensure cleanliness in the kitchen; foods were labeled, dated and sealed; adequate hairnet use; glove use; and ensure expired foods were disposed. This affected one of one kitchen and one of two dining rooms. Cross Reference: F925 Findings included: a) Cleanliness The kitchen was observed on [DATE] at 8:13 AM with the following: -The handwashing sink near the coffee station was observed without soap in the dispenser. -The inside of the ice machine was observed as dirty. -The walls behind the large mixer and [NAME]ot Coupe station (blender for preparing pureed food) was observed with liquid spatter. -There was food spatter on the wall behind the 2-sink prep area. -The hood over the stove was observed as dirty. The kitchen was observed on [DATE] at 10:27 AM. The utensil storage area along the wall above the 2-sink prep area was observed with a dirty ladle with holes. There was visible food debris. -The wall behind the utensil storage was observed as dirty. -The outside of the tall refrigerator near the coffee station was observed as dirty. -The ice machine was observed with a white plastic portion along the inside as dirty. -At 11:44 AM, food spatter was observed along the ceiling and on the overhead light fixtures throughout the kitchen. Maintenance was observed cleaning out the ice machine on [DATE] at 3:07 PM. Review of the Department Sanitation policy on [DATE] at 3:54 PM, revised [DATE], revealed cleaning schedules are followed and cleaning procedures are utilized. b) Labeling, Dating and Sealed The walk-in refrigerator in the kitchen was observed on [DATE] at 8:13 AM with the following: -A hard-plastic container with a green lid was unlabeled and undated. The contents appeared to be a thick brown mixture. -A clear plastic bag of turkey slices was observed open to air, unsealed. The walk-in refrigerator in the kitchen was observed again on [DATE] at 10:22 AM with the following: -There were two strawberry health shake cartons in a large black bin. These were undated as to when they were taken out of the freezer. -At 10:25 AM, there were 19 vanilla health shakes in a box and more than 10 strawberry health shakes in a box, undated as to when they were taken out of the freezer. Review of the Use By Dating Guidelines policy on [DATE] at 2:51 PM, revised [DATE], revealed frozen shakes: use by date of 14 days once thawed- use labels for individual items when removed from the carton. Review of the Refrigerated/Frozen storage policy on [DATE] at 3:49 PM, revised [DATE], revealed prepared foods are labeled and dated with the name of the product, date opened, and use by date. c) Hair net The kitchen was observed on [DATE] at 9:38 AM. The dietary aide #120 was observed washing dishes. He had several inches of brown hair coming out the back and sides of his hat, uncovered. -At 11:39 AM, this dietary aide was observed preparing for lunch service at the main dining room steam table. He was serving lunch meal with several inches of brown hair coming out the back and sides of his hat, uncovered. Review of the Personal Hygiene policy on [DATE] at 3:50 PM, revised [DATE], revealed hair restraints such as hats, hair coverings, or nets are worn to effectively keep hair from contacting exposed food. c) Glove Use The main dining room was observed on [DATE] at 12:07 PM. Dietary aide #120 was observed serving food from the steam table. He had a pair of gloves on and was observed sorting through meal tickets brought from the nursing staff, after taking resident orders. He then reached in a plastic bag and pulled out a sandwich with the same gloves and placed the sandwich in the skillet. This was observed two times. Review of the Personal Hygiene policy on [DATE] at 3:50 PM, revised [DATE], revealed disposable gloves are single use items and are changed between tasks. e) Expired Food The main kitchen was observed on [DATE] at 10:27 AM. The tall refrigerator near the coffee station was observed to have had a half gallon container of lactose free milk. This milk was dated with a sell by date [DATE]. f) Staff Interviews The District Manager (DM) of Dining and Nutrition Services was interviewed on [DATE] at 8:33 AM. He stated the facility did not have a dietary manager currently. They hired a new dietary manager but the person had not started yet. He was filling in the kitchen until the replacement started. The DM was interviewed again on [DATE] at 3:20 PM. He stated he was covering multiple buildings and was not aware of any trainings the previous manager completed with the staff. He confirmed the above findings.",2020-09-01
2049,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2018-11-15,925,F,0,1,EJZP11,"Based on observations and interviews, the facility failed to maintain an effective pest control program so that the facility is free of pests. This affected one of one kitchen and one of two dining rooms. Findings included: The kitchen was observed on 11/12/18 at 8:13 AM. Several gnats were observed flying around the handwashing sink, coffee station area. The main dining room was observed on 11/13/18 at 11:39 AM. A gnat was observed around the steam table. A visitor was observed to swat at the gnat. The main kitchen was observed on 11/14/18 at 10:30 AM. There were four gnats flying around the hand washing sink, coffee station area. There were two gnats observed flying around the food prep area. -At 11:14 AM, there was one gnat flying around the steam table. -At 11:25 AM, there was a pile of dirty dishes, pans stacked up next to the food prep area. One gnat was observed to land on an empty, dirty pitcher. -At 11:31 AM, there was a gnat on the hood. There were seven gnats flying around the hand washing sink, coffee station. -At 11:44 AM, one gnat was observed flying around the stove across from the steam table. Review of the Pest Control policy on 11/17/18 at 3:55 PM, revised 06/15/18, revealed food service areas are maintained in a clean and sanitary condition at all times. Purpose: To maintain the department and facility in a pest-free condition. The District Manager (DM) for Dining and Nutrition Services was interviewed on 11/14/18 at 11:40 AM. He stated he noticed the gnats for about a week. He did not know where they were coming from. He placed vinegar out to help draw the gnats. At 12:40 PM, he stated he talked to maintenance and they could install a catcher in the kitchen. That had not been done yet. Cook #111 was interviewed on 11/14/18 at 11:42 AM. She stated she noticed the gnats occasionally. She noticed a couple this day. The maintenance director #30 was interviewed on 11/14/18 at 12:40 PM. He stated they had a pest program in which they had been in the building and kitchen on 11/02/18. He stated he was not aware of the gnat problem in the kitchen.",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
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
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
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
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
3917,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,226,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview, record review and policy/procedure review, the facility failed to implement its written policies and procedures 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 has 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
3918,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,241,D,0,1,VTNG11,"Based on observation, record review, resident interview and staff interview, the facility failed to promote care for residents in a manner that maintained each resident's dignity and respect in full recognition of their identity. Resident #68 experienced a prolonged wait time for lunch to be served. Resident #132 was transferred by the use of his armpits. This failed practice caused affected to two (2) of four (4) residents reviewed. Resident identifiers: #68 and #132. Facility census: 109. a) Resident #68 On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. b) Resident #132 During a Stage 1 observation and interview on 11/01/16 at 9:48 a.m., observation revealed Resident #132 seated in a chair across from the resident lounge. The resident agreed to an interview, but said he required assistance to stand up from the chair. A male employee, who identified himself as a Central Supply employee (CS) #123 said he was not able to assist because he was not a nurse aide (NA), but would request help. CS #123 returned with a nurse aide (NA). The NA placed an arm under Resident #132's right axilla (armpit) and CS #123 placed an arm under the resident's left axilla, assisting him to a standing position. Resident #132 said staff did not recognize him as a person, and felt he was not treated with dignity. The resident stated that staff walked by him without acknowledging him. The resident further stated, All I want is for them to see me as a person. An interview with Licensed Practical Nurse (LPN) #64, on 11/03/16, said staff should not lift under the arms, but did not know whether it was a dignity issue. The director of nursing (DON) interviewed at 1:52 p.m. said, It's (it is) not dignified and that the facility had the proper equipment.",2020-04-01
3919,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,242,D,0,1,VTNG11,"Based on observation, resident interview and staff interview, the facility failed to demonstrate that the resident had the right to choose schedules consistent with their interests and make choices about aspects of their life that were significant to the resident. The facility failed to inform a resident of a prolonged wait during a meal service, prohibiting the resident to make an informed choice. This was a random observation affecting Resident #68. Facility census: 109. On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observation revealed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, and said he was not waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. During a resident interview on 11/02/16 at 11:26 a.m., Resident #68 stated, It was an insult, I felt at their mercy. I don't expect luxury, but they should have had the courtesy to tell me it (lunch) was going to be late and by the time they served me, it was an hour. I feel like I have a boss. Review of Resident #68's medical record on 11/02/2016 at 10:50 a.m. showed a care plan stating that Resident #68 had potential for psycho social impairment due to difficulty adjusting to new environment. During a resident interview, on 11/01/2016 at 8:49 a.m., Resident #68 stated, I didn't like sitting there like a welfare case that lunch was going to be late. Why should you want to sit for an hour and five minutes for something to eat? I would never treat people like this. During a staff interview on 11/02/16 at 10:32 a.m. the Food Service Director (FSD), stated, Some residents are always served last. They (facility) needs to try to rotate the serving order if they can, so that it shouldn't happen as much. It used to happen more often.",2020-04-01
3920,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,250,D,0,1,VTNG11,"Based on resident interview, medical record review, staff interview, and policy review, the facility failed to ensure the provision of medically related social services were sufficient and appropriate to meet resident needs. The facility failed to identify and thoroughly investigate an alleged allegations of physical, emotional, mental and/or sexual abuse. This practice affected one (1) of one (1) residents reviewed for abuse and has 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. Resident #164 has the capacity to make medical decisions as documented by her attending physician on admission to the facility. 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 #164 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
3921,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,253,E,0,1,VTNG11,"Based on observation, facility guidelines and staff interviews, the facility to provide housekeeping and maintenance services necessary to ensure an orderly, sanitary, and comfortable environment by not performing routine and/or preventative maintenance services on oxygen concentrators and resident rooms and/or bathrooms. This affected more than a limited number of residents. Resident room identifiers: #170, #173, #175, #181, #236, #237 and #347. Resident identifiers for the concentrators: #162, #64, #114, #143 and #29. Facility census 109. Findings include: a) Cosmetic imperfections On 11/02/16 observations began at 11:00 a.m., with the Maintenance Supervisor, found the following cosmetic imperfections. --The bathroom commode in Room #170 had yellow, brown discoloration around the base of commode. There were caulking missing from the molding on the top right back side of the bathroom wall. --The bathroom in between Rooms #173 and #175, had the caulking missing and a dark brown discoloration at the doorway entrance of the bathroom. The paint was peeling from the right lower corner of the wall, and on the right side of the wall facing the commode. The caulking was no longer present and the molding is pulled away on the right side behind the commode. --The bathroom entrance in Room #181 had the caulking missing and a dark brown discoloration. The molding along the back wall behind the commode was pulled away and the caulking missing from the bottom of the molding along the wall to the right upon entering the bathroom. --The bathroom heater located along the bottom of the bathroom in Room #236 had brown color rust in the corner and top, and bottom of the heater. The thermostat knob on the heater was missing. --In Room 237 tile was missing under the sink in the right back corner along the wall. The beside stand was covered in a thick layer of dust with fingerprint smudges near the front on 11/01/16 at 1: 59 p.m., the assistant director of nursing (ADON) #87 said, Yeah, that's pretty bad. --In Room #347 entrance to the bathroom had the threshold missing. In an interview with the Maintenance Supervisor #142 on 11/02/16 at 11:48 a.m. He confirmed the rooms observed with were in need of repair. b) Oxygen Concentrator Maintenance Observations during Stage 1 and Stage 2 of the QIS from 10/31/16 to 11/03/16 found Invacare oxygen concentrators had no preventative maintenance sticker to indicate the last date of service for the following residents: #162, #64, #114, #143, and #29. During an interview and observation with the Maintenance Supervisor #142, on 11/02/16 at 3:00 p.m., the Maintenance Supervisor removed the top off of the oxygen concentrators for residents #162, #64, #114, #143, and #29 to visualize each internal filter. The observation revealed that Residents #162, #64,#114, #143, and #29 oxygen concentrator internal filters had no date of when the last time the filter were changed. He reported the facility had just started conducting their own maintenance on the oxygen concentrators which consisted of changing the internal oxygen filters and writing on the internal oxygen filter the date they changed the filter. The Maintenance Supervisor said they had another employee changing the internal filter and he should have indicated on the filter when the filter was last changed. He said the internal filter is changed every six (6) months. He confirmed that he could not tell me when the oxygen concentrator internal filter for Residents #162, #64, #114, #143, and #29 had been changed since there is no date on the internal filter itself. The Maintenance Supervisor, on 11/02/16 at 3:30 p.m., provided the facility's guideline on preventative maintenance record for the oxygen concentrators. The guideline revealed the internal filters are required to be changed every six (6) month.",2020-04-01
3922,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,272,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of one (1) Stage 2 sample residents reviewed for Hospice services. Resident #26's assessment did not identify receiving Hospice services. Resident identifier: #26. Facility census: 109. Findings include: a) Resident #26 On 11/03/2016 at 11:51 a.m. review of the resident's medical record revealed [REDACTED]. The significant change minimum data set (MDS) with an assessment reference date (ARD) of 09/30/16 did not identify the resident as receiving Hospice services in section O0100. Clinical Reimbursement Coordinator (CRC) #11 reviewed this MDS with an ARD of 09/30/16 during an interview on 11/03/16 at 12:38 p.m. and confirmed the MDS was coded incorrectly and did not reflect Resident #26 as receiving Hospice services.",2020-04-01
3923,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,279,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews the facility failed to develop a comprehensive care plan for three (3) of twenty-three (23) Stage 2 residents related to [MEDICAL CONDITION] (GI bleed), ,[MEDICAL CONDITION]. difficle (C. Diff), isolation for the [DIAGNOSES REDACTED], and dental care. Resident Identifiers: #147, #139, #37. Facility census 109. Findings include: a) Resident #147 1) [MEDICAL CONDITION] Record review for Resident #147, on 11/02/16 at 11:50 a.m., found a note dated 05/07/16 from an acute care facility. This note indicated the resident had occasional blood in her stool and she was on Xarelto (a blood thinner) due to a [MEDICAL CONDITION] embolism. The physician for Resident #147 wrote in the admission history and physical, recent GI bleed. diagnosed with [REDACTED]. The admission minimum data set (MDS) with an assessment reference date (ARD) of 05/30/16 was reviewed on 11/02/16 at 12:57 p.m. for Resident #147. This MDS revealed the resident had the [DIAGNOSES REDACTED]. A review of the physician order [REDACTED]. A review of a lab test, complete blood count (CBC), for Resident #147 on 05/30/16 revealed the following results: --[NAME] blood count (WBC) was 13.5 (high); --Hemoglobin (HGB) level of 11.3 (low) with normal noted as 12.0 -16.0 gram/deciliter; and --Hematocrit (HCT) was 34.7 (low) with normal level noted as 37 - 47 percent. The HGB, and HCT is an indicator of [MEDICAL CONDITION] (too few red blood cells). Written on the lab test result was a note stating (typed as written), active GI (gastrointestinal) bleed, loose bm's (bowel movement) with sticky clay color noted. not black, but red visible blood with clots. Resident #147 had a progress note on 06/08/16 revealing a new order to obtain a CBC in the morning. Written on the note said due to active GI bleed/ recent hospitalization . On 06/27/16 the resident was sent to the acute care facility for the GI bleed. 2) ,[MEDICAL CONDITION]. Difficle and contact isolation On 05/31/16 a progress note revealed a stool specimen was positive for ,[MEDICAL CONDITION]. difficle (C. Diff). The physician ordered the resident to start receiving [MEDICATION NAME] (used to treat bacterial infections) 500 milligrams (mg) by mouth for two (2) weeks. The resident continues to have several loose stools daily. The note revealed contact isolation was started. A progress note on 06/01/16 revealed the resident is having several loose stool this shift and the resident remains on [MEDICATION NAME] without any adverse effect. A progress note, dated 06/03/16, revealed the resident continues to take [MEDICATION NAME] for [DIAGNOSES REDACTED]. A note, dated 06/07/16, indicated Resident #147 had a [MEDICATION NAME] appointment scheduled for 06/16/16 to follow up with recent GI bleed as resident persists to have visible blood in stools. A review Resident #147's comprehensive care plan, on 11/02/16 at 2:10 p.m., found no care plan related to the GI bleed, [DIAGNOSES REDACTED], and the contact isolation. In an interview with licensed practical nurses (LPN) #43 and #58, on 11/02/16 at 5:02 p.m., found they reviewed the care plan for Resident #147, and they both confirmed the comprehensive care plans did not address the needed care areas of GI bleed, [DIAGNOSES REDACTED], and the contact isolation. b) Resident #37 During a Stage1 interview and observation, on 10/31/16 at 2:24 p.m., revealed Resident #37 had missing teeth. Resident #37 voiced problems and stated she needed several teeth removed. The resident related she had asked to go to the dentist, and had a broken tooth which caused pain. Resident #37 said she needed an appointment for extraction of five (5) teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 08/29/16 noted Resident #37 had an obvious or likely cavity or broken natural teeth. Section V indicated a care plan would be developed. Further review of the medical record, on 11/02/16 revealed no evidence a care plan had been developed related to dental care needs. c) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order for [REDACTED]. The care plan, revised on 09/11/16, reviewed on 11/02/16 at 9:38 a.m., was silent for a care plan related to dental care. During a medical record review, with Licensed Practical Nurse (LPN) #33, she related she was not sure where to look. The interim director of nursing reviewed the care plan, including resolved issues and stated a care plan had not been developed related to dental/oral health.",2020-04-01
3924,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,280,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise a care plan for one (1) of twenty-three (23) Stage 2 residents reviewed during the annual quality indicator survey. Resident #143's care plan did not identify a decline in urinary incontinence after hospitalization . Resident identifier: #143. Facility Census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was admitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. Resident #143 was admitted to the hospital on [DATE] and returned to the facility on [DATE]. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identify Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident was always incontinent of urine and indicated a toileting program was not attempted. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m. and confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. CRC #93 reviewed the current care plan and acknowledged the care plan lacked a focus, goal or any interventions for urinary incontinence. Nurse Aide (NA) #75 confirmed Resident #143 is always incontinent of urine during an interview on 11/03/16 at 1:42 p.m.",2020-04-01
3925,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,309,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to follow physician orders for three (3) of twenty-three (23) Stage 2 residents. The facility failed to follow a physician order for [REDACTED]. Resident Identifiers: #40, #136, and #139. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine ([MEDICATION NAME]) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and [MEDICATION NAME] (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce [MEDICATION NAME] to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the [MEDICATION NAME], but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 11/03/16 at 12:57 p.m., Resident #40's the pharmacist consultant report, the physician orders, (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she could not find anywhere in the record where the physician wrote in the resident's record contraindication the resident should not have the GDR. b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order for [REDACTED]. The physician services nursing facility subsequent visit form, dated 03/08/16, noted the chief complaint/history record many damaged and non-restorable teeth. A physician's order dated 04/12/16, recorded it was, Ok for dental consult due to clenching mouth when eating. The assessment/plan included a referral to an oral surgeon for a full mouth extraction per the dentist due to, many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 found a progress note dated 04/25/16 which indicated the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. Further record review found the following notes: --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's order for a consult with the oral surgeon with the family, or that the family had denied the consult. The SW said the facility was looking for documentation. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's order to obtain a surgical consultation. c) Resident #136 A medical record review, on 11/01/16, indicated Resident #136 received [MEDICATION NAME] ten (10) milligrams (mg) by mouth daily for major [MEDICAL CONDITION] - single episode and [MEDICATION NAME] 1 mg by mouth daily for dementia with behavioral disturbance. Further review, revealed the resident had a witnessed fall on 10/16/16, losing his balance and falling backwards. A pharmacy recommendation, reviewed on 11/03/16 at 10:30 a.m., noted a recommendation for a gradual dose reduction of [MEDICATION NAME]. The physician's response noted, Not my patient, Need consult. The admission history and physical from the hospital had recorded the resident had been admitted to the hospital due to increased confusion and marked agitation including throwing things and striking out at people. It noted he had baseline mental [MEDICAL CONDITION] with very poor hearing and vision and inability to express himself. Scheduler #127, interviewed at 11:30 a.m., said no information was present to indicate the appointment had been scheduled. At 1:10 p.m. on 11/03/16, the interim director of nursing (DON) reviewed the medical record, and said the psychiatrist visited residents at the facility about every two (2) weeks. She reviewed the medical record and confirmed the order had not been discontinued. The interim DON searched for a consult, said she was unable to find evidence it had been completed, and confirmed the facility failed to carry out the physician's order.",2020-04-01
3926,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,315,D,0,1,VTNG11,"**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 incontinent of bladder receives the appropriate treatment and services to restore normal bladder function to the extent possible. Resident #143's increase in urinary incontinence was not assessed after each admission and interventions were not put into place to address the decline in bladder control. Resident identifier: #143. Facility census: 109. Findings include: a) Resident #143 Review of the medical record on 11/03/16 at 9:51 a.m., revealed Resident #143 was initially admitted to the facility on [DATE]. She was discharged to the hospital on [DATE] and returned to the facility on [DATE]. Resident #143 returned to the hospital on [DATE] and was readmitted to the facility on [DATE]. The three-day continence management diary initiated on 06/29/16 noted Resident #143 was incontinent three (3) out of twenty-eight (28) checks on 07/01/16, 07/02/16, and 07/06/16. The Admission Minimum Data Set (MDS) with an assessment reference date (ARD) of 07/04/16 noted the resident was always continent of urine under section H0300. The activity of daily living forms dated (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) identified Resident #143 as always incontinent of urine since 07/22/16. The quarterly MDS with an ARD of 10/03/16 noted the resident as always incontinent of urine and is marked No under section H0200 indicating a toileting program was not attempted. The medical record was silent in regards to any toileting assessments. The Clinical Records Coordinator (CRC) #93 reviewed the records during an interview on 11/03/16 at 12:11 p.m., confirmed Resident #143 was initially occasionally incontinent of urine and is now always incontinent. She acknowledged the urinary incontinence was not identified during Resident #143's recent quarterly assessment and a plan was not put into place to address this concern. CRC #93 stated it is the restorative nurse's job to conduct the three-day continence management diaries on the residents. Licensed practical nurse (LPN)/restorative nurse #146 presented Resident #143 ' s initial toileting assessment during an interview on 11/03/16 at 12:24 p.m. The form is titled Three-day Continence Management Diary and is completed by the nursing assistants. LPN #146 acknowledged she was not familiar with Resident #143 and reported there were no urinary incontinence assessments completed after readmissions on 07/18/16 and 08/08/16. LPN #146 stated she does not participate in the residents care conferences and is notified when an assessment needs to be completed. During an interview at 2:05 p.m. on 11/03/2016, the Assistant Director of Nursing (ADON) confirmed a three day continent assessment should have been done on Resident #143 after each admission.",2020-04-01
3927,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,371,F,0,1,VTNG11,"Based on observation, staff interviews and policy review, the facility failed to store and serve food in a safe and sanitary manner. Food in the cooler was exposed to air and undated, and food in the nourishment refrigerator rooms was unlabeled and undated. The staff were serving food with contaminated gloves, and touching food items with their bare hands. This has the potential to affect more than a limited number of residents. Facility census 109. Findings include: a) Cooler and nourishment room refrigerator 1. During the initial tour of the kitchen, on 10/31/16 at 11:50 a.m., with food service director, observation of the cooler found fourteen (14) large carrots open, undated and exposed to the air. The food service director acknowledge the need for the carrots to be covered and dated when they were open. Observed the cooler on 11/02/16 at 2:00 p.m., found the fourteen (14) carrots continue to be open and exposed to air and undated. Observation of the cooler on 11/03/16 at 9:40 a.m., found fourteen (14) carrots continued to be opened and exposed to air and undated. 2. Observation and interview with clinical reimbursement coordinator (CRC) #93, on 11/02/16 at 4:45 p.m., found the (a) side of the nourishment room refrigerator with 21 slices of American cheese in a clear plastic zip lock bag, half a gallon (1/8th full) of two (2) percent milk (with a best used by date of 11/01/16), a plastic pitcher full of orange juice, another half a gallon of two (2) percent milk (3/4th full), and a half a gallon of Tru Moo milk (1/3rd full). These items were undated and/or unlabeled. The (b) side of the nourishment room refrigerator was observed with CRC #93, on 11/02/16 at 4:49 p.m., with a half a gallon of 2% milk (1/2 full was open and undated). During the two (2) observations of the nourishment refrigerator with CRC #93, she confirmed someone should have thrown away the milk that was already passed the used by date, and put the date they opened the other milk. The CRC said the orange juice should have had a date on the top when it was put in the refrigerator and the cheese should have had a label and a use by date on the bag. A review of the facility's refrigerated/ frozen storage policy, on 11/03/16 at 3:00 p.m., revealed all food is to be labeled with the name of the product and the date received and use by date once opened. b) Handling food 1. During a dining observation of the Coral dining room, on 11/01/16 from 12:04 p.m. through 12:45 p.m., Nurse Aide (NA) #90 touched bread with bare hands. The NA lifted the top slice of bread, exposing the filling beneath, asked the resident if she wanted lettuce or tomato, placed it back on the sandwich, lifted it again and placed items on the sandwich. The NA held the bread in place with her fingers, while cutting the sandwich in half, then served it to Resident #73. Nurse Aide (NA) #135, also touched bread with bare hands while serving a sandwich to Resident #67. An interview with Nurse Practice Educator (NPE) #38, on 11/02/16 at 1:06 p.m., confirmed staff should not have touched food items with bare hands and related facility practice required staff utilize gloves if touching food items. 3. On 11/01/2016 at 11:59 p.m. observation revealed Dietary Cook #42 wearing gloves handling meal slips. The employee opened bun bags and prepared fish sandwiches while wearing the contaminated gloves. Dietary Cook #42 proceeded to handle dispenser of aluminum foil and cover plates of food. The employee prepared additional sandwiches wearing the contaminated gloves. An additional observation in the presence of the Food Service Director revealed the employee removed buns from the bags and prepared fish sandwiches without changing contaminated gloves. The Food Service Director agreed the employee ' s gloves should have been changed. During an interview on 11/02/16 at 1:00 p.m., the Nurse Practice Educator stated upon orientation, staff are trained on proper food handling, but the kitchen will provide education regarding use of gloves when handling packaged items, serving foods and also holding glasses of beverages by the rims.",2020-04-01
3928,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,411,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicare services. Resident identifier: #139. Facility census: 109. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. Nurse Aide (NA) #135, interviewed on 11/02/16 at 9:07 a.m., stated Resident #139 had dental pain, and staff used sponges for oral care. Licensed Practical Nurse (LPN) #64, present during the interview, and said the resident received [MEDICATION NAME] to the gums and teeth before meals for comfort and was now eating better. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's orders [REDACTED]. The SW said the facility was looking for documentation. The census record indicated Resident #139 received Medicare services at the time of the order on 04/27/16 through 05/16/16. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's orders [REDACTED]. A dining observation, on 11/02/16 at 12:31 p.m., revealed Resident #139 received foods via a cup. The food was puree and a metal spoon was present on the tray. Upon inquiry, NA #69 said she did not use the spoon because it hurt the resident's teeth and she would turn her head away. NA #67 agreed and said Resident #139 received something for pain prior to meals. The medical director, requested an interview on 11/02/16 at 2:13 p.m., and said she wanted to address questions about Resident #139. The physician related she did not think the resident was a surgical candidate for a dental extraction and would not have had surgery. After explaining the appointment was for a surgical consultation, not surgery, the physician related she did not know why the appointment had not been made. Speech Therapist (ST) #31, on 11/02/16 at 3:50 p.m., said the administrator had requested she answer questions regarding Resident #139's dental care, refusal to eat and grinding of teeth. The ST said she had worked with the resident on admission to the facility and had related the grinding to [DIAGNOSES REDACTED] (inability to perform purposeful movements as a result of brain damage), not dental pain. When asked why the resident received [MEDICATION NAME] to her gums and teeth prior to meals if she did not have dental pain, the ST said she was not aware the resident received medication, and related she had not worked with Resident #139 in the last four (4) months. The ST note, dated 03/08/16 through 04/04/16 noted Resident #139 presented with clenched jaw and dental grinding especially during attempts at oral intake. Close jaw impaired; open jaw with resistance - impaired and again noted clenched jaw with dental grinding throughout the evaluation. The evaluation did not address dental pain. A follow-up interview with the interim DON on 11/03/16 at 3:30 p.m. confirmed the order had not been discontinued, no evidence was present to indicate the surgery had been contraindicated, no evidence the family had denied the consult, and verified the facility failed to follow the physician's orders [REDACTED].",2020-04-01
3929,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,412,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review and staff interview, the facility failed to ensure dental services were obtained for one (1) of three (3) residents reviewed. The facility failed to obtain a surgical consultation with an oral surgeon as directed by the dentist, for a resident who received Medicaid services. Facility census: 109. Resident identifier: #139. Findings include: b) Resident #139 During a Stage 1 observation, on 11/01/16 at 8:36 a.m., Resident #139 opened her mouth widely, as though trying to communicate. Observation revealed missing teeth. The minimum data set (MDS) with an assessment reference date (ARD) of 07/26/16, noted obvious or likely cavity or broken natural teeth. Further review of the medical record revealed an order, dated 04/25/16, for a consult with an oral surgeon for extraction of teeth, as recommended by the dentist. The physician services nursing facility subsequent visit form, dated 03/08/16, had noted the chief complaint/history record many damaged and non-restorable teeth. A physician's orders [REDACTED]. The dentist' assessment/plan included a referral to an oral surgeon for a full mouth extraction due to many damaged and non-restorable teeth, and was noted on 04/25/16. The medical record, reviewed from date of admission through 11/03/16 revealed a progress note dated 04/25/16 which noted the dentist assessed Resident #139 and the facility received an order to refer the resident to an oral surgeon for full mouth extraction. --04/28/16 - the resident saw the dentist and a recommendation was made to do a full mouth extraction; --04/30/16 - spoon feed all meals; --05/05/16 - waiting for an appointment for full mouth extraction; --06/30/16 - continue on [MEDICATION NAME] for mouth, resident is very hard to feed meals due to continually closing mouth; --07/07/16 - continue [MEDICATION NAME] to gums of mouth provided, when resident eating lunch because staff noticed resident crunching teeth, face getting red, and nurse provided with pain meds (medication) [MEDICATION NAME] 0.25 (milliliters) via mouth; --08/16/12 - a care plan meeting note was silent to dental issues. The family attended the meeting; and --09/07/16 - weight warning of a five percent (5%) weight loss over 30 days. No evidence was present in the electronic medical record or the paper record to indicate Resident #139 had received the consult with an oral surgeon. Nurse Aide (NA) #135, interviewed on 11/02/16 at 9:07 a.m., stated Resident #139 had dental pain, and staff used sponges for oral care. Licensed Practical Nurse (LPN) #64, present during the interview, and said the resident received [MEDICATION NAME] to the gums and teeth before meals for comfort and was now eating better. During an interview with Social Worker (SW) #54, on 11/02/16 at 11:06 a.m., the SW verbalized she had attended Resident #139's care plan meeting. The SW said the responsible party attended the meeting. When asked what was discussed with the family member, the social worker did not mention dental care. Upon inquiry, SW #54 said no evidence was present to indicate the facility had discussed the physician's orders [REDACTED]. The SW said the facility was looking for documentation. The census record indicated Resident #139 received Medicare services at the time of the order on 04/27/16 through 05/16/16. Scheduler #127, interviewed on 11/02/16 at 11:30 a.m., stated no evidence was present to indicate an appointment had been scheduled for the consult with the oral surgeon. A follow-up interview with the interim director of nursing (IDON) on 11/03/16 at 3:30 p.m. confirmed the facility failed to follow the physician's orders [REDACTED]. A dining observation, on 11/02/16 at 12:31 p.m., revealed Resident #139 received foods via a cup. The food was puree and a metal spoon was present on the tray. Upon inquiry, NA #69 said she did not use the spoon because it hurt the resident's teeth and she would turn her head away. NA #67 agreed and said Resident #139 received something for pain prior to meals. The medical director, requested an interview on 11/02/16 at 2:13 p.m., and said she wanted to address questions about Resident #139. The physician related she did not think the resident was a surgical candidate for a dental extraction and would not have had surgery. After explaining the appointment was for a surgical consultation, not surgery, the physician related she did not know why the appointment had not been made. Speech Therapist (ST) #31, on 11/02/16 at 3:50 p.m., said the administrator had requested she answer questions regarding Resident #139's dental care, refusal to eat and grinding of teeth. The ST said she had worked with the resident on admission to the facility and had related the grinding to [DIAGNOSES REDACTED] (inability to perform purposeful movements as a result of brain damage), not dental pain. When asked why the resident received [MEDICATION NAME] to her gums and teeth prior to meals if she did not have dental pain, the ST said she was not aware the resident received medication, and related she had not worked with Resident #139 in the last four (4) months. The ST note, dated 03/08/16 through 04/04/16 noted Resident #139 presented with clenched jaw and dental grinding especially during attempts at oral intake. Close jaw impaired; open jaw with resistance - impaired and again noted clenched jaw with dental grinding throughout the evaluation. The evaluation did not address dental pain. A follow-up interview with the interim DON on 11/03/16 at 3:30 p.m. confirmed the order had not been discontinued, no evidence was present to indicate the surgery had been contraindicated, no evidence the family had denied the consult, and verified the facility failed to follow the physician's orders [REDACTED].",2020-04-01
3930,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,428,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interviews the facility failed to ensure a pharmacist recommendation was acted upon by failing to ensure an order was written to implement the gradual dose reduction (GDR) for one (1) of five (5) Stage 2 residents for a GDR. Resident Identifiers: #40. Facility census 109. Findings include: a) Resident #40 Review of Resident #40's pharmacy consultant report dated 09/20/16 was reviewed on 11/03/16 at 12:30 p.m., revealed the resident received Quetiapine (Seroquel) 50 milligram (mg) daily for behavioral or psychological symptoms of dementia since 03/24/16 and Clonazepam (Klonopin) 0.5 mg twice a day. The consultant report indicated both were due for a gradual dose reduction (GDR). The pharmacy consultant made the recommendation for a GDR of the resident's Quetiapine 50 mg to 25 mg at night with the end goal of discontinuation of the medication. If medication is to continue at this dose, the prescriber must document a clinical contraindication, defined as a patient-specific rational including, 1) documentation that a target symptom(s) returned or worsened during a dose reduction attempted during the most recent facility admission, and 2) why additional attempted dose reduction would be likely to impair the resident's function or increase distressed behavior. The physician accepted the recommendations with the following modifications to reduce Clonazepam to 0.25 mg in the morning, and 0.5 mg in the evening. The physician signed the recommendations on 10/04/16. A review of Resident #40's physician orders on 11/03/16 at 12:35 p.m., found a physician order was written on 10/04/16 for the GDR for the Clonazepam, but no physician order was written for the Quetiapine. A review of Resident #40's Medication Administration Record [REDACTED]. From 10/10/16 through 10/31/16 there was no documentation the resident received the medication at all. A review of the Resident #40's physician order for [REDACTED]. The (MONTH) (YEAR) MAR indicated [REDACTED]. On 11/03/16 at 12:57 p.m., Resident #40's the pharmacist consultant report, the physician orders, (MONTH) and (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she could not find anywhere in the record where the physician wrote in the resident's record contraindication the resident should not have the GDR.",2020-04-01
3931,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,441,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, staff interview, medical record review and policy review, and Centers for Disease Control and Prevention guidelines, the facility failed to maintain an infection control program to prevent the spread of disease and infection to the extent possible. The facility failed to implement contact precautions for a resident with suspected shingles, soiled linens were handled improperly, and staff failed to utilize proper hand hygiene and/or personal protective equipment (PPE) when handling items contaminated with nasal secretions. This practice affected three (3) residents, but had the potential to affect all residents. Resident identifier: Resident #139, #97, and #57. Findings include: a) Resident #97 During a Stage 1 interview, on 10/31/16 at 3:18 p.m., Resident #97 voiced she had shingles, and pulled up her shirt exposing fluid filled blisters in large patches in a stripe across her abdomen from her left side to her right side. The resident said the areas were painful and she had eaten in her room that date due to the shingles. Shingles is caused by the reactivation of the [MEDICATION NAME]-[MEDICATION NAME] virus (VZV), the same virus that causes chicken pox. Observation revealed no signage on the door or personal protective equipment (PPE) such as gowns, masks, disposable vital signs equipment upon entry of the room. Upon inquiry, Nurse Aide (NA) #22, said the resident required no special precautions. Immediately after the resident interview, during a conversation with Licensed Practical Nurse (LPN) #64 she said the resident did not require precautions because she did not yet have a diagnosis. The nurse said the physician wanted to wait and see if it was a rash. The nurse said staff were using gloves, washing hand and the resident was staying in her room. When asked how long the resident had the areas, the nurse said they were found during the resident's shower on 10/30/16. When asked about the resident's roommate and the roommate's visitors, the nurse related the facility had not considered that factor, and agreed there was a potential for transmission of disease and infection. Another observation, on 11/01/16 at 8:43 a.m., revealed signage on the door and personal protective equipment at the doorway. During a conversation 2:05 p.m., the medical director said the facility had notified her about the shingles after LPN #64's conversation with the surveyor on 10/31/16, said the attending physician should have been contacted and contact precautions were now in place. Nurse Practice Educator (NPE) #88, interviewed on 11/02/16 at 3:15 p.m., said Resident #97 had shingles and was placed in isolation on 11/01/16. The NPE said the resident had the rash, but the physician did not diagnose it as shingles, although he was treating it with medication. She said he did not order isolation. Upon inquiry, the NPE stated she could place a resident in isolation if they were symptomatic or presented with a suspected illness warranting isolation and then notify the physician for an isolation order. The NPE said that in hind sight she should have placed Resident #97 in isolation and phoned the physician for an order. She further added she was not aware that signage and personal protective equipment were not in place initially, but were in place now. physician's orders [REDACTED]. b) Resident #139 A random observation, on 11/02/16 at 9:13 a.m., revealed secretions draining from Resident #39's nasal passages. The clear mucous secretions were draining down and across the resident's mouth and dangling from the chin. Licensed Practical Nurse (LPN) #64, donned gloves and cleaned the resident's face with washcloths and towels. Upon completion, the items were placed on the resident's over-the-bed table where food items were placed. LPN #64 requested Nurse Aide (NA) #135 dispose of the items. The NA picked up the soiled items with bare hands, placed them in a plastic bag, exited the room without performing hand hygiene, carried the items to the soiled utility room, exited the room without utilizing hand hygiene and started down the hallway. NA #135, interviewed immediately after, said she should have worn gloves when picking up the soiled items, did not know the items contained nasal secretions. She also voiced she should have washed her hands. The NA acknowledged the practice created the potential for cross-contamination. c) Resident #57 During a random observation, on 11/02/16 at 12:43 p.m., Nurse Aide (NA) #110 placed soiled linens on the sink. With ungloved hands, the NA placed the linens in a plastic bag, then washed her hands and exited the room. Upon inquiry, the nurse aide said the soiled linens should not have been placed on the sink, but the resident was really dirty and she wanted to get her changed. The NA indicated the facility practice required the linens be placed in a bag. An interview with Nurse Practice Educator (NPE), on 11/02/16 at 3:30 p.m., confirmed the facility practice required staff to utilize gloves when handling soiled linens containing body fluids/secretions and required personal protective equipment when performing tasks which created a potential for cross contamination. The NPE said staff should have performed hand hygiene after performing tasks in the resident's rooms and after handling soiled linens. The Linen Handling Policy, reviewed on 11/02/16 noted all linen would be handled, stored, transported, and processed to contain and minimize exposure to waste products. All linen would be handled the same, using Standard Precautions, to provide effective containment and potential for cross-contamination from soiled linen. The policy directed staff to place soiled linen directly in a covered container at the location where removing the linen. Further guidance indicated staff would remove gloves, wash after handling soiled linen and before transporting bagged linen. Centers for Disease Control guidelines noted people with active lesions caused by herpes [MEDICATION NAME] can spread VZV to susceptible people who have not had [MEDICATION NAME] and never received chicken pox vaccine. The lesions are infectious until they dry and crust over and people with active herpes [MEDICATION NAME] lesions should avoid contact with susceptible people until the lesions dry and are crusted.",2020-04-01
3932,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,490,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel record review, staff interview, medical record review, resident interview and policy review, the facility was not administered in a manner which utilized its resources effectively and efficiently to maintain the highest practicable physical, mental and psychosocial well-being of each resident. The administration failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) 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 live scan 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 card scan 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. b) 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
3933,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,510,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to obtain a physician's order [REDACTED]. Resident identifier: Resident #136. Facility census: 109. Findings include: a) Resident #136 A medical record review, on 11/03/16, revealed a radiology report dated 10/17/16. The report indicated Resident #136 had an x-ray of the left shoulder and ribs. Further review of the electronic and paper medical record revealed no evidence of a physician's orders [REDACTED].>The interim director of nursing, interviewed at 3:30 p.m., reviewed the medical record and confirmed she was unable to find a physician's orders [REDACTED].",2020-04-01
3934,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,513,D,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure x-rays and/or diagnostic reports were signed and dated for two (2) of twenty-two (22) Stage 2 residents. Resident identifiers: Resident #37 and #136. Facility census: 109. Findings include: a) Resident #37 and #136 A medical record review on 11/03/16, revealed chest X-ray reports for Resident #37 dated 08/19/16 and 08/10/16 which had not been signed by the physician. A laboratory report dated 10/10/16 for a hemoglobin A1c lab, basic metabolic panel, complete blood count with differential, and [MEDICAL CONDITION] stimulating hormone had not been signed by the physician. Another laboratory report, dated 08/19/16 for laboratory work which included an hepatic function panel and complete blood count did not have a physician's signature. The medical record for Resident #136, reviewed on 11/03/16, contained X-ray reports of the left shoulder and ribs dated 08/02/16 and 10/17/16. The reports did not contain a physician's signature. The assistant director of nursing (ADON), interviewed at 3:30 p.m., confirmed the reports had been flagged for the physician, but had not yet been signed. Upon inquiry, the ADON stated the physician was in the building frequently.",2020-04-01
3935,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,514,E,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical review and staff interview, the facility failed to complete and accurately document in the medical record for four (4) of twenty- six (26) residents related to what behavior symptom(s) the staff is to monitor on the behavior monitoring forms, incomplete and inaccurate documentation for meal/fluid percentages, bedtime snack, and facility did not fill out a liability notice correctly. This had the potential to affect a limited number of residents. Resident identifiers: #40, #37, #150 and #68. Facility census 109. Findings include: a) Resident #40. A review of the (MONTH) (YEAR) behavior monitoring and intervention form, on 11/03/16 at 1:00 p.m., for Resident #40, found there was no behavior symptoms on the form in order for the staff to know what behaviors they are to be monitoring. The form revealed the resident is on [MEDICATION NAME] and [MEDICATION NAME]. The medication Quetiapine [MEDICATION NAME] ([MEDICATION NAME]) has a marked through the name. A review of Resident #40's physician order [REDACTED]. A review of the psychotherapeutic medication use evaluation form dated 10/04/16, revealed Resident #40 had behaviors of grabbing, repetition, and refusing care. On 11/03/16 at 1:34 p.m., Resident #40's behavior monitoring and intervention form was reviewed by employee #35 licensed practical nurse (LPN), and she confirmed the staff should have written the resident's behavior on the (MONTH) (YEAR)'s form in order to know what behaviors to monitor. She said at one time it was hitting and grabbing, but the forms had changed to rejection of care, and grabbing. The LPN stated, I do not know why the [MEDICATION NAME] was marked through (resident's name) has been receiving the medication. b) Resident #40 A review of Resident #40's Medication Administration Record [REDACTED]. In an interview on 11/03/16 at 1:23 p.m. with licensed practical nurse (LPN) #35, she reviewed the (MONTH) (YEAR) MAR indicated [REDACTED]. The LPN said she did not know why the area are blank because the resident has been receiving the medication. c) Resident #150 During an interview on 11/02/16, the administrator indicated the facility had no demand bills in the past six (6) months for Resident #150. Liability notices, reviewed on 11/02/16 at 4:30 p.m., noted Resident #150 placed an X next to box A which stated, I want my bill for services I continue to receive submitted to the intermediary for a Medicare decision. You will be informed when the bill is submitted. If you do not receive a formal Notice of Medicare Determination within 90 days of this request you should contact: . The verification of receipt was signed by the resident and the Cost Reimbursement Coordinator (CRC) #11, on 07/26/16. During an interview with CRC #11 on 11/03/16 at 9:00 a.m., a request was made to the CRC to explain the form. The CRC said the resident had received notice due to she was discharging to home as a planned discharge and reviewed the medical record, and the resident had not requested an appeal. She said the resident had marked the wrong area on the form, and she had not noticed, and stated the form was inaccurate. d) Resident #37 During a Stage 1 interview on 10/31/16 at 2:05 p.m., Resident #37 said she did not receive the fluids she wanted between meals. Activity of daily living (ADL) records, reviewed on 11/02/16 at 3:07 p.m., revealed multiple omissions of data. Omissions included: October (YEAR): twelve (12) of ninety-three (93) opportunities --Breakfast: 10/31/16, 10/17/16, --Lunch: 10/31/16, 10/28/16, 10/25/16, 10/23/16, 10/17/16, 10/10/16, 10/09/16, 10/01/16 --Dinner: 10/27/16, 10/09/16 Omissions included eleven (11) of thirty-one (31) opportunities as follows: --Snacks: 10/30/16, 10/28/16, 10/27/16, 10/16/16, 10/14.16, 10/13/16, 10/09/16, 10/08/16, 10/07/16, 10/04/16, 10/02/16 September (YEAR): seventeen (17) of ninety (90) opportunities related to meal percent and fluid intake: --Breakfast: 09/30/16, 09/27/16, 09/08/16 --Lunch: 09/30/16, 09/27/16, 09/24/16, 09/15/16, 09/11/16, 09/08/16, 09/07/16 --Dinner: 09/27/16, 09/24/16, 09/21/16, 09/19/16, 09/09/16, 09/08/16, 09/06/16 Omissions included: fifteen (15) of thirty (30) opportunities as follows: --Snacks: 09/27/16, 09/24/16, 09/23/16, 09/22/16, 09/21/16, 09/201/6, 09/19/16, 09/18/16, 09/17/16, 09/14/16, 09/10/16, 09/09/16, 09/18/16, 09/07/16, 09/06/16, The director of nursing reviewed the medical record at 3:30 p.m. on 11/03/16, and confirmed the medical record was incomplete. e) Resident #68 On 10/31/16 at 12:45 p.m. in the Fiesta Dining Room (Dining room A), observed a refused meal for Resident #68. A resident seated at the table stated that Resident #68 waited over an hour for lunch, wasn't waiting any longer and left the dining room. During an interview on 10/31/16 at 12:48 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 did not eat lunch today. Review of Resident #68's medical record on 11/01/16 at 8:00 a.m., showed the activities of daily living (ADL) record dated 10/31/16 failed to reflect Resident #68's meal refusal. An observation on 11/01/16 at 12:20 p.m. showed Resident #68 ate a single ice cream cup and refused alternative food choices. Review of Resident #68's medical record on 11/02/16 at 8:30 a.m., showed the ADL record for meals, and dated 11/01/16 coded as 100% for lunch intake. During an interview on 11/01/16 at 12:25 p.m., the Clinical Reimbursement Coordinator (CRC) #93 stated that Resident #68 sometimes ate one item, such as the ice cream that she ate for lunch today. In this case, CRC #93 states that Resident #68 will be recorded as eating 100% because the single ice cream cup is what the resident chose. During an interview on 11/02/16 at 11:05 a.m., the Director of Food Service states that they are told to divide the plate in quarters and if that ice cream cup is all a resident ate then it is documented as 25%.",2020-04-01
3936,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-11-04,520,F,0,1,VTNG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on personnel records, resident and staff interviews, and policy review, the quality assessment and assurance (QAA) committee failed to identify and/or act upon a quality deficiency within the facility's operations of which it did have (or should have had) knowledge, and implement plans of action to correct these deficiencies, including monitoring the effect of implemented changes and making revisions to the action plans if the desired results were not obtained. The facility failed to ensure the safety of residents after an allegation of sexual abuse, failed to ensure allegations of abuse were thoroughly investigated and/or reported to the appropriate State agencies, failed to ensure the provision of medically related social services, and failed to ensure criminal background checks were completed as required. This practice affected one (1) of one (1) resident reviewed for abuse, and had the potential to affect all residents. Resident identifier: Resident #164. Employee Identifier: Nurse Aide (NA) #20. Findings include: a) 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 live scan 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 card scan 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. b) 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
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
5139,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-03-04,309,G,1,0,PZGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on review of the medical records, concern logs, incident and accident reports, resident interview, and staff interviews, the facility failed to provide the necessary care and services to attain or maintain the highest possible level of well-being in accordance with the individuals comprehensive assessment and plan of care. Resident #98 experienced actual harm when she sustained skin tears while being placed on a Hoyer lift pad. This was found for one (1) of one-hundred forty-nine (149) incident/accident reports reviewed. Additionally, seven (7) of thirteen (13) residents reviewed had not received all of their medications as ordered. Residents #6, #52, and #33 did not receive all of their scheduled medications as prescribed. Resident #27 received the wrong antibiotic; Resident #90 received the wrong nutritional supplement, and Residents #16 and #31 missed prescribed medications because the orders were not transcribed correctly. Resident identifiers: #98, #6, #52, #31, #27, #90, #16, and #33. 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., identifying actual harm to the resident. 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 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 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) Review of the incident/accident forms on 03/01/16 at 3:00 p.m. revealed the following medication errors: 1. Resident #6 Resident #6 did not receive his prescribed pain medication ([MEDICATION NAME] 75 milligrams) on 02/22/16 at 8:00 p.m. and 02/23/16 at 8:00 p.m. The physician's orders [REDACTED]. The order was transcribed on to the Medication Administration Record [REDACTED] Review of the control substance log on 03/02/16 at 9:00 a.m., confirmed this medication was not given at 8:00 p.m. on 02/22/16 and 02/23/16. During an interview on 03/02/16 at 10:00 a.m., Resident #6 reported the staff had not given him his evening pain medication on two (2) occasions. He stated he had a history of [REDACTED]. 2. Resident #52 According to an incident report, Resident #52 reported she had not received her scheduled 1:00 p.m. dose of [MEDICATION NAME] on 12/22/15. No reason for the omission was noted. The (MONTH) (YEAR) MAR indicated [REDACTED]. Give 1 tablet by mouth three times a day related to idiopathic peripheral autonomic [MEDICAL CONDITION], unspecified. The medication was scheduled to be administered daily at 9:00 a.m., 1:00 p.m., and 8:00 p.m. The Director of Nursing (DON) reviewed the MAR indicated [REDACTED]. 3. Resident #31 This resident's readmission order for Glucerna 240 milliliters daily was not transcribed to the MAR. This error was found by staff on 02/01/16 after she had missed twenty-one (21) daily doses. The physician's orders [REDACTED]. Glucerna 240 ml QD (daily). The MAR indicated [REDACTED]. 4. Resident #27 Resident #27 received the wrong intravenous antibiotic at 8:00 a.m. on 12/17/15. The MAR indicated [REDACTED] Resident #27 received [MEDICATION NAME] 1 gram intravenously for his 8:00 a.m. dose on 12/17/15, instead of his prescribed [MEDICATION NAME]. (The physician was notified and issued no new orders.) 5. Resident #90 Licensed Practical Nurse (LPN) #142 identified a transcription order on Resident #90 s MAR indicated [REDACTED]. The physician's orders [REDACTED]. The order was transcribed onto the MAR indicated [REDACTED]. Resident #90 received seven (7) doses of the incorrect medication. 6. Resident #16 This resident's lab work was reviewed by his physician and a fax was returned to the facility on [DATE] with an order to start [MEDICATION NAME] (a medication used to treat high cholesterol and high triglycerides) 48 mg daily. The order was not written in the medical record or transcribed to the MAR until the error was found on 02/14/16. c) Resident #33 Review of the concern logs on 02/29/16 at 2:00 p.m., revealed a report from Resident #33's daughter dated 10/29/16, which stated her father had reported he had not received his night time medications on Monday night (10/26/16). The MAR indicated [REDACTED]. d) The Director of Nursing (DON) and the facility Administrator acknowledged they were aware of these medication errors during an interview on 03/01/16 at 11:10 a.m. The DON reported the medication omissions and errors have decreased since the facility started doing an audit of medication transcriptions, errors and omissions. e) At the time of the investigation, the only inservice education provided regarding these errors was the nurse finding the error/omission educated the nurse who made the error.",2019-03-01
5140,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-03-04,323,E,1,0,PZGV11,"> Based on observation, resident interview, and staff interview, the facility failed to ensure the residents' environment remains as free of accident hazards as is possible. Hallways were cluttered with large chairs, mechanical lifts, clean and soiled linen carts, soiled brief carts, medication and treatment carts, blood pressure machines, wheelchairs, and walkers. These devices prevented resident access to hand rails on either side of the hallway, and/or limited residents' mobility in their wheelchairs. Residents reported maneuverability difficulties during independent travels through the halls. This practice had the potential to affect all residents. Resident census: 107. Findings include: a) Observations during an initial tour of the facility on 02/29/16 at 11:58 a.m., found the following in the residents' hallways: 1. B Hall: -- Outside of rooms #132 to #146, a mechanical lift, two (2) large chairs, an over-bed table and two (2) clean linen carts were blocking the hand rail on the right side of the hallway. 2. C Hall: -- Outside of rooms #169 to #183, three (3) large chairs, an over-bed table, a soiled linen cart and a soiled brief cart were blocking the handrail on the side of the hallway. 3. D Hall: -- A linen cart and wheelchair around the corner from room 232, adjacent to an exit to the residents' courtyard -- A chair and a blood pressure machine outside of room 238 -- A wheelchair outside of room 245 4. E Hall: -- Two (2) large chairs between rooms 334 and 336 -- A wheelchair and large chair outside of room 340 5. F Hall: -- Two medication carts, a dressing cart, two BP machines and a large chair between the nurses' station and room 433 -- A geri-chair and wheelchair outside of the care plan office across from room 432 -- Two (2) large chairs outside of room 439 -- A folded walker leaning against the wall outside of room 436 -- A mechanical lift outside of room 443 -- A folded four-wheel walker leaning against the wall next to the fire door exit b) Random observations of B hall on 03/01/16 between 9:50 a.m. to 10:30 a.m. revealed numerous residents and staff attempting to maneuver the cluttered hallways. Staff, residents, and visitors had to stop to let each other pass or try to stay to one side. Also residents in wheelchairs were trying to move other residents in wheelchairs up the hall or out of the way to get through the hallway. c) Follow up observations A follow up observation on 03/02/16 at 9:50 a.m. found the following: 1. B Hall: -- A soiled linen cart, a soiled brief cart, a mechanical lift, and two (2) clean linen carts were sitting outside of rooms #132 to #146 blocking the handrail on that side of the hallway. 2. C Hall: -- A soiled linen cart, a clean linen cart, and a soiled brief cart were blocking the handrail on the side of the hallway for rooms #169 to #183. 3. D Hall: -- The hand rail was completely blocked on one side of the hall between rooms 238 to 242 with a geri-chair, resident lift, linen cart, and blood pressure machine. -- A wheelchair was found on the other side of the hall, outside of room 245 4. F Hall: -- A wound cart sitting between the medication room and room 443 -- A wheelchair and blood pressure machine were parked on the same side of the hall between the care plan room and activities office -- A large chair, linen cart, and resident lift between rooms 441 and 443 -- A four (4) wheel walker sat in front of the fire exit door at the end of the hall. d) On 02/29/16 at 12:10 p.m. during an interview, Licensed Practical Nurse (LPN) #142 stated, The big high back chairs and the over-bed tables are always sitting in the hall, it is a common occurrence for the nurse aides (NA) to sit and chart in the activities of daily living (ADL) binders. This is done to prevent falls so the NA can observe the residents while they chart in the binders. e) During an interview with the Administrator and the Director of Nursing (DON) at 11:00 a.m. on 03/01/16, they both agreed the halls were cluttered. f) During an interview with the Nurse Practice Educator #84, on 03/01/16 at 11:20 a.m., she confirmed the hall ways are cluttered especially D hall (rooms 232-245), which is a high traffic area. g) On 03/02/16 at 10:00 a.m. during a random interview with Resident #12, he commented that he is in a wheelchair and travels the hallways all the time. He stated, I travel around all the hallways and sometimes it is hard to maneuver around all the stuff and the other residents, because two wheelchairs can't pass everywhere in the halls. It is better now since they moved all of the stuff out of the hallways yesterday. h) During a random interview with Resident #19 on 03/02/16 at 10:05 a.m., he stated, I guess you just get used to it being cluttered after a while, but it is hard to get around, you just have to wait your turn like any road traffic with one lane blocked.",2019-03-01
5141,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-03-04,441,E,1,0,PZGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on observation and staff interview, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Soiled/dirty linen carts and soiled resident brief carts were stored in the main hallways and not in a secured locked area to prevent resident access to these soiled items. In addition, a nurse failed to employ infection control practices during a medication pass observation. These findings had the potential to affect more than an isolated number of residents. Resident identifier: #63. Facility census: 107 Findings include: a) Soiled linen and soiled brief carts An observation on 03/01/16 at 09:55 a.m., revealed a resident sitting next to a soiled linen cart doing embroidery on hallway B. The cart contained opened/unsecured clear plastic bags of various items of easily accessible soiled laundry items. Further down the hall on one side was another unattended soiled briefs cart (numerous random residents were in their wheelchairs traveling this hallway), containing unsecured/open clear plastic bags of briefs soiled with urine and feces. Upon turning the corner to hallway C, observed sitting against the wall an unattended soiled linen cart and a short distance down the hall was another unattended soiled brief cart. Also a soiled linen cart was stored against the wall in Dining room B (the Coral room with numerous residents sitting in this room) containing soiled wash clothes and clothing protectors Accompanied by the Administrator and the Director of Nursing (DON) at 10:30 a.m., the previously described unattended carts remained unmoved in the hallways. The Administrator stated, These are used by staff when making rounds and they are against the wall. But they are not to be left unattended. Upon lifting the lid of the soiled brief cart on hallway B, he agreed it was not a pleasant odor for residents. The DON agreed that the unattended soiled carts were an infection control issue and should be stored in soiled utility rooms. They both agreed the soiled linen carts and soiled brief carts should not be in the hallway, nor in the dining room, and could be readily accessible to residents. The Administrator and DON immediately removed all of the soiled carts from the hallways and they were placed in the soiled utility room that had a push button locked entrance door. During an interview with Infection Control Nurse #84 on 03/01/16 at 10:50 a.m., she stated, Yes, it is an infection control issue with the soiled carts in the hallway, and no, they should not remain in the hallway. They (soiled linen carts) are to be used and then stored away, not to sit in the hallways unattended by staff. Also at this time I am in-servicing the staff on properly storing soiled linen and soiled brief carts. b) Resident #63 On 03/01/16 at 9:00 a.m., Registered Nurse (RN) #97 placed Resident #63's eye drop box directly on the bedside stand in the resident's room. The nurse administered the resident's eye drops ([MEDICATION NAME] Solution 22.3-6.8 mg/ml), placed the eye drop bottle back in the box, and returned the eye drops and the box to the medication cart. In addition she touched the resident's eyelid with the tip of the eye drop bottle during administration. During an interview on 03/01/16 at 9:30 a.m., RN #97 agreed touching the eyelid with the bottle tip and placing the eye drops directly on the bedside stand without a barrier was a break in aseptic technique. She also agreed she should have not returned the box and eye drops to the medication cart.",2019-03-01
5142,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2016-03-04,514,D,1,0,PZGV11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on record review and staff interview, the facility failed to ensure the completeness and accuracy of the clinical record for three (3) of thirteen (13) residents reviewed. Resident #90's medication was inaccurately transcribed to the Medication Administration Record (MAR); Resident #31's nutritional supplement was not transcribed to the MAR and administered for twenty-one (21) days; and Resident 16's medication order was transcribed into the medical record and onto the MAR two (2) days after the physician's orders [REDACTED]. Resident identifiers: #90, #31, and #16. Facility census: 107. Findings include: a) Resident #90 Review of the incident/accident form and medical record on 03/01/16 at 3:00 p.m. revealed Resident #90 received seven (7) doses of the wrong medication before the transcription error was identified. Licensed Practical Nurse (LPN) #142 identified a transcription error on Resident #90's MAR during her medication pass on 02/20/16 when she did not have the correct medication for the resident. The physician order [REDACTED]. The order was transcribed onto the MAR as, Folic Acid po daily 400 mg DX (diagnosis) supplement. b) Resident #31 Review of the incident/accident form and medical record on 03/01/16 at 3:15 p.m., revealed Resident #31's readmission orders [REDACTED]. This error was found by staff on 02/01/16 after she had missed twenty-one (21) daily doses. The physician order [REDACTED]. Glucerna 240 ml (milliliters) QD (daily). The MAR dated (MONTH) (YEAR) was silent in regards to the readmission order for Glucerna. c) Resident #16 Review of the incident/accident form on 03/01/16 at 3:00 p.m., and the medical record on 03/02/16 at 11:30 a.m., revealed Resident #16's lab work was reviewed by her physician and a fax was returned to the facility on [DATE] with an order to start [MEDICATION NAME] 48 mg daily. The order was not written in the medical record or transcribed to the MAR until the error was found on 02/14/16. d) During an interview with the Director of Nursing (DON) and the Administrator on 03/01/16 at 11:10 a.m., they confirmed they were aware of the transcription errors for Residents #90, #31, and #16. The DON stated the medication omissions and errors have decreased since the facility started doing an audit of medication transcriptions, errors and omissions.",2019-03-01
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
5383,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,253,E,0,1,ZLZ811,"Based on observation, policy review, and staff interview, the facility failed to provide housekeeping and maintenance services necessary to ensure an orderly, sanitary, and comfortable environment by not performing routine and/or preventative maintenance services on oxygen concentrators. This was found for five (5) of five (5) residents reviewed during Stage 1 of the annual Quality Indicator Survey (QIS). Resident identifiers: #103, #111, #33, #52 and #42. Facility census: 111. Findings include: a) Observations during Stage 1 of the QIS, on 08/17/15 and 08/18/15, found the following: 1) Resident #103's Invacare oxygen concentrator labeled with a preventative maintenance sticker indicating the last service completed (MONTH) 2014 and due again in (MONTH) (YEAR). 2) Resident #111's Invacare oxygen concentrator's preventative maintenance sticker indicates the last service completed on 10/07/14 and was due again on 04/07/15. 3) Resident #33's Invacare oxygen concentrator's preventative maintenance sticker indicates services were last performed on 10/07/14 and were due on 04/07/15. 4) Residents #52 and #42's Perfecto2 oxygen concentrators were void of routine maintenance stickers. b) The facility policy titled: Oxygen: Concentrator with an effective date of 01/01/14, stated under section 13: Perform maintenance according to manufacturer's instructions and by approved preventative maintenance personnel. c) During a staff interview with Maintenance Supervisor #109, on 08/19/15 at 2:30 p.m., he reported the facility had just started conducting their own maintenance on the oxygen concentrators which consisted of changing the oxygen tubing and filters, and checking the oxygen flow. He was unaware of the maintenance stickers or any required routine maintenance due every six (6) months. In addition, he reported the Perfecto2 oxygen concentrators were new machines that had been recently put into service, and they did not have maintenance stickers in place. During a follow-up interview, at 2:45 p.m. on 08/19/15, Maintenance Supervisor #109 presented a copy of the Perfecto2 oxygen concentrator user manual from Invacare which verified routine maintenance required every six (6) months and consisted of: checking the oxygen concentration, clean/replace cabinet filters, check the outlet for the high efficiency particulate air (HEPA) filter and the compressor inlet filter, and check the power loss alarm.",2019-01-01
5384,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,371,F,0,1,ZLZ811,"Based on observations and staff interview, the facility failed to follow proper sanitation and food-handling practices to prevent the potential for outbreak of foodborne illness. The facility failed to maintain appropriate temperatures of milk during food service in both the kitchen and the Coral dining room. They failed to ensure the cleanliness of a section of flooring and a trash can in the kitchen. In addition, the facility did not maintain the faucet of a handwashing sink and a faucet on a pot-filler to prevent leakage. This had the potential to affect all residents. Facility census: 111. Findings include: a) During the initial observation of the kitchen area at 11:45 a.m. on 08/17/15, the handwashing sink had a steady stream of water from the hot side of the faucet. There were splashes on the floor and the wall surrounding the sink. The faucet on the pot-filler was also leaking and dripping on equipment surfaces and the floor below it. At 12:10 p.m. on 08/19/15, during the follow-up visit to the kitchen, the faucet on the handwashing sink was again dripping. When brought to the attention of Maintenance Supervisor #109, he agreed it could only be turned off with extra force. He said he would fix it at once. b) During a follow-up visit in the kitchen at 11:40 a.m. on 08/19/15, for observation of preparation and service of the noon meal, the following infractions were observed: 1. A trash can located in the kitchen next to the double sink was dirty with dried food particles and liquid stains on both the inner and outer surfaces. 2. A strip of the floor located outside the walk-in refrigerator/freezer had bare/rough-surfaced concrete. The lower area of the wall meeting the concrete was dirty, stained, and missing areas of plaster. There were heavy accumulations of rust in both corners where concrete met the metal doors of walk-in refrigerator/freezer. Debris and rust could be seen in the pitted concrete. This area was shown to Food Service Director #110 and Maintenance Supervisor #109 at 12:10 p.m. on 08/19/15. They both acknowledged the area could not be thoroughly cleaned and could harbor germs. 3. Upon entry into the kitchen at 11:40 a.m. on 08/19/15, multiple individual cartons of milk were observed stacked in two (2) large rubber containers on the metal counter at the end of the steam table. There was no ice in the containers. At 12:20 p.m. (approximately 1/2 way through service) the temperature of the milk in these cartons was checked by Cook #84 and found to be 47 degrees Fahrenheit. This was relayed to Executive Chef #133, who was present and removed the remaining milk was from the tray line, replacing it from the cooler. (Milk is considered a potentially hazardous food. Holding it above 41 degrees Fahrenheit allows the rapid growth of pathogenic microorganisms that can cause foodborne illness.) - Observations at 12:20 p.m. on 8/20/15, during plating of the noon meal, noted Server/Cook #84 stood behind the steam table in the kitchen with her name tag attached to her waist. The name tag hung at a height allowing it to come into contact and slide across the top of trays as they were moved in front of her. The name tag also came contact with the surfaces of several plates. This was relayed to Dietary Manager #110, who also observed the contact. - At 12:30 p.m. on 08/19/15, observations found Food Service Director (FSD) #111 moving between kitchen serving area and the serving area located in the Fine Dining Room. She opened the connecting door with her hand, brought a tray of food from the kitchen to the dining room, and then returned to kitchen, again touching the door. Without washing her hands, FSD #111 retrieved a clean utensil and handed it to Cook #84 who was plating food. This was relayed to Dietary Manager #110 at 12:40 p.m. who acknowledged FSD #111's practices were unsanitary during the observations made at 12:30 p.m. on 08/19/15. b) During a dining observation in the Coral dining room on 08/17/15 from 12:15 p.m. to 1:15 p.m., a half-gallon of white and a half gallon of chocolate milk sat on the counter top. Both milk cartons were placed on the cart after lunch with plans to return them to the kitchen for further use. On 08/17/15 at 1:17 p.m., Executive Chef #133 confirmed the unused milk was returned to the kitchen and used at a later time. Director of Food Service #110 checked the milk temperatures on 08/17/15 at 1:18 p.m. in the Coral dining room. The half-gallon of white milk was sixty (60) degrees Fahrenheit and the half-gallon of chocolate milk was fifty-eight (58) degrees Fahrenheit. She agreed both bottles of milk were at unsafe temperatures and not safe for consumption.",2019-01-01
5385,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,425,D,0,1,ZLZ811,"Based on observation, staff interview, review of manufacturer's drug insert, and review of recommendations from the Centers for Disease and Prevention Control (CDC), the facility, in collaboration with the pharmacy, failed to ensure all medications were labeled with an expiration date. One (1) of two (2) medication rooms had a vial of Humalog regular insulin was not labeled with a date as to when the medication was opened. One (1) resident also had expired medications. Resident identifier: #145. Facility census: 112. Findings include: a) During an observation on 08/20/15 at 2:00 p.m., the F hall medication room had one (1) opened Humalog 30 cc (cubic centimeters) vial of regular insulin. The vial of insulin was not dated to indicate when the vial was opened. According to the CDC Once a multi dose vial of medication has been opened or accessed (e.g. needle punctured); the vial should be dated and discarded within twenty-eight (28) days unless the manufacturer specifies a different (shorter or longer) date for the opened vial. Using a medication from a multi-dose vial for greater than what is recommended by the manufacturer and/or pharmacy has the potential to negatively impact the potency of the medication. Without dates to indicate when the vial of Humalog regular insulin was first opened, staff members could not know when the vial should be discarded. According to the manufacturer's guidelines the Humalog vial should be discarded 28 days after opening. During an interview, on 08/20/15 at 2:15 p.m., Assistant Director of Nursing #89 stated she would give the insulin vial that did not have a date on it to the director of nursing to be destroyed.",2019-01-01
5386,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,428,D,0,1,ZLZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure irregularities identified by the pharmacist were acted upon. The physician did not provided the rationale for declining a gradual dose reduction (GDR) recommended by the consultant pharmacist in a timely manner. This was found for one (1) of five (5) residents whose records were reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #107. Facility census: 111. Findings include: a) Resident #107 Medical record review on 08/19/15 at 1:45 p.m., revealed Resident #107, admitted on [DATE], had [DIAGNOSES REDACTED]. He received the medication Zoloft 25 milligrams (mg) by mouth (PO) daily for a depressive disorder. A consultant pharmacist's recommendation, dated 09/23/14, requested a gradual dose reduction (GDR) of the Zoloft. It stated the resident had been receiving the dose since 04/16/14 from a previous GDR. The recommendation was to decrease the dose to 25 mg every other day for 2 weeks and then to discontinue. The pharmacist's form contained a box to be checked by the attending physician (typed as written), I decline the recommendation(s) above as GDR is CLINICALLY CONTRAINDICATED for this individual as indicated below. (NOTE: Please check option #1 or #2 and provide patient specific rationale on the lines below.) This was not checked by the Physician, but a line was drawn over option #1 (typed as written), 1. ___ continued use is in accordance with the current standard of practice and a GDR attempt at this time is likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder as documented below. The lines below were blank for a patient-specific rationale and the form was signed by the Physician and previous Director of Nursing (DON). During an interview with the Administrator on 08/19/15 at 2:25 p.m., he agreed and verified the attending physician had not provided a rationale for declining the pharmacist's recommendation for Resident #107. After reviewing the pharmacy consultation report on 08/19/15 at 2:45 p.m., the DON agreed the attending physician had not provided a rationale for declining the GDR. He further commented the physician would be educated to document a rationale when declining a pharmacy recommendation for a GDR.",2019-01-01
5387,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2015-08-20,500,D,0,1,ZLZ811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's agreement with a [MEDICAL TREATMENT] provider, and staff interview, the facility failed to have a current agreement that specified in writing that the facility assumed responsibility for obtaining services that meet professional standards and principles that apply to professionals providing services in such a facility; and the timeliness of the services. The facility did not have an agreement with the [MEDICAL TREATMENT] it currently used. This had the potential to affect any resident who entered the facility and required [MEDICAL TREATMENT] treatment. Resident #129 received [MEDICAL TREATMENT] services. Resident identifier: #129. Facility census: 112. Findings include: a) Resident #129 Review of Resident #129's medical record on 08/18/15 at 11:30 a.m., found the resident required [MEDICAL TREATMENT]. A review of the [MEDICAL TREATMENT] agreement, on 08/18/15 at 11:50 a.m., revealed [MEDICAL TREATMENT] services were provided by Provider #1. The agreement was dated 01/01/08. During an interview, on 08/20/15 at 1:25 p.m., Administrator #125 stated the facility had been using the services of [MEDICAL TREATMENT] Provider #2 for several years. The Administrator stated he contacted Provider #2 and found the facility did not have a current [MEDICAL TREATMENT] agreement with Provider #2.",2019-01-01
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
6114,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,241,E,0,1,L8JN11,"Based on observation, staff interview, and policy review, the facility failed to promote care in a manner that maintained each resident's dignity during the dining experience. This practice had the potential to affect any resident that required assistance with dining. Staff stood while feeding residents, reached across residents' plates while assisting with meals, did not interact socially with residents during the dining experience, and one staff member responded to a resident in an undignified manner. Eleven (11) of twenty-seven (27) residents observed in the Coral dining room were affected. Resident identifiers: Resident #35, #38, #63, #66, #70, #78, #87, #92, #112, #117, and #151. Facility census: 111. Findings include: a) Residents #63, #38, #70, #92, #35, and #87 A dining observation in the Coral Dining Room, on 0512/14 between 12:00 p.m. and 12:45 p.m., found two (2) C-shaped tables were set up to create a circle. Residents were seated along the outside of the table and a nursing assistant (NA), Employee #45 was in the middle of the circle. She sometimes stood and fed a resident and would sit on a chair to feed others. When standing to feed a resident, the NA leaned across the table with a hovering appearance. While seated, the NA reached across the residents' plates to provide assistance. In addition, staff did not converse with the residents to create a social environment. b) Resident #151 At 12:10 p.m., Employee #83, a NA, spoke in a matter of fact tone to Resident #151,telling her to Stop kicking the table. The second time the resident kicked the table, the NA had a frown on her face, and spoke in a curt tone to Resident #151. Employee #83 shook her head slightly, side to side and said, I don't know why. The rest of the sentence was inaudible. The vocal tone was not a loud yelling tone, but was said in a disrespectful manner. No other resident or facility staff appeared to notice the interaction, as they were busy assisting other residents who were eating. During an interview with the administrator on 05/19/14 at 2:30 p.m., he confirmed staff violated the resident's dignity. c) Residents #70, #92, #78, #112, #87, #66, and #117 Another dining observation, on 05/13/14 at 5:22 p.m., revealed Residents #70, #92, and #78 required assistance to eat. Staff were again standing while assisting the residents with their meals. Employee #4 (NA) was observed standing while feeding Residents #78 and #112; Employee #91 was feeding Resident #87; and Employee #64 was feeding Residents #66 and #117. An interview with Employee #24, a registered nurse (RN), confirmed staff was should not be standing while feeding residents, and it was against facility practices. Again, staff were not conversing with the residents. c) A lunch observation on 05/19/14 at 12:00 p.m., again revealed staff were feeding residents while standing, and were not interacting with them. Employee #77 was feeding a resident with no interaction, conversation. Employee #138, (corporate acting director of nursing) was observing the dining process. She confirmed staff were not supposed to stand up while feeding a resident, and also confirmed staff did not interact with the residents while feeding them. d) Review of the facility's OPS213 Treatment: considerate and respectful policy, with a revision date of 09/01/13 revealed staff . will show respect when communicating with, caring for, or talking about. 1.3 Dining: promote patient independence and dignity in dining such as avoidance of: . standing over patients while assisting them to eat; staff interacting/conversing only with each other rather than with patients while assisting patients. An interview with the acting director of nurses, at 12:30 p.m. on 05/19/14, confirmed staff provided care without respect for the residents' dignity. The administrator was interviewed at 2:30 p.m., and also confirmed staff had not respected the residents' dignity.",2018-05-01
6115,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,247,D,0,1,L8JN11,"Based on resident interview, record review, and staff interview, the facility failed to ensure two (2) residents were informed of a room transfer, and the change in roommates, prior to the change taking place. Resident identifiers: #134 and #155. Facility census: 111. Findings include: a) Resident #134 During a resident interview with Resident #134 at 3:20 p.m. on 05/12/14, he stated he was stopped in the hall on his way to therapy by Employee #56 (Social worker) who said to him, We're thinking about moving you. When he finished therapy he found he had been moved to a different room and all his personal belongings had been transferred. He stated no one had introduced him to the new roommate. In a follow-up interview, at 9:30 a.m. on 05/15/14, he stated, That was just too fast. They should have let me get my things together. There was no evidence in the resident's record to indicate he was informed of the room change, where the new room was located, or who his roommate would be. There was no discussion regarding his satisfaction with the change; only that it had been done. During an interview with Employees #56 and #38 (Social Workers) at 1:30 p.m. on 05/15/14, Employee #56 reviewed the form in the EHR (electronic health record) and agreed it only contained the date and time of the transfer and a check mark by the word Informed. She stated she always documented under Comments if the resident refused to transfer and explained Resident #134 was admitted for skilled care and was informed on admission if his status changed . he may be asked to move to another room. She stated she would review the record further for evidence she had discussed this with the resident and asked for his agreement, but no additional information was received prior to exit on 05/19/14. The Administrator was informed of the above finding at 2:00 p.m. on 05/15/14. He agreed the resident should be informed in advance of a need to transfer to a different room and should be introduced to the new roommate. b) Resident #155 A closed record review for Resident #155, at 10:00 a.m. on 05/14/14, revealed she was transferred to a different room during her admission (04/22/14). The only information in the record was a note by Employee #56 (Social Worker) stating, Notified of room change on 04/22/14. There was nothing which indicated the reason for the room change and/or any comments. During an interview with Employee #56 and #38 (Social Worker) at 1:30 p.m. on 05/15/14, neither of them, after reviewing the record, could identify why the resident was moved. They both stated the assumption was because she had changed from skilled care status to long term care status, but could not supply evidence of discussing this with the resident. It should be noted, that all of the facility's beds were dually certified for both Medicare and Medicaid, so a change in skilled status to long term status should not have been relevant. The Administrator was informed of the above finding at 2:00 p.m. on 05/15/14. He agreed the resident should be informed in advance of a need to transfer to a different room and should be introduced to the new roommate.",2018-05-01
6116,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,253,E,0,1,L8JN11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services to adequately maintain a sanitary and comfortable environment in nine (9) of fifty-eight (58) resident rooms. The disrepair created a potential to interfere with the routine cleaning of the rooms meant to assist in preventing the development and transmission of infection. These deficiencies had the potential to affect more than a minimal number of residents. The rooms affected were: 138, 147, 170, 173, 177, 179, 181, 242, and 238. Facility census: 111. Findings include: a) Rooms 177 and 179 During the initial tour of the facility, at 1:40 p.m. on 05/12/14, the bathroom sprayer hose in the bathroom shared by rooms 177 and 179 was observed with stool on the end of the handle, and there was splatter on the walls and floor. On the same visit, the sink in room 177 was movable and not secured in place. The caulking around the sink was cracked and some of it was missing. There were dark rings present indicating that cleaning could not be performed adequately for disinfection. b) Rooms 170, 181, 238, 242, and 138 During a second tour, at 11:30 a.m. on 05/19/14, the sinks in rooms 170, 181, 238, 242, and 138 were also observed movable and had gaps and cracks in the caulking. These areas were reported to the Administrator at 12:35 p.m. on 05/19/14 and pointed out to Employee #121 (Maintenance Director) at 3:35 p.m. on 05/19/14. c) Rooms #147, #179, and #173 - Room #173 - an observation on 05/12/14 at 2:47 p.m., revealed the bathroom wall behind the commode had paint peeled off in the right lower corner and the molding was not sealed. - Room #147 - observation on 05/13/14 at 9:15 a.m., found the caulking was loose from the right lower corner of the bathroom wall. Additionally, the paint was bubbling and peeling from the wall above the molding. The area behind the heater in the room had large chunks of wall board missing. - Room #170 - observation on 05/13/14 at 9:17 a.m., revealed the molding was loose from the wall behind the sink. Further observation revealed a gap between the molding and floor below the heater/window area. Room observations were completed with the maintenance director on 05/19/14 at 3:35 p.m. He observed rooms #147, #170 and #173 and confirmed the plaster was cracked, and the tile was separated from the wall/floor board.",2018-05-01
6117,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,272,D,0,1,L8JN11,"Based on observation, resident interview, record review, and staff interview, the facility failed to ensure Resident #104's comprehensive assessment accurately reflected the resident's dental status. This was found for one (1) of fifty-one Stage 2 sample residents. Resident identifier: #104. Facility census: 111. Findings include: a) Resident #104 During an interview, on 05/12/14 at 3:00 p.m., Resident #104 was observed with multiple dark tooth fragments and with one (1) upper front tooth protruding. This tooth was blackened along the gum line. During the interview, an inquiry was made regarding making an appointment with a dentist. Resident #104 stated she did not want dentures. In addition, this resident stated her jaw had been broken and she was told nothing could be done about her teeth except to pull all the teeth and have dentures. Medical record review, on 05/15/14 at 10:00 a.m., found the resident's annual minimum data set (MDS) assessment, with an assessment reference date (ARD) of 06/15/13, was coded as D. Obvious or likely cavity or broken natural teeth in Section L Oral/Dental Status for item L0200. The next MDS, a significant change in status assessment, with an ARD of 08/01/13 revealed Section L Oral/Dental Status, item L0200 - Dental, was marked as Z. None of the above were present. The none of the above included: - A. Broken or loosely fitting full or partial denture - B. No natural teeth or tooth fragments(s) - C. Abnormal mouth tissue - D. Obvious or likely cavity or broken natural teeth - E. Inflamed or bleeding gums or loose natural teeth - F. Mouth or facial pain, discomfort or difficulty with chewing - G. Unable to examine. On 05/15/14 at 2:30 p.m., the clinical reimbursement coordinator (CRC) reviewed the MDSs completed on 06/14/13 and 08/01/13. She agreed the MDS with an ARD of 08/01/13 was incorrect.",2018-05-01
6118,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,274,D,0,1,L8JN11,"Based on record review, review of the Centers for Medicare and Medicaid (CMS) resident assessment manual, and staff interview, the facility failed to complete a significant change in status minimum data set (MDS) assessment when a resident elected to receive hospice benefits. This was true for one (1) of fifty-one (51) sample residents. Resident identifier: #68. Facility Census: 111. Findings include: a) Resident #68 Review of the resident's medical record at 1:14 p.m. on 05/19/14, found her payer source changed to Hospice on 01/11/14. This was verified by telephone with a Hospice representative at 3:30 p.m. on 05/19/14. Review of the resident's comprehensive assessments found a significant change in status minimum data set (SCSA MDS) was completed 12/17/13. Another SCSA MDS would have been due within 14 days after Resident #68 elected to receive the hospice benefit on 01/11/14. An interview was conducted with Employees #58 and #62, of the Clinical Reimbursement department. They both stated they were not aware the resident had begun receiving Hospice benefits because there was no physician's order in the computer for Hospice until 03/31/14. They were unable to explain why they had not completed a SCSA MDS within 14 days of the 03/31/14 date if they used physician's orders as a basis for scheduling the MDS. CMS's RAI Version 3.0 Manual, includes in Chapter 2, page 21, A SCSA (significant change in status assessment) is required to be performed when a terminally ill resident enrolls in a hospice program (Medicare Hospice or other structured hospice) and remains a resident at the nursing home. The ARD must be within 14 days from the effective date of the hospice election (which can be the same or later than the date of the hospice election statement, but not earlier than). A SCSA must be performed regardless of whether an assessment was recently conducted on the resident.",2018-05-01
6119,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,278,D,0,1,L8JN11,"Based on record review and staff interview, the minimum data set (MDS) did not accurately reflect the resident's status for two (2) of fifty-one (51) Stage 2 sample residents. Hospice was not reflected on the MDS for Resident #68. Resident #104's dental condition was not accurately reflected on the MDS. Resident identifiers: #68 and 104. Facility census: 111. Findings include: a) Resident #68 Medical record review, at 1:14 p.m. on 05/19/14, found the resident's payer source changed to Hospice on 01/11/14. This was verified in a telephone conversation with a Hospice representative at 3:30 p.m. on 05/19/14. Review of the resident's MDS revealed hospice was not indicated on the MDS. An interview was conducted with Employees #58 and #62 of the Clinical Reimbursement department. They both stated they were not aware the resident had begun receiving hospice because there was no physician's order in the computer for Hospice until 03/31/14. They were unable to explain why there was no revision of the MDS after the became aware of the order dated 03/31/14. b) Resident #104 During an interview, on 05/12/14 at 3:00 p.m., Resident #104 was observed with dark tooth fragments and with one (1) upper front tooth protruding. This tooth was blackened along the gum line. A medical record review was conducted on 05/15/14 at 10:00 a.m The minimum data set (MDS), with an assessment reference date (ARD) of 08/01/13 revealed Section L Oral/Dental Status, item L0200. Dental Z. was marked as as Z. None of the above were present. The none of the above included: - A. Broken or loosely fitting full or partial denture - B. No natural teeth or tooth fragments(s) - C. Abnormal mouth tissue - D. Obvious or likely cavity or broken natural teeth - E. Inflamed or bleeding gums or loose natural teeth - F. Mouth or facial pain, discomfort or difficulty with chewing - G. Unable to examine. An interview with the clinical reimbursement coordinator (CRC), on 05/15/14 at 2:30 p.m., confirmed the MDS with an ARD of 08/01/13 was incorrect.",2018-05-01
6120,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,312,D,0,1,L8JN11,"Based on observation, resident interview, staff interview, and medical record review, the facility failed to ensure one (1) of three (3) Stage 2 residents reviewed for activities of daily living (ADL) was provided services to maintain good grooming. Three (3) of Resident #25's fingernails were very long and dirty. The resident was dependent for ADL care. Resident #25. Facility census: 111. Findings include: a) Resident #25 The minimum data set, with an assessment reference date (ARD) of 03/25/14, reviewed on 05/14/14 at 4:30 p.m., revealed the resident was dependent for activities of daily living (ADL). Review of the 03/11/14 care plan, at 4:45 p.m., also indicated the resident was dependent for ADL care. An observation, on 05/12/14 at about 2:30 p.m., revealed a family member spoke with Employee #51, a licensed practical nurse (LPN), and requested Resident #25's nails be clipped. The nurse assured the family member nail care would be provided. An interview with Employee #26, a nursing assistant (NA), on 05/15/14 at 9:45 a.m., revealed NAs performed ADL care, including nail care, with the exception of residents with diabetes mellitus. She said the nurse usually cut those nails. The NA said staff were to clean nails daily. She related Resident #25 would not allow care when she was angry, but would usually agree after she calmed down. She related staffing was not what it should be, and nails did not receive the care they should. She indicated someone had been scheduled to clean nails, but staffing no longer allowed it. Employee #42, a licensed practical nurse (LPN), was interviewed on 05/15/14 at 1:50 p.m. This revealed nurses completed nail care twice a week, including cleaning and filing them to ensure the resident did not get a skin tear. She related staff looked at nails twice a week. The LPN said Resident #25 liked her nails kept longer and painted. She also related the resident would not allow her to clip them. Upon inquiry, the LPN confirmed the care plan did not address nail care, or a preference for having long nails. Another interview at 2:00 p.m., revealed the LPN was unaware the family requested the nails be clipped on 05/13/14. Review of progress notes and ADL records with Employee #42, on 05/15/14 at 2:00 p.m., revealed no evidence nail care was attempted and the resident declined. An observation, at 2:15 p.m. 05/15/14 with Employee #42, revealed the resident still had the three (3) long nails. The resident said, I wish someone would cut these. They always get in the way. The nails were brown underneath the nail bed. The LPN inquired why the nails were not short like the others, and Resident #25 replied, I don't know, but I wish they were. They always get in the way. A follow-up observation on 05/19/14 at 11:30 a.m., revealed Resident #25's nails had been clipped.",2018-05-01
6121,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,328,D,0,1,L8JN11,"Based on observation, resident interview, record review, and staff interview, the facility failed to ensure one (1) of twenty-four (24) Stage 2 sampled residents received proper diabetic treatment and care of her feet. Resident #56 was not provided preventative podiatry services to trim and thin her toe nails. Resident identifier: #56. Facility census: 111. Findings include: a) Resident #56 An observation of the resident's toenails was made during an interview in her room on 05/13/14 at 11:00 a.m. The resident was sitting in the chair with her feet uncovered and propped up. Her toenails were noted to be extremely long. A few of them were thickened, and her big toes were slightly crossed inward, causing her nail to press against the top of the second toe. She agreed her toenails needed to be trimmed. Review of the resident's medical record, on 05/14/14 at 4:30 p.m., found the resident's son signed a form titled, Consent To Treat For Services, on 07/05/13, and check marked the box labeled, Podiatry services: Evaluate/treat podiatric problems and nail care approximately every sixty-three (63) days. The care plan, initiated on 07/16/13 and updated on 04/08/14, listed Podiatry consult as indicated under the focus area for diabetes. No documentation was found to indicate the resident had ever been seen by a podiatrist. An interview with registered nurse (RN) #90, on 05/15/14 at 11:40 a.m., confirmed the resident had never been seen by a podiatrist. The nurse then placed the resident on the list to be evaluated by the podiatrist on his next scheduled visit on 05/23/14. The assistant director of nursing (ADON) #25, examined the resident's nails on 05/15/14 at 2:50 p.m., and agreed the resident needed to have her toenails trimmed and thinned. The ADON was unable to provide any evidence the resident had ever refused an exam or treatment by the podiatrist.",2018-05-01
6122,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,356,B,0,1,L8JN11,"Based on observation and staff interview, the facility failed to ensure the residents and/or public were informed on a daily basis of the nurse staffing data as required by 42 CFR 483.30(e). The facility failed to include the actual hours worked by the direct care staff on the posting. This had the potential to affect more than a limited number of residents. Facility census: 111. Findings include: a) On 05/15/14 at 1:30 p.m., the nurse staffing data posted daily was reviewed. The actual hours worked by the licensed and unlicensed nursing staff directly responsible for resident care each shift was not included in the postings. The form in use did not require inclusion of the hours worked for registered nurses, licensed practical nurses, and nurse aides. This was pointed out to the Administrator at 3:00 p.m. on 05/15/14. He stated he would have this corrected.",2018-05-01
6123,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,371,F,0,1,L8JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews, the facility failed to ensure food was stored, prepared, and served under sanitary conditions. Food handlers gloves were not worn while handing foods and a staff member touched foods with potentially contaminated hands. Foods in a refrigerator in a nourishment pantry were not dated. In addition, the ice machine in the kitchen was not set up to ensure the ice remained free from contamination. These practices had the potential to affect all residents who were served food from the dietary department and/or the nourishment pantry. Employee Identifier: #129. Facility Census: 111 Findings include: a) Ice Machine During the initial tour of the kitchen, on 05/12/14 at 11:15 a.m., the drain tubing for the ice machine was observed placed down through the grate covering the floor drain. On 05/12/14 at 2:15 p.m., the observation regarding the ice machine was brought to the attention of Employee #40, the director of food services (DFS). She said it had always been like that, and asked why the tubing should not be on the floor or in the floor drain. When informed that it allowed for back flow or insects to enter the tubing, contaminating the ice, she replied, That makes sense, I will report that and have it taken care of. She said (name of company) services the ice machine, and she would call to have the drain tubing properly placed. At 1:48 p.m. on 05/12/14, Employee #81, the administrator, reported the company that serviced the ice machine had been called to properly place the drain tubing for the ice machine. Observations at 2:00 p.m. on 05/15/14, found the ice machine drain tubing was still placed through the grate on the floor drain. b) Nourishment Pantry On 05/15/14 at 9:10 a.m., observation of the refrigerator in the nourishment pantry on the 300/400 hall revealed a covered and labeled bowl of soup for a resident. The soup was labeled with the resident's return address mailing labels, however, it was not dated. Underneath the resident's soup, was a covered container of peaches for the same resident, labeled in the same manner. This container was also not dated. These items were found in the back of the refrigerator on the bottom shelf. During an interview on 05/15/14 at 9:15 a.m., Employee #17, a ward clerk for the 300/400 hall, said the resident was discharged on [DATE]. She agreed the food should have been dated when placed in the refrigerator, and also should have been discarded after the resident was discharged . On 05/15/14 at 10:10 a.m., upon notification of the findings in the refrigerator of the 300/400 hall nourishment pantry, the DFS agreed all food items should be dated. During an interview on 05/15/14 at 10:20 a.m., the administrator agreed the food items found in the nourishment pantry's refrigerator should have been dated when they were placed in the refrigerator, and disposed of when the resident was discharged . c) Employee #129 On 05/14/14 at 9:30 a.m. Employee #129, a speech therapist, (ST) was observed in the kitchen making toast. She was not wearing food handler's gloves. The ST placed the bread in the toaster and pushed the lever down to begin toasting the bread. When the toast popped up, Employee #129 picked the toast up with her bare hands and placed it on a piece of foil. She then left the kitchen, carrying the toast on the piece of foil and entered the dining room to work with a resident. Employee #129 did not wash her hands between contacts with non-food and food items, when she touched the toaster lever, and then retrieved the toast from the toaster. Employee #40, the DFS, also observed this occurrence and confirmed Employee #129 should have been wearing gloves when touching the bread, and should have washed her hands between non-food and food contact. During an interview on 05/15/14 at 8:35 a.m., the administrator revealed the DFS had already brought the incident about the ST making toast to his attention. The administrator also stated the facility's policy prohibited direct contact of food with ungloved hands. He said from this point forward, no staff other than dietary staff, would be permitted entrance into the kitchen. The administrator said this information would be passed on to all of the employees.",2018-05-01
6124,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,431,E,0,1,L8JN11,"Based on observation and staff interview, the facility failed to maintain a separately locked, permanently affixed compartment for storage of controlled medications. Six (6) vials of Lorazepam were stored in an unattached locked box in the medication storage refrigerator. This practice had the potential to affect more than a limited number of residents. Facility census: 111. Findings include: a) On 05/13/14 at 9:35 a.m., a clear plastic, unattached locked box was found in the medication storage refrigerator. The locked box contained six (6) vials of Lorazepam. On 05/15/14 at 3:20 p.m., an interview was conducted with the administrator (NHA) and acting director of nursing (DON). During the interview, the NHA and acting DON were informed the controlled medication storage box was unattached in the medication refrigerator. The acting DON stated there was a memorandum sent out regarding the need to permanently affix the controlled substance storage box, and agreed the box needed to be permanently affixed.",2018-05-01
6125,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2014-05-19,441,E,0,1,L8JN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review, and staff interview, the facility failed to maintain an infection control program which ensured a sanitary environment and/or ensure staff compliance with infection control guidelines to assist in preventing the development and transmission of infection. These practices had the potential to affect more than a minimal number of residents. Facility census: 111. Findings include: a) Environment 1) During the initial tour of the facility, at 1:40 p.m. on 05/12/14, the bathroom sprayer hose in the bathroom shared by rooms [ROOM NUMBERS] was observed with stool on the end of the handle, and there was splatter on the walls and floor. On the same visit, the sink in room [ROOM NUMBER] was observed to be movable and revealed the caulking around the sink was cracked in places and missing in others. There were dark rings present indicating cleaning could not be performed adequately to ensure disinfection. 2) During a second tour, at 11:30 a.m. on 05/19/14, the sinks in rooms 170, 181, 238, 242, and 138 were also observed with gaps and cracks in the caulking. These areas were reported to the Administrator at 12:35 p.m. on 05/19/14 and pointed out to Employee #121 (Maintenance Director) at 3:35 p.m. on 05/19/14. 1) Observation of room [ROOM NUMBER], on 05/13/14 at 9:15 a.m., revealed the caulking was loose from the right lower corner of the bathroom wall. Additionally, the paint was bubbling and peeling from the wall above the molding. The area behind the heater in the room had large chunks of wall board missing. 2) room [ROOM NUMBER], observed on 05/13/14 at 9:17 a.m., found the molding was loose from the wall behind the sink. Further observation revealed a gap between the molding and floor below the heater/window area. 3) An observation of room [ROOM NUMBER] on 05/12/14 at 2:47 p.m., revealed the bathroom wall behind the commode had the paint peeled off in the right lower corner and the molding was not sealed. 4) Room observations were completed with the maintenance director, on 05/19/14 at 3:35 p.m. He observed rooms #147, #170, and #173 and confirmed the presence of the issues noted on 05/12/14 and 05/13/14. The maintenance director agreed the areas could not be adequately cleaned and disinfected. c) Hand washing 1) During observation of medication administration, on 05/14/14 at 9:48 a.m., Employee #68, a licensed practical nurse (LPN) administered medications to Resident #82. The nurse removed the old [MEDICATION NAME] without donning gloves. She took the patch to the restroom and wrapped it in toilet tissue. A bedpan was across the commode, impeding flushing the toilet paper. The LPN donned a glove, removed the bedpan, placed the toilet tissue containing the [MEDICATION NAME] in the commode, flushed the toilet, and removed her glove. The water, mixed with bowel movement flowed to the top of the toilet. She donned a new glove, waited a moment, and placed the bedpan back on the commode. She removed the glove and exited the restroom without washing her hands or utilizing sanitizer. Without donning a glove or sanitizing her hands the LPN placed a new [MEDICATION NAME] on Resident #82's left upper arm, touching the inside tip of the [MEDICATION NAME]. She exited the room, and returned to the medication cart, without washing her hands. 2) During another medication administration observation, Employee #65, a registered nurse (RN) entered the resident's room. The RN placed a syringe containing insulin and a cup of water on the sink counter without utilizing a barrier to prevent the transfer of microorganisms from the sink area to the syringe and cup, and subsequently to her hands and the resident. She washed her hands, and administered the medication to the resident. Upon completion of the administration, she stated, . and I probably just made ten (10) violations. 3) Employee #36 (RN) was observed completing medication administration on 05/15/15 at 9:15 a.m. After washing her hands, she turned off the faucet without utilizing a paper towel to prevent recontamination of her hands. Upon inquiry, the RN said the facility protocol utilized a paper towel to turn off the faucet. She confirmed what she did created a potential for infection and cross contamination. She did not return to the room to wash/sanitize hands prior to accessing the medication cart. 4) An observation of medication administration on 05/14/14, between 4:07 p.m. and 4:16 p.m., revealed Employee #42 did not sanitize her hands after administering medication to Resident #19. She continued the medication pass. She passed medication to three (3) additional residents, utilizing hand sanitizer. The LPN completed a finger stick blood sugar to determine whether Resident #132 required insulin. The glucometer was not cleaned prior to, or after the finger stick. Review of the facility's policy, on 05/15/14 at 5:00 p.m., indicated staff .disinfect the meter before patient use . Upon exiting the room she utilized hand sanitizer. An interview with the nurse educator, revealed she expected hand washing after administering medication, and prior to exiting the room. She confirmed the medication administration techniques provided a mechanism for transmission of infection and cross contamination.",2018-05-01
7843,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,226,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews, the facility failed to report allegations of abuse within the required time frames for 2 of 4 residents (Residents #107 and #143). Findings include: 1. Resident #107 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A significant change Minimum Data Set (MDS) assessment was completed on 08/13/2012. Resident #107 had a brief interview for mental status (BIMS) score of 14 (score of 13-15 notes a resident is cognitively intact). The facility Abuse Policy was dated as revised on 12/01/2011. The policy noted under Section 6 Upon receiving information concerning a report of suspected or alleged abuse, the Administrator or designee will: file an immediate report to the Department of Health and Human Resources. An interview was completed with Resident #107 on 09/24/2012 at 11:33 AM. Resident #107 was asked if staff had ever yelled at her. She said, Yes. I don't do what they tell me to do. They yell at me like once a week then they walk out. Resident #107 said that she had not reported the staff yelling at her. On 09/25/2012 at 2:50 PM, Resident #107 said, Most of the girls are really nice. One day one walked out and said, That's your problem. I don't remember what we were talking about or who it was. That's why I'm here, I can't remember anymore. I didn't tell anyone. That's the only time I've ever had a problem. On 9/25/2012 at 5:00 PM, the facility administrator was notified of the allegation from Resident #107. On 09/26/2012 at 6:23 PM, an interview was conducted with the Administrator. The Administrator said, If an aide hears an allegation (of abuse), they would tell the nurse. The nurse removes the alleged perpetrator, and then reports to the DON (Director of Nurses) or me. After hours, the supervisor would start getting the witness statements, start the investigation and call the DON. We (DON and Administrator) do the investigation. Internally we decide if it is substantiated, then report to DHHR (Department of Health and Human Resources), APS (Adult Protective Services), the ombudsman and any pertinent licensing board. We have 24 hours to report to DHHR. We start the investigation immediately, but have 24 hours to get the paper work in. If the investigation isn't complete in 24 hours, we indicate that the investigation is ongoing and we have a specific 5 day follow up form that we fill out that goes to DHHR and APS. On 09/27/2012 at 8:19 AM, an interview was conducted with the Director of Nurses (DON). The DON said that she talked to Resident #107 about the concern. The resident said it happened a long time ago and she couldn't remember who it was. I asked her what shift it was and she didn't know. She said everything was fine now. I asked what happened and she said, 'she yelled at me'. When I asked what the resident had responded, she stated, 'She said do it yourself. I guess she was mad at me.' I am going to try to check out the shifts and do some education about customer service and resident rights. We do that ongoing. Anytime they (residents) say anything, even if it's vague, you have to investigate it. I'm pretty sure it will go to the State for reporting. Anything that has to do with care or abuse is reported. It's late, but I'm working on it. It will get sent in to the State. I am going to talk to the administrator about it today. 2. Resident #143 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. A review of the facility investigation for an allegation from Resident #143 was completed. On 9/18/2012, Nursing Assistant #88 (NA #88) documented that she overheard NA #65 being verbally abusive to Resident #143. The Immediate Fax Reporting of Allegations form noted the alleged verbal abuse had occurred on 09/18/2012 and was signed by Social Worker #41 (SW #41) on 09/20/2012. The form indicated the incident had not been reported within 24 hours. The written explanation for the delay was, Due to shifts witnesses worked it took time to gather information. There was one witness statement from staff that was dated 09/19/2012. SW #41 wrote statements dated 9/20/12 for 4 residents he interviewed. On 09/26/2012 at 6:23 PM, an interview was conducted with the Administrator. The Administrator said, If an aide hears an allegation (of abuse), they would tell the nurse. The nurse removes the alleged perpetrator, and then reports to the DON (Director of Nurses) or me. After hours, the supervisor would start getting the witness statements, start the investigation and call the DON. We (DON and Administrator) do the investigation. Internally we decide if it is substantiated, then report to DHHR (Department of Health and Human Resources), APS (Adult Protective Services), the ombudsman and any pertinent licensing board. We have 24 hours to report to DHHR. We start the investigation immediately, but have 24 hours to get the paper work in. If the investigation isn't complete in 24 hours, we indicate that the investigation is ongoing and we have a specific 5 day follow up form that we fill out that goes to DHHR and APS. An interview was completed on 09/27/2012 at 10:06 AM with SW #41. SW #41 said, I did the paperwork. The incident occurred on 09/18 (2012), I think on the evening shift. I faxed it in on the 20th. It is supposed to be in within 24 hours. It should have gone in on the 19th. The DON gave it to me to look at on the 20th, she started working on it on the 19th. SW #41 requested a follow up interview on 09/27/2012 at 10:30 AM. SW #41 said, The aide (NA #88) was new. She didn't realize she had to report it (allegation of abuse) immediately. She didn't report it until the 19th. The DON then gave it to me to look at and we did the reporting on the 20th. The aide was counseled about the abuse policy. An interview was completed with the DON on 09/27/2012 at 10:36 AM. The DON said, I remember the incident. It happened on the 18th, but the new aide (NA #88) didn't report it until late on the 19th. We reported it to the State on the 20th. When she came to me on the 19th, I told her that she should have gone to the supervisor immediately. I reviewed it with her that night. I don't know if I documented anything about that. I would normally write it on my statement. If I interview anyone, I write a statement. I should have written a statement on that one. On 9/27/2012 at 11:15 AM, the DON produced a Witness Statement Form dated 09/19/2012. It was signed by the DON and dated 09/19/2012. Review of the form noted that NA #88 reported verbal abuse that she witnessed on 09/18/2012 to the DON on 09/19/2012 at the start of her shift noted to be the 2:00 PM to 10:00 PM shift. The DON wrote that NA #88 said she did not report the concern on 09/18/2012 because she did not know who to report to. The DON also noted that she instructed NA #88 to immediately report concerns of abuse to the nurse, to contact the DON, or to contact the assistant DON.",2017-01-01
7844,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,248,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations and resident and staff interviews, the facility failed to provide an activity program to meet the needs of the residents for 2 of 3 sampled residents whose activity program was reviewed (Residents #26 and #95) from the Stage 2 sample of 31 residents. Findings include: 1. Resident #26 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Activity Calendar for August and September 2012 noted various religious activities each Sunday, Monday and Thursday. Review of Resident #26's Care Plan dated 08/16/2012 noted that she was at risk for social isolation due to being confined to bed. An intervention was, Staff will provide with up-lifting spiritual stories and inform volunteers from Bible groups of her admission for 1:1 visits. The Activity log for Resident #26 for the months of August and September 2012 revealed no spiritual visits. An interview was completed with Resident #26 on 09/24/2012 at 3:10 PM. Resident #26 stated that she did not participate in the activity programs because she would not get out of bed and that no one came to her room to do activities with her. On 09/25/2012 at 3:46 PM, an interview was completed with the Activity Director (AD #58). AD #58 stated that she was familiar with Resident #26. She doesn't go out to activities. She has family in every day. She loves to crochet, however she can't now because of her hands. I go into her room once a week or so. The other girls (activity assistants) go in too. Someone is in there 1-3 times a week depending on family visits. She doesn't want to get up. She hurts. The other girls go in and read to her. Her interests are her family and her husband, and they visit. She doesn't go to church services. There is a service about twice a month. The Catholics come in once each month. There is a Bible study with singing twice a week. As far as I know, they haven't gone in to see her. She hasn't said anything to me about having any desire for 1:1 visits. I haven't talked to the visitors (church volunteers) about visiting her 1:1. On 09/26/2012 at 9:10 AM, an interview was completed with Nursing Assistant (NA) #12. NA #12 stated that she was familiar with Resident #26. She doesn't go out to activities, although occasionally I've seen activities staff go in to her room for a visit. An interview was completed with a visitor of Resident #26 on 09/26/2012 at 12:45 PM. The visitor stated that she visits the facility almost daily. There is a minister from Hospice that sees her. The church minister where she used to go comes to see her once in a while. She liked to go to the services, but she can't get up and bend her leg. The aides and nurses are very busy here. They don't always have time to get her up. I read the Bible with her. 2. Resident #95 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], indicated the resident felt it was very important to do favorite activities, do things with groups of people and to keep up with the news. The most recent activities assessment dated [DATE] indicated the resident liked watching television, music, reading/writing and sensory activities. The assessment indicated the resident continued to have family visits daily and would participate in sensory visits and 1:1 visits as tolerated. The most recent plan of care for the resident indicated that she considered it important to have the opportunity to engage in activities that were meaningful. The resident was determined to be at risk for social isolation due to dementia, and she would be appropriate for the STAR sensory group, 1:1 visits and social events. The care plan indicated the staff would take necessary actions to accommodate her routines and preferences. The care plan listed the following description of interventions related to the resident's activities. The resident felt it was important to go outside and get fresh air and staff should assist her with transfers to go outside. The staff would invite to outdoor social events i.e.: popsicles and trivia and would respect if she refused the invitation. The Care Plan confirmed that the resident wished to continue favorite activities, such as being with family, talking and watching television. The resident had stated it was important to do things in groups with people. Staff will invite the resident to Bible groups, church services and social and special events. The resident has stated it is important to listen to music and staff should provide a radio, if desired, and invite to musical events. The resident had stated it was important to keep up with the news, and staff planned to include the resident in the Morning Greet, a program to promote reminiscing about past events and to discuss the news. In addition, staff would offer to take the resident to the resident's lounge to view local and world wide news on television. The resident had stated it was important to participate in religious services and practices. Staff would inform or invite the resident to church services and Bible groups and inform church volunteers of her admission so visits might be provided. The activity calendars for June, July, August and September were reviewed. The calendars included activities that had been listed on the resident's care plan and that that were important for the resident to attend. The calendars included: STAR sensory, religious services, Bible study, gospel music, 1:1 visits, sundae social, coffee chat, popsicles on the porch, trivia and many other activities. The resident's activity participation record for June, July, August and September included 1:1 visits, family and watching television. The participation record did not identify that the resident had attended any of the other events which had been identified as appropriate for the resident, such as conversing, reading, television, sensory and correspondence. On the back of the September participation log Individual Programming was identified. There was only one individual activity identified, nail care on 9/7/12, and the resident was documented to have refused to participate. In summary, the participation records did not indicate that the resident had been invited to activities the resident had expressed interest in, such as: religious services, Bible study, music or music events, group activities, going outside for popsicles, trivia and special events. On 9/27/12 at 10:45 A.M., the Director of Activities (AD) #58 was interviewed. The AD #58 stated there had been difficulty with staff retention from February through August or September. The AD #58 stated the participation record for activities should have been completed if the resident refused the activity that was offered and the resident's interests should have been listed on the forms. The AD verified the resident participation records were lacking. She stated the activity aides are supposed to complete the logs in full and document if the activity didn't occur or if the resident refused. At 10:50 A.M., Activity Aide #114 was interviewed. She stated she did not know the resident liked to go outside. She verified the resident had no television or radio in her room and it would be difficult for her to see her roommate's television if she was lying in bed. She stated she had not seen the resident in group activities. She stated that she knew the resident liked painting. She stated the residents are told in the morning what the activities will be during the day via the Meet and Greet newspaper. She stated she remembered what residents told her in the morning when she passed out the paper regarding which activities they wanted to attend and went back for them throughout the day. She stated she asked as many residents as possible. She stated the interactions she had with the residents was listed on the resident participation record and reflected her brief conversations as she distributed the Meet and Greet paper. During an interview at 10:55 A.M. with the AD #58, she stated Activity Aide #114 got this resident mixed up with another resident that had passed away and stated this resident had not done any painting activities because she did not go to painting. During an interview at 11:00 A.M. with Activity Aide #93, she stated that if the resident refused activities the refusals should be documented on the resident participation record. Activity Aide #93 stated she was not sure who was responsible for completing the interests on the participation records, but verified they should be filled out. Observations were made on 9/2512 at 12:40 P.M. of the resident in the dining room feeding herself. At 2:16 P.M. the resident was observed to be lying in bed on her right side asleep. On 9/26/12 at 10:25 A.M. observations were made of the resident lying in bed. At 11:10 A.M. the resident was ambulating with restorative staff in the dining room with a rolling walker, gait belt and wheelchair behind the resident. On 9/26/12 at 1:05 P.M. the resident was feeding herself lunch in the dining room. The resident was observed to participate in just one activity during the week of 9/24/12 - a sensory program on 9/27/12 at 11:00 A.M. with Activity Aide #93. During the week the activity calendar had included activities the resident had expressed interest in attending, such as: religious activities, Bible Study, gospel music, coffee chat, sundae social, word scramble and bingo.",2017-01-01
7845,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,253,D,0,1,92HC11,"Based on observations and staff interviews, the facility failed to maintain a clean, homelike environment as evidenced by marred walls and dead insects in light fixtures. Findings include: During the annual recertification survey conducted from 09/24/2012 through 09/28/2012, dead insects were noted in light fixtures in the following bathrooms: 232, 233, 243, 238, 336, 338 and 341. Observations of walls and door frames with missing paint were made in the following rooms: 135, 234, 443, 338, 232, 438, 233 and 137. During observation on 09/24/2012, the shower drain cover in room #443 was noted to be covered with rust. An interview was completed with the Maintenance Supervisor (MS #64) on 9/28/2012 at 8:20 AM. MS #64 said, The pest control guy comes once a month. If he sees a problem, he takes care of it. Once in a while we have issues with flies and a while back there were some stink bugs, but nothing now. We would normally clean out the light fixtures. On 09/28/2012 at 8:25 AM, a follow up interview was completed with MS #64. MS #64 was shown multiple rooms with damage to walls. MS #64 said, We try not to paint while the resident is in the room and sometimes they don't leave. If there is an empty room, they can move them. If the staff see an issue, they write it in the book and we go around every day and find things ourselves. There isn't anything waiting to be done now (no pending work orders).",2017-01-01
7846,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,272,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations the facility failed to comprehensively assess residents for the use of side rails. This affected three of three ( #26, #95 and #110) residents who were reviewed for the use of potential restraints of the 31 residents reviewed in the Stage 2 sample. Findings include: 1. Sample resident #95 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent Minimum Data Set (MDS), dated [DATE], indicated the resident's side rail had not been assessed to be a restraint. The most recent Expanded Nursing assessment dated [DATE] indicated the reason the bed rail was used was because the resident had a desire for the rail. The resident used the side rails to assist herself to a supine or sitting/standing position and was able to demonstrate the use of the side rail during the assessment. The most recent plan of care indicated the resident required assistance or was dependent upon staff for ADL care, for bed mobility, for transfer, and for locomotion. However, bilateral half side rails were in place to assist the resident with turning and repositioning. The care plan indicated the resident was at risk for falls related to being dependent on staff for mobility and transfer and had a lack of safety awareness related to dementia. A bed alarm to the bed and chair alarm to chair/wheelchair were in place to alert staff members of the resident's need to ambulate. The care plan indicated the resident had poor safety awareness. Observations were made on 9/27/12 at 10:25 A.M. of Certified Nurse Aides (CNA) #85 and #111 go into the resident's room to get her up and provide personal care. The resident was rolled onto her side by the two CNAs, but did not reach out on her own to hold onto the side rails until she was asked to do so by one of the CNAs. When instructed, the resident was able to hold onto the side rail, however CNA #85 was required to guide the resident's hand to the side rail. The CNAs provided incontinence care and then rolled the resident to the other side to provide care. Again, the resident was told to hold onto the side rail and was able to do so after instructed. CNA #111 was interviewed at 10:30 A.M. and stated the resident required extensive assistance with her Activities of Daily Living (ADL's). CNA #111 stated the resident can hold onto the rails if she was told, but did not always reach out for them. CNA #111 stated the resident required extensive assistance from the staff with transferring, turning, toileting, bathing, and ambulation. The resident would be unable to do those things without help from staff. On 9/27/12 at 9:05 A.M., Registered Nurse (RN) #59 was interviewed. RN #59 stated the side rail on the MDS had not been coded as a restraint and that the coding automatically populated on the MDS from the Expanded Nursing Assessment. At 10:00 A.M., RN #83 was interviewed. RN #83 stated she completed the Expanded Nursing Assessment for the MDS dated [DATE] which had included the restraint assessment. RN #83 stated she completed the assessment, but did not have the resident return a demonstration to ensure that the resident could use the side rails to assist herself to a supine or sitting/standing position with the use of the side rails. RN #83 stated that when she completed the assessment for the use of the side rail she only asked the resident if she could use the side rail for positioning and support. RN #83 verified that the assessment indicated the resident could use the side rail to assist herself to a supine or sitting/standing position and would be able to demonstrate the use. RN #83 stated she should not have marked the assessment as completed when she hadn't actually seen the resident demonstrate the full use of the side rail as indicated on the assessment. RN #83 verified that she had not comprehensively assessed for the use of the side rails as a restraint. The policy for The Use of Restraints was reviewed. The policy indicated the resident would be assessed for the use of restraints or protective devices during the nursing assessment process. If it was determined that a protective device was being used as an enabler, no further assessment was needed. 2. Resident #26 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of Resident #26's Care Plan dated 8/20/2012 noted that she used upper side rails on the bed to assist with turning and repositioning. A Quarterly Nursing assessment dated [DATE] documented that Resident #26 used the bedrail as an enabler. A box was checked that noted, Patient uses side rails for positioning and support and is able to demonstrate use. A second box was checked that noted, Patient uses side rails to assist self to supine or sitting/standing and is able to demonstrate use. On 09/26/2012 at 8:18 AM, Resident #26 was observed receiving care. Staff assisted the resident to turn and reach the side rail. Resident #26 grabbed the side rail and held on, but staff provided significant assistance to turn the resident to her right side. An interview was completed with Nurse #83 on 09/27/2012 at 1:25 PM. Nurse #83 confirmed that she had completed the Nursing assessment dated [DATE]. Nurse #83 reported that she had checked the boxes noting that Resident #26 used the side rails to go to a sitting or standing position. Nurse #26 said that she did not see Resident #26 use the side rail. She (Resident #26) won't try to do that (use the rail to sit or stand). If you ask her to reach for the siderail to help turn, she will turn. She will reach for the rail and we will help her over to grab it, then, while she pulls and we lift, we get her turned. An interview was completed with Nursing Assistant #109 (NA #109) on 09/27/2012 at 2:00 PM. NA #109 stated that she was familiar with Resident #26. We turn her. She will reach for the rail but we have to help her turn over. She will grab the rail and hold on, but we have to push her over, then we use pillows to position her. Resident #26 cannot pull herself or reach the siderail on her own. NA #109 said that Resident #26 cannot maintain her position. 3. Review of the medical record for Resident #110 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognition. Resident #110 was assessed to require total care from 1 to 2 staff members for most Activities of Daily Living. Review of the most recent nursing assessment, dated 08/07/12, revealed: Resident #110 has expressed a desire to use side rails, the resident is able to use the side rails for positioning and support and the resident is able to demonstrate use of the side rails. Review of the care plan for Resident #110 revealed a plan of care dated 09/14/11 which stated Resident #110 was dependent for all Activities of Daily Living. The care plan also stated Resident #110 used side rails as an enabler. On 9/27/12 at 11:32 A.M.,Certified Nurse Aide (CNA) #81 was observed providing care to Resident #110. Bilateral quarter side rails were observed to be in the up position on the resident's bed. Resident #110 made no attempt to use the side rails. CNA #81 had to physically assist Resident #110 to turn her from side to side. At the time of the observation CNA #81 verified Resident #110 does not use the side rails to shift from side to side during care nor when lying in bed independently and unattended by staff.",2017-01-01
7847,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,280,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff and resident interviews, the facility failed to notify 1 of 3 residents reviewed to determine whether residents were able to participate in development of their plan of care (Resident #54). The facility also failed to revise a plan of care for 2 residents of thirty-one care plans reviewed. (Residents #22 and #110). Findings include: 1. Sample Resident #54 was admitted to the facility on [DATE]. Admitting [DIAGNOSES REDACTED]. Record review revealed physician orders [REDACTED]. A Care Plan entry noted as revised on 7/06/11 noted a potential risk for skin breakdown. An intervention documented, Provide patient and/or healthcare decision maker education regarding risk factors and interventions. On 07/11/12 a Progress Note written by Nurse #61 revealed, Responsible party notified of change in condition. nNw orders obtained. Start [MEDICATION NAME] 100 mg po (orally) x 14 days (sic). There was no documentation that Resident #54 was notified of the medication change. On 8/23/12 at 1:23 PM, Nurse #8 noted, Resident has [MEDICAL CONDITION] to top of right foot, new order: apply [MEDICATION NAME] cream 0.1% to [MEDICAL CONDITION] to top of right foot every day. There was no documentation that Resident #54 had been informed about the new medication. An interview was completed with Resident #54 on 09/24/2012 at 3:51 PM. Resident #54 stated that she had not been notified regarding changes in her medication regimen. On 09/25/2012 at 4:40 PM, an interview was completed with Nurse #52. Nurse #52 stated that if a resident or family member is notified of any change to a resident's treatment regimen, it is documented in the Nurse Progress notes. On 09/26/2012 at 2:40 PM, an interview was completed with Nurse #61. Nurse #61 was asked whom was notified of medication changes. Nurse #61 said, If the person (resident) is not their own POA (power of attorney), we call the family. If they (the resident) ask what the medicine is, we tell them. If they are alert and oriented we would tell them what we are doing. I think (Resident #54) would be someone we would tell. I would also call her family because sometimes she (the resident) is in and out with knowing what is going on. It would be documented that we told the resident. An interview was completed with Nurse #8 on 9/26/12 at 2:53 PM. Nurse #8 said, If there is a change in an order, what I do is tell the resident. Even if they aren't capable since sometimes you don't know how much they comprehend. I also call the POA and chart it. On 09/26/2012 at 3:02 PM, an interview was completed with the Director of Nurses (DON). The DON said, If there is a change in medication or a treatment, the nurse should tell the resident if they are capable of understanding. If they are not capable, they would call the POA. It would be documented in the nurse's notes. An interview was completed on 09/26/2012 at 3:20 PM with Nurse #8. Nurse #8 said, I remember telling her and her daughter that I was going to order the cream. (Resident #54) would remember me telling her. It is on her Care Plan that I tell them about any changes. On 09/28/12 9:05 AM, a follow up interview was completed with Nurse # 8. Nurse #8 stated that when Resident #54 first wakes up in the morning she may be confused while she gets her bearings. If you give her a few minutes, she is pretty clear and knows what is going on. If I wake her up, I may have to wait a few minutes to ask her questions, and then she is right on. 2. Review of the medical record for sample resident #110 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident has severely impaired cognition. Resident #110 was assessed to require total care from 1 to 2 staff members for most Activities of Daily Living (ADL) including dependency on staff for eating. At the time of the assessment Resident #110 was assessed to be 67 inches tall and weighed 112 pounds. Review of the care plan for Resident #110 revealed a plan dated 9/20/11 and last revised on 9/10/12 which identified the resident to be at a nutritional risk due to a texture modified diet, a [DIAGNOSES REDACTED]. The interventions for the plan of care included: provide rehabilitative eating devices - specifically 2 handled sippy cups during meals; dine in the Coral Room; evaluate for proper consistency of diet; honor the resident's food preferences within the meal plan; encourage consumption of the fluids provided; weigh the resident as ordered; alert the dietitian and physician to any significant weight loss or gain; monitor for changes in nutritional status, such as changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to physician as indicated; monitor intake at all meals; offer alternate choices as needed; provide regular pureed diet as ordered; offer snacks; supervise, cue and assist Resident #110 as needed with meals. A second plan of care for Resident #110 revealed the resident was at risk for impaired swallowing related to dysphagia. The interventions for the plan of care included to provide extensive to total assistance during meals, obtain a speech and language pathologist (SLP) evaluation, as ordered, provide pureed consistency diet as ordered, provide sippy cup for all meals and observe for signs and symptoms of aspiration - if coughing occurs - no food or liquids until coughing resolves. Review of the Kardex, identified by the facility to direct the care Certified Nurse Aides provide the facility residents, revealed interventions related to Resident #110's eating. The interventions included to provide extensive to total assistance during meals, provide pureed consistency diet as ordered and provide a sippy cup for all meals and Resident #110 was to dine in the Coral Room for all meals. During interview with RD #156 on 9/25/12 at 3:44 P.M., it was stated she reviews resident weights every month and the dietary manger gets weekly weight reports. According to RD #156 the dietary manger communicates with the RD and the unit managers when weight loss is identified. The computerized/electronic charting system has weight warnings which are distributed to the nurses. RD #156 stated a resident would be weighed weekly if the resident was having a decline in weight or if a resident had a significant weight loss. RD #156 also stated during the interview that the regular diet in the facility is planned to provide 2500 calories a day and 85 grams of protein. For residents who receive a pureed diet, the diet provides 3000 daily calories and 100 grams of protein each day. RD #156 stated that on 7/12/12 she had recommended for resident #110 that the dietary department send whole milk with meals, ice cream on each lunch tray and fortified cereal with breakfast daily. On 08/10/12 RD #156 made an additional recommendation to send cottage cheese on each lunch tray and pudding with the dinner tray. RD #156 verified that these specific interventions to address the resident's weight loss had not been added to the plan of care and felt the interventions currently in place on Resident #110's care plan encompassed the aforementioned recommendations. RD #156 also verified that the task of updating the plan of care is a shared task. RD #156 stated if she goes into the care plans she could add the intervention. RD #156 also stated that since Resident #110's September nutritional assessment, the resident would be weighed weekly. Resident #110's plan of care was not revised to reflect RD #156's recommendations and did not reflect the revised assessment tool of weekly weights. Nor did the Kardex, which guides the care provided to the facility Certified Nurse Aides, include the updated recommendations made by RD #156. 3. Review of the medical record for Resident #22 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed Resident #22 had been assessed to have a score of 6/15 on the Brief Interview for Mental Status (BIMS). This score indicated the resident had moderate cognitive impairment. The MDS also revealed no signs or symptoms of [MEDICAL CONDITIONS] or behavioral symptoms. Resident #22 was assessed to require extensive assistance from 1 to 2 staff members for most Activities of Daily Living (ADL). Review of the physician orders [REDACTED]. Review of the plan of care for Resident #22 revealed a care plan related to the [DIAGNOSES REDACTED]. Another plan of care related to the depression diagnosis. Interventions for this care plan included to allow the resident time for verbalization of feelings and needs, encourage activities of interest/ choice, observe for signs and symptoms of depression or anxiety and provide a structured environment with as much routine as possible. Review of the plan of care for resident #22 revealed no plan of care for the use of the antipsychotic medication [MEDICATION NAME]. During interview on 9/28/12 at 2:48 P.M., with the Director of Nursing (DON) it was stated Resident #22 was hospitalized [DATE] to a special geriatric psychiatric center and returned on 8/01/12 with an order for [REDACTED].",2017-01-01
7848,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,282,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview and observations the facility failed to implement the plan of care for 5 of 31 care plans reviewed. The Care Plans for 4 residents (#95, #110, #126, and #159) with care plans to prevent weight loss had not been implemented. The Care Plan for 1 resident with a care plan related to her activity participation (#26) had not been implemented. Findings included: 1. Review of the medical record for Resident #110 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment dated [DATE], revealed the resident scored a 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognition. Resident #110 was assessed to require total care from 1 to 2 staff members for most Activities of Daily Living (ADL) including dependency on staff for eating. At the time of the assessment Resident #110 was assessed to be 67 inches tall and weigh 112 pounds. Review of the care plan for Resident #110 revealed a plan dated 09/20/11 and last revised on 09/10/12 which identified the resident to be a nutritional risk due to a texture modified diet, a [DIAGNOSES REDACTED]. The interventions for the plan of care included to provide rehabilitative eating devices - specifically 2 handled sippy cups during meals, the resident was to dine in the Coral Room, the resident should be evaluated for the proper consistency of diet, honor the resident's food preferences within the meal plan, encourage consumption of the fluids provided, weigh the resident as ordered and alert the dietitian and physician to any significant weight loss or gain, monitor for changes in nutritional status such as changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to physician as indicated, monitor intake at all meals, offer alternate choices as needed, provide regular pureed diet as ordered, offer snacks, supervise, cue and assist Resident #110 as needed with meals. A second plan of care for Resident #110 revealed the resident was at risk for impaired swallowing related to dysphagia. The interventions for the plan of care included to provide extensive to total assistance during meals, obtain a speech and language pathologist (SLP) evaluation as ordered, provide pureed consistency diet as ordered, provide sippy cup for all meals and observe for signs and symptoms of aspiration, if coughing occurs no food or liquids should be offered until the coughing resolved. Review of the Kardex, used to direct the care provided by Certified Nurse Aides, revealed interventions related to Resident #110's eating. The interventions included to provide extensive to total assistance during meals, provide pureed consistency diet as ordered and provide a sippy cup for all meals. Resident #110 was to dine in the Coral Room for all meals. Meal observations were made of Resident #110 at noon on 9/25/12, at breakfast on 9/26/12, and at breakfast on 9/27/12. Additionally, provision of a mid afternoon snack was observed on 9/26/12. At none of the above observations was a sippy cup observed to be available to the resident for her fluids. The plan of care had not been implemented as planned. On 9/27/12 at 8:16 A.M. SLP #148 was observed at Resident #110's bedside conducting a speech evaluation. SLP #148 stated she was conducting the evaluation that had been ordered on [DATE] and had never been done. The plan of care had not been implemented as planned. 2. Resident #26 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Review of the Activity Calendar for August and September 2012 noted various religious activities each Sunday, Monday and Thursday. Review of Resident #26's Care Plan dated 08/16/2012 noted that she was at risk for social isolation due to being confined to bed. An intervention was Staff will provide with up-lifting spiritual stories, inform volunteers from Bible groups of her admission for 1:1 visits. Review of the activity participation log for Resident #26 for August and September 2012 noted no spiritual visits. An interview was completed with Resident #26 on 09/24/2012 at 3:10 PM. Resident #26 stated that she did not participate in the activity programs because she would not get out of bed and that no one came in to her room to do activities with her. On 09/25/2012 at 3:46 PM, an interview was completed with the Activity Director (AD #58). AD #58 stated that she was familiar with Resident #26 and that the resident did not go out to activities. She had family visits nearly every day. The resident loves to crochet; however, she can't now because of her hands. I visit her once a week or so. The other activity assistants also go into the resident's room for visits. Someone is in there 1-3 times a week depending on family visits. She doesn't want to get up. She hurts. The other girls go in and read to her. Her interests are her family and her husband, and they visit. She doesn't go to church services. There is a service in the facility about twice a month. The Catholics come in every month. There is a Bible study and singing twice a week. As far as I know, they haven't gone in to see her. She hasn't said anything to me about having any desire for 1:1 visits. I haven't talked to the visitors (church volunteers) about visiting her 1:1. On 09/26/2012 at 9:10 AM, an interview as completed with Nursing Assistant #12 (NA #12). NA #12 stated that she was familiar with Resident #26. She doesn't go out to activities. Occasionally I've seen activities staff go in. An interview was completed with a visitor of Resident #26 on 09/26/2012 at 12:45 PM. The visitor stated that she visits almost daily and added, There is a minister from Hospice that see's her. The church minister where she used to go comes to see her once in a while. She liked to go to the services, but she can't get up and bend her leg. The aides and nurses are very busy here. They don't always have time to get her up. I read the Bible with her. 3. Sample resident #159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], indicated the resident required limited assistance of one person for eating. A Nutritional assessment dated [DATE] indicated the resident was on a regular pureed diet and recently experienced a 5% weight loss in one month. Her Body Mass Index was 36. The documentation indicated the resident had received Speech Therapy, but it had been discontinued on 8/10/12 because the resident required extensive assistance with meals and continued to pocket food in her mouth. The weights and vital summary document identified that beginning on 8/7/12 the resident should be weighed weekly. Recorded weights since that time were: 8/07/12 weight of 235 pounds, 8/14/12 weight of 230.4 pounds, 8/20/12 weight of 225.8 pounds, 8/28/12 weight of of 228 pounds, 9/10/12 weight was 221.8 pounds, 9/17/12 weight was 221.8 pounds, 9/26/12 weight was 218.6 pounds. On 8/22/12 the dietitian had ordered pudding with lunch and dinner, whole milk with meals and fortified cereal at breakfast due to the recent significant weight loss in one month and the oral intake was not meeting the resident's nutritional needs. Care Plan interventions included: Encourage resident participation while providing appropriate ADL care, use simple concrete statements, dine in the Coral dining room for lunch and dinner, whole milk three times a day, fortified cereal and pudding for lunch and dinner, weigh as ordered and alert dietitian and physician to any significant weight loss, monitor for changes in nutritional status including unplanned weight loss and report to food and nutrition/physician as indicated. Observations were made on 9/27/12 at 8:17 A.M. of Certified Nurse Aide (CNA) #111 assisting the resident with breakfast in her room. The CNA was interviewed and stated she did not know how to identify if the resident received a fortified cereal or any other fortified product. The diet card had FCC printed on the bottom of the card. A potential for failure to provide the interventions designated by the plan of care exists when the staff are unfamiliar with the facility systems for implementation of delivery of fortified food products. On 9/28/12 at 3:00 P.M. the Director of Nursing (DON) verified the resident's weight had decreased in September and the Registered Dietitian had not been informed, as the plan of care identified should have occurred. The DON verified the interventions on the care plan were not followed by the staff to notify the dietitian of the weight loss as indicated. The DON also verified the staff had not been inserviced on how to identify foods on the meal tray that had been fortified or to have a higher nutritive value. The DON verified the meal percentages of all foods were calculated together and liquids on the trays were all calculated together. The DON verified supplements with additional calories to promote weight gain on the tray were not calculated separately to determine if the interventions were providing extra nutrition. 4. Resident #126 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Difficile, hepatic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Most Recent (MDS) assessment dated [DATE] indicated the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the past 6 months and received a mechanically altered diet. The most recent plan of care, dated to be in place through 10/14/12, indicated the resident was at risk for nutritional weight loss due to a textured modified diet, dementia, anxiety, [MEDICAL CONDITION] and significant weight loss. Interventions included: encourage resident to consume all fluids during meals, honor food preferences on tray card, weigh per order, alert physician of significant changes, monitor all intakes of meals, provide regular pureed diet, offer snacks, dine in Coral dining room for meals, supervise/cue/assist with meals, monitor for changes in nutritional status - including unplanned weight loss, abnormal labs and report to food/nutrition and physician as needed. Physician notes dated 8/7/12 indicated the resident continued to lose weight and her condition was progressively worsening due to progressive dementia. Nurses notes were reviewed and on 4/5/12 documentation by the nurse indicated the resident had lab results that were negative for [MEDICAL CONDITION]. However, on 4/24/12 and 4/25/12 laboratory results were received which indicated the resident's urine was positive for infection and had tested positive for [MEDICAL CONDITION]. Antibiotics were ordered and administered through 5/31/12. Nutrition notes were reviewed. On 5/22/12 the dietitian documented the resident was on a house supplement and would benefit from fortified cereal and whole milk with meals. On 6/29/12 a nutrition note indicated the resident had no significant weight changes, however staff would continue to monitor weights and the Body Mass Index (BMI) was within normal limits. On 7/18/12 the dietitian added pudding or ice cream with lunch and dinner and whole milk with meals due to further weight loss. On 8/7/12 the resident's weight was documented to have increased by two pounds to 111.6 pounds. On 9/5/12 the resident's weight was 105.4 pounds with a 5% weight loss in the previous 30 days. The physician was notified, however, there were no new orders. There was no documentation regarding whether the dietitian had been notified. Observations were made on 9/25/12 at 12:50 P.M. of the resident in the Coral Dining Room being fed by Certified Nurse Aide (CNA) #16. The resident was eating a pureed diet for lunch. On 9/26/12 at 1:05 P.M. the resident was observed in the Coral Dining Room being fed by CNA #23. The resident was eating a pureed diet. Interview with CNA #23 stated she did not know if the resident had any foods on her tray that were fortified or contained additional calories. During interview with CNA #31 at 1:07 P.M., she stated that they previously put the fortified foods in a different colored bowl so the staff would know if the foods had extra calories, but that practice had been discontinued. Observations were made on 9/27/12 at 8:15 A.M. of CNA #53 feeding the resident in bed. The diet card was observed with FCC written on the bottom of the card. CNA #53 stated he didn't know if the resident had Fortified Cereal or not on her tray. He verified that all foods that came on the resident's tray were calculated together as a percentage to give the total of the resident's meal intake. On 9/28/12 at 9:15 A.M. an interview was conducted with the Assistant Director of Nursing (ADON) #27. The ADON #27 stated the dietitian had not been notified of the resident's continuing weight loss. The ADON #27 stated LPN #5 does the weight alerts and notifies the physician, but doesn't notify the dietitian. The facility failed to implement the care plan to notify the dietitian when weight loss occurred. On 9/28/12 at 3:00 P.M. the Director of Nursing (DON) verified the resident's weight had decreased to 103.6 pounds on 9/28/12 and had not been re-assessed by the RD on 9/27/12. The DON verified the interventions on the care plan were not followed by the staff to notify the dietitian of the weight loss as indicated. The DON also verified the staff had not been inserviced on how to identify foods on the meal tray that had been fortified or contained higher nutritive value. The DON verified the meal percentages of all solid foods were calculated together and liquids on the trays were all calculated together. The DON verified supplements with additional calories to promote weight gain on the tray were not calculated separately to determine if the interventions were providing extra nutrition. 5. Resident #95 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The most recent Minimum Data Set (MDS) assessment dated [DATE] indicated the resident had a weight loss, required a mechanically altered diet and required a one person assist for eating. The most recent Nutritional assessment dated [DATE] indicated that Speech Therapy was working with the resident and nutritional interventions were in place. The Speech Therapy notes were reviewed and indicated the resident received speech therapy from 6/15/12 through 7/25/12 and then again from 8/2/12 to 9/12/12. The therapy notes indicated the resident had inconsistency with progression due to periods of lethargy. The most recent care plans for dysphagia and nutritional risk were reviewed. The plan of care indicated the resident was at risk for impaired swallowing related to dysphagia and was at nutritional risk for weight loss due to dementia, dysphagia and the requirement for a modified texture diet. The care plan interventions included: provide a pureed consistency diet as ordered, monitor for signs and symptoms of aspiration, dine in the Coral Dining Room for lunch and dinner, resident to be up in wheelchair for all meals related to the need for proper positioning for self feeding, monitor for changes in nutritional status including ability to feed self and supervise/cue/assist as needed. Observations were made on 9/2512 at 12:40 P.M. of the resident in the Coral Dining Room feeding herself. Certified Nurse Aide (CNA) #12 was observed sitting next to the resident while she ate. During interview with CNA #12 she stated the resident can feed herself for most meals and if not the staff assist her. On 9/26/12 at 1:05 P.M. the resident was observed in the Coral Dining Room feeding herself lunch and staff were observed at the table with the resident as she ate. On 9/26/12 at 6:00 P.M. the resident was observed in bed eating alone and the head of the bed was observed to be positioned at 35 to 40 degrees. At 6:10 P.M. CNA #102 was interviewed and stated the resident didn't want to go to the dining room, so he had left her in bed. CNA #102 stated he gave the resident her dinner tray and proceeded to pass the other trays to the residents in the hall. He stated she required assistance and he would come back to her when he finished passing the trays to the other residents. At 6:15 P.M. the Director of Nursing (DON) was interviewed and she made the observation of the resident eating dinner in bed with the head of the bed positioned at 35 to 40 degrees. The DON was not sure why she wasn't in the dining room because she usually went to the Coral Dining Room. The DON was reminded of the resident's care plan to be in the wheelchair for all meals for proper positioning and self feeding and she stated she would check into it. At 6:20 P.M. an observation and interview was done with the Licensed Practical Nurse (LPN) #61. LPN #61 verified the resident required supervision or cueing with meals and normally the CNA passed the trays to residents who don't require any assistance and then later passes the trays to residents who require assistance with meals. Interview with Speech Therapist #147 on 9/26/12 at 3:50 P.M. indicated the resident received speech therapy after her re-admission to the facility on [DATE]. She had received speech therapy from 8/2/12 through 9/12/12 and was discharged due to lethargy. The resident had not progressed with therapy goals. ST #147 stated the resident was able to fed herself on some days, but on other days required assistance from the staff for eating. The facility failed to implement the plan of care thereby placing the resident at risk for choking or inadequate intake to meet nutritional needs.",2017-01-01
7849,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,323,D,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, observations and review of policy the facility failed to prevent falls for one of three residents (#50) sampled for the care area of accidents out of a total of forty residents reviewed in stage one of the survey. Findings included: 1. Sample Resident #50 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's most recent quarterly Minimum Data Set (MDS) dated ,[DATE] was reviewed. The MDS indicated the resident was totally dependent on staff for Activities of Daily Living (ADL's) including bed mobility, transfers, locomotion off the unit, dressing, grooming, bathing and toilet use. No recent falls were identified on the MDS. The resident's most recent plan of care dated 6/21/12 indicated the resident was at risk for fractures related to osteoporosis. The care plan indicated the resident had impaired mobility and used an antianxiety medication and was at risk for falls. Additionally, the resident was at risk for injury related to the use of an anticoagulant. Interventions included: assess changes in medical status, place glasses within reach and encourage their use, medication evaluation as needed, place call light within reach, when in bed place all items within reach, monitor labs and x-rays and report to physician. Nurses notes dated 9/9/12 at 3:45 P.M. indicated the resident had been found sitting in front of her wheelchair on her buttocks on the floor in her room. The resident was assessed and had complaints of pain in the left knee and obtained an abrasion to her left chin. The physician was notified and an x-ray of the left knee was obtained. The x-ray was negative for a fracture. An Occupational Therapy (OT) evaluation was ordered on [DATE] after the fall. The OT notes indicated the resident had a fall from the wheelchair and modifications were made. No therapy sessions were recommended. The OT note indicated a bolt was unattached from the base of the seat of the resident's wheelchair. The resident was provided with a cushion and the legs of the wheelchair were adjusted. On 9/27/12 at 2:40 P.M. an interview was conducted with Physical Therapist (PT) #154. PT #154 stated that the first bolt on the resident's wheelchair near the front of the seat had broken and the vinyl of the seat pad had been pulled downward approximately four inches - just enough for the resident to slide out of the chair and onto the floor. At 5:15 P.M. the Director of Maintenance was interviewed. The Director of Maintenance stated he does monthly rounds for the whole building, but does not have a system to check any resident equipment. He stated he only makes repairs or looks at equipment if the staff put in a maintenance repair slip following identification of a problem. Facility Policy #12.8 - Use of Wheelchairs was provided and reviewed. The policy indicated wheelchair use and safety were to be monitored by staff on an ongoing basis.",2017-01-01
7850,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,325,G,0,1,92HC11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and interview, the facility failed to prevent unintended weight loss in three of four residents reviewed for nutritional concerns. The facility's multiple system failures identified during the investigation yielded significant weight loss resulting in harm for one ( #110) of the three (#159, #126) residents. Findings include: 1. Review of the medical record for Resident #110 revealed an admission date of [DATE] and [DIAGNOSES REDACTED]. Review of the most recent Minimum Data Set (MDS), a comprehensive assessment, dated 08/07/12, revealed the resident scored 4 out of 15 on the Brief Interview for Mental Status (BIMS), which indicated the resident had severely impaired cognition. Resident #110 had been assessed to require total care from 1-2 staff members for most Activities of Daily Living (ADL) including dependency on staff for eating. At the time of the assessment Resident #110 had been assessed to be 67 inches tall and to weigh 112 pounds. Resident #110 was also assessed to have recently experienced weight loss. The MDS also indicated Resident #110 received a mechanically altered diet. The Care Area Assessment (CAA) revealed Resident #110 received a texture modified diet, had a history of [REDACTED]. The Care Plan for Resident #110 had been created on 09/20/11 and revised on 09/10/12. The plan of care identified the resident to be at nutritional risk due to: a texture modified diet, a [DIAGNOSES REDACTED]. The interventions for the plan of care included: provide rehab eating devices - specifically 2 handled sippy cups during meals; dine in the Coral Room; evaluate for proper consistency of diet; honor the resident's food preferences within the meal plan; encourage consumption of the fluids provided; weigh the resident as ordered and alert the dietitian and physician to any significant weight loss or gain; monitor for changes in nutritional status - such as changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs and report to physician as indicated; monitor intake at all meals; offer alternate choices as needed; provide regular pureed diet as ordered; offer snacks; supervise; cue; and assist Resident #110 as needed with meals. A second plan of care for Resident #110 revealed that the resident was at risk for impaired swallowing related to dysphagia. The interventions for the plan of care included: provide extensive to total assistance during meals; obtain a speech and language pathologist (SLP) evaluation, as ordered; provide pureed consistency diet as ordered; provide sippy cup for all meals; and, observe for signs and symptoms of aspiration - if coughing occurs no food liquids until coughing resolves. The Kardex was identified by the facility as the source of directives for the Certified Nurse Aides providing care to the residents. The Kardex revealed the following interventions related to Resident #110's eating: provide extensive-to-total assistance during meals; provide pureed consistency diet, as ordered; provide a sippy cup for all meals; and, dine in the Coral Room for all meals. Review of the computerized/electronic dietary assessment for Resident #110 revealed an assessment dated [DATE] which had been completed by dietary staff #34, identified as the Assistant Food Service Director and a Certified Dietary Manager. The assessment identified Resident #110 had a Body Mass Index (BMI) of 17.6, and was on a regular pureed diet and no nutritional supplements had been ordered. The weight used in the calculation of the BMI was 112.4 pounds and came from a weight recorded on 07/03/12. The assessment also identified that Resident #110 had experienced a 5% weight loss (6.6 pounds) in the preceding month and a significant or severe weight loss (13.8 pounds) in the last 6 months. Additionally, the assessment identified that Resident #110 was not on a prescribed weight loss regimen. The assessment also indicated that the resident consumes greater than 50% of her meals. Review of the summary and plan for this assessment revealed the resident's physician and medical power of attorney (MPOA) had been notified on 07/13/12 of the weight loss. The plan related to the assessment findings were documented to: provide the diet as ordered by the physician; monitor intake of meals; review weight per protocol; and, the Registered Dietitian should assess as needed. Review of the progress notes for Resident #110 revealed a note written by dietary staff #34 on 08/07/12 which stated a nutrition assessment had been completed on that date and there were no nutritional concerns. Review of an 08/10/12 computerized/electronic assessment completed by the Registered Dietitian (RD) # 156 revealed Resident #110's weight at 111.8 pounds on 08/07/12. RD #156 identified that Resident #110 had experienced a 7% weight loss over the previous 3 months and that the resident was not on a prescribed weight loss regimen. The assessment stated Resident #110 consumes 50% of the meals provided to her. Review of the summary and plan related to this assessment revealed the resident's diet is regular puree, appetite is fair to poor and the resident's average intake is 50% of meals. Resident #110 dines in the Coral Dining Room for lunch and dinner. The resident's weight loss over the previous 6 months was 15.6 pounds or 12% of body weight. The documentation stated that the physician and POA had been notified on 07/13/12 of the weight loss. The RD's plan was to provide the physician ordered diet, monitor the resident's intake of meals, review weight per protocol, and re-assess as needed. Review of the progress notes for Resident #110 revealed a nutritional progress note completed by the RD #156 on 08/10/12. The progress note stated a nutrition assessment had been completed on 08/07/12 and there was a nutrition concern of involuntary weight loss. Further review of earlier computerized/electronic progress notes for Resident #110 revealed that on 07/12/12 a nutritional assessment had been completed and a nutritional concern of involuntary weight loss had been identified. A progress note on 07/13/12 revealed a computer generated weight warning which stated Resident #110 had a documented weight of 112.4 pounds which was a 5.5% change over the previous 30 days and a 11.2% change over the previous 180 days. The progress note added that the physician and MPOA were aware of the weight loss. Another weight warning appeared in the progress notes on 09/05/12 which stated Resident #110 had a documented weight of 110.8 pounds and a 10.1 % change/loss in weight over the previous 180 days. The progress note goes on to say Resident #110 had lost weight over the last few months and the physician and MPOA were aware. The documented weights (in pounds) for Resident #110 were as follows: 127.4 on 02/06/12 124.0 on 02/13/12 124.8 on 02/20/12 125.8 on 03/06/12 123.2 on 04/02/12 121.2 on 05/01/12 119.0 on 06/06/12 112.4 on 07/03/12 111.8 on 08/07/12 110.8 on 09/05/12 The physician's progress notes for Resident #110 revealed a 05/11/12 order to discontinue the medication [MEDICATION NAME] (an appetite stimulant) after 2 doses were given the following day. The physician also wrote on the order that it was a trial, to watch the resident's weight and weigh Resident #110 weekly. On 05/23/12 a physician's orders [REDACTED]. On 06/15/12 a physician's orders [REDACTED]. On 06/22/12 a physician's orders [REDACTED]. Physician notes since June 2012 did not address the resident's declining weight. An undated document, identified by the facility as a faxed communication to the physician from the facility, revealed that the resident had experienced a weight loss. Weights provided were 119.0 pounds on 06/06/12 and 110.8 pounds on 09/05/12. The area on the form for the physician's response and comments was blank. There was no evidence that the form had actually been faxed to the physician. Nor was there documentation in the medical record by the physician in response to Resident #110's continuing weight loss. Review of the CNA documentation of percentage of meals eaten by Resident #110 revealed the following: April 2012: out of 90 meals offered, Resident #110 refused 22 of them, ate 25% of 22 meals, and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. May 2012: out of 93 meals offered, Resident #110 refused 14 of them, ate 25% of 25 meals and ate 50% of 17 meals. The remaining meals were recorded at 75-100%. June 2012: out of 90 meals offered, Resident #110 refused 20 of them, ate 25% of 26 meals, and ate 50% of 12 meals. The remaining meals were recorded at 75-100%. July 2012: out of 93 meals offered, Resident #110 refused 10 of them, ate 25% of 28 meals and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. August 2012: out of 93 meals offered, Resident #110 refused 9 of them, ate 25% of 19 meals and ate 50% of 20 meals. The remaining meals were recorded at 75-100%. September 2012: out of the meals offered thus far in the month of September, Resident #110 refused 2 of them, ate 25% of 14 meals and ate 50% of 18 meals. The remaining meals were recorded at 75-100%. The CNA documentation also indicated Resident #110 had consistently taken 0% of a snack in the evening since 05/01/12. Certified Nurse Aide (CNA) #51 stated during interview at 3:27 P.M. on 09/25/12 that Resident #110 eats about 25% of her meals when she assists her with eating. Review of a policy provided by the facility titled, Assessment and Management of Patient Weights dated 06/01/01 and last revised on 11/15/08 revealed the staff member entering the verified weights into the computerized charting system would print the Weights Exception Report for review and follow up would be provided by a licensed nurse. Significant weight changes were to be reviewed by the licensed nurse for evaluation. The licensed nurse would then: document verified significant weight changes in the medical record and on the 24 hour change of status report; notify the physician and dietitian of significant weight changes and document the notification of the physician and dietitian. The dietitian should then document the nutritional assessment and weight management recommendations in the medical record. The unit manager or licensed nurse should notify the physician of the dietitian's recommendations. Residents who have significant weight change were to be weighed weekly and discussed at the Customer At Risk or other clinical meeting to determine possible causes of the weight loss (or gain) including goals for care. The interdisciplinary care plan will then be updated to reflect individualized goals and approaches for managing the weight change. Resident #110 was observed on 09/25/12 at 12:58 P.M. eating lunch in the Coral Dining room while being fed by Certified Nurse Aide (CNA) #126. Resident #110 was observed to have pureed lasagna, a green vegetable, vanilla ice cream, a pureed desert, a yellow liquid and a small disposable 6 ounce glass of chocolate milk. At 1:40 P.M. on 09/25/12 CNA #98 approached Resident #110 and mixed the chocolate milk with the ice cream then offered it to the resident. There was no sippy cup observed on the table for Resident #110. During interview with CNAs #98 and #126 on 09/25/12 at 1:17 P.M., the CNAs stated they were not aware of any item on the resident's tray that had been provided for additional calories to promote weight gain. During interview with RD #156 on 09/25/12 at 3:44 P.M. the RD stated that she reviews resident weights every month and the dietary manger gets weekly weight reports. According to RD #156 the dietary manger communicates with the RD and the nursing unit managers. The computerized/electronic charting system includes weight warnings which go to the nurses. RD #156 stated residents would be weighed weekly if the resident was experiencing a decline or if a resident had a significant weight loss. RD #156 also stated that a regular diet is 2500 calories a day and 85 grams of protein. The pureed diet provides 3000 calories and 100 grams of protein each day. According to RD #156 Resident #110 should have her nutritional needs met with the diet she is on and if less than 75% of the meal is being eaten she would investigate the foods eaten. RD #156 stated that on 07/12/12 she had recommended that dietary send whole milk with meals, ice cream on each lunch tray and fortified cereal with breakfast daily. On 08/10/12 RD #156 recommended that in addition to the 7/12/12 recommendations, the resident also receive cottage cheese on each lunch tray and pudding with the dinner tray. RD #156 verified that these specific interventions to avert weight loss had not been added to the plan of care and felt the interventions currently in place on Resident #110's care plan encompassed the aforementioned recommendations. RD #156 also verified the task of updating the plan of care is a shared task. RD #156 stated if she goes into the care plans she will add the intervention. RD#156 also stated that since Resident #110's September nutritional assessment, the facility would weigh the resident weekly. On 09/26/12 at 7:58 A.M., Resident #110 was observed being fed in bed by CNA #81. Resident #110 had pureed eggs, pureed sausage, cream of wheat, orange juice and whole milk on her tray. During interview with CNA #81 at the time of the observation it was verified she was not aware if any of the foods on the resident's tray was fortified or provided additional calories which would promote weight gain. On 9/26/12 at 2:21 P.M., Resident #110 was observed seated in the Coral Dining Room with a cup of chocolate milk in front of her. CNA #126 stated during interview on 9/26/12 at 12:23 P.M. that Resident #110 is able to drink from the disposable cup. There was no 2 handled sippy cup observed near Resident #110. At 1:13 P.M. on 9/26/12 Resident #110 was observed being fed by CNA #98. The CNA stated the meal ticket, which identified the resident's diet, supplements, and likes/dislikes, identified that the resident disliked oatmeal. The meal ticket listed beverage preferences as juice, coffee, and whole milk. Also under the area of meal preferences the letters FFC were written. During interviews with CNAs #98, #126 and #31 none were able to identify what FFC stood for. CNA #31 stated the facility previously placed fortified foods in different colored bowls so the staff could easily identify the fortified foods. CNA #31 also stated during the interview that the restorative nurse aides are in charge of obtaining the weights in the facility. CNA #31 also stated that if a resident had a 5 pound weight loss or gain they would re-weigh the resident and notify the nurse. On 9/27/12 at 8:16 A.M., SLP #148 was observed at Resident #110's bedside. SLP #148 stated she was there to conduct a speech evaluation. The speech evaluation that had been ordered on [DATE] had never been done and she suspected the eval had been ordered due to weight loss. SLP #148 also stated that when she entered the resident's room the nurse aide had already assisted the resident with her meal, however, she was trying again. SLP #148 verified that resident #110 had eaten less than 25%. It was also verified that the carton of whole milk had been opened and poured on the cream of wheat but had not been stirred in and did not appear to have been offered to Resident #110. At 8:21 A.M. CNA # 108 entered the resident's room and stated she had attempted to feed Resident #110 earlier and felt the resident had eaten 25%. CNA #108 verified the resident had not been offered the whole milk or the cream of wheat (fortified cereal). CNA #108 also stated during the interview that she was not aware of any food on the resident's meal tray that had been provided for extra calories to avert the weight loss. During interview with RD #156 on 09/27/12 at 2:10 P.M., she stated that she is not notified immediately of weight loss. According to RD #156 the Assistant Director of Nursing (ADON) would notify her of weight losses after the weight loss meeting on Thursdays. RD #156 verified she is not present at all of the weight loss meetings. RD #156 also stated the nurse aides are trained to record meal points of foods and liquids consumed by the residents however, the only way to be certain how much the resident consumes is to do a calorie count. It was verified during the interview the letters FFC on the meal tickets were indicators for fortified cereal. During interview with the Director of Nursing on 09/27/12 at 3:41 P.M., it was stated the nursing assistants had never had training regarding dietary interventions for weight loss, such as adding whole milk, cottage cheese, pudding or fortified cereal. The DON verified during the interview the nursing assistants would not be aware of what the term FCC means on the meal ticket delivered with resident trays. During interview with Rehab Manager #154 on 09/27/12 at 9:35 A.M. she stated that she had been asked to review Resident #110's chart and had discovered that the resident had a physician's orders [REDACTED]. The Rehab Manager stated the Rehab department receives a written referral from nursing when such an order is received. The Rehab Manager stated she keeps the written referrals but could not locate one for the speech evaluation ordered on [DATE]. Rehab Manager #154 also stated during the interview that dietary staff #34, identified as the Assistant Food Director and a Certified Dietary Manager, would bring up weights at the Care Area Assessment (CAA) meetings. She added that a weight sheet is filled out and distributed on Tuesdays and she thought nursing and dietary staff were handling all weight loss issues. She was not aware that Resident #110 had a significant weight loss. During interview on 09/28/12 at 10:26 A.M., Licensed Practical Nurse (LPN) #5 stated that the Assistant Food Director brings the list of residents with weight loss to the weekly meetings. LPN #5 added that the weight warnings automatically show in the computerized charting system. LPN #5 stated she's been in this position for a short period of time and had not received training regarding how the computerized charting system works for potential weight loss alerts and was not clear as to who was responsible for follow up with the physician or dietitian. During interview on 09/28/12 at 10:32 A.M. Dietary staff #34 stated the facility discusses weight loss each every Thursday. If a resident has had weight loss, nursing will fax the doctor. When asked who alerts the dietitian, Dietary staff #34 stated RD #156 runs her own weight report when she comes to the facility and nobody is in charge of notifying her. It was confirmed that RD #156 does not have set days to work. Dietary staff #34 stated there is nothing in place to monitor resident weight losses when RD #156 is not there. (According to Dietary staff #156 it is nursing's job to notify RD #156.) Dietary staff #34 stated she had previously been involved and would contact the physician when weight losses occurred, but now nursing staff is involved and she no longer has input regarding weight loss interventions. When asked if the facility utilizes nutritional supplements Dietary staff #34 stated nursing provides them and those types of supplements are not on dietary's formulary. During interview with ADON #27 on 09/28/12 at 2:06 P.M. it was confirmed that no weekly weights had been obtained for Resident #110 as ordered by the physician and there was no documentation that the physician had been notified of Resident #110's significant weight loss. 2. Resident #159 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The resident's admission Minimum Data Set (MDS), dated [DATE], indicated the resident required limited assistance of one person for physical assist with eating. A Nutritional assessment dated [DATE] indicated the resident was on a regular pureed diet and had experienced a 5% weight loss in one month and her Body Mass Index was 36. The documentation indicated the resident had received Speech Therapy, but it had been discontinued on 8/10/12 because the resident required extensive assistance with meals and continued to pocket food in her mouth. The weights and vital summary document listed weekly weights for the resident that began on 8/7/12. Recorded weights were: 08/07/12 weight of 235 pounds, 08/14/12 weight of 230.4 pounds, 08/20/12 weight of 225.8 pounds, 08/28/12 weight of 228 pounds. On 8/22/12 the registered dietitian had ordered pudding with lunch and dinner, whole milk with meals and fortified cereal at breakfast due to a significant weight loss in one month and the oral intake was not meeting the resident's needs. The most recent care plan, dated 6/1/12, indicated the resident required extensive assistance for Activities of Daily Living (ADL's) due to failure to thrive and [MEDICAL CONDITION] and required limited to extensive assist of one for eating. The care plan also indicated the resident was at nutritional risk due to dementia and depression which may affect oral intake and result in significant weight loss. Interventions included: encourage resident participation while providing appropriate ADL care; use simple concrete statements; dine in the Coral dining room for lunch and dinner; serve whole milk three times a day; serve fortified cereal and pudding for lunch and dinner; weigh as ordered; alert dietitian and physician to any significant weight loss; monitor for changes in nutritional status including unplanned weight loss and report to physician as indicated On 9/26/12 at 2:40 P.M. Speech Therapist (ST) #148 was interviewed and stated the resident had received speech therapy for pocketing food, but she had not progressed with her goals. She stated there were no reasons medically why she didn't progress and her continued weight loss was discussed in the weekly meeting. She had talked to the dietitian for an assessment due to the resident ' s food pocketing. When her weight loss was discussed in the meeting, behavior, as a possible link to the weight loss was considered. ST #148 stated the resident was discharged from speech therapy and staff cue her to eat and swallow at times. She stated the pureed diet was the safest diet for the resident and there are no choking issues because the food usually dissolves in her mouth. She stated the resident received a regular textured diet upon admission, but had declined to a pureed texture. At 2:50 P.M. an interview with Restorative Certified Nurse Aide (RCNA) #31 was conducted and she stated that the resident pockets food at times and has to be reminded to swallow. She sits at a table with staff so she can be monitored and cued when she eats. Some days she does well and other days she requires assistance. At 3:00 P.M. the Licensed Social Worker (LSW) #41 was interviewed. LSW #41 stated that on 7/23/12 the physician had ordered a psychiatric evaluation, however, the resident had not yet been seen. LSW #41 stated the psychiatrist was in the facility and would see the resident today. Observations were made on 9/27/12 at 8:17 A.M. of Certified Nurse Aide (CNA) #111 assisting the resident with breakfast in her room. The CNA was interviewed and stated she did not know how to identify if the resident received a fortified cereal. (The meal ticket had FCC printed on the bottom of the card.) During interview on 9/27/12 at 2:40 P.M. the dietitian stated the resident had a weight loss in August 2012 and new interventions had been put in place on 8/22/12. There had been no new recommendation on 9/7/12 when the dietitian was in the facility. The dietitian stated the resident had issues with pocketing food and had been seen by speech therapy and was now being assisted by the staff for meals. The nutritional note indicated the resident had a significant weight loss, but the Body Mass Index indicated obesity. The dietitian stated the 9/7/12 assessment was her last assessment of the resident, however she would see the resident again today, 9/27/12, for the continuing weight loss. The Minimum Data Set (MDS) Registered Nurse (RN) #59 was interviewed at 4:40 P.M. and confirmed the accuracy of the MDS for the period of decline. The ADL flow records were reviewed for the past three months and showed the resident had an up and down trend for eating. During interview on 9/28/12 at 1:55 P.M. Registered Nurse (RN) #105 stated the resident's weight on 9/10/12 had been 221.8 pounds, on 9/17/12 the weight was 221.8 pounds and on 9/26/12 the weight was 218.6 pounds. RN #105 stated the physician had been notified and there had been no further documentation from the dietitian regarding the weight loss. The policy and procedure for Assessment and Management of Patient Weights was reviewed. The significant weight change management indicated the weights would be reviewed by the LPN. The LPN would document the weight in the medical record, notify the physician and the dietitian and document the notification. The dietitian would then evaluate the resident who has a significant weight change and complete a nutritional assessment, if appropriate, and document the assessment and weight management recommendations in the medical record. The unit manager or licensed nurse will notify the physician of the dietitian ' s recommendations and family notification documented in the medical record. If the physician chooses not to implement the dietitian's recommendations, they must document in the medical record the rationale. Residents who have a significant weight change will be weighed weekly and discussed at the Customer at Risk meeting or other clinical meeting to determine possible causes of the weight change including goals for care. On 9/28/12 at 3:00 P.M. the Director of Nursing (DON) verified the resident's weight had decreased in September and the Registered Dietitian had not been informed. The DON verified the interventions on the care plan had not been followed by the staff to notify the dietitian of the weight loss. The DON verified the staff had not been in-serviced on how to identify foods on the meal tray that were fortified or to have a higher nutritive value. The DON verified the meal percentages of all foods were calculated together and liquids on the trays were all calculated together. The DON verified supplements with additional calories to promote weight gain were not considered separately to determine if the interventions to provide extra nutrition had been successful. 3. Resident #126 was re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Difficile, hepatic [MEDICAL CONDITION], hypertension, [MEDICAL CONDITION] and [MEDICAL CONDITION]. The Most Recent (MDS) Assessment, dated 7/15/12, indicated the resident had a weight loss of 5% or more in the last month or a loss of 10% or more in the past 6 months and received a mechanically altered diet. The most recent plan of care, dated 7/14/12 and to be in place through 10/14/12, indicated the resident was at risk for nutritional weight loss due to a texture modified diet, dementia, anxiety, [MEDICAL CONDITION] and significant weight loss. Interventions included: encourage resident to consume all fluids during meals; honor food preference on meal ticket; weigh per orders; alert physician of significant changes; monitor all intake of meals; provide regular pureed diet; offer snacks; dine in Coral Dining Room; supervise/cue/assist with meals; monitor for changes in nutritional status including unplanned weight loss, abnormal labs and report to food/nutrition and physician as needed. Physician notes dated 8/7/12 indicated the resident continued to lose weight and her condition was progressively worsening due to progressive dementia. Physician notes dated 7/10/12 indicated that progressive dementia was the reason for the resident's continued weight loss. Nurses notes were reviewed and on 4/5/12 documentation by the nurse indicated the resident had lab results that were negative for [MEDICAL CONDITION]. On 4/21/12 the nurse documented the resident was incontinent of bowel and bladder. On 4/23/12 the nurse documented that a urinalysis had been obtained for a possible urinary tract infection. On 4/24/12 and 4/25/12 laboratory results were received and indicated the resident's urine was positive for infection and the resident had [MEDICAL CONDITION]. The physician ordered [MEDICATION NAME] for 10 days and [MEDICATION NAME] for 7 days to treat the urinary tract infection and the [MEDICAL CONDITION]. On 5/4/12 the nurse documented the resident continued on [MEDICATION NAME] for [MEDICAL CONDITION]. On 5/16/12 nursing documentation indicated the resident had loose, foul smelling stools and the physician gave orders to repeat a stool sample for [MEDICAL CONDITION]. On 5/17/12 the physician ordered [MEDICATION NAME] for 2 weeks. Nutrition notes were reviewed and on 5/22/12 the dietitian documented that the resident was on a house supplement due to weight loss, would benefit from fortified cereal and whole milk with meals, had [MEDICAL CONDITION] and the course of [MEDICATION NAME] had been completed on 5/31/12. On 6/29/12 a nutrition note indicated the resident had no significant weight changes, the Body Mass Index (BMI) was within normal limits and continue to monitor. On 7/18/12 the dietitian added pudding or ice cream with lunch and dinner and whole milk with meals due to the recent weight loss. On 8/7/12 the resident's weight increased by two pounds. On 9/5/12 the resident's weight was 105.4 pounds with a 5% weight loss in 30 days. The physician was notified with no new orders. There was no documentation of the dietitian being notified. The resident's previous weight on 8/7/12 had been 111.6 pounds. There were no new interventions documented for the resident's weight loss from 111.6 pounds on 8/7/12 to 105.4 pounds on 9/5/12. Observations were made on 9/25/12 at 12:50 P.M. of the resident in the Coral Dining Room being fed by Certified Nurse Aide (CNA) #16. The resident was eating a pureed diet for lunch. On 9/26/12 at 1:05 P.M. the resident was observed in the Coral Dining Room being fed by CNA #23. The resident was eating a pureed diet. Interview with CNA #23 stated she did not know if the resident had any foods on her tray that were fortified or had additional calories. Interview with CNA #31 at 1:07 P.M. stated they previously served the fortified foods in a different colored bowl so the staff would recognize the foods with extra calories, but they don't do that anymore. Observations were made on 9/27/12 at 8:15 A.M. of CNA #53 feeding the resident in bed. The meal ticket was observed to have FCC written on the bottom. CNA #53 stated he didn't know if the resident had fortified cereal or not on her tray. He verified that all foods that came on the resident's tray were calculated together as a percentage to give the total of the resident's meal intake. On 9/27/12 at 11:45 A.M. an interview was conducted with Licensed Practical Nurse (LPN) #5. LPN #5 stated that after she receives the weights from the restorative aides she enters the weights into the computer. If she identifies weight loss she faxes details related to the weight loss to the physician. On 9/27/12 at 2:10 P.M. an interview was conducted with the Registered Dietitian (RD) #156. RD #156 stated the resident receives whole milk at all meals and pudding with lunch and dinner and the interventions",2017-01-01
7851,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,362,E,0,1,92HC11,"Based on record review, observation and interview the facility failed to have enough staff to provide dining service to residents in the main dining room and failed to deliver a meal to facility residents within the scheduled timeframe. This had the potential to affect all residents who dined in the main dining room and who received oral nutrition. Findings include: Review of the facility's menu revealed a frosted orange cake was to be served to facility residents for dessert at the noon meal on 09/24/12. During observation of the noon meal on 09/24/12, grapes and bananas were observed to be served for dessert. During interview on 09/24/12 with dietary staff #86, identified as the Food Service Manager, it was verified the frosted orange cake was on the menu for that day's lunch, however due to a staff call-in on 09/23/12 the cake was not made so a substitution of grapes and bananas had to be used. During confidential interview with two facility residents on 09/24/12 it was stated they were not permitted to eat their evening meal in the main dining room on 09/23/12. It was stated they were told because someone in the kitchen called in sick. During interview with dietary staff #86 on 09/28/12 at 3:02 P.M., it was verified they did not serve the evening meal in the main dining room on 09/23/12 because of staff calling in sick to work. It was stated during the interview that a cook called in sick, the front office staff called in sick and activities staff called in sick. Dietary staff #86 stated during the interview the front office staff is in charge of taking the orders for residents in the main dining room and the activities staff are in charge of passing out the drinks to the residents who are dining in the main dining room. During the observation of food service for the evening meal on 09/26/12, dietary staff # 78 stated she usually starts putting food on plates at 4:45 P.M. The food was not placed on the steam table and temperatures checked until 5:07 P.M., on 09/26/12. The first resident tray was prepared and placed on the meal service cart at 5:32 P.M., The first meal service cart was delivered to the residents at 5:54 P.M. Review of a document titled Food and Nutrition Services Meal Delivery Schedule revealed the meal service cart observed to be delivered at 5:54 P.M., should have been delivered at 5:00 P.M., Further review of the document revealed all areas of the facility which includes two dining rooms and three different meal service carts should have been served food or delivered by 5:30 P.M. Dietary staff #34, the assistant food service director, verified during interview on 09/26/12 the meal evening meal on 09/26/12 had been served 54 minutes late because of a staff meeting earlier in the day.",2017-01-01
7852,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,364,E,0,1,92HC11,"Based on observation and interview the facility failed to serve food to residents at the proper temperature. This had the potential to affect all facility residents who received oral nutrition. Findings include: During observation of the noon meal served from a steam table in the main dining room on 09/24/12 at 12:24 P.M., Dietary staff #66 was observed to check the temperature of the food prior to meal service. Dietary staff #66 verified the temperature of the cottage cheese was 44 degrees Fahrenheit. At 12:30 P.M., dietary staff #66 was observed to attempt to serve the cottage cheese to a resident. During interview at the time of the observation dietary staff #66 verified the cottage cheese should be served at no more than 40 degrees Fahrenheit. The facility's food service manager, dietary staff #86, verified the cottage cheese was not being held at a safe temperature and should not be served to residents. During observation of food service on 9/26/12 at 4:59 P.M., pans of food were placed on the steam table. At 5:07 P.M., on 09/26/12 dietary staff #78 was observed to check the temperatures of food prior to service to facility residents. The following temperatures were obtained: 1. Chicken Breast, 170 degrees Fahrenheit 2. Potato Medley, 160 degrees Fahrenheit 3. French Fries, 160 degrees Fahrenheit 4. Sausage with Peppers and Onions, 190 degrees Fahrenheit 5. Mashed Potatoes, 159 degrees Fahrenheit 6. Corn Relish, 40 degrees Fahrenheit 7. Cottage Cheese, 39.5 degrees Fahrenheit A test tray was requested on 09/26/12 at 5:15 P.M., The test tray was placed on the facility's meal delivery cart at 5:26 P.M. The meal delivery cart that contained the test tray was observed to leave the kitchen at 5:54 P.M. The first resident meal tray left the cart at 5:57 P.M. At 6:15 P.M., on 09/26/12 the test tray was taken from the meal delivery cart after the last resident meal tray was delivered. The following temperatures were obtained by dietary staff # 34, identified as the Assistant Food Director; 1. Chicken Breast, 109.1 degrees 2. Potatoes, 104.6 degrees 3. Corn Relish, 71.6 degrees 4. Tapioca Pudding, 72.3 degrees 5. Carton of Whole Milk, 56.7 degrees During interview on 09/26/12 at the time of the observation, dietary staff #34 verified that the hot foods were barely warm and cold foods were not served cold.",2017-01-01
7853,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,371,E,0,1,92HC11,"Based on observation and interview the facility failed to properly store food in the freezer and failed to distribute food to residents while maintaining sanitary conditions. This facility practice affected all residents residing in the facility who received oral nutrition. Findings include: During the initial tour of the kitchen on 09/24/12 at 8:21 A.M., 2 boxes were observed in the freezer to be open and undated. One box contained pork chops inside an opened bag and the second box contained beef patties also inside a box with an open bag. The storage of both boxes exposed the frozen meat to air. During interview with dietary staff #17 at the time of the observation it was verified the food should be sealed and dated. During a dining observation on 09/24/12 at 12:35 P.M., Dietary staff #66 was observed placing food on plates from a steam table located in the dining room. Dietary staff #66 was observed to have a glove on the right hand only. There were plates observed to be stacked up on a three tier cart near the left side of the steam table. Dietary staff #66 was observed to grab a plate from the top tier of the cart. When doing so, Dietary staff #66 was observed to place her un-gloved hands on the portions of the plate that food was placed on. During observation of meal service on 9/26/12 at 5:40 P.M., Dietary staff #122 was observed to be plating food for residents while wearing disposable gloves. After placing the food on the residents' plates Dietary staff #122 was observed to wipe his hands on the front of his shirt near his waist. Dietary staff #122 then proceeded to grab another plate, grab another bun, place chicken on the bun with tongs, place potatoes on the plate with a scoop, grab a piece of lettuce with his hands and place a scoop of corn relish on the lettuce. Dietary staff #122 then wiped his hands on his shirt again and was never observed to change his gloves or wash his hands. Review of the facility's policy for personal hygiene dated 07/01/98 and revised on 12/14/09 revealed disposable gloves are for single use only and are to be changed between tasks. Review of a facility policy for hand washing, dated 07/01/98 and revised on 12/14/09 revealed the staff are to wash their hands after handling food, before touching any clean utensils, plates, cups or pans, when moving from one task to another. The policy also stated the use of disposable gloves does not replace proper hand washing. During interview on 09/26/12 at 6:53 P.M., with dietary staff #34, identified as the Assistant Director of Food Services, it was verified the dietary staff should not handle the plates with their bare hands where resident food would be placed and should not wipe their gloved hands on their shirts then proceed to place food on resident plates with the same gloved hands.",2017-01-01
7854,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-28,441,D,0,1,92HC11,"Based on observation, interview and record review the facility staff failed to follow the infection control policy when providing care to one of five residents whose direct care was observed out of the 31 sampled residents (Resident # 110). Findings include: During observation of care on 09/27/12 at 11:32 A.M., for Resident #110, Certified Nurse Aide (CNA) #81 discovered Resident #110 had been incontinent of urine. CNA #81 was observed to don clean gloves and provide perineal care. CNA #81 maintained those same gloves afterwards while dressing Resident #110 with clean clothes. CNA #81 was also observed to open and close the drawers next to the shared sink with the same gloves in search of the resident's hair brush. Review of a 3/1/12 policy provided by the facility titled Hand Hygiene revealed facility staff are to remove gloves after caring for a resident. Review of a second facility policy titled ADL: Perineal Care, dated 12/01/06, revealed the facility staff are to remove gloves and wash hands after assisting the resident with perineal care. CNA #81 verified during interview on 09/27/12 at 11:50 A.M., that she did not change her gloves after providing incontinence care to Resident #110. During interview with the Director of Nursing (DON) on 09/28/12 it was verified the nurse aide should have removed the gloves and washed her hands before assisting the resident to put on the clean clothes and open the drawers.",2017-01-01
9414,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-11-07,282,D,1,0,I0U011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, grievance review, resident interview, and staff interview, the facility failed, for one (1) of ten (10) sampled residents, to follow the care plan related to the time for transporting a resident to [MEDICAL TREATMENT] appointments. The facility also failed to follow the care plan related to a resident's preference for supplement for one (1) of ten (10) sampled residents who was identified as experiencing weight loss. Resident identifiers: #51 and #35. Facility census: 102. Findings include: a) Resident #51 Record review found that Resident #51 was a [AGE] year old individual, with [DIAGNOSES REDACTED]. Review of a grievance/concern, dated 10/29/12, revealed that Resident #51 had expressed a concern with having to gobble down breakfast before [MEDICAL TREATMENT], then being transported too early, approximately an hour before her [MEDICAL TREATMENT] appointment was scheduled. This caused her to incur a total of 6.25 hours out of the facility on that date. During an interview with Resident #51, on 10/31/12 at 5:00 p.m., she said her [MEDICAL TREATMENT] appointments were always scheduled for 10:30 a.m. on Mondays, Wednesdays, and Fridays, and it was only a 20 minute drive to the [MEDICAL TREATMENT] center. She said she was not supposed to leave the facility until 10:00 a.m. However, on 10/29/12, she left the facility around 9:00 a.m., then had to wait uncomfortably at the [MEDICAL TREATMENT] center for an hour before beginning her four-hour long [MEDICAL TREATMENT] treatment. She said she had to hurry and eat breakfast in order to get dressed and be ready for the 9:00 a.m. transport. The resident said she had barely gotten to touch her food before leaving the facility. She said it was too tiring for her to be up that long at one time. According to the resident this was not the first time this had happened, but she wished it to be the last time. Review of the current care plan found that she was care planned to be transported by the facility van or ambulance at 10:00 a.m. on Monday, Wednesday, and Friday for [MEDICAL TREATMENT] treatments. During an interview with the licensed social worker, Employee #64, on 11/02/12 at 11:15 a.m., she said the van picked the resident up for transport at 9:00 a.m. one day this week. The resident's breakfast was supposed to have been sent to her at 8:20 a.m. to allow her time to enjoy eating. During an interview at this time with the van driver, Employee #40, he said he transported Resident #51 at 9:00 a.m. on 10/29/12 due to a scheduling conflict that involved transporting another resident to the hospital for a 10:15 appointment. The van driver acknowledged this had happened before. b) Resident #35 This resident was interviewed on 11/05/12. He stated he sometimes refused his house supplement because he wanted strawberry flavored. The medical record was reviewed on 11/05/12. A physicians's order for a house supplement three (3) times daily had been written on 10/19/12. The registered dietitian had completed a nutritional assessment on 10/18/12. It noted the resident did not like chocolate and would not like vanilla supplements. She noted the facility will try strawberry supplements. The care plan for 10/26/12 indicated the resident was to receive a strawberry flavored house supplement. The food service director was interviewed on 11/06/12. She stated the resident was to receive a strawberry supplement. She further added it had not been available, but might be now. Employee #37, the assistant food director, was interviewed on 11/06/12. She said the chocolate supplement was exchanged for a strawberry supplement at the 3:00 p.m. nourishment pass. She further added the supplement for the 8:00 p.m. nourishment pass was changed to a strawberry flavored supplement. She confirmed he had not been receiving the strawberry flavored supplement. Interview with Employee #109, a nursing assistant, on 11/06/12 also confirmed the resident had not been receiving strawberry supplements. She stated the resident received chocolate or vanilla house supplements during nourishment pass.",2015-11-01
9415,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-11-07,464,D,1,0,I0U011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide tables of suitable height to meet the needs of three (3) of four (4) residents observed eating at a table in the Coral / Restorative dining room. Resident identifiers: #44, #98, and #83. Facility census: 102. Findings include: a) Resident #44 This resident was observed eating lunch on 10/30/12 at 12:15 p.m. in the Coral / Restorative dining room. The resident was being assisted by restorative nursing assistant Employee #104. The table was at the level of the resident's axilla, making it difficult for her to see her food and feed herself more independently. Resident #44 was a [AGE] year old, 102 pound female with [DIAGNOSES REDACTED]. Her minimum data set (MDS) notes she is rarely understood. The care plan stated she was to eat in the Coral / Restorative dining room for staff supervision and cueing. All meals were to be monitored, alternate choices were to be offered as needed, and staff were to alert the dietitian and physician if a decline in intake was noted. An additional observation was made on 10/31/12 at 12:30 p.m. Restorative nursing assistants, Employees #82 and #130 were observed assisting the resident during lunch in the Coral / Restorative dining room. During an interview with Employees #82 and #130 at that time, they agreed Resident #44 would benefit by the table being lowered further to allow the resident to see what she was eating and possibly improve her desire to eat. Employee #130 thought the table legs could be adjusted lower and stated she would contact maintenance and have them evaluate the table legs. A final observation on 11/07/12 at 12:30 p.m., found evidence the table had been lowered and Resident # 44 was more active in feeding herself. b) Resident #98 This was observed eating lunch on 10/30/12 at 12:15 p.m. in the Coral / Restorative dining room being assisted by restorative nursing assistant Employee #104. The resident was seated at a table that was level with her axilla, making it difficult for her to see her food and attempt to feed herself independently. She required extensive cueing and was not always cooperative in response to staff requests. Employee #104 had to repeatedly suggest the resident take a drink or bite of food. Resident #98 was an [AGE] year old, 108 pound female with a [DIAGNOSES REDACTED]. The care plan stated the resident was to eat in the Coral / Restorative dining room for staff supervision and cueing. All meal intakes were to be monitored, alternate choices offered, and pudding and ice cream added to lunch and dinner. Staff were to alert the dietitian and physician if an intake decline was noted. An additional observation was made on 10/31/12 at 12:30 p.m. Restorative nursing assistants Employees #82 and #130 were observed assisting the resident during lunch in the Coral / Restorative dining room. During an interview with Employees #82 and #130 at that time, they agreed Resident #98 would benefit by the table being lowered further to allow the resident to see what she was eating and possibly improve her desire to eat. Employee #130 thought the table legs could be adjusted lower and stated she would contact maintenance and have them evaluate the table legs. A final observation on 11/07/12 at 12:30 p.m. found evidence the table had been lowered and Resident # 98 was more active in attempting to feed herself. c) Resident #83 This resident was observed eating lunch on 10/30/12 at 12:15 p.m. in the Coral / Restorative dining room being assisted by restorative nursing assistant, Employee #104. The resident was seated at a table that was level with her upper chest, making it difficult for her to see her food and feed herself independently. Resident #83 was a [AGE] year old, 89 pound female with [DIAGNOSES REDACTED]. The resident's care plan identified her as being a nutritional risk because of a texture modified diet and a history of dysphagia and dementia. Plans include fortified cereal and pudding between meals and dining in the Coral / Restorative dining room for assistance. An additional observation was made on 10/31/12 at 12:30 p.m. Restorative nursing assistants Employees #82 and #130 were observed assisting the resident during lunch in the Coral / Restorative dining room. During an interview with Employees #82 and #130 at that time, they agreed Resident #83 would benefit by the table being lowered further to allow the resident to see what she was eating and possibly improve her desire to eat. Employee #130 thought the table legs could be adjusted lower and stated she would contact maintenance and have them evaluate the table legs. An final observation on 11/07/12 at 12:30 p.m. found evidence the table had been lowered and Resident #83 was more active in feeding herself.",2015-11-01
9416,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-11-07,514,B,1,0,I0U011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to document percentages or acceptance of supplement intake. This was evident for three (3) of ten (10) sampled residents. Resident identifiers: #35, #66, and #11. Facility census: 102. Findings include: a) Resident #35 Review of the physician's orders [REDACTED].#35 was to receive a house supplement three (3) times daily. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 found the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment list records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. This afforded forty-two (42) opportunities for the resident to receive a supplement. An interview with Employee #102, the director of nurses, Employee # 92, the director of food services, and Employee #37, the assistant food director, revealed no evidence was available to indicate the resident had been offered the supplement on six (6) of fourteen (14) days. A nourishment list was not available for the dates of 11/03/12, 11/02/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. The nourishment forms for this resident were blank for five (5) of forty-two (42) opportunities reviewed. These dates included 11/04/12, 11/01/12 and 10/29/12. Acceptance only, with no percentage of consumption noted, occurred on two (2) occasions. Additionally, consumption was unable to be identified on one (1) occasion due to the report indicated both acceptance and refusal of the same date and time of distribution. b) Resident #11 Review of the medical record indicated this resident had an order to receive a house supplement twice daily. This afforded twenty-eight (28) opportunities for consumption during the fourteen (14) days reviewed. The dates reviewed were 10/24/12 through 11/06/12. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 indicated the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Employee #102, the director of nurses; Employee # 92, director of food services and Employee #37, assistant food director, were interviewed on 11/07/12. A nourishment list (1) was not provided for the dates of 11/03/12, 10/30/12, 10/28/12, 10/27/12, and 10/25/12. Review of the nourishment record for the dates of 11/04/12, 11/01/12, 10/29/12, and 10/26/12 found no evidence the supplement had been offered. The form was not completed on four (4) occasions. On 10/26/12 the nourishment record indicated the supplement was not sent up. No evidence was provided to indicate a supplement was obtained, offered, or consumed. Staff documented acceptance for the date of 11/05/12, but the percentage of consumption was not recorded. c) Resident #66 The medical record was reviewed on 11/07/12. It revealed this resident had an order to receive a house supplement once daily at bedtime. Review of the snack, nourishment, supplements and pantry stock policy (3.14) on 11/07/12 indicated the nourishment list was printed from the tray tracker and used as a guide for delivery of supplements to residents and to record acceptance. Nourishment records were reviewed for a sample of fourteen (14) days. The dates reviewed were 10/24/12 through 11/06/12. Review of the nourishment list on 11/07/12 revealed no evidence the supplement had been offered or consumed on six (6) dates. The nourishment list was not provided for 11/03/12, 11/02/12, 10/30/12, 10/29/12, 10/28/12 and 10/26/12. No further evidence was provided by the nursing or dietary department to substantiate distribution of the supplement. Additionally, review of the nourishment list on 11/07/12 revealed the percentage intake was not completed on five (5) occasions. These dates include: 11/04/12, 11/01/12, 10/31/12, 10/27/12 and 10/25/12. This information was shared with Employee #102, the director of nurses, and Employee # 92, the director of food services and Employee #37, the assistant food director, on 11/07/12. No further information was provided.",2015-11-01
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
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
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
9639,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,225,E,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's grievance / complaint files and staff interview, the facility did not ensure six (6) allegations of neglect were reported immediately to the State survey and certification agency, in accordance with State law. Complaints were reviewed for the previous three (3) months. This was found for six (6) of forty-three (43) complaint records reviewed. Resident identifiers: #112, #67, #113, #3, #45 and #46 (a married couple), and #108. Facility census: 105. Findings include: a) Record Review 1. Resident #112 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, found an allegation made by the daughter of Resident #112. The daughter complained she had visited on 10/05/09, and found soiled pants balled up on the floor, and the pad used to lift the resident smelled so badly from urine that it made her eyes burn. She further stated the facility was filthy. These are allegations of neglect. There was no evidence these allegations were reported to the appropriate State agency. 2. Resident #67 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, found Resident #67 had complained, to facility staff on 12/07/09, that a certified nursing assistant (CNA) told him he was not allowed out of bed when he needed to go to the bathroom. He alleged the CNA made him use the bedpan and would not help him get into his wheelchair so he could use the bathroom. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 3. Resident #113 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #113 complained, to facility staff on 11/25/09, that when she asked a CNA to take her to the dining room for the activity, the CNA stated she needed to push herself, because she needed to exercise her arms. She was upset because she was not assisted to the dining room. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 4. Resident #3 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #3's family complained, to facility staff on 11/24/09, that she was upset at how long the resident's hair had been when she was in to visit. She said she had asked numerous times for him to have his hair cut every six (6) weeks and was quoted as saying, This is neglect and I won't stand for it. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. 5. Residents #45 and 46 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Residents #45 and #46 (a married couple) complained, to facility staff on 11/02/09, that staff was not assisting them with anything. They were quoted as saying, The people you have working for you should be trained enough to know how to help a person. They also complained the bed hadn't been made in six (6) days and that they were not being given the results of labs and x-rays. These are allegations of neglect. There was no evidence these allegations were reported to the appropriate State agency. 6. Resident #108 Review of the facility's resident / family complaint file, on the afternoon of 12/15/09, revealed Resident #108's family complained, to facility staff on 12/08/09, that the resident's [MEDICAL CONDITION] was now so bad that three toes, or possibly entire foot, now had to be amputated. The family wanted to know how it got to this point without staff knowing or doing anything about it. This is an allegation of neglect. There was no evidence this allegation was reported to the appropriate State agency. b) Staff interview The facility's administrator (Employee #1), when interviewed on 12/15/09 at 2:30 p.m., stated that any complaints or concerns were reviewed by him and his management team every day, and decisions were made regarding what complaints required reporting to the appropriate State agency. Each of these complaints was discussed, and he concurred that they constituted allegations of neglect and required reporting to the appropriate State agency under State law.",2015-10-01
9640,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,246,D,0,1,6HX711,"Based on observation and staff interview, the facility failed to accommodate the individual needs of one (1) of eighteen (18) sampled residents and one (1) randomly observed resident, who were seated at a table during meals that required them to reach up in unnatural manner to obtain food from their plates. The food was not placed at height that would allow the residents to independently eat from their plates in a comfortable manner. Resident identifiers: #37 and #87. Facility census: 105. Findings include: a) Residents #37 and #87 During the noon meal in the B Dining Room on 12/15/09 at 12:30 p.m., observation found two (2) residents seated at a table that was so high, the residents had to reach up in an unusual manner to obtain food from their plates, which were at about chin level. Resident #37 was seated in an upholstered facility chair with a very low seat, and Resident #87 was seated in a small wheelchair with a seat that was too low to put her into a natural position at the table to access her plate. This observation was bought to the attention of a facility staff member and a restorative nursing assistant (Employee #81) who was seated at the table encouraging the two (2) residents (as well as several others) to eat. Employee #81 confirmed the two (2) residents being observed were part of the Restorative Feeding Program and required encouragement / reminders to eat. Employee #81, when asked if the position the residents were in in relation to their plates was one that was normally assumed by individuals while eating, stated, They're low. When asked if she thought this was an optimal position to encourage the residents to feed themselves, she stated, No, they're too low.",2015-10-01
9641,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,278,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure a quarterly minimum data set (MDS) assessment was accurate. This was true for one (1) of eighteen (18) sampled residents, whose quarterly MDS was inaccurate relating to bowel incontinence and the presence of pressure ulcers. Resident identifier: #16. Facility census: 105. Finding include: a) Resident #16 Resident #16's medical record, when reviewed on 12/16/09 at 9:45 a.m., revealed a [AGE] year old female who was admitted to the facility on [DATE]. The resident was currently receiving treatment at a wound center for a Stage III pressure ulcer, and the resident required assistance with all personal care. Review of the facility form titled Activities Of Daily Living Flow Chart for November and December 2009 disclosed the resident was incontinent of bowels. Resident #16 was observed in her room at 4:00 p.m. on 12/15/09. The treatment nurse (Employee #114) was providing treatment to the resident's Stage III pressure ulcer on the sacrum. The resident was noted to be incontinent of bowel at that time. The quarterly MDS, with an assessment reference date of 10/08/09, indicated the resident did not have any pressure ulcers and was continent of bowels. The MDS coordinator (Employee #97), when interviewed on 12/16/09 at 2:30 p.m., acknowledged the quarterly MDS, dated [DATE], was inaccurate relating to pressure ulcers and bowel incontinence.",2015-10-01
9642,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,280,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed, for three (3) of eighteen (18) residents reviewed, to review and revise their care plan following a change in condition and/or care needs. One (1) resident experienced a fall with a resulting fracture with no update / revision to the care plan. One (1) resident was determined to be nearing the end-of-life and was admitted to the services of Hospice with no revision to the care plan. One (1) resident's resident assessment protocol (RAP) summary stated that a care plan was necessary for the use of [MEDICAL CONDITION] medications, but the care plan did not contain this information. Resident identifiers: #66, #13, and #49. Facility census: 105. Finding include: a) Resident #66 The medical record of Resident #66, when reviewed on 12/16/09, disclosed this [AGE] year old female had multiple [DIAGNOSES REDACTED]. An incident / accident report, dated 09/05/09, stated the resident was found lying on the floor on her back with both feet in front, complaining of right leg and hip pain. The resident was transferred to a local emergency room for evaluation. A nurse's note, on 09/07/09, stated the resident's admitting [DIAGNOSES REDACTED]. The resident returned to the facility at 1:45 p.m. on 09/09/09. The resident's history and physical related to this hospitalization , when reviewed, disclosed the resident was confused as usual, her general condition was very poor, and prognosis was guarded. The document described a decline in condition over the previous several months. The resident had been admitted to the services of Hospice on 07/07/09, with an admitting [DIAGNOSES REDACTED]. The resident's plan of care was last updated on 11/30/09. A focus area for the resident was documented to be: At risk for falls r/t (related to) hx (history) of chronic pain. The goal for this focus area, which was the same goal that had been initiated on 08/15/08, stated: Resident will have no falls with injury requiring hospitalization thru next review. The interventions determined by staff to be necessary to meet these goal had not been revised since 08/15/08 and included: Evaluation of medications, monitor for orthostatic [MEDICAL CONDITION], place all personal items within reach, monitor for and assist with toileting needs. No additional interventions had been developed following the resident's fall on 09/05/09 which resulted in new fractures of the vertebrae. The only mention of the resident's fractured vertebrae was noted in another focus area which described the resident's need for assistance with activities of daily living due to cognitive loss / dementia, recent falls and has compression fractures. The only added intervention following the fall of 09/05/09 was up with assistance only. The resident was noted by the physician to be confused as usual and her [DIAGNOSES REDACTED]. Her care plan described cognitive loss and dementia which, all combined, would typically render the resident unable to call for assistance before attempting any ambulation. There was no mention of lowering the resident's bed, placing mats, etc., that may have been beneficial to the resident. b) 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]. The resident had returned to the facility from her most recent hospitalization on [DATE], after 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 available plan of care, when reviewed, made no mention of Hospice Services. The document entitled Resident Care Plan Conference, which the facility used to document attendance at resident care plan meetings, stated a conference was held on 12/08/09, with the resident's family and a Hospice nurse present. No notation on the care plan reflected any review or revision to the plan having occurred on this date. The facility's director of nurses (DON - Employee #99), was made aware of this finding at approximately 1:00 p.m. on 12/15/09. At 3:30 p.m. on 12/15/09, the DON provided documentation that had been faxed to the facility by the Hospice agency, which was entitled Plan of Care for: (name of Resident #13). The document was a generic form which had not been individualized for this resident, nor was there evidence that any of the interventions mentioned on the generic care plan had, indeed, been implemented. At the time of exit on 12/17/09, no further evidence was provided to reflect the resident's care plan had been updated to address her needs at the time of the admission to Hospice services on 12/08/09. c) Resident #49 Review of Resident #49's medical record revealed she incurred a significant change in condition, an increase in moods and behaviors, and the use of [MEDICAL CONDITION] medications following a urinary tract infection which required a hospitalization . Subsequently, a comprehensive MDS, with an assessment reference date 11/21/09, was completed to reflect the significant change in condition. The accompanying RAP summary, dated 11/29/09, noted the interdisciplinary team's decision to revise the care plan to address the use of [MEDICAL CONDITION] medications. However, the interdisciplinary team failed to develop a care plan for [MEDICAL CONDITION] medications as they said they would. Review of the medical record revealed the resident was prescribed antipsychotic, antidepressant, and antianxiety medications for daily use. The DON was informed of these findings 12/16/09 at 3:00 p.m., and by the end of the day, the care plan for Resident #49 was updated to include the use of [MEDICAL CONDITION] medications.",2015-10-01
9643,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,309,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to administer medications ordered by the physician in a timely manner. This was evident for one (1) of eighteen (18) sampled residents. Resident identifier: #49. Facility census: 105. Findings include: a) Resident #49 Review of the medical record revealed Resident #49 was exhibiting uncommon behaviors attributed to the onset of a urinary tract infection. A urinalysis and culture and sensitivity was ordered by the physician 10/30/09, but it was not obtained until 11/03/09, due in part to the resident's lack of cooperation. An oral antibiotic ([MEDICATION NAME]) was prescribed three (3) times daily beginning 11/03/09, but it was not begun until at 8:00 a.m. on 11/04/09. The physician's order did not specify to wait until the following day to begin the antibiotic. [MEDICATION NAME] was discontinued after she was seen by the physician on 11/04/09, and new orders were given to begin [MEDICATION NAME] 0.5 mg IM (intramuscular) one (1) hour prior to [MEDICATION NAME] 1 Gram IM daily for one (1) week for a urinary tract infection. However, the injectable antibiotic was not begun until the following day, at 8:00 a.m. on 11/05/09. The physician's order 11/04/09 did not specify to wait until the following day to begin the [MEDICATION NAME]. Documentation in the evening shift nurse's notes, dated 11/04/09, recorded Resident #49 refused all evening (PM) medications, refused all PM care, and refused to eat; however, there was no documentation in the nurse's notes on 11/4/09 staff having notified the physician of the medication refusal, nor was there any documentation by the 11-7 shift of any attempts to initiate the new orders for the injectable antibiotic, nor were there any nurse's notes for the resident's condition on the 11-7 shift of 11/05/09. The urine culture and sensitivity report, dated 11/05/09, noted the organism was resistant to [MEDICATION NAME] (Bactrim), but was susceptible to [MEDICATION NAME] ([MEDICATION NAME]); [MEDICATION NAME] was discontinued at 1:00 p.m. on 11/05/09. The resident had received only two (2) of a potential five (5) opportunities to receive [MEDICATION NAME], and received only one (1) of a possible three (3) opportunities to receive [MEDICATION NAME]. Subsequently, she was admitted to the hospital on [DATE], after having received only one (1) dose of the injectable [MEDICATION NAME]. During interview with the director of nursing on 12/16/09 at 3:00 p.m., she said she would have expected the nurses to initiate medication changes more promptly.",2015-10-01
9644,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,323,E,0,1,6HX711,"Based on observation and staff interview, facility staff failed to assure the resident environment was as free as possible of accident hazards, by leaving the entry keys in the door of the medication preparation room on the A Hall and in the absence of supervision of any staff member. This practice had the potential to affect all residents who resided on the A Hall of the building. Facility census: 105. Findings include: a) During a random tour of the facility on 12/15/09 at approximately 12:15 p.m., the medication preparation room on A Hall was observed to have a set of keys hanging in the door knob. There was no staff in direct observation of the keys. The facility's administrator (Employee #1) was in the vicinity, across the hall involved in conversation with staff. The keys were bought to the attention of the administrator, who immediately removed them and stated his plan to find out who had left them there. This medication room was entered on 12/15/09 at approximately 4:00 p.m., to assess the contents of the room. Although the refrigerator for medication was locked, the shelves did display bottles of stock medications such as mild pain medication, laxatives, vitamins, etc.",2015-10-01
9645,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,371,F,0,1,6HX711,"Based on observation and staff interview, the facility failed to store and serve food under sanitary conditions. This was evident in three (3) separate instances, and had the potential to affect all residents in the facility who obtain nourishment from the dietary department. Facility census: 105. Findings include: a) Observation of the kitchen work area, during initial tour on 12/14/09 at 2:35 p.m., revealed the presence of a service technician repairing a juice dispensing machine. He wore a full, thick beard with no hair restraint prior to surveyor intervention. The director of food service (Employee #102) agreed he should have worn a beard restraint and began locating an appropriate beard cover for him to wear. b) Observation, upon initial tour on 12/14/09 at 2:30 p.m., revealed the presence of approximately one and a half (1-1/2) to two (2) dozen washed plastic glasses inverted on a plastic tray with no mat beneath them, nor any other method whereby the glasses could air dry and drain appropriately. The director of food service lifted one (1) of the glasses from the tray, which revealed the rim of the glass setting in water and a small amount of water pooled beneath the glass. She cited the reason for having no mat or anything beneath this tray of glasses to facilitate air drying was because dietary staff planned to use these glasses soon and not store them. c) Observation of the emergency food supply, on 12/14/09, revealed one (1) large can of Ravioli that was past the expiration date printed on the can from the factory. Also noted were twelve (12) large cans of sausage gravy dated 04/22/08 with black marker on the box with no manufacturer's expiration dates upon them; a box of canned tomato juice dated 08/27/08 in black ink; and a box of canned apple juice dated 08/08 in black ink; none of which had manufacturer's expiration dates printed on the cans. The director of food service said the dates in black ink represented the dates they were placed in the emergency food supply closet; they typically rotate stock every six (6) months to prevent waste; and she will remove those cans tomorrow when the food order arrives. The above findings were reported to the director of nursing at 3:00 p.m. on 12/16/09. She then asked the director of food service for the policy on food rotation. Subsequently, the policy for Emergency Menu and Food Supply Guidelines was produced, which stated the emergency food supply was to be rotated every six (6) months to maintain quality. Employee #102 stated a shipment of food arrived today, and she replaced the canned juice and sausage gravy, and had removed the outdated large can of Ravioli yesterday.",2015-10-01
9646,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,428,D,0,1,6HX711,"Based on record review and staff interview, the facility failed to ensure the physician acted upon irregularities reported by the pharmacist in the medication regimens of two (2) of eighteen (18) residents, to include documenting the rationale for declining to implement a gradual dose reduction for Resident #80's antidepressant and failing to document the risk versus benefit of continuing the use of an antipsychotic three (3) times a day for Resident #61. Resident identifiers: #80 and #61. Facility census: 105. Findings include: a) Resident #80 Review of the medical record revealed the facility's pharmacist made the recommendation, on 10/20/09, for Resident #80 to have a gradual dose reduction (GDR) of an antidepressant she had been on for the preceding six (6) months. The physician declined to order a gradual dose reduction at this time but failed to document a rationale for this decision. The director of nursing (DON) was informed of this finding at 3:00 p.m. on 12/16/09. At 4:33 p.m., she received a fax from the physician's office in response to her fax on 10/20/09, requesting the rationale for the contraindication for the GDR. It was signed and dated by the physician on 10/21/09 declining the GDR at that time, as it was deemed likely to impair this individual's function or cause psychiatric instability by exacerbating an underlying medical condition or psychiatric disorder. However, the rationale was not written. No further evidence nor physician's progress note was produced giving the rationale. b) Resident #61 Review of the medical record revealed Resident #61 was prescribed Seroquel 150 mg three (3) times daily. Further review of the medical record revealed the pharmacist made the recommendation on 07/08/09, for Resident #61 to have a re-evaluation of the current dose of Seroquel; if it is to be continued at the current dose, the pharmacist asked for the physician to document an assessment of risk versus benefit. The physician signed but did not date the pharmacist's Consultation Report, and did not document the rationale for continuing the medication in that dosage. Instead, he noted he had re-evaluated this therapy and did not wish to implement any changes, and the area to record the rationale was left blank. The DON was informed of this finding at 3:00 p.m. on 12/16/09. She noted the facility did document behaviors and employ non-pharmacological interventions for her behaviors, and the resident had monthly psychiatric visits to monitor her. However, no physician's progress notes or other documentation was produced with the prescriber's assessment of risk versus benefit indicating Seroquel at that dosage continued to be a valid therapeutic intervention for the individual, in response to the pharmacist's request for this information.",2015-10-01
9647,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,441,E,0,1,6HX711,"Based on observation and staff interview, the facility failed to implement infection control practices to provide a safe and sanitary environment to residents, by storing the ice scoop used to obtain ice for resident water pitchers on the B Hall in an unclean receptacle. This practice had the potential to affect all residents who reside on the B Hall of the facility. Facility census: 105. Findings include: a) During a random tour of the facility at approximately 12:15 p.m. on 12/15/09, the nourishment room on the B Hall was entered. This room housed an ice maker from which staff obtained ice to refill resident water pitchers. Upon closer observation, it was noted that the receptacle on the wall in which the ice scoop was held had a build up of a white substance in the bottom. The facility's administrator (Employee #1), when asked to observe the wall receptacle, confirmed the presence of debris in the bottom of the receptacle, which would touch the scoop when stored, and immediately removed the receptacle for proper cleaning.",2015-10-01
9648,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2009-12-17,514,D,0,1,6HX711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure clinical records were accurate. The monthly physician's orders were inaccurate relating to nutritional supplements for one (1) of eighteen (18) sampled residents. Resident identifiers: #28. Facility census: 105. Findings include: a) Resident #28 Resident #28's medical record, when reviewed on 12/15/09 at 9:00 a.m., revealed a [AGE] year old male who was readmitted to the facility on [DATE], after a hospitalization for pneumonia. Review of the dietitian's nutritional assessment, dated 11/13/09, noted the dietitian's recommendation was to discontinue the Ensure supplement and start house supplement three (3) times a day. Review of the current physician's orders for December 2009 revealed the house supplement was ordered twice a day. The unit manager registered nurse (RN - Employee #86), when interviewed on 12/16/09 at 10:30 a.m., confirmed the December 2009 monthly physician's orders for the house supplement was inaccurate. The RN provided written evidence the house supplement was offered to the resident three (3) times a day per the dietitian's recommendation.",2015-10-01
9798,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-06,272,D,1,0,H1IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observation, and staff interview, the facility failed to develop an accurate comprehensive assessment related to contractures for one (1) of four (4) sampled residents in the facility with contractures. Resident identifier: #45. Facility census: 116. Findings include: a) Resident #45 Observation during the initial tour of the facility, on 09/03/12, found that Resident #45 had noticeable contractures of his wrists and ankles. Other body parts were not visualized. Record review revealed his admitting [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS), with an assessment reference date (ARD) of 07/25/12, in Section S for functional status assessment, the assessor had coded him as having no contractures. During an interview with a restorative nurse, Employee #7, on 09/06/12 at 10:30 a.m., she said she would consider him as having multiple joint contractures, but the Physical Therapist would be the one to make that determination. She said she performs passive range of motion to his extremities daily, six (6) days per week. During an interview with the Physical Therapist, on 09/06/12 at noon, she said most of his joints have what is termed contractures, due to [DIAGNOSES REDACTED] related to [MEDICAL CONDITION]. He was admitted with multiple joint contractures which he has had for many years. In an interview with the Director of Nursing, on 09/06/12, at approximately 1:00 p.m., she acknowledged that Resident #45 had contractures of multiple joints when admitted to the facility in July 2012. This information contradicted the MDS admission assessment in which the resident was coded as having no contractures. .",2015-09-01
9799,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-06,279,D,1,0,H1IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, record review and staff interview, the facility failed to develop care plans related to the functional abilities for one (1) of nine (9) sampled residents, and failed to care plan for the use of [MEDICAL CONDITION] medications for one (1) of nine (9) sampled residents. A resident with a functional disability of the left hand, had no care plan goals or interventions developed to address this issue. A resident prescribed an antipsychotic medication was not care planned for the use of this medication. Resident identifier: #76. Facility census: 116. Findings include: a) Resident #76 1) Observation during the initial tour of the facility, on 09/03/12, found Resident #76 wore a splint to the left hand. Observation the following day, during the evening meal, found she was not wearing the splint at the dining room table. She let her left hand dangle and did not use it while she ate. During an interview with a restorative nurse, Employee #7, on 09/06/12 at 10:30 a.m., she said this resident wore a palm guard to the left hand for protection of the skin, and prevention of a pressure ulcer. She said she does not perform passive range of motion on this hand due to the resident being combative when this was attempted. In an interview with the Physical Therapist, on 09/06/12 at 12:00 p.m., she said this resident's left hand had a tightness which almost resembled trigger fingers, and the other fingers drew into a similar position. She said this resident had a magnetic resonance imaging (MRI), but the resident would not cooperate to complete the entire test. Review of the medical record found a physician's orders [REDACTED]. Record review also revealed a physician's orders [REDACTED]. Review of the resident's care plan revealed no goals or interventions related to her left hand deficit. During an interview with the Director of Nursing, on 09/06/12, at approximately 1:00 p.m., she had no further information to provide. 2) Record review found this resident was prescribed an antipsychotic medication, [MEDICATION NAME], on 06/06/12. Review of the care plan revealed no goals or interventions related to the use of an antipsychotic medication, and no [DIAGNOSES REDACTED]. .",2015-09-01
9800,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-06,280,D,1,0,H1IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to revise a care plan with identifiable goals and measurable outcomes, related to the level of assistance required for transferring, and for toileting, a resident. Resident identifier: #91. Facility census: 116. Findings include: a) Resident #91 This resident had [DIAGNOSES REDACTED]. Her most recent re-admission to the facility was 05/09/12. During an interview with Resident #91, on 09/03/12, at approximately 3:15 p.m., she said she tried to toilet in the larger resident bathroom earlier today without much success, and said it hurt staffs' backs when they tried to assist her to the toilet. She said when she goes to another city for medical appointments, the aide who goes with her lets her hold her (the aide's) neck, and she swings her onto the toilet. She said there are no toilets in the facility that are handicapped accessible. According to the resident, all of the toilets are too low, and she cannot transfer that low. She said she also cannot bear weight on her left leg since her hip surgery that was performed several months ago. During an interview with a nurse (Employee #9). on 09/03/12, at approximately 3:15 p.m., she said she was unaware this resident used the toilet now, as she had been using the bedpan in recent months. The nurse said she did not have an order for [REDACTED]. She said she would check with therapy to see what they could do, and perhaps get her a bedside commode. The resident said a bedside commode would not assist her with transferring because the bedside commode bar would be in the way of her transfer. During an interview with a nursing assistant, Employee #107, she said Resident #91 had not used the toilet since admission to the facility. She said prior to the resident's hip surgery, approximately four (4) months ago, she would transfer to a shower chair by the resident holding the staff member around the neck, then staff would pivot her. She said Resident #91 would help put herself back to bed from the wheelchair because the arm of the wheelchair could be moved away, allowing her to transfer. She said Resident #91 had good upper body strength. Record review revealed this resident was care planned for limited assistance of one for transferring, dressing, and personal hygiene and bathing. Staff were to encourage her to participate while providing appropriate ADL (activities of daily living) care. Another section of the care plan directed for her to have mechanical lifts for transfers. Review of the physician's orders [REDACTED]. Review of the ADL book that was used by nursing assistants to review written care needs, found no mention of toileting or transfer needs or abilities for this resident. During an interview with the Director of Nursing, on 09/03/12, at approximately 1:00 p.m., the conflicting ADL needs and abilities were discussed, as well as the lack of revision of the care plan for her toileting and transfer needs since her recent hip surgery. No further information was provided prior to exit. .",2015-09-01
9801,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-06,323,E,1,0,H1IF11,". Based on observations, resident interview, and staff interview, the facility failed to provide an environment as free of accident hazards as possible. The safety rails for both the A Hall and the B Hall common use residents' toilets were found to be unstable. This had the potential to affect more than an isolated number of residents who uses the A Hall and B Hall common toilets. Facility census: 116. Findings include: a) Resident #91 During an interview with Resident #91, on 09/04/12, at approximately 3:15 p.m., she said the safety rails attached to the toilet in the residents' common use toilet on the B Hall, were wobbly and unsafe. Observations, on 09/03/12, at approximately 4:00 p.m., of the B Hall resident common toilet room, found that the safety/grab rails were unstable and wobbled when touched. Both legs of the safety rails could easily be lifted up off the floor of the bathroom approximately nine (9) inches, and turned sideways to some degree. During an interview with the Director of Nursing (DON) at that time (09/03/12 at approximately 4:00 p.m.), she stated she would have maintenance tighten up the rails. During an interview with the DON, on 09/04/12 at 1:40 p.m., she said maintenance would have to order new safety rails/grab bars for the toilet, as tightening would not stabilize them. Observation of the A Hall resident toilet room, on 09/06/12, shortly after noon, found the safety/grab rails were unstable and wobbled when touched. Both legs of the safety rails could easily be lifted up off the floor of the bathroom. One leg could be lifted approximately nine (9) inches, and the other leg could be lifted up approximately four (4) inches, off the floor. Both could be turned sideways to some degree. A nurse, Employee #106, observed the rails and agreed they needed repaired or replaced. She entered the problem in the maintenance log and informed the DON. .",2015-09-01
9802,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-09-06,428,D,1,0,H1IF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure drug irregularities were identified and addressed during the monthly medication regimen reviews by the pharmacist. One (1) of five (5) sampled residents, who received psychoactive medications, had no diagnoses to warrant the use of the medication. Resident identifier: #76. Facility census: 116. Findings include: a) Resident #76 Record review revealed that Resident #76 was admitted to the facility on [DATE]. On 06/06/12, she was prescribed, and received, Risperdal 0.25 milligrams (mg.) by mouth twice daily for dementia, related to behaviors of hitting and biting others. Review of Nursing 2013 Drug Handbook found that Risperdal is an antipsychotic medication that is used to treat psychoses. Review of the medical record found that Resident #76 did not have a [DIAGNOSES REDACTED]. Further record review found no evidence the consultant pharmacist had noted this irregularity during the monthly medication regimen review for Resident #76. There was no evidence the pharmacist had submitted a request to the physician asking for the rationale or diagnoses which supported the use of this medication. Record review found this resident was seen by a psychiatrist on 06/06/12, 06/20/12, and 08/01/12. During an interview with the Director of Nursing, on 09/06/12, at approximately 1:30 p.m., she said it was her expectation that antipsychotic medications be prescribed only for psychoses or other diagnoses that supported their use. .",2015-09-01
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
10339,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,272,D,1,0,VNEB11,". Based on record review and staff interview, the facility failed, for one of ten (10) sampled residents, to ensure the accuracy of a comprehensive assessment. Review of a discharge minimum data set (MDS) assessment, found it was coded incorrectly. The assessment indicated the resident had no pressure ulcers at the time of discharge. However, there was documented evidence in the resident's medical record to establish the resident had a decubitus ulcer on her buttocks. Resident identifier: #103. Facility census: 102. Findings include: a) Resident #103 Review of Section M of the discharge MDS for Resident #103, dated 12/06/11, revealed it was coded as the resident having no pressure ulcers at the time of discharge. Review of the discharge summary note, dated 12/06/11, found a notation signed by the physician which stated in part ""Upon discharge she did have decubitus on buttocks"". A skin integrity report noted the initial recording of a Stage II pressure ulcer on Resident #103's coccyx was on 11/06/11. Review of weekly measurements found it remained a Stage II ulcer until 12/06/11, when it was then described as unstageable. In an interview with the director of nursing (DON), on 01/12/11, at approximately 5:30 p.m., she said she would have to check with her MDS nurse to see if the discharge MDS for Resident #103 was coded incorrectly related to skin conditions at discharge. On 01/13/11, at approximately 11:00 a.m., the DON agreed Section M of the 12/06/11 discharge MDS had been coded incorrectly. The resident had had a decubitus ulcer at the time discharge. .",2015-05-01
10340,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,441,D,1,0,VNEB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation and staff interview, the facility failed to ensure residents were free from the potential for transmission of organisms via inanimate objects. Observation of treatments found one instance of a key, which hung from the nurse's neck, touching a resident's foot and towel, then came in contact with the lift sheet of another resident. Also, observation of another treatment found the name tag of an employee rested on the bare hip of a resident as she helped position the resident during a dressing and wound vac change. Resident identifiers: #81 and #13. Facility census: 102. Findings include: a) Resident #81 Observation of a treatment for [REDACTED].#22, touched the resident's bare foot and a towel that was lying on the bed during the treatment. Observation of a treatment to Resident #81 on 01/11/12 at 12:30 p.m., revealed the same key touched the lift sheet on which the resident had been lying. He had multiple small, slightly opened areas on the posterior left thigh surrounded by areas of reddened skin. Immediately after the treatment was completed, the nurse, Employee #22, was asked about the key touching items in both residents' beds. She stated she does not typically wear the key, but had been in a hurry when a resident became ill unexpectedly a short while before. She had forgotten to remove the key from her neck. She did not realize the key had touched anything in either bed. b) Resident #13 Observation, on 01/11/12 at 5:00 p.m., of a decubitus ulcer on the coccyx of Resident #13, and changing of the wound vac, revealed a malodorous wound. During observation of this treatment, the name tag of Employee #1 (a nursing assistant) was seen lying on the bare left hip of Resident #13 as she helped hold and position the resident on her right side as nurse Employee #22 changed the wound vac. This was brought to Employee #1's attention immediately after the treatment was completed. She removed her name badge and washed and sanitized it. She did not realize her name badge had been lying on the resident's hip. c) Findings for the above two (2) incidents were relayed to the director of nursing on 01/11/12, at approximately 5:30 p.m., with no further information or comments provided. .",2015-05-01
10341,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2012-01-13,514,D,1,0,VNEB11,". Based on record review and staff interview, the facility failed to ensure all documents in a resident's medical records were complete. Review of medical records found incomplete entries for the amount of food and fluids consumed at all meals for one (1) of ten (10) sampled residents. Additionally, there were incomplete entries on the intake and output record for the same resident. Resident identifier: #13. Facility census: 102. Findings include: a) Resident #13 Review of activities of daily living (ADL) books found spaces to record the percentages of breakfast, lunch, and dinner, and for the amount of liquids the resident had consumed at each meal. Spaces were also provided for staff to record the intake and output of each resident for each shift. Review of the ADL book for Resident #13 found blank spaces for the consumption of food and fluids for the noon meal on 01/03/12, 01/05/12, 01/08/12, 01/10/12, and the evening meal on 01/08/12. The intake and output record had blank spaces also. The resident's oral intake was not recorded as follows: 11-7 and 3-11 on 01/02/12; 11-7 and 3-11 on 01/03/12; 7-3 on 01/04/12 and 01/05/12; 7-3 and 3-11 on 01/06/12; all shifts on 01/08/12, 7-3 on 01/09/12 and 01/10/12. The following dates had blank spaces, indicating the Foley catheter output for Resident #13 was not recorded as follows: 11-7 and 3-11 on 01/02/12, 7-3 on 01/03/12 and 01/04/12, 11-7 and 7-3 on 01/05/12, all shifts on 01/08/12, 7-3 on 01/09/12 and 01/10/12. Further review of the ADL books found instructions signed by the director of nursing stating that, beginning July 01, nursing assistants ""are not allowed to leave at the end of the shift until the nurse's have checked that all of your books are done. The nurses will be held accountable."" During interview with the director of nursing on 01/11/12 at 10:20 a.m., when asked where to find meal and fluid percentages that residents' consume, and the intake and output measurements, she said the ADL books had that information. When informed of the missing meal and fluid recordings, and missing intake and output recordings for Resident #13, she stated she would look for the missing information. No further information was provided prior to exit. .",2015-05-01
10524,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2011-10-26,386,D,1,0,9O4W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to ensure the attending physician signed all documents in the resident's medical record on each visit for one (1) of thirteen (13) sampled residents. Resident #92 was admitted to the facility on [DATE], with re-admitted s of 06/23/11 and 10/21/11. Medical record review, on 10/24/11, disclosed the resident's capacity determination statement and Physician's Orders for Scope of Treatment (POST) form had not been signed and dated by the attending physician during visits as required. Resident identifier: #92. Facility census: 108. Findings include: a) Resident #92 Medical record review, on 10/24/11, disclosed the attending physician had not signed and dated the resident's capacity determination statement and POST form which were in the medical record. Review of physician progress notes [REDACTED]. When brought to the attention of the facility, these forms were faxed to the physician's office to be signed and dated. During an interview conducted on 10/26/11 at 10:45 a.m., the director of nursing (Employee #88) confirmed these documents had not been signed by the attending physician. .",2015-02-01
10525,BRIGHTWOOD CENTER,515128,840 LEE ROAD,FOLLANSBEE,WV,26037,2011-10-26,514,D,1,0,9O4W11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, the facility failed to ensure a physician documented progress notes in accordance with accepted professional standards for one (1) of thirteen (13) sampled residents. Handwritten physician's progress notes for Resident #92, dated 06/13/11, 07/08/11, and 08/15/11, were not legible to this reader. This practice has the ability to affect all residents attended by this physician. Resident identifier: #92. Facility census: 108. Findings include: a) Resident #92 physician progress notes [REDACTED]. Review of these progress notes on 10/27/11, after the facility was exited, found the physician's handwriting was illegible and the notes did not contain enough information to describe the services provided to the resident. Documentation by the physician should provide a picture of the resident's progress, including response to treatment, change in condition, and changes in treatment.",2015-02-01
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
3463,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2019-08-28,641,D,0,1,70PN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident and staff interviews, the facility failed to accurately complete a Minimum Data Set (MDS) related to a fall and clarity of speech. This failed practice had the potential to affect 2 of 17 residents. Resident Identifers: #57 and #66. Facility census: 86. Findings included: a) Resident # 57 An interview was conducted on 08/26/19 at 11:29 AM. Resident #57 stated she fell last month. The resident revealed she fell trying to go to the bathroom. The 14 day Minimum Data Set (MDS), with the assessment reference date (ARD) of 07/23/19 finds Resident #57 scored a 13 on her brief interview for mental status (BIMS). A score of 13-15 indicate an intact cognitive response. Resident #57's record shows the resident fell on [DATE], 06/23/19 and 07/23/19. The record showed that on 07/23/19 at 5:06 AM, Resident #57 had a unwitnessed fall. The occurrence revealed the staff coming out of another room and saw her Resident #57's legs laying in the floor. The resident was laying supine, head raised and on her buttocks on the floor. The resident was asked, where she was going and the resident stated, To the bathroom. The nursing staff revealed the resident had no injuries noted following a head to toe assessment. A review of Resident #57's, 14 day MDS, with the ARD of 07/23/19 finds the assessment was coded to indicate the Resident had not had any falls since admission/entry or reentry or the prior assessment, whichever is more recent. The director of Nursing (DoN) on 08/28/19 at 12:20 PM, reviewed Resident #57's MDS with the ARD 07/23/19 and confirmed assessment was coded inaccurately . The DoN said she will do a modification. A modification on 08/28/19 at 12:42 PM was completed for Resident #57's MDS with the ARD of 07/23/19, for the section concerning falls. . b) Resident (R#66) On 08/26/19 at 03:37 PM during the initial tour and interviews, R#66 was unable to verbally answer any questions this surveyor asked. R#66 did make a few gestures in response to this surveyor questions. Review of records, on 08/27/19 at 12:29 PM revealed pertinent [DIAGNOSES REDACTED]. Review of the annual minimum data set (MDS) with an assessment reference date (ARD) 08/01/19, on 08/27/19 at 12:40 PM, revealed section B Hearing, Speech, and Vision was marked inaccurately. Number B0600 concerning Speech Clarity is marked clear speech, indicating distinct intelligible words. The resident's Brief Interview for Mental Status (BIMs) score is 6 indicating resident is cognitively severely impaired. An interview with Activities assistant #84, on 08/27/19 at 01:32 PM, revealed R#66 communicates with staff by using hand signals and hand motions. R#66 also types messages on a tablet screen to staff. On 08/27/19 at 01:40 PM, an interview with Nurse Aide (NA#20) revealed the resident has communication problems. NA#20 said R#66 holds up 1 finger to signify yes and 2 fingers to signify no, and types on his tablet to tell staff what he wants. Review of R#66's care plan, on 08/27/19 at 02:52 PM, revealed the resident has a verbal communication problem related to [MEDICAL CONDITION] post [MEDICAL CONDITION]. The goal for R#66 is will be able to make basic needs known by using communication tablet or communication board on a daily basis through the review date. Some interventions include Encourage communication even if patient is having difficulty and Ensure availability and functioning of adaptive communication equipment. An interview with, Register Nurse Assessment Coordinator (RNAC#151) responsible for developing resident's MDS, on 08/27/19 at 03:02 PM, revealed R#66's MDS was inaccurate concerning clarity of speech in Section B. Instructions for B0600 is Select best description of speech pattern choices are 0 Clear speech, distinct intelligible words; 1 Unclear speech, slurred or mumbled words; and 2 No speech, absence of spoken words. (RNAC#151) confirmed B0600 should not have been marked '0' clear speech, it was an error.",2020-09-01
3464,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2019-08-28,656,D,0,1,70PN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement a care plan related to wearing hipsters. This was true for 1 of 5 resident's care plans reviewed for falls. This practice had the potential to affect more than a limited number of residents. Resident identifier: R#78. Facility census: 86. Findings included: a) Resident #78 Observations of Resident (R#78), on 08/27/19 at 02:37 PM, revealed the resident was not wearing hipsters. Review of records on 08/28/19 at 08:35 AM, revealed a physician order [REDACTED]. (MONTH) remove for showers/hygiene purposes. Interview with RN#124, on 08/28/19 at 08:50 AM, confirmed R#78 did not have hipsters on when she attempted to do wound care on 08/27/19 at 02:37 PM, according to a physician order [REDACTED]. Review of Resident (R#78)'s record, on 08/28/19 at 10:12 AM, revealed resident was admitted [DATE] and has multiply falls since admission. Records showed resident fell on [DATE], 06/17/19, and 08/14/19. Review of Resident #78's recent quarterly minimum data set (MDS) with an assessment reference date (ARD) 07/12/19 revealed the resident is dependent for bathing and needs extensive assistance with all other activities of daily living. Pertinent [DIAGNOSES REDACTED]. On 08/28/19 at 01:37 PM, review of R#78's care plan revealed a focus area . at risk of falls due to weakness, use of psychoactive medication, poor safety awareness, hx (history) of prior falls, and attention seeking behaviors (throwing cups, silverware) One of the interventions included, Hipsters on at all times. (MONTH) remove for showers/hygiene purposes. Hipsters are briefs with impact absorbing pads over the hip area designed to minimize any potential damage or injury to a person wearing them if they have a fall.",2020-09-01
3465,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2019-08-28,657,D,0,1,70PN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise Resident #38's care plan when there was a change in her advance directives. This deficient practice was found for 1 of 1 resident reviewed for the care area of advance directives. Resident identifier: #38. Facility census: 86. Findings included: a) Resident #38 Resident #38's physician's orders [REDACTED]. The form, signed by the facility's Nurse Practitioner on 06/17/19, directed to provide intravenous (IV) fluids to Resident #38 for a trial period of no longer than two (2) weeks. At the same time, a review of Resident #38's medical record found that Resident #38's physician's orders [REDACTED]. A copy of Resident #38's current care plan was reviewed on 08/27/19 at 2:27 PM. The care plan contained an intervention, last revised on 03/25/19, that stated, Special directives or limitations: Limited Interventions; IV fluids 3-5 days; No Feeding Tube. During an interview on 08/27/19 at 2:58 PM regarding the length of time that Resident #38 requested to receive IV fluids, Social Worker (SW) #129 stated, It looks like her POST was updated, but her care plan was not updated to match. SW #129 then added that she would revise Resident #38's care plan to match her orders and POST form to reflect the length of time IV fluids were to be provided. The above information was discussed with the facility's Administrator on 08/27/19 at 3:38 PM. No further information was provided prior to exit.",2020-09-01
3466,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2019-08-28,686,D,0,1,70PN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to provide care and services consistent with professional standards of practice to promote healing of an existing pressure ulcer. This was true for 1 of 3 residents reviewed for pressure ulcers. This practice had the potential to a limited number of residents. Resident identifier: R#78. Facility census: 86. Findings included: a) Resident #78 Review of Resident (R#78) records on 08/27/19 at 02:30 PM, revealed an order dated 08/07/19 for pressure ulcer care. Order read Cleanse coccyx with normal saline, pat dry apply Santyl to wound, cover with [MEDICATION NAME] change qd (every day) and prn (as needed) every day shift for wound and Santyl Ointment 250 UNIT/GM ([MEDICATION NAME]) Apply to pressure wound to sacrum topically every day shift for wound healing. Debridement (removal of nonliving tissue) medications are indicated for the debridement of necrotic (dead) tissue and liquefaction of slough (a mass of dead tissue) in pressure ulcers to speed healing. Enzymatic debridement is a method of wound debridement that uses naturally occurring [MEDICATION NAME] enzymes manufactured by the pharmaceutical industry for the specific elimination of devitalized tissue. [MEDICATION NAME] refers to enzymes that break down molecules of proteins. SANTYL Ointment is a FDA (Food and Drug Administration) approved prescription enzymatic [MEDICATION NAME] medicine used to remove dead tissue from wounds so they can start to heal. Topical application of these enzymes to the wound surface breaks down necrotic tissue. Proper wound care management is important to help remove nonliving tissue from a wound appropriately, because wounds containing necrotic tissue take longer to heal. Instructions for application for SANTYL Ointment, on the manufacture's web page include Apply SANTYL Ointment only to the area of the wound, avoid application to the surrounding skin. The manufactures product insert stated A slight transient [DIAGNOSES REDACTED] (redness) has been noted occasionally in the surrounding tissue, particularly when [MEDICATION NAME] SANTYL* Ointment was not confined to the wound. Therefore, the ointment should be applied carefully within the area of the wound. Observations of wound care, on 08/28/19 at 12:19 PM, revealed Register Nurse (RN#124) applied Santyl ointment all over dressing in its entirety, from each corner to corner. Observations of the wound showed slough covering the wound bed. As RN#124 was about to apply the dressing this surveyor stopped her and asked what Santyl ointment was used for, RN#124 replied it was for debridement of the pressure wound. This surveyor then asked, Should it not then only be placed on the wound, and not over the good tissue that the dressing you are about to apply would cover? RN#124 stated, It's alright to place it on healthy tissue it won't hurt it., then proceeded to apply and secure the wound dressing on the resident. This surveyor requested the insert from the manufacturer for Santyl. This surveyor and RN#124 reviewed the insert together. The manufactures instructions stated, Therefore, the ointment should be applied carefully within the area of the wound. After review of the manufacturer's instructions RN#124 agreed the debridement medication should be placed on the wound only, not deliberately on healthy tissue. RN#124 went to remove the dressing and reapply according to the manufacturer's instructions. .",2020-09-01
3467,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2019-08-28,883,D,0,1,70PN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of pneumococcal vaccination records, record review and staff interview, the facility failed to ensure all residents received the pneumococcal vaccination. A resident was not offered the Pneumococcal Conjugate Vaccine Prevnar 13 or (PCV13). This was evident for 1 of 5 residents reviewed for Pneumonia Vaccination status. This has the potential to affect a limited number of residents. Resident identifiers: #53. Facility census: 86. Findings included: a) Resident #53 On 08/27/19 at 9:05 AM, record review revealed a Pneumococcal Vaccination consent form signed on 01/12/18. Handwritten on the pneumococcal vaccination form revealed Resident #53 had received the PPSV 23 in the Fall of (YEAR). The Pneumococcal Vaccination consent form was marked for the PPSV 23 and PCV13 to be administered to Resident #53. The resident representative signed the vaccine information statement, and beside her name is refused. There were no consent forms in Resident #53 record to show that Resident #53 or her representative was offered the pneumococcal vaccination PCV13 in the Fall (YEAR), in which is one (1) year after the staff had written Resident #53 had received PPSV 23 vaccine. According to the CDC's (Centers for Disease Control and Prevention) vaccine information statement for influenza and pneumococcal some people should not get the vaccine. The CDC recommends screening people by having them answer a few pertinent questions. The facility consent forms have the recommended screening questions, however there is no indication the questions were ever asked. The Influenza and pneumococcal vaccination consent forms each have five (5) questions and an area to mark yes or no. Instructions on the pneumococcal vaccination consent states Please circle yes or no for each question. An interview on 08/027/19 at 10:25 AM with the Director of Nursing (DoN), she confirmed the facility staff had obtained a consent form for Resident #53 to receive a Pneumococcal Vaccination, but the resident did not receive either one (1) of the vaccines. The DoN was shown the pneumococcal vaccination form with the date of 01/12/18, which these words were hand written on the form : Fall (YEAR)/23 (physician name). DoN was asked why is the form marked for Resident #53 to receive both the PPSV 23 and PCV13, the five (5) screening question was not answered, and following the Resident's representative's signature, the word refused was wrote on the form. DoN replied that she had no answers to these question. The DoN said that once she was asked for Resident #53's, Pneumococcal history, she then attempted to notify outside sources to obtain the resident's Pneumococcal vaccination history, but the history was unclear whether the resident had received any pneumococcal vaccination. The DoN stated that, Resident #53, representative was notified and a consent form was obtained at this time on 08/27/19 for the resident to receive the Prevnar 13. The physician was notified and he was agreeable for Resident #53, to receive Prevnar 13 due to unknown vaccination history, and to give Resident #53 the PPSV 23 in one (1) year. Resident #53 received the pneumococcal vaccination PCV13 on 08/27/19. Review of the current Center for Disease Control and Prevention (CDC) recommendations found that the CDC recommends routine administration of pneumococcal conjugate vaccine (PCV13 or Prevnar 13) for all adults [AGE] years or older. CDC recommends that adults [AGE] years or older who have not previously received PCV13, should receive a dose of PCV13 first, followed one (1) year later by a dose of PPSV 23 or [MEDICATION NAME] 23. If the patient already received one (1) or more doses of PPSV 23 or [MEDICATION NAME] 23, the dose of PCV13 should be given at least one (1) year after they received the most recent dose of PPSV 23.",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
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
3470,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,226,D,0,1,ITHZ11,"Based on review of grievance/concerns and written statements, staff interview, policy review and family interview, the facility failed to implement their policy for reporting and/or identifying an allegation of neglect made on 07/27/17. Resident #78's daughter indicated she had come to the facility on e afternoon and found Resident #78 wet and still in her pajamas. The facility had not identified this as neglect. Therefore, it was not reported. Resident identifier: #78. Facility census: 83 Findings include: a) Resident #78 During a Stage 2 record review on 09/20/17 revealed a grievance/complaint report dated 07/27/17 involving Resident #78. The resident's daughter complained to the multidisciplinary team that she came to the facility for a visit on 07/23/17 and found her mother wet and still in her pajamas. The report stated the concern would be resolved by 07/30/17. Clinical Care Supervisor (CCS) #91 and Social Service Supervisor (SSS) #85 were the individuals assigned to take action on this concern. 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 reisdents. (Resident #78) daughter did visit during lunch hour and requested washclothes (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. The resolution of the grievance stated the facility had spoken with Resident #78's daughter and she reported to the facility that she was ok and knew they were busy with another resident who was sent to the hospital. A review of the facility's Freedom from Abuse, Neglect and Exploitation policy, dated 06/30/17, on 09/20/17 at 9:50 a.m. revealed the policy defined neglect as, The failure of the facility, its employees or service providers to provide goods and services to a resident that are necessary to avoid physical harm, pain, mental anguish, or emotional distress. Step 5 of the policy discusses investigation. Under this step the policy stated, The facility will refer to WV (West Virginia) Office of Health Facility Licensure and Certification website (www.ohflac.wvdhhr.org) for additional information about reporting requirements. The OHFLAC requirements for neglect defined neglect as, Failure to provide goods and services necessary to avoid physical harm, mental anguish, or mental illness. The OHFLAC requirements also revealed that allegations of neglect would be reported to OHFLAC, Adult Protective Services and the Ombudsman. On 09/20/17 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
3471,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,241,D,0,1,ITHZ11,"Based on observation and staff interview, the facility failed to ensure Resident #95 had a dignified dining experience during the breakfast meal on 09/19/17 and 09/21/17. These were random opportunities for discovery during the observation of the breakfast meal on 09/19/17 and 09/21/17. Resident identifier: #95. Facility Census: 83. Findings include a) Resident #95 1. Resident #95's breakfast meal on 09/19/17. On 09/19/17 at 9:00 a.m., observation found Resident #95 in bed with her tray in front of her. During my observation, I observed her repeated picking up her spoon and immediately laying it back down without eating. The resident also was observed moving the bowl, plate and cup around on her plate, never taking a bite and/or drink during this observation. On 09/19/17 at 9:03 a.m. , Employee #12, nursing assistant (NA) entered Resident #95's room to pick up the roommates tray and said to Resident #95, I will be back in a few minutes to assist you to eat. At 9:08 a.m. on 09/19/17, Employee #12, NA, returned to the room to begin to assist Resident #95 to eat her breakfast after reheating the food. At 9:30 a.m. on 09/19/17, Employee #12, NA, had finished assisting Resident #95 with her breakfast, I asked how much of breakfast had Resident #95 consumed. She stated, Almost all of it, about 75%. I then asked about her ability to feed herself. She said, Sometimes she will feed herself, like after I started to assist her today, she took the spoon and started feeding herself with me giving her directions occasionally. Review of Resident #95's medical records on 09/19/17 at 2:00 p.m., found a Minimum Data Set (MDS) with a reference date (ARD) of 08/07/17,this assessment indicated her Brief Mental Instrument (BMI) was nine (9); which indicates moderate cognitive problems. Additionally, the MDS indicated Resident #95 required the assistance of one for supervision and frequent cueing during meals. 2. Resident #95's breakfast meal on 09/21/17 On 09/21/17 at 8:35 a.m., observation found Resident #95 in bed with her tray in front of her. During my observation, I observed the resident sleeping. never taking a bite and/or drink during this observation. On 09/21/17 at 8:38 a.m., and interview with Employee #49,licensed practical nurse (LPN), found she did not know Resident #95 had not eaten breakfast. She said, Give me a minute and I will check and see.' At 8:50 a.m. on 09/21/17, Employee #49, LPN, entered the residents room and found Resident #95s tray sitting in front of her untouched and the resident was sleeping. At 9:20 a.m. on 09/21/17, Employee #49, LPN, had finished assisting Resident #95 with her breakfast, I asked how much of breakfast had Resident #95 consumed. She stated, Almost all of it, if the NA finish her she should consume all of it. During an interview with the Director of Nursing (DON) and the Nursing Home Administer (NHA) at 11:10 a.m. on 09/21/17, it was confirmed the breakfast meal trays for the unit Resident #95 was a resident came to the unit around 7:30 a.m., give and/or take five (5) minutes. The observations of the breakfast meals on 09/19/17 and 09/21/17 concerning Resident #95 were communicated. No further information was given",2020-09-01
3472,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,242,E,0,1,ITHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and record review, facility failed to honor the showering schedule preference for one (1) out of four (4) residents interviewed for the care area of choices. Resident Identifier: #37. Facility Census: 83. Findings include: During the Stage I interview on 09/18/17 at 3:36 p.m., Resident #37 stated she was scheduled for two (2) showers a week, but some weeks only received one (1) shower. Resident #37 stated she would like to receive two (2) showers a week. During a follow-up interview on 09/20/17 at 8:32 a.m., Resident #37 stated she was sometimes offered a shower after she had already taken medication to help her sleep. She stated she was too sleepy to shower after she had taken medication to help her sleep. Resident #37 stated would prefer to shower before she took medication to help her sleep. A review of the Medication Administration Records for Resident #37 revealed that she was taking [MEDICATION NAME] 3 mg by mouth at bedtime for trouble sleeping due to unspecified [MEDICAL CONDITION] and [MEDICATION NAME] 50 mg by mouth at bedtime for [MEDICAL CONDITION]. Review of the Documentation Survey Reports for 07/01/17 through 09/19/17 revealed the following responses to the section Was patient showered this shift? - 07/01/17 at 9:46 p.m. resident refused - 07/06/17 at 12:40 a.m. resident refused - 07/09/17 at 12:05 a.m. yes - 07/13/17 at 8:42 p.m. yes - 07/15/17 at 10:42 p.m. yes - 07/20/17 at 12:17 a.m. resident refused - 07/22/17 at 10:56 p.m. yes - 07/26/17 at 11:10 p.m. resident refused - 07/29/17 at 11:56 p.m. yes - 08/03/17 at 12:52 a.m. no - 08/05/17 at 9:46 p.m. yes - 08/10/17 at 1:35 a.m. yes - 08/13/17 at 5:50 a.m. resident refused - 08/17/17 at 1:52 a.m. yes - 08/19/17 at 9:30 p.m. yes - 08/23/17 at 9:22 p.m. yes - 08/26/17 at 11:31 p.m. resident refused - 08/30/17 at 11:42 p.m. yes - 09/03/17 at 6:14 a.m. yes - 09/06/17 at 10:45 p.m. yes - 09/10/17 at 1:00 a.m. resident refused - 09/14/17 at 12:59 a.m. yes - 09/16/17 at 9:18 p.m. yes A General Patient Note written on 07/02/17 at 6:35 a.m. stated, Resident refused shower this shift .will ask again at a later time. A General Patient Note written on 07/06/17 at 6:46 a.m. stated, Resident did not want shower due to it was getting too late for her to take one. She wants to see about getting a day shift shower due to she likes to go to bed around 8 p.m. A General Patient Note written on 07/20/17 at 6:56 a.m. stated, Resident refused shower this shift due to she said it was too late to take it. A General Patient Note written on 07/26/17 at 9:48 p.m. stated, Resident did not receive a shower this shift .Resident went to bed and did not receive a shower this shift. A General Patient Note written on 08/13/17 at 6:52 a.m. stated, Resident refused shower due to late in the night. A General Patient Note written on 08/23/17 at 9:22 p.m. stated, Resident did not receive a shower this shift .Resident stated she wants one tomorrow. A General Patient Note written on 08/27/17 at 2:49 a.m. stated, Resident refused shower due to the late hour. A Summary Note written on 08/27/17 at 2:20 a.m. stated, Refuses showers at times. A General Patient Note written on 09/10/17 at 6:56 a.m. stated, Resident refused shower this shift due to late hour. Clinical Care Supervisor (CCS) #91 was interviewed 09/19/2017 at 4:20 p.m. and stated Resident #37 is scheduled to receive showers on Saturday and Wednesday during night shift. CCS #91 stated residents' preferences for showers are taken into account, and shower schedules are changed to accommodate resident preferences. The Task List Report for Resident #37 documented Resident #37 was scheduled to receive showers on night shift on Saturdays and Sundays. During an interview on 09/20/17 at 11:51 a.m., the Director of Nursing (DoN) was notified Resident #37 stated she was offered a shower after she had already taken her sleeping pill. The DoN was also notified about the General Patient Note written on 07/06/17 stating that resident would like to shower on day shift. The DoN clarified that the time noted on the Documentation Survey Reports was the time the information was documented, and not the time that the shower was offered or performed. The DoN also stated night shift is from 7:00 p.m. to 7:00 a.m. because the nursing assistants for the hallway where Resident #37 resides work twelve (12) hour shifts. A General Patient Note written on 09/21/17 at 1:33 a.m. stated, Resident is now on a day shift shower.",2020-09-01
3473,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,252,B,0,1,ITHZ11,"Based on observation and staff interview, the facility failed to that six (6) of 32 rooms observed during Stage 1 of the Quality Indicator Survey was home like. Each of the sic (6) bathrooms had the following on the floor just inside the bathroom door, SV2. It appeared this was spray painted. Also the carpet in hallway of the 300 hall was stained and discolored which was not home like. Room Identifiers: 110, 111, 112, 301, 303, 304. Facility Census: 83. Findings Include: a) Room 110 Observations of Room 110 at 8:54 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. The maintenance supervisor indicated that the contractors when they built the building spray painted the letters SV2 on the concrete to let the men laying the floor know what type of flooring to put down. She indicated in some of the rooms these spray painted letter have bleed through and are now visible on the bathroom floors. b) Room 111 Observations of Room 111 at 8:47 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. c) Room 112 Observations of Room 112 at 11:06 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. d) [RM #]1 Observations of [RM #]1 at 9:59 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. e) [RM #]3 Observations of [RM #]3 at 10:11 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. f) [RM #]4 Observations of [RM #]4 at 10:07 a.m. on 09/19/17, found just inside the bathroom door the following on the floor, SV2 . It appeared these letters were spray painted on the floor. A tour with the Nursing Home Administrator (NHA) beginning at 1:52 p.m. on 09/19/17 confirmed that the letters visible in each of the bathrooms was a result of the contractors spray painting the letters on the concrete and now those spray painted letter are coming up thru the flooring and is now visible. He stated that the flooring would have to be replaced. g) 300 hallway Observations during Stage 1 of the QIS survey found the carpet in the 300 hall way was stained and discolored in multiple areas. A tour with the NHA at 11:09 a.m. on 09/21/17, confirmed the carpet was stained and discolored in multiple areas. He indicated that they clean the carpet every Monday but some of the stains will just not come up. He indicated the discolored areas were just something with the carpet and no matter what they do the discolorations never improve. He indicated they would have to replace the carpet.",2020-09-01
3474,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,272,D,0,1,ITHZ11,"Based on record review, staff interview and resident observation the facility failed to ensure Resident #7 and #37's comprehensive Minimum Data Sets (MDS) were coded correctly in the care of dental status. This was true for two (2) of four (4) residents reviewed for the care area of dental status during Stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #7 and #37. Facility Census: 83. Findings Include: a) Resident #7 During Stage 1 of the QIS Resident #7 was observed at 10:31 a.m. on 09/19/17, during observations it was note Resident #7 had missing bottom teeth. She had teeth on either side of her mouth but was missing her bottom middle teeth. A review of Resident #7's medical record on 09/21/17 at 8:21 a.m., found an Annual MDS Assessment with an Assessment Reference Date (ARD) of 10/05/16. This MDS under section Section [MI] Oral/Dental Status indicated Resident #7 was edentulous with no natural teeth or tooth fragments. Review of the Dental Care Area Assessment worksheet for the MDS with the ARD of 10/05/16 found the following under the section titled, Nature of the problem/condition: She is edentulous and has upper and lower dentures. An interview with Nurse Aide (NA) #17 at 9:47 a.m. on 09/21/17 confirmed Resident #7 has and upper denture and a lower partial plate that she refuses to wear on most occasions. An interview with Registered Nurse Assessment Coordinator (RNAC) at 10:26 a.m. on 09/21/17 confirmed Resident #7 wears a full set of dentures on the top and she has a partial for the bottom but she refuses to wear it. She stated that she had looked into the residents mouth and found the resident had about four (4) natural teeth on the bottom that were in good shape. She confirmed Resident #7 was not edentulous and the Annual MDS with an ARD of 10/05/16 was inaccurate. b) Resident #37 The Admission Nursing Assessment performed on 03/22/17 at 7:27 p.m. for Resident #37 documented the resident had missing, decayed, or broken teeth. Resident #37's teeth were described as 4 regular teeth on bottom, have cavities and are decaying. Full upper dentures were also documented. A Speech Therapy evaluation for Resident #37 was performed on 03/23/17. The evaluation documented Natural teeth in poor condition with several teeth missing. The Admission minimum data set (MDS) with assessment reference date (ARD) of 03/29/17, Section L, Oral/Dental Status, documented no obvious or likely cavity or broken natural teeth. Review of medical records showed Resident #37 was seen in a dental office on 04/20/17. The dentist documented resident requested extraction of her four (4) remaining natural teeth due to pain. The four (4) teeth were extracted in the dental office that day according to the dentist's office records. During an interview on 09/20/2017 at 12:30 p.m. Registered Nurse Assessment Coordinator (RNAC) #46 stated she did not feel that the MDS dental assessment was inaccurate. RNAC #46 stated that she would have reviewed the Admission Nursing Assessment and the Speech Therapy evaluation. However, the presence of cavities is a dental assessment. She stated the dental records showed Resident #37 had requested removal of her remaining natural teeth.",2020-09-01
3475,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,280,D,0,1,ITHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and staff interview, the facility failed to revise the care plan for two (2) of 16 residents when these residents experienced a change in condition. Resident #78's comprehensive care plan was not revised after the resident experienced a decline in bladder functioning. Resident #37's care plan was not updated to reflect a change in nutrition and dental status. Resident #37's nutritional status and dental status were not updated. Resident Identifiers: #78 and #37. Facility census: 83. Findings include: a) Resident #78 During a Stage 2 interview with Resident #78 at 3:29 p.m. on 09/19/17, when asked if she received and drank enough fluids between meals, Resident #78 replied, I drink a lot of water, and I had tea for dinner. When asked if she was continent of bladder, Resident #78 replied, I am having problems with my bowels moving due to constipation, and they are working on that. I always wear a brief, and they change my brief when I'm incontinent. When asked how often the staff ask her if she needs to go to the restroom to urinate and/or check her brief, she replied, They check me every 2 hours. During the night, they check me every 3 hours. When asked if she feels the urge to use the bathroom, for bowel and bladder, and she replied, I use my call light when I need something. I can feel the urge to urinate before I urinate. I use the call light if I need assistance to use the bathroom and/or bedpan, but sometimes I have to use the brief if I don't make it to the bathroom in time. Sometimes, when I call, I make it to the bathroom in time. It's been like that since I came down here. When asked if she has any burning with urination, soreness and/or redness between legs. Resident replied No, not so far. A review of the Minimum Data Set (MDS) with an assessment reference date (ARD) of 05/27/17 revealed an admission assessment which assessed the resident as occasionally incontinent (less than seven (7) episodes of incontinence. The quarterly MDS with an ARD of 07/24/17 found the resident always incontinent (no episodes of continent voiding). Further review of Resident #78's record, found the Minimum Data Set (MDS) Admission 05/02/17, found a Brief Interview Mental Status (BIMS) Score: 12. The BIMS is a brief assessment that assists in detecting if a person has cognitive impairment. The BIMS Score scale is 0-7: severe impairment, 8-12: moderately impaired and 13-15: cognitively intact. The items in Section C: Cognitive Patterns of MDS are intended to determine the resident's orientation, attention and ability to understand and recall new information. The care plan dated 06/24/17 indicated Resident #78 was incontinent of bladder at times. A review of Resident #78's care plan, dated 07/24/17, noted, Incontinent of bowel & bladder frequently. Care Plan for Skin Breakdown. The care plan did not reflect the resident's decline to always incontinent and contained no goals or interventions to attempt restoration of bladder function. During an interview with DoN #8 on 09/20/17 12:00 p.m., she was questioned about the Resident #78's decline in bladder continence. Record review indicated Resident #78 was admitted in (MONTH) (YEAR), was occasionally incontinent and began experiencing total incontinence by (MONTH) (YEAR). DoN #8 was asked about interventions used to attempt bladder restoration, and she replied the family did not want any interventions used because the resident has a [DIAGNOSES REDACTED]. DoN #8 said this was documented in a Care Conference note. Record review of Resident #78's multidisciplinary Care Conference note did not reflect the family's refusal to work with the resident on bladder restoration. b) Resident #37 Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Admission Nursing Assessment performed on 03/22/17 at 7:27 p.m. for Resident #37 documented the resident had missing, decayed, or broken teeth. Resident #37's teeth were described as 4 regular teeth on bottom, have cavities and are decaying. Full upper dentures were also documented. Upon admission on 03/22/17, Resident #37's weight was 154 pounds (lbs). A regular, regular texture, regular consistency diet was ordered for Resident #37 upon admission. --On 03/27/17, Resident #37's weight was 138.8 lbs. --On 03/29/17, Resident #37's weight was 139.1 lbs. --On 04/05/17, Resident #37's weight was 138.6 lbs. --On 04/07/17, Resident #37's weight was 140.1 lbs. --On 04/12/17, Resident #37's weight was 137.7 lbs. --On 04/18/17, Resident #37's weight was 137.2 lbs. On 04/19/17 at 5:37 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 10.9% had occurred. The average food intake for the past week was noted to be 81%. According to the note, She is on regular diet. We will continue to monitor her weight two (2) more weeks, as she is currently stable with her weights. After that, we will monitor her weight monthly as she plans on staying long term. Review of medical records showed Resident #37 was seen in a dental office on 04/20/17. The dentist documented resident requested extraction of her four (4) remaining natural teeth due to pain. The four (4) teeth were extracted in the dental office that day according to the dentist's office records. On 04/26/17, a Dietician Nutritionist Nutritional Assessment was performed. Resident #37 was noted to have a weight change of 5% or greater in the last 30 days. The weight change was noted to be 10.9%. The current diet order was noted to be regular diet, regular texture, regular consistency. Resident was noted to be eating 72% of her meals and 71% of her bedtime snack. The note stated Resident had her teeth extracted on 04/20/17. The dietician recommended soup with lunch and dinner to increase intake due to jaw pain. On 05/04/17, a regular diet, National Dysphagia Diet level 1, pureed texture, regular consistency was ordered. This diet change was noted in the care plan interventions. On 05/08/17, Resident #37's weight was 135.1 lbs. On 05/08/17 at 1:32 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 12.3% had occurred. The average food intake for the past week was noted to be 54%. According to the note, Resident has had dental appointment in the past month. She does have missing teeth. She requested pureed diet .She is on a regular diet, and changed today from pureed to regular consistency. On 05/08/17, a regular diet, ground meat texture, regular consistency was ordered. This remained the diet order through the survey process. The diet change was noted in the care plan interventions. On 06/06/17, Resident #37's weight was 131.7 lbs. On 06/07/17 at 3:15 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 14.5% had occurred. The average food intake for the past week was noted to be 75%. According to the note, She is on regular diet with ground meat texture. Her BMI is 25.7. We will continue to monitor her weight monthly. On 06/22/17, a Nutritional Risk Note was performed. Resident #37 was noted to have less than a 5% weight loss in the last 30 days with the last weight of 131.7 lbs. obtained on 06/06/17. Resident was not on a planned weight loss program. Her ideal body weight was noted to be 123-149 lbs. The current diet order was noted to be ground meat. Resident was noted to have an average meal intake of 62% and 57% of bedtime snack for the past week. The current plan of care was to be continued. On 07/07/17, Resident #37's weight was 126.8 lbs. On 07/07/17 at 4:59 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 17.7% occurred overall. A weight change of 3.7% was noted over the last 30 days. The average food intake for the past week was noted to be 76%. According to the note, She is on regular diet with ground meats. She will continue to be monitored monthly. On 08/07/17, Resident #37's weight was 125.6 lbs. On 08/09/17 at 1:08 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 18.4% had occurred overall. The average food intake for the past week was noted to be 79%. According to the note, She is on regular diet, with ground meat texture. We will continue to monitor her weight monthly as she is stable with her weights. On 09/06/17, Resident #37's weight was 124.7 lbs. During the Stage I interview on 09/18/2017 at 1:31 p.m., Resident #37 stated she had upper dentures only but she would like lower dentures, too. She stated her lower teeth had been removed while she was a resident at the facility. Resident stated that during an evaluation by (a home health agency), resident stated that she would like dentures. However, she did not know if anything had been done to obtain lower dentures for her. During an interview on 09/20/17 at 10:57 a.m., Resident #37 stated she could not chew her food because she had no natural teeth and upper dentures only. She stated she could only swallow her food. She stated she could eat meat on her tray because it was ground. She stated she could not eat some items that were also provided to her, such as vegetables and salads. During an interview on 09/20/17 at 11:51 a.m., the Director of Nursing (DoN) was informed of the failure to update the care plan to reflect that Resident #37's remaining natural teeth had been removed and she was edentulous. The DoN also notified that after Resident #37's remaining natural teeth were extracted, the care plan focus was not revised to reflect that this was an additional risk for further weight loss. Additionally, the care plan was not revised to document goals and interventions for the relationship between Resident #37's edentulous status to her weight loss. During an observation of Resident #37's lunch tray and an interview with the resident on 09/20/17 at 12:30 p.m., the resident was observed to have eaten almost of all of the ground meat provided on her tray. She also had egg roll, mixed vegetables, and rice. Resident stated she could not eat the mixed vegetables or egg roll due to her inability to chew. She stated she did not like rice. A Nutritional Risk Note was written on 09/19/17. The weight change was noted to be less than 5% in the last 30 days and less than 7.5% in the last 90 days. Resident was not on a planned weight loss program. The current diet was noted to be regular with ground meat. Resident #37's average meal intake was 74% and bedtime snack 71% for the past week. The current plan of care was to be continued. On 09/20/17 at 11:51 a.m., the Director of Nursing (DoN) was interviewed regarding findings of Resident #37's weight loss, her inability to chew her food, and her edentulous status with upper dentures only. The DoN stated the facility was unaware Resident #37 wanted lower dentures until Resident #37 stated this to the nursing staff on 09/18/17. According to the DoN, Social Services had been notified of the resident's desire for lower dentures. A Social Services Progress note written on 09/20/17 at 11:58 a.m. stated, Resident requesting lower dentures. Social Services will get with van driver to see when she can be taken to affordable dentures. A Social Services Progress note written on 09/20/17 at 3:23 p.m. stated, Resident will be going to affordable dentures on 09/27/17 to have lower dentures made. A Physician's Contact Note, written on 09/20/17 at 5:02 p.m., stated, Resident stated to state worker that she was unable to chew lunch on this day. Her diet order is: regular diet, ground meat texture, regular consistency .ST (speech therapy) to evaluate; notified by this nurse of resident's complaint. She has a pending appointment for denture fitting due to residents' new concern/request for bottom dentures .Resident will be given soft food this evening per her preference due to complaints this day of difficulty chewing. A Speech Therapy (ST) Evaluation and Plan of Treatment was performed on 09/21/17 for possible difficulty with mastication with current diet of regular texture with ground meats. According to the Speech Therapy Evaluation, ST asked patient about deficits with mastication with lunch meal yesterday. Patient stated the egg roll was tough for her to chew so she broke it apart and consumed the inside of the egg roll. She stated she does not like rice nor broccoli and they were both served yesterday. ST stated to patient that dietary will be notified of this and she will no longer be served rice nor broccoli. During breakfast, patient was noted to take the crust off of her bread and asked about this. Patient stated the crust is tough for her to chew. ST asked if she would like for the kitchen to cut the crust off of all of her breads that have crust and she stated yes. ST to notify kitchen of this modification as well. ST provided education to patient regarding the current diet she is on as well as information regarding the other diets and modifications that can be made to her diet. Patient stated to ST that she does not want her food changed and she only wants teeth. ST further inquired and asked if she would like lower dentures or a full new set and she stated she only wanted lower dentures. ST asked about her upper teeth and she stated they are fine and she only wants new lower teeth. Patient then stated again that she does not want her foods changed. On 09/21/17 at 8:40 a.m., ST #77 stated she evaluated Resident #37 today. ST #77 stated Resident #37 did not want her diet changed to pureed. Resident #37 wanted lower dentures rather than a diet change. Until lower dentures can be obtained, ST #77 was going to let the dietary staff know the foods Resident #37 could eat and the foods Resident #37 did not like to eat. During an interview on 09/21/17 at 9:35 a.m., the Dietary Services Supervisor stated Resident #37 had not been on a weight loss program. He stated most residents lose weight upon admission to the facility from home because they are receiving nutritional foods. The Dietary Services Supervisor stated Resident #37's body mass intake was within normal limits. He stated the care plan goal weight was adjusted downward because he likes to care plan to keep residents within ten (10) lbs.of their current weight if they are at a healthy weight. The Dietary Services Supervisor stated Resident #37 was provided soup for lunch and dinner for a time period after the extraction of her teeth. She currently only wanted pureed meat and didn't want the rest of her food pureed. The Dietary Services Supervisor stated the resident had not mentioned difficulty chewing certain foods or disliking certain foods. He stated foods such as vegetables were served soft so she could chew them. The Dietary Services Supervisor stated he had been notified today about Resident's food preferences and the food she was unable to eat with only upper dentures. During an interview on 09/21/17 at 10:15 a.m., Registered Dietician (RD) #109 stated he had evaluated Resident #37 one time. He recommended soup for lunch and dinner due the recent extraction of the resident's teeth. RD #109 stated he agreed with the care plan goals adjusting her desired weight downward, from 135-145 lbs. to 120-130 lbs. During an interview on 09/21/17 at 11:10 a.m., the Dietary Services Supervisor wanted to clarify Resident #37 had been on a pureed diet for approximately 4 days, but did not tolerate the diet well. According to the Weight and Nutrition Meeting note on 05/08/17, Resident #37's average food intake fell to 54% while on a pureed diet. The resident had asked for the pureed diet to be discontinued. On 03/23/17, the following care plan focus was initiated, (Resident name) has shown weight loss since admission and is at risk for further loss (gradual loss) related to [MEDICAL CONDITIONS], diabetes, [MEDICAL CONDITION]([MEDICAL CONDITION] reflux disease). This care plan focus was in effect during the care plan review on 09/15/17. The care plan goal initiated on 03/23/17 was Patient will comply with recommended diet for weight reduction daily through review date. The care plan goal was revised on 03/28/17 and stated, Patient will maintain adequate nutritional status as evidenced by maintaining weight within 135-145 pounds, no signs/symptoms of malnutrition, and consuming at least 50% daily through review date. On 04/10/17, the following care plan focus was initiated, She has had oral pain/infection. This care plan focus was resolved on 05/01/17. On 04/21/17, the following care plan focus was initiated, (Resident name) is receiving [MEDICATION NAME] treatment due to teeth extraction. The following revision was made on 06/08/2017, Resident recently had a bone spur removed from her gums increasing her risk of dental pain. She wears upper dentures. This care plan focus was resolved on 05/01/2017. On 06/08/17, the following care plan focus was initiated, (Resident name) is at risk of oral complications r/t having some natural teeth. She wears upper dentures. However, her remaining natural teeth had been extracted at the time this care plan focus was initiated. This care plan focus was in effect at the care plan review completed on 09/15/17. On 09/06/17, the care plan goal was revised to state, Patient will maintain adequate nutritional status as evidenced by maintaining weight within 120-130 lbs., no signs/symptoms of malnutrition, and consuming at least 50% of at least 2 meals daily through review date.",2020-09-01
3476,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,309,E,0,1,ITHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide diabetic management as ordered by the physician to provide consistent treatment to Resident #133, who had a [DIAGNOSES REDACTED]. Additionally, the facility failed to administer Resident #133's pain medication ([MEDICATION NAME]) as ordered by the physician This was true for one (1) of six (6) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #133. Facility census: 83. Findings include: a) Resident #133 1. Diabetic Management A review of Resident #133's medical record beginning at 2:00 p.m. on 09/19/17 found the following physician's orders [REDACTED]. Order with start date of 09/01/16, (date of admission to the facility)- [MEDICATION NAME], inject 30 units subcutaneously (sq.) at bedtime (9 pm). Notify the physician if blood sugar (BS) is less than 60 or greater than 400. Review of Resident #133's Medication Administration Record [REDACTED] --BS at 9:00 p.m. on 09/02/17 was 463. No physician notification. --BS at 9:00 p.m. on 09/03/17 was 446. No physician notified. Order with start date of 09/07/17, [MEDICATION NAME] regular (R) insulin, inject as per sliding scale: 151-200 = 2 units; 201-250 = 4 units; 251-300 = 6 units; 301-350 = 8 units; 351-400 = 10 units; 401- 9999= 12 units twice daily (8 am and 5 pm). Notify physician if blood sugar is less than 60 or greater than 400. Review of Resident #133 MAR found on the following dates and times blood sugar was above 400 with no physician notification: --09/08/17 at 8:00 a.m. BS was 487. --09/09/17 at 8:00 a.m. BS was 586. --09/10/17 at 8:00 a.m. BS was 454. --09/10/17 at 5:00 p.m. BS was 414. --09/13/17 at 5:00 p.m. BS was 420. --09/18/17 at 5:00 p.m. BS was 571. 2. Pain management ([MEDICATION NAME]) Resident #133 was admitted on [DATE] with a physician's orders [REDACTED]. Review of Resident #133's MAR found Resident #133 did not receive her [MEDICATION NAME] (pain management) until 09/06/17 at 9:00 a.m. On review of the MAR indicated [REDACTED] Further review of Resident's Controlled Medications and Pharmacy Order Records found the [MEDICATION NAME] was not available at the facility for administration until 09/06/17. During an interview at 12:30 p.m. on 09/20/17, when asked to review the resident's orders, The Director of Nursing (DON) agreed the orders for Resident #133's diabetes management had not been followed. She confirmed the nursing staff did not notify the physician when the blood sugar was greater than 400. Additionally, she confirmed the [MEDICATION NAME] had not been administered until 09/06/17 at 9:00 a.m. The [MEDICATION NAME] was not available for administration until 09/06/17.",2020-09-01
3477,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,315,D,0,1,ITHZ11,"**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 ensure Resident #78 receive the services and assistance necessary to address a decline in bladder continence status. Resident #78 suffered a decline in bladder continence status from occasional incontinence (less than 7 episodes of incontinence to total incontinence (no episodes of continent voiding) since admission to the facility. The facility failed to provide any interventions to attempt bladder restoration. This practice affected one (1) of three (3) residents reviewed for the care area of urinary incontinence during Stage Two (2) of the Quality Indicator Survey (QIS). Resident Identifier: #78. Facility Census: 180. Findings Include: a) Resident #78 During a Stage 2 interview with Resident #78 at 3:29 p.m. on 09/19/17, when asked if she received and drank enough fluids between meals, Resident #78 replied, I drink a lot of water, and I had tea for dinner. When asked if she was continent of bladder, Resident #78 replied, I am having problems with my bowels moving due to constipation, and they are working on that. I always wear a brief, and they change my brief when I'm incontinent. When asked how often the staff ask her if she needs to go to the restroom to urinate and/or check her brief, she replied, They check me every 2 hours. During the night, they check me every 3 hours. When asked if she feels the urge to use the bathroom, for bowel and bladder, and she replied, I use my call light when I need something. I can feel the urge to urinate before I urinate. I use the call light if I need assistance to use the bathroom and/or bedpan, but sometimes I have to use the brief if I don't make it to the bathroom in time. Sometimes, when I call, I make it to the bathroom in time. It's been like that since I came down here. When asked if she has any burning with urination, soreness and/or redness between legs. Resident replied No, not so far. On 09/19/17 at 1:59 p.m., a review of Resident #78's record, indicated Resident #78 was admitted to the facility on [DATE], at which time she was primarily continent of urine. Record review on 9/19/17 at 2:18 p.m., indicated Resident #78's [DIAGNOSES REDACTED]. The Nursing Assessment on 04/25/17, revealed Section 1, [MI] Continence & Elimination: Uses toilet. Section 2, [NAME] Moisture: Rarely Moist: Skin is usually dry, linen only requires changing at routine intervals. Record review of a later Nursing Assessment for Resident #78, indicated Section 1 [MI] Continence & Elimination: Episodes of incontinence Further review of Resident #78's record, found the Minimum Data Set (MDS) Admission 05/02/17, found a Brief Interview Mental Status (BIMS) Score: 12. The BIMS is a brief assessment that assists in detecting if a person has cognitive impairment. The BIMS Score scale is 0-7: severe impairment, 8-12: moderately impaired and 13-15: cognitively intact. The items in Section C: Cognitive Patterns of MDS are intended to determine the resident's orientation, attention and ability to understand and recall new information. A review of Resident #78's Care Area Assessment, dated 05/12/17, noted 6. Urinary Incontinence & Indwelling Catheter: Triggered Modified. CP Decision: Yes; however, the urinary incontinence was not addressed in the care plan. Care Plan Review dated 06/24/17 1:58 indicated Reasons of Care Plan Update(s) to care plan. (First name of Resident #78) is incontinent of bowel and bladder at times. The Facility failed to identify the type and frequency of toileting assistance the resident would benefit from. Further record review noted an incontinence program was not ordered and/or in place now. A toileting program was also not in place. Record review of Resident #78's MDS, dated [DATE]: Transfers with assistance of 1 person, Functional Status: 2 assist with transfers, Not on toileting plan, Not on any medications that would lead to increased urinary incontinence. A review of Resident #78's Care Plan, dated 07/24/17, noted, Incontinent of bowel & bladder frequently. Care Plan for Skin Breakdown The Nursing Summary Notes 06/24/17 through 09/16/17 for Resident #78, included the following: -06/24/17 at 5:23 p.m. Incontinent episodes at times. Toilets x 1 assist -07/2/17 at 2:17 p.m. Incontinent of bowel and bladder -07/8/17 1:53 p.m. Continent of bowel and bladder. Will voice need for toileting -08/19/17 1:27 p.m. Incontinent of bowel and bladder with some control -08/26/17 2:47 p.m. Incontinent of bowel and bladder with some control. Will often voice need for toileting during the day. Most incontinent episodes during the night. -09/02/17 4:47 p.m. Incontinent of bowel and bladder with some control. Will voice need for toileting at times -09/09/17 3:39 p.m. Incontinent of bowel and bladder with some control, voices needs for toileting at times. -09/16/17 3:50 p.m. Incontinent of bowel and bladder with control. Will voice need to toileting at times. The Activities of Daily Living Report (ADL) report for (MONTH) (YEAR) Resident was incontinent of Urine on 1st, 2nd, 4th, 9th, 15th, 17th, 26th, 28th, 30th & 31st. (10 out of 23 times. No documentation noted for 8 days in May. The ADL report for (MONTH) (YEAR) Resident was incontinent throughout the month of June, with exception of 6/1/17. The ADL report for (MONTH) (YEAR) Resident was incontinent throughout the month of July The ADL report for (MONTH) (YEAR) Resident was continent 3 times (1st, 10th, 28th: all on day shift) during the month of August, and was incontinent the remainder of August. During an interview with Nurse Aide (NA) #12, regarding Resident #78, on 09/19/17 at 3:46 p.m., the NA said, I've worked here 4 years in October, but I haven't worked with her very much. This Resident will usually turn her call light on in morning when she's ready to get up for breakfast. After breakfast, she will ask to get up in her chair. I always make sure her call light is within her reach, whether she has in her bed or chair, and she will turn her light on when she wants to go to the bathroom. Today, she asked me at 9:15 a.m., 11 AM & 1:30 to help her the to restroom &/or needed to be changed. She made it to the restroom twice today. When she was in another room, her routine was about the same routine. Her continence & incontinence was about the same then as well. Sometimes she will try to get up from her chair. She has a chair alarm, bed alarm and another alarm when she is sitting in her recliner. She has done better since she's moved to this room. I do not know why, unless it's where she is closer to the nursing station. If I'm assigned in another section, and I see a light on down the hall, I'll go check and that resident, if I'm not busy. During an interview with Licensed Practical Nurse (LPN) #92, regarding Resident #78, on 09/19/2017 3:59 p.m., the LPN stated, For the most part, I'm familiar with her care. She does toileting and will actually request to go to restroom. Occasionally, she's incontinent. She is incontinent more than continent, mostly. If she wants to go to toilet, it's usually to have a bowel movement. During an interview with Quality Coordinator (QC) #107, on 09/19/2017 4:08 p.m., the QC stated, The type of incontinence this resident has is related to her [DIAGNOSES REDACTED]. With her Alzheimer's, I don't know that she could tell you each time she needs to use the bathroom. She does have overactive bladder. QC #107 was also asked if Resident #78 was on a toileting plan, and she replied, Let me check her record. It says 'Check for incontinence as needed. Wear briefs. Provide peri-care after incontinence and toileting.' No, I don't see that she is on a toileting plan. Interview with Resident Nursing Assessment Coordinator (RNAC) #46 on 09/19/2017 4:14 p.m., revealed Resident #78's Care Plans are discussed every 3 months in her Care Plan meeting. The care plan for her now is check for incontinence & provide peri-care after incontinence and toileting. She wears briefs. Staff are to check her for incontinence when they do her rounds. When RNAC #46 was asked if Resident #78 had a toileting plan, she replied, They do rounds every 2 hours since she doesn't have a specific toileting plan. When asked if Resident #78 had a urinary tract infection [MEDICAL CONDITION], RNAC #46 replied, They monitor that with incontinence. She had one UTI in (MONTH) (YEAR). RNAC #46 was asked if Resident #78 had any perineal skin problems, she replied, No. When RNAC #46 was asked if Resident #78's urinary incontinence was getting worse, she replied, She is totally incontinent. RNAC #46 had no reply when it was pointed out to her that Resident #78 was continent occasionally when she came here. When RNAC #46 was asked if staff were trained to do peri-care, she replied, I'll have to check with Director of Nursing (DoN) #8 When RNAC #46 was asked, How are staff trained to do peri-care?, she replied, I'll have to check with DoN #8 about that, too. RNAC #46 was asked Is there any kind of voiding plan? and the reply was No. During an interview with DoN #8 on 09/20/17 12:00 p.m., she was questioned about the Resident #78's decline in bladder continence. Record review indicated Resident #78 was admitted in (MONTH) (YEAR), was occasionally incontinent and began experiencing total incontinence by (MONTH) (YEAR). DoN #8 was asked about interventions used to attempt bladder restoration, and she replied the family did not want any interventions used because the resident has a [DIAGNOSES REDACTED]. DoN #8 said this was documented in a Care Conference note. Record review of Resident #78's multidisciplinary Care Conference note did not reflect the family's refusal to work with the resident on bladder restoration.",2020-09-01
3478,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,325,D,0,1,ITHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, staff interview, and observation, facility failed to maintain nutritional status and failed to provide an appropriate diet for one (1) out of four (4) residents reviewed for the care area of nutritional status. Resident #37 lost 29.3 pounds (lbs) or 19% of her body weight from 03/22/17 to 09/06/17. Resident identifier: #37. Facility census: 83. Findings include: Resident #37 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Upon admission on 03/22/17, Resident #37's weight was 154 pounds. The Admission Nursing Assessment performed on 03/22/17 at 7:27 p.m. for Resident #37 documented the resident had missing, decayed, or broken teeth. Resident #37's teeth were described as 4 regular teeth on bottom, have cavities and are decaying. Full upper dentures were also documented. Upon admission on 03/22/17, a regular diet, regular texture, and regular consistency was ordered. A care plan goal was initiated on 03/23/17 and stated, Patient will comply with recommended diet for weight reduction daily through review date. A Speech Therapy evaluation for Resident #37 was performed on 03/23/17. The evaluation documented Natural teeth in poor condition with several teeth missing. Swallowing was within functional limits. On 03/27/17, Resident #37's weight was 138.8 lbs. The care plan goal was revised on 03/28/17 and stated, Patient will maintain adequate nutritional status as evidenced by maintaining weight within 135-145 pounds, no signs/symptoms of malnutrition, and consuming at least 50% daily through review date. On 03/29/17, Resident #37's weight was 139.1 lbs. On 04/05/17, Resident #37's weight was 138.6 lbs. On 04/07/17, Resident #37's weight was 140.1 lbs. On 04/12/17, Resident #37's weight was 137.7 lbs. On 04/18/17, Resident #37's weight was 137.2 lbs. On 04/19/17 at 5:37 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 10.9% had occurred. The average food intake for the past week was noted to be 81%. According to the note, She is on regular diet. We will continue to monitor her weight two (2) more weeks, as she is currently stable with her weights. After that, we will monitor her weight monthly as she plans on staying long term. Review of medical records showed Resident #37 was seen in a dental office on 04/20/17. The dentist documented resident requested extraction of her four (4) remaining natural teeth due to pain. The four (4) teeth were extracted in the dental office that day according to the dentist's office records. On 04/26/17, a Dietician Nutritionist Nutritional Assessment was performed. Resident #37 was noted to have a weight change of 5% or greater in the last 30 days. The weight change was noted to be 10.9%. The current diet order was noted to be regular diet, regular texture, regular consistency. Resident was noted to be eating 72% of her meals and 71% of her bedtime snack. The note stated Resident had her teeth extracted on 04/20/17. The dietician recommended soup with lunch and dinner to increase intake due to jaw pain. On 05/04/17, a regular diet, National Dysphagia Diet level 1, pureed texture, regular consistency was ordered. On 05/08/17, Resident #37's weight was 135.1 lbs. On 05/08/17 at 1:32 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 12.3% had occurred. The average food intake for the past week was noted to be 54%. According to the note, Resident has had dental appointment in the past month. She does have missing teeth. She requested pureed diet .She is on a regular diet, and changed today from pureed to regular consistency. On 05/08/17, a regular diet, ground meat texture, regular consistency was ordered. This had remained the diet order through the survey process. On 06/06/17, Resident #37's weight was 131.7 lbs. On 06/07/17 at 3:15 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 14.5% had occurred. The average food intake for the past week was noted to be 75%. According to the note, She is on regular diet with ground meat texture. Her BMI is 25.7. We will continue to monitor her weight monthly. On 06/22/17, a Nutritional Risk Note was performed. Resident #37 was noted to have less than a 5% weight loss in the last 30 days with the last weight of 131.7 lbs. obtained on 06/06/17. Resident was not on a planned weight loss program. Her ideal body weight was noted to be 123-149 lbs. The current diet order was noted to be ground meat. Resident was noted to have an average meal intake of 62% and 57% of bedtime snack for the past week. The current plan of care was to be continued. On 07/07/17, Resident #37's weight was 126.8 lbs. On 07/07/17 at 4:59 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 17.7% occurred overall. A weight change of 3.7% was noted over the last 30 days. The average food intake for the past week was noted to be 76%. According to the note, She is on regular diet with ground meats. She will continue to be monitored monthly. On 08/07/17, Resident #37's weight was 125.6 lbs. On 08/09/17 at 1:08 p.m., a Weight and Nutrition Meeting was held. According to the meeting note, a weight change of 18.4% had occurred overall. The average food intake for the past week was noted to be 79%. According to the note, She is on regular diet, with ground meat texture. We will continue to monitor her weight monthly as she is stable with her weights. On 09/06/17, Resident #37's weight was 124.7 lbs. On 09/06/17, the care plan goal was revised to state, Patient will maintain adequate nutritional status as evidenced by maintaining weight within 120-130 lbs., no signs/symptoms of malnutrition, and consuming at least 50% of at least 2 meals daily through review date. During the Stage I interview on 09/18/2017 at 1:31 p.m., Resident #37 stated she had upper dentures only but she would like lower dentures, too. She stated her lower teeth had been removed while she was a resident at the facility. On 09/18/17 at 2:30 p.m., another surveyor observed Resident #37 as resident went to nursing desk and asked for lower dentures. Registered Nurse #107 stated she would put resident on the list. During an interview on 09/20/17 at 10:57 a.m., Resident #37 stated she could not chew her food because she had no natural teeth and upper dentures only. She stated she could only swallow her food. She stated she could eat meat on her tray because it was ground. She stated she could not eat some items that were also provided to her, such as vegetables and salads. During an observation of Resident #37's lunch tray and an interview with the resident on 09/20/17 at 12:30 p.m., the resident was observed to have eaten almost of all of the ground meat provided on her tray. She also had egg roll, mixed vegetables, and rice. Resident stated she could not eat the mixed vegetables or egg roll due to her inability to chew. She stated she did not like rice. On the Documentation Survey Report, 50% of the meal was reported as consumed for lunch 09/20/17. During an interview, on 09/21/17 at 9:40, Nursing Assistant #50 stated the percentage of food documented as consumed was a straight percentage of the amount of food eaten. No foods were weighted at a higher percentage than other foods. A Nutritional Risk Note was written on 09/19/17. The weight change was noted to be less than 5% in the last 30 days and less than 7.5% in the last 90 days. Resident was not on a planned weight loss program. The current diet was noted to be regular with ground meat. Resident #37's average meal intake was 74% and bedtime snack 71% for the past week. The current plan of care was to be continued. On 09/20/17 at 11:51 a.m., the Director of Nursing (DoN) was interviewed regarding findings of Resident #37's weight loss, her inability to chew her food, and her edentulous status with upper dentures only. The DoN stated the facility was unaware Resident #37 wanted lower dentures until Resident #37 stated this to the nursing staff on 09/18/17. According to the DoN, Social Services had been notified of the resident's desire for lower dentures. A Social Services Progress note written on 09/20/17 at 11:58 a.m. stated, Resident requesting lower dentures. Social Services will get with van driver to see when she can be taken to affordable dentures. A Social Services Progress note written on 09/20/17 at 3:23 p.m. stated, Resident will be going to affordable dentures on 09/27/17 to have lower dentures made. A Physician's Contact Note, written on 09/20/17 at 5:02 p.m., stated, Resident stated to state worker that she was unable to chew lunch on this day. Her diet order is: regular diet, ground meat texture, regular consistency .ST (speech therapy) to evaluate; notified by this nurse of resident's complaint. She has a pending appointment for denture fitting due to residents' new concern/request for bottom dentures .Resident will be given soft food this evening per her preference due to complaints this day of difficulty chewing. A Speech Therapy (ST) Evaluation and Plan of Treatment was performed on 09/21/17 for possible difficulty with mastication with current diet of regular texture with ground meats. According to the Speech Therapy Evaluation, ST asked patient about deficits with mastication with lunch meal yesterday. Patient stated the egg roll was tough for her to chew so she broke it apart and consumed the inside of the egg roll. She stated she does not like rice nor broccoli and they were both served yesterday. ST stated to patient that dietary will be notified of this and she will no longer be served rice nor broccoli. During breakfast, patient was noted to take the crust off of her bread and asked about this. Patient stated the crust is tough for her to chew. ST asked if she would like for the kitchen to cut the crust off of all of her breads that have crust and she stated yes. ST to notify kitchen of this modification as well. ST provided education to patient regarding the current diet she is on as well as information regarding the other diets and modifications that can be made to her diet. Patient stated to ST that she does not want her food changed and she only wants teeth. ST further inquired and asked if she would like lower dentures or a full new set and she stated she only wanted lower dentures. ST asked about her upper teeth and she stated they are fine and she only wants new lower teeth. Patient then stated again that she does not want her foods changed. On 09/21/17 at 8:40 a.m., ST #77 stated she evaluated Resident #37 today. ST #77 stated Resident #37 did not want her diet changed to pureed. Resident #37 wanted lower dentures rather than a diet change. Until lower dentures can be obtained, ST #77 was going to let the dietary staff know the foods Resident #37 could eat and the foods Resident #37 did not like to eat. During an interview on 09/21/17 at 9:35 a.m., the Dietary Services Supervisor stated Resident #37 had not been on a weight loss program. He stated most residents lose weight upon admission to the facility from home because they are receiving nutritional foods. The Dietary Services Supervisor stated Resident #37's body mass intake was within normal limits. He stated the care plan goal weight was adjusted downward because he likes to care plan to keep residents within ten (10) lbs.of their current weight if they are at a healthy weight. The Dietary Services Supervisor stated Resident #37 was provided soup for lunch and dinner for a time period after the extraction of her teeth. She currently only wanted pureed meat and didn't want the rest of her food pureed. The Dietary Services Supervisor stated the resident had not mentioned difficulty chewing certain foods or disliking certain foods. He stated foods such as vegetables were served soft so she could chew them. The Dietary Services Supervisor stated he had been notified today about Resident's food preferences and the food she was unable to eat with only upper dentures. During an interview on 09/21/17 at 10:15 a.m., Registered Dietician (RD) #109 stated he had evaluated Resident #37 one time. He recommended soup for lunch and dinner due the recent extraction of the resident's teeth. RD #109 stated he agreed with the care plan goals adjusting her desired weight downward, from 135-145 lbs. to 120-130 lbs. During an interview on 09/21/17 at 11:10 a.m., the Dietary Services Supervisor wanted to clarify Resident #37 had been on a pureed diet for approximately 4 days, but did not tolerate the diet well. According to the Weight and Nutrition Meeting note on 05/08/17, Resident #37's average food intake fell to 54% while on a pureed diet. The resident had asked for the pureed diet to be discontinued.",2020-09-01
3479,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,329,E,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 Resident #15's dug regimen was free from unnecessary medications. Resident #15 was administered an as needed (PRN) [MEDICATION NAME] with out any attempts o of non pharmacological interventions prior to the administration of the PRN anitanxiety medication. This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident Identifier: #15. Facility Census: 83. Findings Include: a) Resident #15 A review of Resident #15's medical record at 2:02 p.m. on 09/19/17 found a physician order [REDACTED]. Review of Resident #15's individual controlled substance log for her [MEDICATION NAME] .5 mg found Resident #15 was administered her as needed atiavn on the following dates: 01/19/17 at 9:00 p.m. -- 02/11/17 at 11:30 a.m. -- 02/13/17 at 3:00 a.m. -- 02/25/17 at 10;00 p.m. -- 03/25/17 at 11:00 p.m. -- 04/08/17 at 11:00 p.m. -- 04/27/17 at 10:00 p.m. -- 05/28/17 at 9:00 p.m. -- 06/19/17 at 2:00 a.m. Further review of the medical record found no evidence to suggest Resident #15 exhibited targeted behaviors nor did the facility attempt any non pharmacological interventions prior to the administration of the PRN [MEDICATION NAME]. An interview with the Director of Nursing at 10:42 a.m. on 09/20/17 confirmed there was no documented behaviors or non pharmacological interventions prior to administering Resident #15's PRN [MEDICATION NAME] on the above mentioned dates.,2020-09-01
3480,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2017-09-21,514,E,0,1,ITHZ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility failed to ensure the medical record was complete and accurate for three (3) of 16 medical records reviewed. Resident #15 received multiplied doses of as needed (PRN) [MEDICATION NAME] (an antianxiety medication) that was not recorded on the Medication Administration Record (MAR). This was true for one (1) of five residents reviewed for the care area of unnecessary medications. For resident #7 and Resident #37 the medical record did not accurately reflect their dental status. This was true for two (2) of four (4) residents reviewed for the care area of Dental Status during stage 2 of the Quality Indicator Survey (QIS). Resident Identifiers: #15, #7 and #37. Facility Census: 83. Findings Include: a) Resident #15 A review of Resident #15's medical record at 2:02 p.m. on 09/19/17 found a physician order [REDACTED]. This order had a start date of 11/23/16 and was discontinued on 06/19/17. Review of Resident #15's individual controlled substance log for her [MEDICATION NAME] .5 mg found Resident #15 was administered her as needed atiavn on the following dates: -- 01/05/17 at 10:00 p.m. -- 01/19/17 at 9:00 p.m. -- 02/02/17 at 2:00 a.m. -- 02/04/17 at 3:00 a.m. -- 02/08/17 at 12:00 a.m. -- 02/09/17 at 1:30 a.m. -- 02/11/17 at 11:30 a.m. -- 02/13/17 at 3:00 a.m. -- 02/22/17 at 10:00 p.m. -- 02/25/17 at 10;00 p.m. -- 03/02/17 at 10:00 p.m. -- 03/13/17 at 2:00 a.m. -- 03/21/17 at 10:00 p.m. -- 03/22/17 at 8:00 p.m. -- 03/25/17 at 2:00 a.m. -- 03/25/17 at 11:00 p.m. -- 03/26/17 at (unknown time) -- 03/30/17 at 11:30 p.m. -- 04/01/17 at 10:00 a.m. -- 04/06/17 at 2:00 a.m. -- 04/08/17 at 11:00 p.m. -- 04/15/17 at 12:00 a.m. -- 04/18/17 at 11:00 p.m. -- 04/22/17 at 11:00 p.m. -- 04/23/17 at 9:00 p.m. -- 04/27/17 at 10:00 p.m. -- 05/03/17 at 10;00 p.m. - -05/06/17 at 10:00 p.m. -- 05/16/17 at 9:00 p.m. -- 05/19/17 at 9:00 p.m. -- 05/20/17 at 9:00 p.m. -- 05/21/17 at 9:00 p.m. -- 05/25/17 at 9:00 p.m. -- 05/26/17 at 9:00 p.m. -- 05/28/17 at 9:00 p.m. -- 06/08//17 at 11:00 p.m. -- 06/09/17 at 10;00 p.m. -- 06/13/17 at 11:00 p.m. -- 06/14/17 at 11:00 p.m. -- 06/17/17 at 10:00 p.m. -- 06/19/17 at 2:00 a.m. Review of the MAR from 01/01/17 through 06/19/17 found none of the administered dosages of [MEDICATION NAME] listed above were recorded on the MAR. An interview with the Director of Nursing (DON) at 10:42 a.m. on 09/20/17 confirmed that the listed dosages of as needed [MEDICATION NAME] were not administered on the MAR. She agreed they were signed out on the controlled substance log but were not documented on the MAR. b) Resident #7 During Stage 1 of the QIS Resident #7 was observed at 10:31 a.m. on 09/19/17, during observations it was note Resident #7 had missing bottom teeth. She had teeth on either side of her mouth but was missing her bottom middle teeth. A review of Resident #7's medical record on 09/21/17 at 8:21 a.m., found two (2) nursing's assessments dated 08/04/16 and 02/02/17. Both nursing assessments indicated Resident #7 was edentulous and had an upper and lower denture. An interview with Nurse Aide (NA) #17 at 9:47 a.m. on 09/21/17 confirmed Resident #7 has and upper denture and a lower partial plate that she refuses to wear on most occasions. An interview with Registered Nurse Assessment Coordinator (RNAC) at 10:26 a.m. on 09/21/17 confirmed Resident #7 wears a full set of dentures on the top and she has a partial for the bottom but she refuses to wear it. She stated that she had looked into the residents mouth and found the resident had about four (4) natural teeth on the bottom that were in good shape. She confirmed Resident #7 was not edentulous and did not have a lower set of dentures but instead had partial plate for the bottom. c) Resident #37 During the Stage I interview on 09/18/2017 at 1:31 p.m., Resident #37 stated she had upper dentures only but she would like lower dentures, too. She stated her lower teeth had been removed while she was a resident at the facility. Review of medical records showed Resident #37 was seen in a dental office on 04/20/17. The dentist documented resident requested extraction of her four (4) remaining natural teeth due to pain. The four (4) teeth were extracted in the dental office that day according to the dentist's office records. The Physician's Contact Note written on 04/20/17 at 12:20 p.m. stated, Resident had two (2) teeth extracted today at dentist. Following the extraction of Resident #37's remaining natural teeth, the weekly nursing summaries continued to state Resident #37 had natural teeth. The weekly nursing summaries contained the following information regarding Resident #37's Oral/Dental Status: - 05/07/17: Has own teeth. Has had recent dental work. Has missing teeth. No problems with teeth/gums at this time. - 05/14/17: Resident has upper dentures and few natural teeth. Is offered oral care daily by staff. - 05/21/17: Has natural teeth, some missing. No problems with teeth. - 05/28/17: Resident has upper dentures and few natural teeth. Provided dental care daily by staff. - 06/04/17: Has no issues with teeth or chewing. Has had teeth removed within the past three (3) months. - 06/10/17: Resident has dentures and few natural teeth. Oral care provided daily by staff. - 06/17/17: Has some natural teeth. No issues with teeth or gums. - 06/25/17: Resident has some natural teeth and oral care provided by staff daily. - 07/02/17: Has natural teeth, some missing. No issues with chewing. - 07/08/17: Natural teeth, some missing. No issues with chewing and oral care is provided by staff daily. - 07/16/17: Has some natural teeth. No issues at this time with chewing or gums. - 07/22/17: Some natural teeth and some missing. No problems with eating or chewing and oral care is provided by staff daily. - 07/29/17: Has some natural teeth. No complaints. Staff does oral care. - 08/05/17: No dental issues at this time. - 08/12/17: Has natural teeth, no issues at this time. - 08/19/17: Some natural teeth with no dental issues at this time. Oral care provided by staff daily. - 08/27/17: Has own natural teeth, no issues with teeth at this time. During an interview on 09/20/17 at 9:21 a.m., Nursing Assistant (NA) # 79 stated Resident #37 had natural teeth according to the Kardex. NA #79 was asked to examine Resident #37's mouth so surveyor could verify if resident had natural teeth. During examination at 09/20/17 at 9:23 a.m., Resident #37 was found to have upper dentures and no natural teeth. During an interview on 09/20/17 at 11:51 a.m., the Director of Nursing was informed the nursing summaries stated Resident #37 had natural teeth although she is edentulous.",2020-09-01
3481,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,559,D,0,1,DXEI11,"Based on resident interview, staff interview and record review, the facility failed to explain to Resident #385 the reason for her room change. This was during a random opportunity for discovery. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 On 09/24/18 at 1:30 PM, Resident #385 and her son were interviewed. They stated Resident #385 was moved to a new room and not notified of the reason for the room change. A progress note written in Resident #385's medical record on 09/13/18 at 1:21 PM stated, (Resident #385) was moved from 201 to 217 B. The details regarding this room change can be found on the form, Room Change Notification. The form Room Change Notification - V 3 was reviewed. The form was completed by Social Services Supervisor #92 on 09/13/18. Under item four, Reason for Room/Bed Change, the reason was noted as Moving to a semi private room. No further explanation was documented. Under item five of the form, Social Services Supervisor #92 documented the resident was notified of the room change 09/13/18 01:00. Item six c. of the form was checked for A copy of this notice is being provided to the resident's representative. On 09/25/18 at 10:21 AM, Social Services Supervisor #92 was interviewed regarding the actual room change, the room change form, and resident notification of the room change. She stated that Resident #385's new roommmate (Resident #386) was about to come to blows with her previous roommate (Resident #53), so Resident #53 was swapped with Resident #385. Resident #53 was getting in (Resident #386)'s stuff and Social Services Supervisor #92 was afraid for (Resident #53)'s safety. She also stated Resident #385 was agreeable to move. She said she did not want to put information about Resident #53 and Resident #386 into Resident #385's Room Change Notification form or into Resident #385's progress notes. On 09/26/18 at 4:03 PM, Resident #385 reiterated she was not asked if she wanted to move or notified of the reason for the move.",2020-09-01
3482,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,561,D,0,1,DXEI11,"Based on resident interview and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for the care area of choices, had the opportunity to exercise autonomy regarding those things that are important in her life. Resident #76 was not offered a choice in choosing her shower schedule. Resident identifier: #76. Facility census: 89. Findings included: a) Resident #76 On 09/24/18 at 11:21 a.m., the resident said she only gets 2 showers per week but she would prefer more showers. She did not believe it was possible to have any more showers because the facility just offers 2 showers per week. At 10:23 a.m., on 09/25/18, the resident's nursing assistant (NA) #32, said the resident gets showered on Tuesday and Friday. Review of the look back report report for activities of daily living (ADL) care found the resident received showers every Tuesday and Thursday from 08/25/18 to 09/25/18 as directed. The resident did not refuse any of her showers according to the documentation. On 09/25/18 at 10:26 AM, the resident was interviewed with the director of nursing present. The resident asked the DON, What are my options? The DON told the resident she could shower every day of the week if she wanted. The resident chose to have a shower on Monday, Wednesday, Friday and Saturday. The DON said residents are asked upon admission what shower schedule they prefer. The DON said she had nothing in written form to verify her statement.",2020-09-01
3483,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,580,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, record review and staff interview, the facility failed to notify Resident #24 when there were changes made in her plan of care. On multiple occasions Resident #24's family was notified of medication changes and diagnostic testing results with no evidence that Resident #24 was also notified of the changes or the results. This was a random opportunity for discovery. Resident identifier: #24. Facility census: 89. Findings included: a) Resident #24 An interview with Resident #24 at 3:35 p.m. on 09/26/18 found her medication for her heartburn was discontinued without her knowledge. She stated, They took me off that medicine for heart burn without talking to me first and I have had heartburn ever since. I need that medicine back as soon as they can give it back to me. Resident was referring to her pantoprazole which was decreased on 09/06/18 and eventually discontinued two weeks later. A review of Resident #24's medical record at 4:00 p.m. on 09/26/18 found a physician's determination of capacity dated 04/19/18 which indicated the resident has capacity to make health care decisions. Further review of the record found the following notes: Note dated 07/10/18 at 9:02 p.m. read as follows, Two view right ankle. Right ankle fracture. NP (Nurse Practitioner) notified gave orders for NWB (non weight bearing) right foot and schedule ortho consult. (Name of Husband), her husband was notified of the fracture and the ortho consult. He stated that he had no preference for orthopedic physicians. I informed him that I would ask Diane and we would schedule the appointment and call back with place, date, and time. Note dated 07/30/18 at 12:21 p.m. read as follows, (Name of Nurse Practitioner) new orders: obtain stool for[DIAGNOSES REDACTED] clear liquid diet X3 days [MEDICATION NAME] 4 mg po (by mouth) q6 (every 6 hours) prn (as needed) d/t (due to) nausea X 7 days. (Name of Husband) (husband) notified and in agreement. Note dated 08/23/18 at 7:09 p.m. read as follows, Dr. (Last name of physician) in facility. New order to increase [MEDICATION NAME] to 50 mg daily due to depression. (First and Last name of husband) husband notified. Note dated 09/06/18 at 11:57 a.m. read as follows, New order to decrease pantoprazole 20 mg by mouth for one week. Then decreased to 20 mg by mouth every other day for one week, then discontinue. TUMS 2 tablets by mouth every 6 hours de to reflux. There was no documentation contained in the medical record to indicated Resident #24 was notified of this new order. Note dated 09/06/18 at 5:32 p.m. read as follows, Complains of increased pain and discomfort to right ankle. Pain with range of motion. Update provided with MD. New order for x ray AP and Lat of right ankle. Husband in facility notified of new order. Note dated 09/07/17 at 4:02 p.m. read as follows, Appointment with Brace Shoppe on (MONTH) 7 at 11:00 a.m. Transportation: Facility van every day and night shift for brace shoppe fitting until 09/07/18 11:59 p.m. Appointment canceled per (first and last name of husband). Note dated 09/20/18 2:15 p.m. read as follows, Dr. (Last name of physician) in facility. Check vitamin D level. (First and Last name of daughter in law) notified and in agreement. An interview with the Director of Nursing (DON) at 5:02 p.m. on 09/26/18 confirmed the above findings. She indicated she saw nothing in the record indicating Resident #24 was notified of the new orders or diagnostic testing results. She agreed, Resident #24 should be notified because she is capacitated to make medical decisions.",2020-09-01
3484,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,582,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure two (2) of three (3) residents reviewed for the care area of beneficiary protection notifications, received the required notification when Medicare Part A services ended. Resident identifiers: #35 and #79. Facility census: 89. Findings included: a) Entrance conference information The entrance conference worksheet for beneficiary notice-Residents discharged within the last six months was provided to the facility upon entrance to the facility on [DATE] at 10:45 a.m. The form instructs the facility to please complete and return this worksheet to the survey team within 24 hours. Please provide a list of residents who were discharged from Medicare covered Part A stay with benefit days remaining in the past 6 months. Please indicate if the resident was discharged home or remained in the facility. (Exclude beneficiaries who received Medicare Part B benefits only, were covered under Medicare Advantage insurance, expired, or were transferred to an acute care facility or another SNF (skilled nursing facility) during the sample date range.) b) Resident #35 Review of the residents discharged from Medicare, Part A services within the last six months, with benefit days remaining, was provided by the facility on [DATE]. According to the beneficiary notice form, Resident #35 was discharged from Medicare services on [DATE] and continued to remain in the facility with benefit days remaining. On [DATE], the facility provided, the Centers for Medicare and Medicaid Services, (CMS) form # , to the resident/responsible party. b) Resident #79 Review of the residents discharged from Medicare, Part A services within the last six months with benefit days remaining was provided by the facility on [DATE]. According to the beneficiary notice form, Resident #79 was discharged from Medicare services on [DATE] and continued to remain in the facility with benefit days remaining. On [DATE], the facility provided, (CMS) form # , to the resident/responsible party. c) Interview with the facility social worker At 8:05 a.m. on [DATE], the facility social worker, (SW) #92 said CMS form # was not issued to Residents #35 or #79. An audit was completed on [DATE] by a corporate employee who found the proper notification was not always provided to residents. She said she received an in-service and notices after this in-service had been given as directed. The SW verified both Residents #35 and #79 should have received both CMS forms # and CMS # but they only receied CMS # . d) The guidance to surveyors directs: The Skilled Nursing Facility Advanced Beneficiary Notice (SNFABN) provides information to residents/beneficiaries so that they can decide if they wish to continue receiving the skilled services that may not be paid for by Medicare and assume financial responsibility. If the SNF (Skilled Nursing Facility) provides the beneficiary with SNFABN, form CMS- , the facility has met its obligation to inform the beneficiary of his or her potential liability for payment and related standard claim appeal rights. Issuing the Notice to Medicare Provider Non-coverage (NOMNC), form CMS- , to a beneficiary only conveys notice to the beneficiary of his or her right to an expedited review of a service termination and does not fulfill the facility's obligation to advise the beneficiary of potential liability for payment. A facility must still issue the SNFABN to address liability for payment.",2020-09-01
3485,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,583,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview and during a random opportunity for discovery, the facility failed to ensure two residents' health information was protected. The facility also failed to ensure a resident's privacy was maintained in the spa room. Resident identifiers: #74, #81, and #6. Findings included: a) Resident #74 During a random observation on 09/25/18 at 3:30 PM, [MEDICATION NAME] packaging was found in the trash can on the side of a med cart with Resident #74's name printed on the packaging, visible to passersby. Licensed Practical Nurse (LPN) #17 was notified. LPN #17 then shredded the packaging. b) Resident #81 On 09/25/18 at 10:59 AM, [MEDICATION NAME] and KlorCon packaging with Resident #81's name visible on the label were found in the trash can on the side of a med cart, visible to passersby. LPN #88 and LPN #17 were notified and they shredded the packaging. c) Resident #6 On 09/25/18 at 3:55 PM a nurse aide (NA) opened the door to the spa room to reveal Resident #6, who was lying unclothed on the shower bed. The curtain was not drawn. LPN #17 was notified and she said the curtain should have been drawn. LPN #17 then went into the spa room to ensure the curtain was drawn.",2020-09-01
3486,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,585,D,0,1,DXEI11,"Based on review of grievance/concern forms, policy review, record review and staff interview, the facility failed to reflect in their investigation the steps taken to resolve a grievance. This occurred during a random opporunity for discovery. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 On 09/24/18 at 1:30 PM, Resident #385 and her son were interviewed. They stated Resident #385 was moved to a new room and not notified of the reason for this room change. After the room change, Resident #385 had problems with her roommate (Resident #386) yelling out and being disruptive. Resident #385 then filed a grievance (concern form) with the social services department, but this did not resolve the issue. Resident #385 then began sleeping on the couch in the common area on her unit to escape the noise in her room. Resident #385's son stated he asked the facility multiple times to move his mother over the previous week, but they repeatedly told him the facility was full and they could not accommodate the request. On 09/25/18 at 10:21 AM, Social Services Supervisor #92 was interviewed. She said Resident #385 would likely be going home with her son within forty-eight hours. She stated interventions with Resident #385's roommate were completed per nursing and said nurses have called the roommate's daughters in to sit with her as an intervention. When asked about the reason that Resident #385 could not move to a quieter room, Social Services Supervisor #92 said the facility didn't have a room to put her in right now. We're full. She said, We tried to figure out somebody who might be compatible with her. We did talk about it. I did offer her earplugs and she didn't want that. When asked how it was decided there were no compatible residents for Resident #386, Social Services Supervisor #92 stated, We just talked about it amongst ourselves. She said staff did not approach any residents about moving in with Resident #386. She also said that a hospice resident was a possibility, but staff did not want to move the hospice resident due to her fragile state. On 09/25/18 at 10:48 AM, Resident #385 stated she was not given a copy of the results from the grievance report and Social Services Supervisor #92 did not speak to her about them. A review of the concern form that Resident #385 had filed on 09/20/18 revealed no information regarding the steps taken by the social services department to resolve this issue. During another interview with Social Services Supervisor #92 on 09/25/18 at 02:01 PM, she stated the date on the bottom of the form was the date she completed the form; not the date the resident was informed of the results of the investigation. Social Services Supervisor #92 was asked what a group meeting was, who would be involved, and why this option would be selected on the form. She stated the interdisciplinary team would get together sometimes to discuss concerns, but this usually only happened when a family came into the facility to discuss the issue. The team typically did not meet for just an individual. Social Services Supervisor #92 was then asked what she gave Resident #385 to show her the work on the issue. Social Services Supervisor #92 stated she had not given written notification to Resident #385 regarding the results of the grievance and that she would be providing written notification later that day. A review of the facility's grievance policy, effective 06/12/18 revealed, A written report of the investigation, results, and actions taken to resolve the grievance is provided to the Executive Director. The written report will include: --The date the grievance was received; --A summary statement of the resident's grievance; --The steps taken to investigate the grievance; --A summary of the pertinent findings or conclusions regarding the resident's concerns. In another section of the policy titled 'Grievance Procedure' effective 06/01/18, revealed, A report of the findings and the actions taken if any will then be explained to the resident, the resident representative, and/or the individual filing the complaint. The appropriate designee shall be notified of all efforts made to resolve complaints. It also stated, The Grievance Official will follow up on each complaint with the individual filing the complaint to ensure satisfaction with the facility's handling of the complaint. All complaints/ results and follow up of the investigation will be documented and kept on file in the Social Services Directors office. The grievance policy did not address the specific steps to be taken to investigate and resolve grievances. A review of the concern form and interviews with both Resident #385 and Social Services Supervisor #92 revealed the facility's grievances and complaints policy was not followed.",2020-09-01
3487,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,641,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, facility failed to accurately complete the Minimum Data Set (MDS) to reflect each resident's status. This was true for five (5) of twenty-five (25) sampled residents. Resident #52's section, Preferences for Customary Routine and Activities was blank for the resident and/or responsible party interview. Resident #87's was inaccurate for prognosis. For Residents #73 and #47 was inaccurate in area of dental status. Additionally, Resident #386s was inaccurate in area of behavioral and emotional status. Resident identifiers: #52, #87, #73, #47 and #386. Facility census: 89. Findings included: a) Resident #52 A review of Resident #52's medical records, found an admission MDS with an ARD of [DATE]. Review of the MDS found Section F Preferences for Customary Routine and Activities was not completed; it was indicated with a 0, which is No this indicates the resident is rarely/never understood and family/significant other not available for the interview. Further review found an Activity Assessment which was completed on [DATE]. This assessment was noted to be completed via telephone with the daughter. Interview with Director of Nursing on [DATE] at 2:10 pm, found no reason documented to indicate why the Activity Director (AD) did not complete Section F of the MDS. She acknowledged the AD had completed the activity assessment via the telephone with the daughter. b) Resident #87 A review of Resident #87's medical record, on [DATE] at 1:00 PM, found an admission MDS with an (ARD) of [DATE]. Review of section J1400- Prognosis was coded 0, this indicates the resident does not have a condition or chronic disease that may result in a life expectancy of less than 6 months. (Requires physician documentation. Review of the discharge summary from acute care facility dated [DATE] (this was also her date of admission to the facility. This discharge summary read, She is otherwise very weak, in fact too weak to go to rehab. In fact, her daughter was considering hospice, but they felt that since we already had the ball in motion for rehab over the weekend, and the patient had been waiting for some time, that we could go ahead and have her go there, but she was not even showing signs of wanting to participate. More than likely, they are going to place her on palliative and then transition her to hospice care Additionally, review found an admission History and Physical (H&P) completed on [DATE] by the attending physician. This assessment read, weakness is patient's chief complaint. Possible [MEDICAL CONDITION], family refused bone marrow biopsy. Family interested in hospice. Final [DIAGNOSES REDACTED]. this H&P also read, . Poor/Terminal prognosis. Plan of care: Recommend comfort measures and a hospice consult. She will not be able to participate with physical and occupational therapy. Family accepting. Will add [MEDICATION NAME]. Interview with the Director of Nursing (DON) on [DATE] at 2:15 p.m., a review of the discharge summary and the H&P, found the MDS with the ARD of [DATE] was inaccurate. She confirmed the resident had a prognosis of six months or less. She confirmed Resident # 87 had expired in the facility on [DATE]. c) Resident #73 Observation and interview on [DATE] at 1:15 pm, found Resident #73, had an upper partial on top, she stated it kept falling out due to not fitting, also noted to have one upper tooth remaining which was broken and discolored. Resident states, This tooth is starting to hurt and my upper partial is too big. She was also noted to have full lower denture in place. Observation and interview with Employee #5, Clinical Care Supervisor (CCS) on [DATE] at 11:10 am, found the resident had one tooth on top, which was discolored and broken. Additionally, she noted her upper partial was in fact loose and ill-fitting. Review of the annual MDS with ARD of [DATE], found Section L Oral/Dental Status indicated the resident had no broken or loosely fitting full or partial dentures and no obvious or likely cavity or broken natural teeth. The DON was notified of the inaccurate MDS with ARD of [DATE] on [DATE] at 1:05 pm. No further information was provided. d) Resident #47 Observation and interview on [DATE] at 2:00 pm, found Resident #47, had an upper and lower partial with missing, broken, decayed natural upper and lower teeth. Resident #47 was unable to remove the upper partial. Observation and interview with Employee #5, Clinical Care Supervisor (CCS) on [DATE] at 10:10 am, found the resident had an upper and lower partial with missing, broken, decayed natural upper and lower teeth. Resident #47 was unable to remove her upper partial and after several attempts by the resident and the assistance of CCS #5 her upper partial was removed with minor discomfort. The upper partial was stained a brown color. Review of the annual MDS with ARD of [DATE], found Section L Oral/Dental Status indicated the resident had no broken or loosely fitting full or partial dentures. The DON was notified, on [DATE] at 1:05 pm, of the inaccurate MDS with ARD of [DATE]. No further information provided. e) Resident #386 On [DATE] at 2:44 PM, Resident #386 was heard yelling out loudly for (male name) during an interview with another resident in a common area on the unit. Resident #386 was also heard from the hallway yelling loudly in her room for nurses instead of using her call light. On [DATE] at 2:59 PM Resident #386's family was interviewed in Resident #386's room. They stated Resident #386 was recently hospitalized after a suspected [MEDICAL CONDITIONS] and was placed in the nursing home after her hospital discharge. They stated Resident #386 had two recent environment changes due to her medical status as well as dementia and a probable stroke. The family said she was much calmer today, and this was the best she had been. They also stated Resident #386 had recently yelled and screamed quite a bit and this was not normal for her. The family said her medications were being adjusted to try to calm her down. She had a routine at home and a schedule, and now she had to adjust to life in the nursing home. Progress notes for Resident #386 were reviewed. Multiple instances of yelling and combativeness were present in the resident's progress notes. On [DATE] at 4:44 PM, a progress note written by Licensed Practical Nurse (LPN) #17 stated, On waking resident attempted to get out of bed unassisted. CNA x2 attempted to dress resident and complete personal care. Resident hit both CNAs (one in the arm and one in the stomach). Yelling as loud as she could 'Help!' Resident taken to TV lounge. Removed shirt. Began yelling and cursing. CNA attempted to cover resident with gown. Resident aggressively removed gown. On [DATE] at 5:56 PM, a progress note written by Registered Nurse (RN) #71 stated, Resident yelling and screaming. This nurse and CNA were assisting resident up in bed for dinner. Resident begins hitting this nurse and cna. Resident pinches CNA on the abdomen. Resident screams at this nurse You and your girls aint nothing but idiots. On [DATE] at 11:30 PM, a note written by RN #6 stated, Resident has been yelling off and on since 5 pm, she has been yelling at staff when they offer assistance, calling staff names and cursing at them, she also threw her dinner tray on the floor, with her food and fluids. Family arrived and was able to calm resident down, family was also able to feed a small amount, and family was able to convince resident to take her medication. During an interview on [DATE] at 4:30 PM, Resident #39 stated she had a complaint about a resident who resides in the room next door (Resident #386). She indicated the resident was in the room down the hallway, or room [ROOM NUMBER]. Resident #39 stated the resident next door disturbed her by frequently yelling out. She stated this happened throughout the day and night, and not during any particular time. Section [NAME] (Behavior) of the Minimum Data Set (MDS) with an Assessment Reference Date (ARD) of [DATE] was reviewed for Resident #386 and found inaccurate for Section E0600C, completed by Social Services Supervisor #92. Section E0600 dealt with the impact of a resident's behavior on others and section E0600C asked if the behavior of a resident significantly disrupted the care or living environment of others. This section was coded '0' for an answer of 'no.' However, progress notes outlining disruptive behavior and complaints from Resident #386's roommate and another resident on the same unit suggested disruption of the care and living environment of others. Social Services Supervisor #92 was interviewed on [DATE] at 3:50 PM and agreed that section E0600C of the MDS was coded inaccurately. A correction was made to the MDS and this surveyor was provided with a copy of the correction.",2020-09-01
3488,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,656,E,0,1,DXEI11,"**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 develop and or implement a comprehensive person-centered care plan for four (4) of twenty-five (25) residents reviewed. The care plan for activities of daily living (ADL) related to meal assistance was not implemented for Resident #78. A care plan was not developed for Resident #74 to include non-pharmacological interventions for use of an antipsychotic medication. Resident #52's care plan was not implemented for activities. A care plan was not developed for Hospice services for Resident #55. Resident identifiers: #78, #74, #52, and #55. Facility census: 89. Findings included: a) Resident #78 Observation of the first meal served, after entrance to the facility, was the noon meal on [DATE] at 12:30 PM. The resident was in bed when the noon meal was served. Staff delivered the resident's tray, set up the tray, on the over the bed table, and left the room. The resident was sleeping in bed, laying on her right side in a fetal position. The resident did not get out of bed for the meal. Approximately ten minutes after serving the tray, staff returned to pick up the tray. Documentation on the meal intake noted the resident refused the tray. Review of the medical record found the resident's diet orders: NDD level 1, pureed texture, regular consistency, Kennedy cup with straws for all meals. A level 1 national dysphagia diet (NDD) includes only pureed foods. Pureed foods should have the same texture as pudding. They should be smooth and free of lumps. Review of the resident's care plan found the following problem: Resident has a ADL (activities of daily living) self care Performance deficit related to impaired mobility, weakness, impaired memory. The goal associated with the problem: Patient is expected to have variations in her ADL's due to Alzheimer's. She will have no complications related to current level of function in bed mobility, transfers, eating, dressing, toilet use and/or personal hygiene through next review date. Interventions included: Patient requires set up assistance, she is to be in wheelchair or recliner for breakfast, lunch and dinner. At 7:50 a.m. on [DATE], the Speech Therapist (ST) #83 was observed in the resident's room. ST #83 said the resident needs to be fed. ST #83 introduced a student who was feeding the resident under the supervision of ST #83. ST #83 said the resident occasionally drinks her liquids by herself. The resident was in bed during the feeding of the morning meal. When asked if ST #83 knew the care plan said the resident was to be up in the wheelchair or her recliner for all meals, she replied, It isn't a problem, she is up in bed and positioned for her meal. Continued observation found the student fed the resident the entire meal while the resident was in bed. The resident was not up in her recliner or wheelchair for the noon meal served on [DATE] or the breakfast meal served on [DATE] as directed by the care plan. On [DATE] at 8:54 AM, the dietary manager (DM) #75 said the resident is to be up for all meals as directed by the care plan. He was unaware the ST had a student feed the resident in bed while she was in bed. At approximately 11:00 a.m. on [DATE], the above observations, record review, and staff interview was relayed to the director of nursing (DON). No further information was provided. b) Resident #74 Review of the physician's orders [REDACTED]. Review of the current care plan found the following problem: Resident receives antipsychotic medication [MEDICATION NAME] related to major Dementia with episodes of paranoia and believing others are out to get her, frequently changing mind about care and false allegations toward others, mood disorder. The goal associated with the problem: Attempted titration of antipsychotic/hypnotic/mood stabilizer medication. Interventions included: Attempt gradual dose reduction of [MEDICATION NAME] in accordance with physician orders [REDACTED]. Monitor/record report to physician as needed side effects and adverse reactions of psychoactive medications: [REDACTED] The care plan did not include any non-pharmacological interventions to attempt in addition to the medication. At 4:50 PM on [DATE], the director of nursing (DON) and a corporate quality standards coordinator, #108 were interviewed regarding the absence of the non-pharmacological interventions on the care plan. The DON noted the non-pharmacological interventions were listed on the care plan for the use of the antianxiety medication, [MEDICATION NAME]. The DON said they would probably just be the same for the use of [MEDICATION NAME]. However, the DON verified the non-pharmacological interventions for the use of [MEDICATION NAME] were not listed on the care plan. c) Resident #52 Observation on [DATE] and [DATE] Resident #52 was in bed all day. Interview [DATE] 01:20 PM with Resident #52's daughter found the daughter states she comes in every day at lunch and dinner to feed her mother. Review of the progress notes found on two (2) occasions on [DATE] at 1:13 pm. Progress note written by Employee #8, activity director, Catholic priest attempted to conduct a clergy and communion on this date, however, resident was involved in another activity. and on [DATE] at 11:41 am Catholic priest attempted to conduct a clergy and communion on this date, however, resident was in bed, sleeping per preference. Interview with the activity director on [DATE] at 12:40 pm when asked about the priest not being able to visit with the resident she said, on [DATE] the other activity was a shower. And on [DATE] the resident was asleep no evidence the staff attempted to awaken the resident. Interview with family (two (2) daughters and son-in-law) on [DATE] at 12:10 pm, they all expressed the resident always attended Mass when she was able and although she can not participate in communion due to her physical condition she would want to visit and pray with priest. Activity assessment was completed on [DATE] at 2:55 pm with the daughter's assistance. Admission MDS with Assessment Reference date of [DATE] section Preferences for Customary Routine and Activities was completed by the activity director on [DATE] at 1:50 pm. This was marked 0 which indicates No (resident is rarely/never understood and family/significant others is not available) Skip to and complete F 0800 , Staff assessment of daily and activity preference. The only item marked was Family or significant other involvement in care discussions. Care plan reviewed: Last reviewed and updated on [DATE] found a Focus- Irene has little or no activity involvement and is rarely understood due to [MEDICAL CONDITION]. Intervention Honor patient's preference to participate Catholic church services. The DON was notified, on [DATE] at 1:10 pm, of the inability of the Catholic preast to visit Resident #52 on two (2) separate occassions. The Catholic preist was notified and he was able to visit the resident in the afternoon of [DATE]. She agreed the intervention had not been implemented. d) Resident #55 During an observation and interview on [DATE] at 12:40 PM, Nurse Aide (NA) #13 said that, she has not seen hospice, and does not know when hospice is to come to the facility, she said she provides a bed bath daily for Resident # 55. She is at bedside currently feeding Resident # 55. During an interview on [DATE] at 12:46 PM, Clinical Care Supervisor #73 was asked about communications and correlations with hospice. She said that the hospice registered nurse may have been to the facility, but she is not sure when. She said that, she has not seen an aide come to provide care for Resident #55. Hospice started on [DATE]. She said that she is not sure when the Hospice nurse and aide are supposed to come. She was asked if she could find any notes from the Hospice nurse. She could only find two (2) notes dated [DATE] and [DATE], both in regard to a giving the resident Intravenous (IV) fluids. She also called the DON and asked her when Hospice was scheduled to come and provide care and where can she find their notes. She the Hospice nurse and/or aide is supposed to complete a note and give it to the Charge nurse, then it will be scanned into the Resident's Chart. During an interview on [DATE] at 1:28 PM, DON was asked if she can find any notes from the hospice nurse about when a Nurse Aide, Social Worked, Clergy, and Nurse has been here. She said that, the only note she can find is that the Registered Nurse was in the facility on Thursday [DATE]. During an interview on [DATE] at 4:05 PM, Administrator was informed that staff is unaware of when the Hospice services are to provide care for Resident #55. During a phone interview on [DATE] 02:14 PM, with the Resident's daughter of the resident, she was told hospice did not have any NAs at this time, SW and the RN was in to see her on ,[DATE] or ,[DATE] for her initial assessment and Minister has been to see her mother on ,[DATE] or ,[DATE]. She said it was started on [DATE]. On [DATE] 02:28 PM DON provided Hospice notes she said she had Hospice fax to her today. This revealed that Hospice has been to the Facility for visits a total of seven (7) times. Hospice has also had eight (8) phone call communications. Dates of visits are as follows: --Social Worker visit on [DATE] at 11:15 AM until 12:00 PM. --Licensed Practical Nurse visit on [DATE] at 1:10 PM until 1:40 PM. --Registered Nurse visit on [DATE] at 1:10 PM until 1:45 PM. --Registered Nurse visit on [DATE] at 1:45 PM until 3:15 PM. --Registered Nurse visit on [DATE] at 10:06 AM. --Clergy visit on [DATE] at 2:00 PM until 2:30 PM. --Registered Nurse vast on [DATE] at 4:47 PM. --Registered Nurse visit on [DATE] at 12:15 PM until 12:45 PM. Review of records, Operations Policy Hospice Services was started on (MONTH) 25, 2014 with (name of hospice provider) stated the following: --An integrated plan of care between the resident and/or responsible party, the facility, and hospice agency will be developed that delineates the services that will be provided by the hospice staff and the survives that will be provided by the facility staff. --The integrated plan of care will be recorded in the resident's medical record, periodically reviewed, and updated, as necessary. --All communications between the hospice and facility when any changes are indicated or made to the plan of care. --The Care Plan will include Hospice services included nursing care; Medical Social Services; Counseling services (including bereavement, dietary and spiritual counseling); physical therapy, occupational therapy and speech-language pathology services; health aide/homemaker services; management of terminal illness SPECIFIED BY THE CARE PLAN. Physicians Oder's Dated [DATE] revealed Resident #55 had expressed preferences for end-of-life care [DATE]. Facility Care Plan: Review of Care Plan revealed the following dated [DATE]: --Patient shall receive treatment in accordance with expressed wishes as documented on POST --No CPR -- DO NOT attempt resuscitation (CNA) --POST form will be sent with patient to physician appointments and upon transfer/discharge --Special directives or limitations: Comfort Measures; Antibiotics, IV Fluids for a Trial Period of 30 Days; No Feeding Tube; Hospices services Palliative Care due to Hospice --To be comfortable --To be pain free --Activities will visit in room, she prefers to stay in her room. --Hospice nurse to visit at least weekly --Initiate Spiritual care consult if indicated Palliative Care due to Hospice [DATE] --Resident receives hospice services through (name of hospice provider) --Notify hospice of any change in condition or acute transfer to hospital. --Turn and reposition every 2 hours The care plan does not contain information regarding when the Registered Nurse, Licensed Practical Nurse, Social Worker, Aide and Clergy will visit or how often.",2020-09-01
3489,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,657,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, staff interview, family interview, and resident interview, the facility failed to ensure review and revision of the comprehensive care plan for two (2) of twenty-five (25) residents reviewed during the Long-term Care Survey process. Additionally, the facility failed to ensure participation of the resident in the comprehensive care plan process for one (1) of two (2) residents reviewed in the are of Care Planning. Resident identifiers: #285, #74, #24. Facility census: 89. a) Resident #285 Resident #285 had a suprapubic catheter. On 09/25/18 at 11:13 AM, Certified Nursing Assistant #13 was observed during performance of suprapubic catheter care to Resident #285. The suprapubic catheter tubing was noted not to be secured to the resident's leg. Securing the catheter tubing is the standard of care to prevent the catheter from being accidently dislodged due to extensive tension on the catheter. Resident #285's comprehensive care plan contained the intervention to secure catheter. On 09/25/18 at 11:55 AM, Quality Standards Coordinator #108 was informed Resident #285's suprapubic catheter tubing was not secured to his leg as instructed in his comprehensive care plan. When this surveyor and Quality Standards Coordinator #108 went into Resident #285's room at this time, the resident's daughter stated she and the resident preferred not to have the suprapubic catheter tubing not secured to his leg. Quality Standards Coordinator #108 stated she would revise Resident #285's comprehensive care plan to reflect the resident's preferance to not have his suprapubic catheter tubing secured to his leg. b) Resident #74 On 09/24/18 at 1:18 PM, the resident was observed with her noon meal tray. She was in bed with the meal on the over the bed table. The resident asked the surveyor to feed her because, I need help because of my hands. Observation found both of the residents hands were severely contracted. The resident was eating her grilled cheese sandwich. She said she could not use her spoon to eat the rest of her meal. The resident did have a 2 handled cup, divided plate and plate guard. Staff were alerted of the resident's request and came to assist the resident. Review of the current care plan found the problem: Resident has a nutritional problem related to [MEDICAL CONDITION], dysphagia and GERD. The goal associated with the problem: Patient will maintain adequate nutritional status as evidenced by maintaining weight within 125 to 135 pounds, no signs or symptoms of malnutrition and consuming at least 50% of at least 2 meals daily through next review date. Interventions included: Eating, Provide adaptive equipment for dining as ordered 2 handled cup with all meals, divided plate, plate guard with all meals. There was no intervention to assist the resident with meal service. Again during the noon meal on 09/25/18 at 12:39 PM the resident said she needed some help eating her soup. The resident was attempting to feed herself. At 12:50 PM on 09/25/18, the physical therapy assistant, PTA #65 and Registered Nurse (RN) #5 were present in the resident's room when the resident demonstrated she could put the spoon into her soup but she could not turn the spoon sideways to get the soup onto her spoon until it could reach her mouth. She said I can only stick the spoon straight up and down today, I can't turn it. On 09/25/18 at 1:21 PM, the occupational therapy registered/licensed therapist, (OTR) #63 came into the room to observe the resident. The resident related the same story regarding the spoon and provided a demonstration. OTR #63 said he was going to order some assistive devices for the resident, such as a wrap to put around the spoon to hold it to the resident's hand. OTR #63 put a piece of red foam tubing around the spoon to see if this would enable the resident to feed herself. The OTR said he last worked with the resident in June, (YEAR) and she could eat by herself when he discharged her from therapy. He said he never ordered any splinting devices for her hands because, She is to far gone. He said her hands were severely contracted upon admission to the nursing home. On 09/25/18 at 2:49 PM the director of nursing (DON) said this was the first she had ever heard about the resident not being able to feed herself. On 09/26/18 at 5:02 PM, OTR #63 said when he stood outside the door during lunch today, he observed the resident feeding herself just fine without assistance. He said she was doing just fine without adaptive equipment. After surveyor intervention, the care plan was updated with the intervention: Eating self performance: Patient requires set up assist. (Name of resident) prefers to eat most meals in her bed per her preference. At times has poor intake when self feeding, staff to assist with meals when has decreased intake if she's agreeable to assistance. c) Resident #24 An interview with Resident #24 at 3:35 p.m. on 09/26/18 found she has not been invited to her care plan meeting. She stated that she has not been to any meeting with a group of staff members nor has any group of staff ever come to her room to meet with her. She stated, I might like to go to that and talk about what's going on with my care. A review of Resident #24's medical record at 4:00 p.m. on 09/26/18 found a physician determination of capacity dated 04/19/18 which indicated Resident #24 was able to make her own health care decisions. Further review of the record found a care plan meeting summary note dated 07/24/18 which contained the signatures of everybody who attended Resident #24's care plan meeting on this dated the signatures included were, the Resident assessment nurse coordinator (RNAC), the Social Worker, the Certified Dietary Manager, and the activities director. Resident #24's husband also signed the form as being in attendance. The section where the resident could have signed was blank and the form indicated Resident #24 was not in attendance. The form indicated for more information you could refer to the Multidisciplinary note in PCC (point click care). A review of the Multidisciplinary Note in PCC found the following information contained in the note, Care plan team meet with Residents husband. Resident is alert and orientated .the attendees were listed as the Social Services Supervisor, The RNAC, CCS (Clinical Care Supervisor), the activity director, and the residents husband. An interview with the Social Services Supervisor #70 at 4:00 p.m. on 09/26/18 confirmed the resident did not attend her 07/24/18 and there was no evidence in the medical record to indicate Resident #24 was ever invited to her care plan meeting.",2020-09-01
3490,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,677,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview and staff interview, the facility failed to ensure two (2) of three (3) dependent residents received assistance with activities of daily living (ADL's) Resident #78 did not receive assistance with meals when needed. Resident #20 did not receive assistance with personal grooming as desired. Resident identifiers; #78 and #20. Facility census: 89. Findings include: a) Resident #78 Observation of the first meal served, after entrance to the facility, was the noon meal on 09/24/18 at 12:30 PM. The resident was in bed when the noon meal was served. Staff delivered the resident's tray, set up the tray, on the over the bed table, and left the room. The resident was sleeping, laying on her right side in a fetal position. The resident did not get out of bed for the meal. Approximately ten minutes after serving the tray, staff returned to pick up the tray. Documentation on the meal intake noted the resident refused the tray. Review of the medical record found the resident's diet orders: NDD level 1, pureed texture, regular consistency, Kennedy cup with straws for all meals. A level 1 national dysphagia diet (NDD) includes only pureed foods. Pureed foods should have the same texture as pudding. They should be smooth and free of lumps. At approximately 12:30 PM on 09/25/18, the resident received the noon meal tray. She was seated in a personal recliner beside her bed. The nursing assistant (NA) set up her tray by opening the silverware and removing the lids from bowls. The resident's milk was poured in her Kennedy cup and she had a straw. The NA left the resident's room. At 1:06 p.m. on 09/25/18, the resident was observed with a bite of a pureed sandwich pocketed in her mouth. It appeared the resident had only taken 1 bite of the pureed sandwich. Her spoon was still sticking straight up in the bowl of pureed broccoli cheese soup, which she had not attempted to feed herself. She was slumped to the right side of the recliner, sleeping. At 1:08 p.m. on 09/25/18, the physical therapy assistant (PTA) observed the resident in her room. She verified the resident had pocketed her food, which was still in her lower lip, between the lip and the gum. The PTA verified the positioning of the resident in her recliner was, Poor. The PTA stated, Normally she is up in the wheelchair, it has lateral supports so she doesn't lean to the side. She does better in the wheelchair. The over the bed table was too high making it difficult for the resident to reach her food. The Kennedy cup with her milk had been placed at the back of the over the bed table. The PTA said most likely the resident could not reach her drink. The PTA said she would get the resident's NA to help the resident with her meal. At 1:10 PM on 09/25/18, the resident's NA #72 entered the resident's room. NA #72 said she is suppose to set up the resident's meal tray. NA #72 tried to talk the resident into eating her meal. The resident did not respond, only stared at the N[NAME] The NA did give her a drink of her milk and the resident finally swallowed the pocketed food in her mouth. The NA said she did not know how long the resident was unable to feed herself. The NA said, therapy was in here yesterday trying to get her to eat. NA #72 did not attempt to reposition the resident in her chair while feeding the resident. The resident did not eat by herself. At 1:23 PM PM 09/25/18, the resident was observed eating the broccoli cheese soup being fed by NA #72. Staff later recorded the resident ate 30% of her meal in the documentation of meal intake in the electronic medical record. Review of the resident's current care plan found the problem: Resident has a nutritional problem related to Alzheimer, [MEDICAL CONDITION] a GERD. She has decreased meal intake at times. The goal associated with the problem: Patient will maintain adequate nutritional status as evidenced by maintaining weight within 75 to 85 pounds, no signs or symptoms of malnutrition and consuming at least 50% of at least 2 meals daily through review date. Interventions included: Provide adaptive equipment for dining as ordered Kennedy cup with straw. A second care plan problem: Resident has a ADL (activities of daily living) self care Performance deficit related to impaired mobility, weakness, impaired memory. The goal associated with the problem: Patient is expected to have variations in her ADL's due to Alzheimer's. She will have no complications related to current level of function in bed mobility, transfers, eating, dressing, toilet use and/or personal hygiene through next review date. Interventions included: Patient requires set up assistance, she is to be in wheelchair or recliner for breakfast, lunch and dinner. A third problem on the care plan: Resident has a swallowing problem related to holding food in mouth/cheeks (pocketing). The goal associated with the problem: Patient will have no choking episodes when eating through the review date. Interventions included: Resident tends to pocket food and push them out, she consumes food with greater ease when pancake syrup is drizzled over it. If you notice pocketing of foods or poor intake please ask kitchen for syrup. Check mouth after meal for pocketing and debris. Report to unit charge nurse. Provide oral care to remove debris. On 09/25/18 at 01:49 PM, the administrator was advised of the above observations related to the resident's meal service. At 7:50 a.m. on 9/26/18, the Speech Therapist (ST) #83 was observed in the resident's room. ST #83 said the resident needs to be fed. ST #83 introduced a student who was feeding the resident under the supervision of ST #83. ST #83 said the resident occasionally drinks her liquids by herself. The resident was in bed during the feeding of the morning meal. When asked if ST #83 knew the care plan said the resident was to be up in the wheelchair or her recliner for all meals, she replied, It isn't a problem, she is up in bed and positioned for her meal. Continued observation found the student fed the resident the entire meal while the resident was in bed. On 09/26/18 at 8:54 AM, the dietary manager (DM) #75 said the resident is to be up for all meals as directed by the care plan. He was unaware the ST had a student feed the resident in bed while she was in bed. He was aware the resident has gradually been loosing weight. Weight on 03/26/18 was 87.1 pounds. The resident's weight on 09/17/18 was 80.6 pounds. The facility addressed the resident's weight loss by changing her diet, adding supplements and protein, getting her up for meals, etc. At 9:41 AM on 09/26/18 the occupational therapist registered/licensed, (OTR) #63, said he was going to evaluate the resident to determine how much assistance the resident requires with eating. On 09/26/18 at 2:00 PM, the Registered Nurse Assessment Coordinator (RNAC) provided at copy of a new intervention for the care plan. Eating self performance: Patient requires set up assistance; she is to be in wheelchair or recliner for breakfast, lunch, and dinner. Please assure dentures are in for all meals. Staff to assist with meal intake as needed if (Name of Resident) has poor intake. (The care plan modification noted staff are to assist with meals as needed if the resident has poor intake.) At 10:23 a.m. on 09/27/18, the OTR said the resident requires supervision during meal time. Supervision is more than just set up the tray. There are some of those days when the resident needs more. Now we have it care planned for a short table when in the wheelchair and if needed the short table when she is in her reclining chair. She can use the regular table when she is in bed. The OTR provided a copy of his note completed on 09/26/18.Patient continues to require supervision with self feeding during all meals. Patient was observed during lunch using a standard bedside table while sitting in wheelchair. Patient presented with mild difficulty due to height of table. Maintenance was notified that patient would benefit with shorter bedside table while sitting in wheelchair. Maintenance was able to supply patient with shorter bedside table in order to improve positioning during self feeding. At approximately 11:00 a.m. on 09/27/18, the above observations, record review, and staff interview was relayed to the director of nursing (DON). No further information was provided. b) Resident #20 An observation of Resident #20 on 09/24/18 at 4:23 p.m. found hair on this female residents chin at least one half inch in length. When asked if she was okay with having the hair on her chin, Resident #20 stated, No I am not okay with it. When asked if she would like someone to help her to remove the hair she stated that she would like that. At this time Registered Nurse (RN) #71 indicated she would get someone to help shave the resident. She confirmed the hair on Resident #20's chin needed to be removed and Resident #20 was not able to remove it herself. A review of Resident #20's care plan at 4:23 p.m. on 09/24/18 found Resident #20 required extensive assistance with her personal hygiene with a staff assistance of one (1).",2020-09-01
3491,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,679,D,0,1,DXEI11,"Based on medical record review, family/responsible party interview and staff interview, the facility failed to ensure for each resident an ongoing resident centered activities program that incorporates the resident's interests, hobbies and cultural preferences which is integral to maintaining and/or improving a resident's physical, mental, and psychosocial well-being and independence. Resident #52' s priest from the Catholic church attempted to visit on two (2) separate occasions and was unable to meet with the resident. Resident identifier: #52. Facility census: 89. Findings include: a) Resident #52 Observation on 09/24/18 and 09/25/18 Resident #52 was in bed all day. Interview 09/24/18 01:20 PM with Resident #52's daughter found the daughter states she comes in every day at lunch and dinner to feed her mother. Review of the progress notes found on two (2) occasions on 08/31/18 at 1:13 pm. Progress note written by Employee #8, activity director, Catholic priest attempted to conduct a clergy and communion on this date, however, resident was involved in another activity. and on 09/07/18 at 11:41 am Catholic priest attempted to conduct a clergy and communion on this date, however, resident was in bed, sleeping per preference. Interview with the activity director on 09/25/18 at 12:40 pm when asked about the priest not being able to visit with the resident she said, on 08/31/18 the other activity was a shower. (Review of Resident #52's Activities of Daily Living documentation indicated the resident received a shower at 2:46 pm) Additionally, on 09/07/18 the resident was asleep no evidence the staff attempted to awaken the resident. Interview with family (two (2) daughters and son-in-law) on 09/25/18 at 12:10 pm, they all expressed the resident always attended Mass when she was able and although she cannot participate in communion due to her physical condition she would want to visit and pray with priest. At 1:41 p.m. on 09/27/18, these observations and interviews with staff were discussed with the Administrator and the Director of Nursing. At the close of the survey on 09/27/18, no further information was provided.",2020-09-01
3492,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,684,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, policy review and record review, the facility failed to ensure received quality care. This was true for 3 of 25 residents reviewed in the quality care area. Resident #55 the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care and/or communicate and collaborate with hospice. This was true for one resident of one in the care area of hospice. For Resident #74 the facility failed to identify skin issues. For resident #68 the facility failed to complete neuro checks after an unwitnessed fall. Resident identifiers: # 55, #74 and #68. Facility census 89. Finding included: a) Resident #55 During an observation and interview on [DATE] at 12:40 PM, Nurse Aide (NA) #13 said that, she has not seen hospice, and does not know when hospice is to come to the facility, she said she provides a bed bath daily for Resident # 55. She is at bedside currently feeding Resident # 55. During an interview on [DATE] at 12:46 PM, Clinical Care Supervisor #73 was asked about communications and correlations with hospice. She said that the hospice registered nurse may have been to the facility, but she is not sure when. She said that, she has not seen an aide come to provide care for Resident #55. Hospice started on [DATE]. She said that she is not sure when the Hospice nurse and aide are supposed to come. She was asked if she could find any notes from the Hospice nurse. She could only find two (2) notes dated [DATE] and [DATE], both in regard to a giving the resident Intravenous (IV) fluids. She also called the DON and asked her when Hospice was scheduled to come and provide care and where can she find their notes. She the Hospice nurse and/or aide is supposed to complete a note and give it to the Charge nurse, then it will be scanned into the Resident's Chart. During an interview on [DATE] at 1:28 PM, DON was asked if she can find any notes from the hospice nurse about when a Nurse Aide, Social Worked, Clergy, and Nurse has been here. She said that, the only note she can find is that the Registered Nurse was in the facility on Thursday [DATE]. During an interview on [DATE] at 4:05 PM, Administrator was informed that staff is unaware of when the Hospice services are to provide care for Resident #55. During a phone interview on [DATE] 02:14 PM, with the Resident's daughter of the resident, she was told hospice did not have any NAs at this time, SW and the RN was in to see her on ,[DATE] or ,[DATE] for her initial assessment and Minister has been to see her mother on ,[DATE] or ,[DATE]. She said it was started on [DATE]. On [DATE] 02:28 PM DON provided Hospice notes she said she had Hospice fax to her today. This revealed that Hospice has been to the Facility for visits a total of seven (7) times. Hospice has also had eight (8) phone call communications. Dates of visits are as follows: --Social Worker visit on [DATE] at 11:15 AM until 12:00 PM. --Licensed Practical Nurse visit on [DATE] at 1:10 PM until 1:40 PM. --Registered Nurse visit on [DATE] at 1:10 PM until 1:45 PM. --Registered Nurse visit on [DATE] at 1:45 PM until 3:15 PM. --Registered Nurse visit on [DATE] at 10:06 AM. --Clergy visit on [DATE] at 2:00 PM until 2:30 PM. --Registered Nurse vast on [DATE] at 4:47 PM. --Registered Nurse visit on [DATE] at 12:15 PM until 12:45 PM. Review of records, Operations Policy Hospice Services was started on (MONTH) 25, 2014 with (name of hospice provider) stated the following: --An integrated plan of care between the resident and/or responsible party, the facility, and hospice agency will be developed that delineates the services that will be provided by the hospice staff and the survives that will be provided by the facility staff. --The integrated plan of care will be recorded in the resident's medical record, periodically reviewed, and updated, as necessary. --All communications between the hospice and facility when any changes are indicated or made to the plan of care. --The Care Plan will include Hospice services included nursing care; Medical Social Services; Counseling services (including bereavement, dietary and spiritual counseling); physical therapy, occupational therapy and speech-language pathology services; health aide/homemaker services; management of terminal illness SPECIFIED BY THE CARE PLAN. Physicians Oder's Dated [DATE] revealed Resident #55 had expressed preferences for end-of-life care [DATE]. Facility Care Plan: Review of Care Plan revealed the following dated [DATE]: --Patient shall receive treatment in accordance with expressed wishes as documented on POST --No CPR -- DO NOT attempt resuscitation (CNA) --POST form will be sent with patient to physician appointments and upon transfer/discharge --Special directives or limitations: Comfort Measures; Antibiotics, IV Fluids for a Trial Period of 30 Days; No Feeding Tube; Hospices services Palliative Care due to Hospice --To be comfortable --To be pain free --Activities will visit in room, she prefers to stay in her room. --Hospice nurse to visit at least weekly --Initiate Spiritual care consult if indicated Palliative Care due to Hospice [DATE] --Resident receives hospice services through (name of hospice provider) --Notify hospice of any change in condition or acute transfer to hospital. --Turn and reposition every 2 hours The care plan does not contain information regarding when the Registered Nurse, Licensed Practical Nurse, Social Worker, Aide and Clergy will visit or how often. b) Resident #74 Observation of the resident at 1:28 PM on [DATE], found the resident had long strips of dry skin on the heels of both feet. Some of the strips were barely secured to the heel and were hanging from the resident's heels. Dry patchy skin was also present on the tops of the resident's feet. Record review found a summary note, completed on [DATE] at 10:42 PM, noting no skin issues just preventive care was being provided. A second summary note completed at 3:52 AM on [DATE], (approximately 6 hours prior to this observation) noted the residents skin conditions/treatments: Preventative. At 10:43 AM on [DATE], the residents heels were again observed with the Registered Nurse, (RN)unit charge manager RN #71, this surveyor and a RN surveyor. RN #71 said, The heels appear to be getting soft but they still blanch so it isn't a pressure ulcer. RN #71 demonstrated by gently pushing into the skin with her index finger on both heels. (Blanching of the skin occurs when the skin becomes white or pale in appearance. Blanching of the skin typically indicates a temporary obstruction of blood flow. If you press gently on an area of your skin, it likely turns lighter before resuming its natural color.) She stated she would call the physician and get an order for [REDACTED].#71 did not know how long the resident's heels had the dry peeling skin. On [DATE] at 11:16 AM the director of nursing (DON) was informed of the observations and interview. The DON was unsure what the nurse was meaning when she documented, preventive care, in the note of [DATE]. A copy of a new order, written on [DATE] was provided. The order directed: apply skin prep to bilateral heels every shift until healed, every day for blanchable pink heels. c) Resident #68 Record review found the resident had an unwitnessed fall with a suspected head injury at the facility on [DATE] at 3:40 pm. Further review of the progress notes found the following description of the event: - The resident was found sitting on the floor on the left side of bed in a sitting position. Injury to right portion of temporal area noted; actively bleeding. Assessed for injury; laceration to right temporal area, vital signs obtained, dressing applied to wound and, neurochecks initiated. Review of the Neurological Evaluation found on [DATE] at 4:00 pm was sent to the hospital. Resident returned from the hospital at 8:30 pm and neurochecks were resumed. The neurochecks for [DATE] at 1:30 am, 3:30 am and 5:30 am were not completed. At 3:15 p.m. on [DATE], the Director of Nursing (DON) confirmed there were no neuro-checks completed on [DATE] at 1:30 am, 3:30 am and 5:30 am. No further information was provided.",2020-09-01
3493,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,686,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to ensure a resident with pressure ulcers received necessary treatment and services, consistent with professional standards of practice, to promote healing, prevent infection and prevent new pressure ulcers from developing. The facility failed to complete an accurate and complete pressure ulcer assessment for one (1) of three (3) residents reviewed for the care area of pressure ulcers. Resident identifier: #50. Facility census: 89. Findings included: a) Resident #50 Resident #50 was readmitted to the facility on [DATE] after a brief stay in the hospital. Prior to being discharged from the facility to the hospital, Resident #50 had a stage two (2) pressure ulcer on her left inner thigh. Review of the resident's medical records revealed no pressure ulcer assessment when the resident returned to the facility on [DATE]. On 09/27/18 at 08:30 AM, the Director of Nursing (DoN) provided a Skilled Service Note dated 09/22/18 which documented the presence of a stage two (2) pressure ulcer on Resident #50's left inner thigh. The DoN stated Resident #50's pressure ulcer was not documented prior to this document. The DoN stated Resident #50's pressure ulcer had not been measured. She stated a Wound Assessment Form should have been completed upon Resident #50's readmission to the faci.lity, but it had not been done.",2020-09-01
3494,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,689,D,0,1,DXEI11,"Based on observation and staff interview, the facility failed to ensure the environment was free of accident hazards for one out of one resident reviewed for the care area of accidents. The hazard was a medicated powder left at the bedside. Resident identifier: #385. Facility census: 89. Findings included: a) Resident #385 During observation on 09/25/18 at 3:30 PM, a bottle of Medline Remedy Phytoplex antifungal powder was found on the Resident #385's bedside table. Package information indicated the product was harmful if swallowed. Licensed Practical Nurse (LPN) #17 was notified and removed the antifungal powder from Resident #385's room and placed it in the med cart. LPN #17 agreed the powder should not have been left at the resident's bedside. During resident council meeting on 09/26/18 at 2:00 PM, residents complained about a wandering resident who was entering other residents' rooms and pilfering their things.",2020-09-01
3495,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,690,E,0,1,DXEI11,"**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) residents reviewed for the care area of urinary catheter. Resident #68 was admitted with an indwelling catheter with no [DIAGNOSES REDACTED]. Resident identifier: #68. Facility census: 89. Findings included: a) Resident #68 The resident was admitted to the facility on [DATE] from an acute care facility. Review of the discharge summary found, a Foley catheter was placed during diuresis. This may be removed and straight catheterization performed after return to the nursing home (NH). Further review found a Physician visit assessment note dated 07/29/18 read, [MEDICAL CONDITION] is chief complaint. She was diuresis in the hospital. a Foley was placed for diuresis and remains (retention?). Plan of care: .will see if the Foley can be discontinued. Physician orders [REDACTED]. Nurses notes were silent to the bladder training completed on 08/16/18. On the morning of 09/26/18, the Director of Nursing (DON) was asked to provide this surveyor with a policy/protocol for bladder training with a Foley catheter. She said the facility did not have a policy addressing bladder training with a Foley catheter. Unable to explain the process for the bladder retraining with a catheter and was given an in-service dated (MONTH) (YEAR). This in-service did not have the contents of the in-service just listed Discontinuing catheters- bladder retraining every 2 hours.",2020-09-01
3496,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,698,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, resident interview and staff interview, the facility failed to ensure a [MEDICAL TREATMENT] resident received appropriate care. Resident #235 has venous access device in her right chest wall which is used for her [MEDICAL TREATMENT] access. Because of this access Resident #235 has a physician's orders [REDACTED].#235's right arm for blood pressures and lab draws. On two (2) separate occasions while at the facility labs were obtained from Resident #235's right arm. This is true for one (1) of one (1) residents reviewed for the care area of [MEDICAL TREATMENT] during the Long Term Care Survey Process. Resident identifier: #235. Facility census: 89. Findings included: a) Resident #235 An interview with Resident #235 and her daughter on 09/24/18 at 3:34 p.m. revealed that on one occasion right after admission to the facility Resident #235's right arm was used to obtain lab work. The residents daughter indicated this caused the resident to have a large hematoma to her right arm. The resident and her daughter both indicated this happened when they were obtaining a PT/INR ([MEDICATION NAME] time/international normalized ratio) one Monday morning. A review of Resident #235's medical record on 11/26/18 at 9:00 a.m. found the following lab/Diagnostic Note, Note Dated 09/10/18 at 7:44 a.m. read as follows, Order: PT/INR. Services Provided (including who collected specimen, obtained x-ray, patient tolerance etc.) : Specimen collected by (name of local lab service) lab tech from RAC(Right Antecubital) on Second Stick. First Stick in LAC (Left Antecubital). Note Dated 09/17/18 at 6:37 a.m. read as follows, Order: PT/INR. Services Provided (including who collected specimen, obtained x-ray, patient tolerance etc.) : Services provided by (Name of Local Lab) lab. Specimen obtained from Right AC (Antecubital). Tolerated well. Further review of the medical record found the following physician order [REDACTED]. An interview with the Director of Nursing (DON) at 11:08 a.m. on 9/26/18 confirmed Resident #235 should not have lab draws in her right arm. She reviewed the notes quoted above and agreed the lab works were obtained from the restricted limb. She indicated that it should be wrote in the lab book that Resident #235 has a restricted limb. She reviewed the lab book information for 09/17/18 and stated, The nurse did not write Resident #235 had a restricted limb and that is likely why they obtained it from the right arm. She stated, I can not find the lab sheet for 09/10/18 and was unable to confirm why that lab was obtained in the right arm.",2020-09-01
3497,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,757,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure Resident #67's drug regimen was free from unnecessary medications. Resident #67 received an extra dose of antibiotic on two (2) separate occasions during the month of August, (YEAR). This was true for one (1) of five (5) residents reviewed for the care area of unnecessary medications during the Long Term Care Survey Process. Resident identifier: #67. Facility census: 89. Findings included: a) Resident #67 A review of Resident #67's medical record at 9:11 a.m. on 09/25/18 found a physician order [REDACTED]. Further review of the record found a progress note related to this order which read as follows, Dr. (last name of attending physician) on facility, [MEDICATION NAME] 500 mg po (by mouth) daily X (for) 7 days . A review of the Medication Administration Record [REDACTED]. Additional review of the medical record found a physician order [REDACTED]. Also contained in the medical record was a hand written prescription from a local hospital dated 08/07/18 which read, [MEDICATION NAME] - [MEDICATION NAME] (Generic name for Bactrim DS) (100 mg - 800 mg) Take 1 tablet by mouth two times per day for three days. This was a hand written prescription given to the resident upon her discharge from the hospital on [DATE]. A review of Resident #67's MAR for the month of August, (YEAR) found Resident #67 received one (1) dose of bactrim on 08/07/18 at 9:00 p.m. and two doses daily beginning on 09/09/18 through 09/11/18. This was a total of seven (7) doses instead of the physician prescribed six (6) doses. An interview with the Director of Nursing (DON) at 3:00 p.m. on 09/25/18 confirmed Resident #67 received an extra dose of the [MEDICATION NAME] and bactrim.",2020-09-01
3498,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,759,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, policy review and staff interview, the facility failed to maintain a medication administration error rate less than 5% the error rate was 5.41%. This was true for 37 opportunities with two (2) errors. Resident identifiers: #14 and #44. Facility census 89. Findings included: a) Resident #14 During an observation and interview on 09/26/18 at 8:01 AM, Licensed Practical Nurse (LPN) #9 approached Resident #14 with his AM medication while he was in the dining room eating his breakfast. LPN #9 spooned the pills into his mouth mixed with apple sauce and handed him the [MEDICATION NAME] (a stool softener) in a cup of water, she did not mix the [MEDICATION NAME] most of the medication remained in the bottom of the cup. This was brought to her attention and she said, Do you want me to give him more? She was instructed to check with her Supervisor. She agreed that most of the powdered medication was remaining in the cup. During an interview on 09/26/18 at 8:51 AM, Director of Nursing was informed about observation. She said she is new has been working at this facility since 08/28/18. b) Resident #44 During an observation on 09/26/18 at 9:43 AM, LPN #9 was holding the measuring cup in the air pouring [MEDICATION NAME]/[MEDICATION NAME] liquid into the cup. It was pointed out to her that she may need to check the measurement on a flat surface. She did place the measuring cup on the medication cart, then had to pour some of the medication back into the bottle. Resident #44 orders revealed she was to receive 5 Milliliters (ML) of [MEDICATION NAME]/[MEDICATION NAME] for a cough. The amount Resident # 44 would have received without surveyor intervention would have been 10 ML., twice the ordered amount. She agreed there was too much of this medication in the medicine cup. During an interview on 09/26/18 at 1:51 PM, Administrator to inform about finding and looking policy for disposal of medications and medication administration. Facility Policy, Administration Oral Medications Revised Dated: 07/1/09 reads as follows: - For liquid medications, shake well Place cup on level surface and read the pour at eye level to check accuracy - For powdered medications. Dissolve immediately before administration",2020-09-01
3499,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,761,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and policy review, the facility failed to appropriately labelled medications with resident's name and open date on the bottle of multi-use eye drops. Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable., the resident's name, and route of administration. The medication should also be labelled with or accompanied by appropriate instructions and precautions (such as shake well, take with meals, do not crush, special storage instructions). For medications designed for multiple administrations (e.g., inhalers, eye drops), the label should identify the specific resident for whom it was prescribed. This was true for three (3) of 12 eye drops in the medication cart. This had the potential to adversely affect two (2) Residents #44 and#37. Facility census 89. Findings included: a) Resident #44 During an observation on 09/26/18 at 9:07 AM, in the medication cart on the light house hall, three (3) of 12 eye drops. For Resident #44 there were two (2) separate eye drops, Fluorometholone (steroid) medicine to prevent inflammation and Ketotifen ([MEDICATION NAME]) eye drops did not have the residents name on the bottle or the date it was opened. The pharmacy label that was supposed to be on the bottle was placed on the lid of the box. Licensed Practical Nurse (LPN) #9 verified there was no name or date they were opened on these eye drops. b) Resident #37 The medication Latanoprost eye drops (is a [MEDICAL CONDITION] Medication to help prevent the pressure from rising inside of the eye. There was not any label on the bottle to indicate whom this medication belonged to or the date it was opened. LPN #9 verified there was no name or date it was opened on this bottle of eye drops. During an interview on 09/26/18 at 10:01 AM, DON informed about findings and asked for the facility policy for labeling medication. Facility Policy, Labeling of Medication dated 2001 Revised 09/2003, reads as follows: --Labels must be permanently affixed to the outside of the prescription container --Labels must include: resident's name, multiuse must be dated and initialed by nurse --Labels for over the counter medications must contain: resident's full name and date opened --Only the issuing pharmacy may place a drug label on medication container.",2020-09-01
3500,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,773,D,0,1,DXEI11,"Based on record review and staff interview, the facility failed to ensure all labs were obtained only when ordered by a physician. Resident #235 had a PT/INR ordered for one (1) week on 09/10/18. The lab was obtained on 09/19/18 instead of the one (1) week as ordered by the physician. This was a random opportunity for discovery. Resident identifier: #235. Facility census: 89. Findings included: a) Resident #235 A review of Resident #235's medical record on 09/26/18 at 9:00 a.m. 09/27/18 found the results of PT/INR that was obtained on 09/17/18. Handwritten on the lab results was the following, Increase to 4.5 mg every day. Repeat INR in one week. This was hand written by the facility's nurse practitioner on 09/17/18. Further review of Resident #235's medical record found a PT/INR result dated 09/19/18. An interview with the Director of Nursing (DON) at 11:08 a.m. on 09/26/18 confirmed the PT/Inr was obtained on 09/19/18. She stated that she will have to look and see if there was additional physicians order changing the dated from 09/24/18 to 09/19/18. An additional interview with the DON on 09/26/18 at 4:58 p.m. confirmed the lab was obtained with out a physician order. She stated the nurse put the date in the computer wrong and they should have not obtained the lab until 09/24/18.",2020-09-01
3501,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,791,D,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation resident interview and staff interview, the facility failed to ensure one (1) of four (4) residents reviewed for dental services received routine dental care. Resident identifier: #76. Facility census: 89. Findings included: a) Resident #76 On 09/24/18 at 2:44 PM, the resident said staff don't always help her brush her teeth 2 times a day. The resident said she had her own natural teeth and she had not been out to get her teeth cleaned at a dental office since her admission. She thought she should at least see a dentist. Record review found a [AGE] year old female admitted to the facility on [DATE]. Review of the activities of daily living, brushing teeth, documentation by nursing assistants, 2 times a day found the resident frequently gets her teeth brushed. The documentation was not completed on 6 occasions for brushing teeth in the morning and at night in a 25 day documentation period. (09/01/18-09/25/18). Observation of residents oral cavity with the director of nursing (DON) found the resident had a medium amount of plaque around the area where the gum meets the teeth on 09/25/18, at 10:30 a.m. The DON verified the resident had most of her natural teeth present. The resident told the DON she would like to see a dentist for a cleaning. The DON told the resident she would have to call her sister to see if she would allow the resident to see the dentist. The DON verified she did not believe the resident had been out to see a dentist since her admission. The DON completed a written oral evaluation on 9/25/18 at 12:08 p.m. The evaluation noted, the right eye tooth had a dull yellow color which could possible be a cavity, she also had plaque build up around the gum lines. SS (social service) notified to make an appointment for cleaning. Review of the medical record on 09/27/18 found an appointment was scheduled at dental office for 10/19/18 at 3:00 PM.",2020-09-01
3502,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,802,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to employ dietary staff with the appropriate competencies and skill sets to carry out the functions of the food and nutrition service. Multiple concerns were found by the survey team which include undated, and expired food available for use, food being held at the wrong temperatures prior to service, staff not following recipes when making pureed food, pureed food being held at the wrong temperature resulting in it being remade and still at the wrong temperature causing a delay in meal service for residents who receive a pureed diet, food being at the wrong temperature at the time of service, and pureed food being served at the wrong consistency. For several of these items the Certified Dietary Manager asserted that he had just inserviced his staff about the concerns but they were still not carrying out the functions of the dietary department to ensure the dietary needs of each resident was met on a daily basis. These failures have the potential to effect all residents currently residing in the facility. Facility Census: 89. Findings included: a) Store and Serve Food in a safe and sanitary manner. 1. Initial Tour of the Kitchen and Facility Pantries An initial tour of the kitchen and the facility's pantries on [DATE] beginning at 10:55 a.m. and concluding at 11:50 a.m. with the Certified Dietary Manager (CDM) found the following concerns: In the walk in cooler the following was found: --A five (5) pound container of sour cream opened on [DATE] and had a use by date of [DATE]. --A five (5) pound container of ricotta cheese opened and not dated as to when it was opened. --An opened roll of hamburger was in a storage container and had an open date of [DATE] and use by date of [DATE]. The CDM stated the use by date should have been [DATE] because that would have been the 7 days from the date it was opened. -- Shredded parmesan cheese had a date of [DATE] in the use by section of the label. The CDM indicated that had to be the open date and the use by date should have been [DATE]. In the freezer the following items were found to be opened and were not dated as to when they were opened: --Garlic Bread --Beef [NAME]es --Steak Fries --Potato Rounds and --French Toast. In the dry storage area the following was found: --Four (4) bottles of Pot and Pan dish soap. The CDM indicated that should not be stored in the dry storage area with food. --A dirty rag in the corner of one of the storage racks the rag was soiled and appeared to have been wet and had since dried. The CDM removed the rag and stated he had no idea why that was there. --11 boxes of tea bags with 100 tea bags each which all had a best by date of ,[DATE]. --A bag of Ziti Pasta which was opened on [DATE] and had a use by date of [DATE]. --Five (5) 32 fl (fluid) oz (ounces) bottles of lemon juice all with the best by date of [DATE]. --Four (4) 5 pound boxes of all purpose baking mix one was opened on [DATE] and had use by date of [DATE] and they all had a manufacture stamped use by date of [DATE]. --Two (2) boxes of lemon bar mixes one had a manufacture stamped best by date of [DATE] and one had a manufacture stamped best by date of [DATE]. Tour of the pantry on the Life steps unit found the following: --The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. --In the refrigerator was three (3) one (1) quart containers of Silk Soy Milk which were beyond there manufacture stamped use by date. Two (2) expired on [DATE]. The other container expired on [DATE]. Tour of the pantry on the Light House unit found the following: --The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. --In the refrigerator was seven (7) half pints of vitamin d milk with a best by date of [DATE] and three (3) with a best by date of [DATE]. Tour of the pantry on the [MEDICATION NAME] unit found the following: --The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. All the above mentioned items were brought to the attention of the CDM during the tour. He stated, I asked them this morning if they had checked the dates and they told me they did. He indicated they had just had an in service about this and he trusted they were telling him the truth. b) Observation of the Noontime Meal Service on [DATE] Observation of the noon time meal service on [DATE] began at 11:40 a.m. at which time the temperature of all food being held for service was obtained by Dietary Service Assistant (DSA) #101. Each temperature obtained was observed and were as follows: --Regular Turkey Club Sandwich was 49.6 degrees Fahrenheit (F) --Bacon was 107 degrees F --Dill Pickles was 41.7 degrees F --Relish was 48.1 degrees F --Pureed Turkey Club Sandwich was 61.7 degrees F. The only item removed from the line was the Pureed Turkey Club Sandwich. All other food was served to residents. Review of the CMS Appendix PP interpretive guidelines for F812 found the following, Nursing home residents risk serious complications from foodborne illness as a result of their compromised health status. Unsafe food handling practices represent a potential source of pathogen exposure for residents. Sanitary conditions must be present in health care food service settings to promote safe food handling. CMS recognizes the U.S. Food and Drug Administration ' s (FDA) Food Code and the Centers for Disease Control and Prevention ' s (CDC) food safety guidance as national standards to procure, store, prepare, distribute and serve food in long term care facilities in a safe and sanitary manner. Effective food safety systems involve identifying hazards at specific points during food handling and preparation, and identifying how the hazards can be prevented, reduced or eliminated. It is important to focus attention on the risks that are associated with foodborne illness by identifying critical control points (CCPs) in the food preparation processes that, if not controlled, might result in food safety hazards. Some operational steps that are critical to control in facilities to prevent or eliminate food safety hazards are thawing, cooking, cooling, holding, reheating of foods, and employee hygienic practices. An interview with DSA #101 confirmed the temperatures obtained were obtained by her. When asked what the temperatures should be she stated, I think they need to be around 40 degrees F. It was then she made the decision to pull the Pureed turkey club sandwich and asked another dietary aide to make some more. The other dietary aide then made some more pureed turkey club sandwich and when the temperature was obtained it remained at 60 degrees F. It had to be placed in the cooler to chill and there was a delay in serving the pureed residents their meals. b) Failure to follow Menus for pureed diets. A kitchen observation of pureed food preparation was conducted on [DATE] at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant #50 did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number of portions needed. Place in food processor and process to a smooth consistency. Add additional liquid (broth, milk, juice, etc.) a little at a time as needed to achieve smooth consistency. Add thickener as needed and blend thoroughly. Allow to stand 60 seconds - mixture should just hold its shape. Add additional thickener or liquid as needed. Serve turkey & vegetables on pureed bread. When adding the pickle relish, Dietary Services Assistant #50 used a slotted spoon and therefore did not include any of the liquid from the jar. Had some of the liquid from the pickle relish been added to the pureed product, the product may have been [MEDICATION NAME] and the pickle relish more fully incorporated into the final product. Dietary Services Supervisor #75 confirmed Dietary Services Assistant #50 should not have added pickle relish to the recipe because it cannot be fully incorporated. As for Employee #50 not following the recipe, Dietary Services Supervisor #75 said that dietitians instructed him that he can add items to recipes, but not take them away. This surveyor asked for a copy of the policy that states that items can be added, but not taken away. Dietary Services Supervisor #75 later approached this surveyor and stated that he found no such policy regarding adding ingredients, but not taking them away. On [DATE] at 10:10 AM, an interview was initiated with facility Registered Dietitian (RD) #109. He stated he visits the facility one day each week and does mainly clinical work, but will assist with foodservice issues as needed. He said he sometimes goes into the kitchen and watches. He added that, things have been up to snuff when he has been in the kitchen, but that there have been new people working in the kitchen recently. RD #109 agreed that it was not appropriate for Dietary Services Assistant #50 not to follow the recipe for pureed turkey clubs due to the aspiration risk this practice could create for residents receiving a pureed diet. RD #109 said he was unaware of this issue and might need to spend more time in the kitchen moving forward to provide support to Dietary Services Supervisor #75. c) Pureed food was not served in proper form. Dining observation 1. During dining observation on [DATE] at 12:29 PM, pureed foods were observed running together on resident #68's plate. The individual food items on the plate did not hold their shape. Throughout the lunch period, multiple pureed items were observed running together on multiple other plates. The pureed foods served on this date were not of the proper consistency. 2. Food preparation observation A kitchen observation of pureed food preparation was conducted on [DATE] at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) The temperature of the finished product was sixty degrees Fahrenheit. A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number of portions needed. Place in food processor and process to a smooth consistency. Add additional liquid (broth, milk, juice, etc.) a little at a time as needed to achieve smooth consistency. Add thickener as needed and blend thoroughly. Allow to stand 60 seconds - mixture should just hold its shape. Add additional thickener or liquid as needed. Serve turkey & vegetables on pureed bread. Dietary Services Supervisor #75 confirmed Dietary Services Assistant #50 should not have added pickle relish to the recipe because it cannot be fully incorporated and therefore should not have been part of a pureed diet. d) Food not attractive and not served at a preferable temperature at the time of service. 1. Meal temperatures at time of services. An interview with Resident #76 at 12:44 p.m. on [DATE] found that the food is not always good and that sometimes the food is cold and not at the proper temperature. An interview with Resident #52's daughter at 1:20 p.m. on [DATE] found they always bring Resident #52's tray last even though the daughter is there to feed her. She stated that when they bring in her mother's tray that the food is always cold and crusted over where it has sat so long. A review of the Resident council meeting minutes for the previous six months found the residents complained of cold food on the following occasions: [DATE]: Stated that the food is cold sometimes and they cook the meat and potato's too long. The facility's response to this concern was to in service dietary staff. [DATE]: Stated warmers are not always being put under plates and the food is not staying warm. The response to this complaint was to again in service staff to use plate warmers. Observation of the noontime meal on [DATE] found the temperatures at the point of service for Resident #76 and Resident #52 to be to warm for the cold foods served on this day. The following temperatures were obtained with the Certified Dietary Manager: Resident #76 a regular consistency diet temperatures were obtained at 12:35 p.m. and were as follows: Turkey Club Sandwich was 62 degrees Fahrenheit (F). [NAME]to's and Lettuce were 58 degrees F. Resident #52's a pureed diet temperatures were obtained at 12:41 p.m. on [DATE] and were as follows: [NAME]to Juice was 54 degrees F. Interview with the CDM confirmed the above mentioned food items were too warm and should have been cooler at the time of service. 2. Meals not attractive. During dining observation on [DATE] at 12:29 PM, pureed foods were observed running together on resident #68's plate. The individual food items on the plate did not hold their shape. Throughout the lunch period, multiple pureed items were observed running together on multiple other plates. The pureed foods served on this date were not of the proper consistency.",2020-09-01
3503,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,803,F,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview the facility failed to follow recipes for the preparation of pureed foods. This affected 17 of 17 residents receiving a pureed diet. Resident identifier: #68. Facility census: 89. Findings included: A kitchen observation of pureed food preparation was conducted on 09/25/18 at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant #50 did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number of portions needed. Place in food processor and process to a smooth consistency. Add additional liquid (broth, milk, juice, etc.) a little at a time as needed to achieve smooth consistency. Add thickener as needed and blend thoroughly. Allow to stand 60 seconds - mixture should just hold its shape. Add additional thickener or liquid as needed. Serve turkey & vegetables on pureed bread. When adding the pickle relish, Dietary Services Assistant #50 used a slotted spoon and therefore did not include any of the liquid from the jar. Had some of the liquid from the pickle relish been added to the pureed product, the product may have been [MEDICATION NAME] and the pickle relish more fully incorporated into the final product. Dietary Services Supervisor #75 confirmed Dietary Services Assistant #50 should not have added pickle relish to the recipe because it cannot be fully incorporated. As for Employee #50 not following the recipe, Dietary Services Supervisor #75 said that dietitians instructed him that he can add items to recipes, but not take them away. This surveyor asked for a copy of the policy that states that items can be added, but not taken away. Dietary Services Supervisor #75 later approached this surveyor and stated that he found no such policy regarding adding ingredients, but not taking them away. On 09/26/18 at 10:10 AM, an interview was initiated with facility Registered Dietitian (RD) #109. He stated he visits the facility one day each week and does mainly clinical work, but will assist with foodservice issues as needed. He said he sometimes goes into the kitchen and watches. He added that, things have been up to snuff when he has been in the kitchen, but that there have been new people working in the kitchen recently. RD #109 agreed that it was not appropriate for Dietary Services Assistant #50 not to follow the recipe for pureed turkey clubs due to the aspiration risk this practice could create for residents receiving a pureed diet. RD #109 said he was unaware of this issue and might need to spend more time in the kitchen moving forward to provide support to Dietary Services Supervisor #75.",2020-09-01
3504,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,804,F,0,1,DXEI11,"Based on observation, staff interview, temperature measurements and resident interviews, the facility failed to ensure that food was served at a preferable temperature at the time of service. Also the facility failed to ensure that pureed food was served at the appropriate texture. This practice has the potential to affect all residents currently residing in the facility. Facility census: 89. Findings included: a) Meal Temperatures at time of service. An interview with Resident #76 at 12:44 p.m. on 09/24/18 found that the food is not always good and that sometimes the food is cold and not at the proper temperature. An interview with Resident #52's daughter at 1:20 p.m. on 09/4/18 found they always bring Resident #52's tray last even though the daughter is there to feed her. She stated that when they bring in her mother's tray that the food is always cold and crusted over where it has sat so long. A review of the Resident council meeting minutes for the previous six months found the residents complained of cold food on the following occasions: 04/19/18: Stated that the food is cold sometimes and they cook the meat and potato's too long. The facility's response to this concern was to in service dietary staff. 07/19/18: Stated warmers are not always being put under plates and the food is not staying warm. The response to this complaint was to again in service staff to use plate warmers. Observation of the noontime meal on 09/25/18 found the temperatures at the point of service for Resident #76 and Resident #52 to be to warm for the cold foods served on this day. The following temperatures were obtained with the Certified Dietary Manager: Resident #76 a regular consistency diet temperatures were obtained at 12:35 p.m. and were as follows: Turkey Club Sandwich was 62 degrees Fahrenheit (F). [NAME]to's and Lettuce were 58 degrees F. Resident #52's a pureed diet temperatures were obtained at 12:41 p.m. on 09/25/18 and were as follows: [NAME]to Juice was 54 degrees F. Interview with the CDM confirmed the above mentioned food items were too warm and should have been cooler at the time of service. b) Texture of pureed food During dining observation on 09/24/18 at 12:29 PM, pureed foods were observed running together on Resident #68's plate. The individual food items on the plate did not hold their shape. Throughout the lunch period, multiple pureed items were observed running together on multiple other plates. The pureed foods served on this date were not attractive due to their thin texture causing them to run together on plates.",2020-09-01
3505,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,805,F,0,1,DXEI11,"Based on observation and staff interview, the facility failed to assure pureed food was prepared in the appropriate form to meet residents' needs. This affected seventeen out of seventeen residents receiving a pureed diet. Resident identifier: #68. Facility census: 89. Findings included: a) Dining observation During dining observation on 09/24/18 at 12:29 PM, pureed foods were observed running together on resident #68's plate. The individual food items on the plate did not hold their shape. Throughout the lunch period, multiple pureed items were observed running together on multiple other plates. The pureed foods served on this date were not of the proper consistency. b) Food preparation observation A kitchen observation of pureed food preparation was conducted on 09/25/18 at 12:00 PM. Dietary Services Assistant #50 began re-making pureed turkey club sandwiches (original container of pureed sandwich was in an unsafe temperature range, so it was discarded and a new batch had to be made). Dietary Services Assistant #50 added mayonnaise, sweet pickle relish, turkey, eggs, and onion, and pureed these together. She did not measure any of these ingredients. This surveyor asked her how she determined if the mixture was the right consistency. She stated that it needed to be a pudding consistency and demonstrated for this surveyor that the mixture stood up on a spoon. She stopped processing the mixture after this demonstration and began spooning it into a dish for serving. The pickle relish was not fully incorporated into the mixture (small chunks were visible throughout the finished product.) A copy of the recipe for the turkey club sandwiches was obtained from Dietary Services Supervisor #75. The pureed recipe for a turkey club sandwich required bread, mayonnaise, lettuce leaf, tomato, salt and pepper, and turkey breast. Dietary Services Assistant did not follow the list of ingredients outlined in the recipe. The recipe instructions stated, Puree turkey & vegetables together; bread separately. Count/measure out number of portions needed. Place in food processor and process to a smooth consistency. Add additional liquid (broth, milk, juice, etc.) a little at a time as needed to achieve smooth consistency. Add thickener as needed and blend thoroughly. Allow to stand 60 seconds - mixture should just hold its shape. Add additional thickener or liquid as needed. Serve turkey & vegetables on pureed bread. Dietary Services Supervisor #75 confirmed Dietary Services Assistant #50 should not have added pickle relish to the recipe because it cannot be fully incorporated and therefore should not have been part of a pureed diet.",2020-09-01
3506,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,812,F,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, measurement of food temperatures prior to service, review of the Centers for Medicare and Medicaid Services (CMS) appendix PP State Operations Manual (SOM) and staff interview the facility failed to store, prepare, distribute and serve food in accordance with professional standards for food safety. There was multiple items in the walk in cooler, freezer, and dry storage area that was not out of date, not dated when opened, and/or beyond the manufactures best by date. There were items in the facility's pantry refrigerators which were beyond the manufactures best by date. Also, all the microwaves in the pantries were dirty and in need of cleaning. Also, the food held on the steam table for service was above and/or below the minimum required temperature prior to service. These practices have the potential to effect all residents currently residing at the facility. Facility census: 89. Findings included: a) Initial Tour of the Kitchen and Facility Pantries An initial tour of the kitchen and the facility's pantries on [DATE] beginning at 10:55 a.m. and concluding at 11:50 a.m. with the Certified Dietary Manager (CDM) found the following concerns: In the walk in cooler the following was found: -- 5 pound container of sour cream opened on [DATE] and had a use by date of [DATE]. -- 5 pound container of ricotta cheese opened and not dated as to when it was opened. -- An opened roll of hamburger was in a storage container and had an open date of [DATE] and use by date of [DATE]. The CDM stated the use by date should have been [DATE] because that would have been the 7 days from the date it was opened. -- Shredded parmesan cheese had a date of [DATE] in the use by section of the label. The CDM indicated that had to be the open date and the use by date should have been [DATE]. In the freezer the following items were found to be opened and were not dated as to when they were opened: --Garlic Bread --Beef [NAME]es --Steak Fries --Potato Rounds and --French Toast. In the dry storage area the following was found: -- Four (4) bottles of Pot and Pan dish soap. The CDM indicated that should not be stored in the dry storage area with food. -- A dirty rag in the corner of one of the storage racks the rag was soiled and appeared to have been wet and had since dried. The CDM removed the rag and stated he had no idea why that was there. --11 boxes of tea bags with 100 tea bags each which all had a best by date of ,[DATE]. -- A bag of Ziti Pasta which was opened on [DATE] and had a use by date of [DATE]. - Five (5) 32 fl (fluid) oz (ounces) bottles of lemon juice all with the best by date of [DATE]. --Four (4) 5 pound boxes of all purpose baking mix one was opened on [DATE] and had use by date of [DATE] and they all had a manufacture stamped use by date of [DATE]. -- Two (2) boxes of lemon bar mixes one had a manufacture stamped best by date of [DATE] and one had a manufacture stamped best by date of [DATE]. Tour of the pantry on the Life steps unit found the following: -- The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. -- In the refrigerator was three (3) one (1) quart containers of Silk Soy Milk which were beyond there manufacture stamped use by date. Two (2) expired on [DATE]. The other container expired on [DATE]. Tour of the pantry on the Light House unit found the following: -- The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. -- In the refrigerator was seven (7) half pints of vitamin d milk with a best by date of [DATE] and three (3) with a best by date of [DATE]. Tour of the pantry on the [MEDICATION NAME] unit found the following: --The Microwave oven in the pantry was very dirty with food debris on the inside and needed to be cleaned. All the above mentions items were brought to the attention of the CDM during the tour. He stated, I asked them this morning if they had checked the dates and they told me they did. He indicated they had just had an in service about this and he trusted they were telling him the truth. b) Observation of the Noontime Meal Service on [DATE] Observation of the noon time meal service on [DATE] began at 11:40 a.m. at which time the temperature of all food being held for service was obtained by Dietary Service Assistant (DSA) #101. Each temperature obtained was observed and were as follows: -- Regular Turkey Club Sandwich was 49.6 degrees Fahrenheit (F) -- Bacon was 107 degrees F -- Dill Pickles was 41.7 degrees F -- Relish was 48.1 degrees F -- Pureed Turkey Club Sandwich was 61.7 degrees F. The only item removed from the line was the Pureed Turkey Club Sandwich. All other food was served to residents. An interview with DSA #101 confirmed the temperatures obtained were obtained by her. When asked what the temperatures should be she stated, I think they need to be around 40 degrees F. It was then she made the decision to pull the Pureed turkey club sandwich and asked another dietary aide to make some more.",2020-09-01
3507,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,842,D,0,1,DXEI11,"**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 complete and accurate medical record for one resident. Resident identifier: #24. Facility census: 89. Findings included: a) Resident #24 During an interview of Resident #24 on [DATE] at 03:52 PM, she stated she was very upset because her husband had died approximately two weeks prior. Upon review of her electronic medical record, it was discovered that her deceased husband was listed as her number one emergency contact and power of attorney (POA). On [DATE] at 03:41 PM, Social Services Supervisor #92 was interviewed regarding Resident #24's deceased husband being listed as her emergency contact/PO[NAME] Social Services Supervisor #92 agreed this was a problem and immediately removed the inaccurate information from the electronic medical record.",2020-09-01
3508,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,849,E,0,1,DXEI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, family interview, policy review and record review, the facility failed to ensure received quality care. This was true for Resident #55 the facility failed to collaborate with hospice for the development, implementation and revision of the coordinated plan of care and/or communicate and collaborate with hospice. This was true for one resident of one in the care area of hospice. Resident identifier: # 55. Facility census 89. Finding included: a) Resident #55 During an observation and interview on [DATE] at 12:40 PM, Nurse Aide (NA) #13 said that, she has not seen hospice, and does not know when hospice is to come to the facility, she said she provides a bed bath daily for Resident # 55. She is at bedside currently feeding Resident # 55. During an interview on [DATE] at 12:46 PM, Clinical Care Supervisor #73 was asked about communications and correlations with hospice. She said that the hospice registered nurse may have been to the facility, but she is not sure when. She said that, she has not seen an aide come to provide care for Resident #55. Hospice started on [DATE]. She said that she is not sure when the Hospice nurse and aide are supposed to come. She was asked if she could find any notes from the Hospice nurse. She could only find two (2) notes dated [DATE] and [DATE], both in regard to a giving the resident Intravenous (IV) fluids. She also called the DON and asked her when Hospice was scheduled to come and provide care and where can she find their notes. She the Hospice nurse and/or aide is supposed to complete a note and give it to the Charge nurse, then it will be scanned into the Resident's Chart. During an interview on [DATE] at 1:28 PM, DON was asked if she can find any notes from the hospice nurse about when a Nurse Aide, Social Worked, Clergy, and Nurse has been here. She said that, the only note she can find is that the Registered Nurse was in the facility on Thursday [DATE]. During an interview on [DATE] at 4:05 PM, Administrator was informed that staff is unaware of when the Hospice services are to provide care for Resident #55. During a phone interview on [DATE] 02:14 PM, with the Resident's daughter of the resident, she was told hospice did not have any NAs at this time, SW and the RN was in to see her on ,[DATE] or ,[DATE] for her initial assessment and Minister has been to see her mother on ,[DATE] or ,[DATE]. She said it was started on [DATE]. On [DATE] 02:28 PM DON provided Hospice notes she said she had Hospice fax to her today. This revealed that Hospice has been to the Facility for visits a total of seven (7) times. Hospice has also had eight (8) phone call communications. Dates of visits are as follows: --Social Worker visit on [DATE] at 11:15 AM until 12:00 PM. --Licensed Practical Nurse visit on [DATE] at 1:10 PM until 1:40 PM. --Registered Nurse visit on [DATE] at 1:10 PM until 1:45 PM. --Registered Nurse visit on [DATE] at 1:45 PM until 3:15 PM. --Registered Nurse visit on [DATE] at 10:06 AM. --Clergy visit on [DATE] at 2:00 PM until 2:30 PM. --Registered Nurse vast on [DATE] at 4:47 PM. --Registered Nurse visit on [DATE] at 12:15 PM until 12:45 PM. Review of records, Operations Policy Hospice Services was started on (MONTH) 25, 2014 with (name of hospice provider) stated the following: --An integrated plan of care between the resident and/or responsible party, the facility, and hospice agency will be developed that delineates the services that will be provided by the hospice staff and the survives that will be provided by the facility staff. --The integrated plan of care will be recorded in the resident's medical record, periodically reviewed, and updated, as necessary. --All communications between the hospice and facility when any changes are indicated or made to the plan of care. --The Care Plan will include Hospice services included nursing care; Medical Social Services; Counseling services (including bereavement, dietary and spiritual counseling); physical therapy, occupational therapy and speech-language pathology services; health aide/homemaker services; management of terminal illness SPECIFIED BY THE CARE PLAN. Physicians Oder's Dated [DATE] Resident #55 has expressed preferences for end-of-life care [DATE]. Facility Care Plan: Review of Care Plan revealed the following dated [DATE]: --Patient shall receive treatment in accordance with expressed wishes as documented on POST --No CPR -- DO NOT attempt resuscitation --POST form will be sent with patient to physician appointments and upon transfer/discharge --Special directives or limitations: Comfort Measures; Antibiotics, IV Fluids for a Trial Period of 30 Days; No Feeding Tube Hospices services Palliative Care due to Hospice --To be comfortable --To be pain free --Activities will visit in room, she prefers to stay in her room --Hospice nurse to visit at least weekly --Initiate Spiritual care consult if indicated Palliative Care due to Hospice [DATE] --Resident receives hospice services through (name of hospice provider) --Notify hospice of any change in condition or acute transfer to hospital. --Turn and reposition every 2 hours The care plan does not contain information regarding when the Registered Nurse, Licensed Practical Nurse, Social Worker, Aide and Clergy will visit or how often.",2020-09-01
3509,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2018-09-27,880,F,0,1,DXEI11,"Based on observation and staff interview the facility failed to ensure, prevent and maintain an infection prevent program to prevent spread of and communicable disease and infections, related to air flow from the soiled laundry room into the clean laundry room . This has the potential to effect more then a limited number of residents. A breech of infection control while providing catheter care and administratoring medication. Resident identifiers: #68 and #64. Facility census 89. Findings included: a) Laundry Room During an observation and interview on 09/26/18 at 2:57 PM, Environment Assistant (EA) #55 was present for the tour. The door from soiled laundry room to the clean laundry had air blowing from soiled to the clean room at the bottom of the door. This was wittnessed by EA#55 and Environment Supervisor #91. Using a dryer sheet standing on the clean side of the door, the dryer sheet was being blowed out from the soiled side of the room. This indicated airflow from the soiled laundry room was blowing into the clean side. ES #91 stated she would have it fixed right away. On 09/27/18 at 8:22 AM, Environment Supervisor #91 came in room to inform surveyor that the problem with the door was fixed last night by placing a door sweep on the doors. b) Resident #68 During an observation of catheter care on 09/27/18 at 9:30 AM, for Resident # 50 Nursing Aide (NA) #27, while preforming catheter care she breeched an infection control by touching her face, glasses and the privacy curtain with her soiled gloves. When asked why she would do that she replied,because my hair was in my eyes and my glasses were sliding down. She was asked if she should have used her arm or removed the soiled gloves then and before touching the privacy curtain. During an interview on 09/27/18 at 9:40 AM, informed Administrator of these finding and he stated he will have the curtain replaced. c) Facility task - medication administration On 09/26/18 at 9:53 AM Licensed Practical Nurse (LPN) #88 was observed for the facility task of medication administration. When administering medications to Resident #64, LPN #88 placed the resident's respiratory inhaler directly onto the resident's bedside table. After administering the inhaler and other medications to the resident, LPN #88 took the inhaler from the room and placed it directly on the top of the medication cart. She then placed the inhaler back into the box and into the medication cart drawer. LPN then placed the inhaler for another resident on the medication cart without cleaning the top of the cart first. LPN #88 was informed she had placed Resident #64's respiratory inhaler directly onto the resident's bedside table without using a barrier to prevent the potential spread of infectious disease. She had no comment regarding the matter. On 09/26/18 at 8:42 AM, Clinical Care Supervisor (CCS) #73 was informed LPN #88 had placed Resident #64's respiratory inhaler directly onto the resident's bedside table without using a barrier to prevent the potential spread of infectious disease. CCS #73 had no further information regarding the matter.",2020-09-01
4521,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,242,E,0,1,8SXB11,"Based on observation, staff interview, family interview, and medical record review, the facility failed to accommodate a resident's choice concerning activities significant to the individual for one (1) of one (1) sample residents. Resident #51 was not afforded the opportunity to participate in religious activities to the extent possible. Facility census: 79. Findings include: a) Resident #51 During stage one observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family interview with FM #1 on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The nurse aide related the resident did not usually attend activities, but the daughter would visit and take Resident #51 outside. The NA #52 related the resident liked church and would sometimes attend. The activity supervisor (AS), interviewed on 07/05/16 at 12:19 p.m., said staff got residents out of bed with a.m. (morning) care and staff assisted those residents to activities. With further inquiry, the AS voiced she did not provide a list of residents targeted for an activity. The medical record reviewed on 07/05/16 at 1:17 p.m., revealed the admission MDS with an ARD of 08/25/15 indicated participation in religious activities or practices was important to the resident. The care plan, reviewed on 07/05/16 at 2:24 p.m., noted Resident #51 was dependent upon staff for activities, cognitive stimulation, social interaction related to cognitive deficits. The goal indicated the resident would maintain involvement in cognitive stimulation, and social activities as desired. Interventions included staff would escort Resident #51 to activity functions, honor her preference to participate in (Denomination) church services; and indicated the resident enjoyed church regardless of denomination. Activity records, reviewed on 07/05/16 at 3:30 p.m., revealed no evidence Resident #51 had participated in a religious service during the month of (MONTH) (YEAR) or (MONTH) (YEAR). Entries were either blank, indicated the resident was in therapy, or that she was in bed. Upon exit of the facility on 07/07/16 at 10:30 a.m., no evidence had been presented to indicate the facility had accommodated Resident #51's preference to attend religious activities to the extent possible.",2019-10-01
4522,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,248,D,0,1,8SXB11,"Based on observation, staff interview, family interview, and medical record review, the facility failed to accommodate a resident's interests concerning activities for one (1) of one (1) sample residents. Resident #51 was not afforded the opportunity to participate in religious activities to the extent possible. Facility census: 79. Findings include: a) Resident #51 During stage one observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family interview with FM #1 on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The nurse aide related the resident did not usually attend activities, but the daughter would visit and take Resident #51 outside. The NA #52 related the resident liked church and would sometimes attend. The activity supervisor (AS), interviewed on 07/05/16 at 12:19 p.m., said staff got residents out of bed with a.m. (morning) care and staff assisted those residents to activities. With further inquiry, the AS voiced she did not provide a list of residents targeted for an activity. The medical record reviewed on 07/05/16 at 1:17 p.m., revealed the admission MDS with an ARD of 08/25/15 indicated participation in religious activities or practices was important to the resident. The care plan, reviewed on 07/05/16 at 2:24 p.m., noted Resident #51 was dependent upon staff for activities, cognitive stimulation, social interaction related to cognitive deficits. The goal indicated the resident would maintain involvement in cognitive stimulation, and social activities as desired. Interventions included staff would escort Resident #51 to activity functions, honor her preference to participate in (Denomination) church services; and indicated the resident enjoyed church regardless of denomination. Activity records, reviewed on 07/05/16 at 3:30 p.m., revealed no evidence Resident #51 had participated in a religious service during the month of (MONTH) (YEAR) or (MONTH) (YEAR). Entries were either blank, indicated the resident was in therapy, or that she was in bed. Upon exit of the facility on 07/07/16 at 10:30 a.m., no evidence had been presented to indicate the facility had accommodated Resident #51's preference to attend religious activities to the extent possible.",2019-10-01
4523,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,272,D,0,1,8SXB11,"Based on medical record review and staff interview, the facility failed to complete accurate comprehensive assessments related to activities, showers, and wounds. This practice affected two (2) of fifteen (15) stage 2 sample residents. Resident identifiers: Resident #51 and Resident #127. Facility census: 79. Findings include: a) Resident #51 A family member (FM) #1 interview on 06/28/16 at 4:23 p.m., revealed Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. The family member said the resident enjoyed the outdoors, and would sometimes propel herself in the rock-n-go wheelchair. During the interview, the family member voiced the preference for showers as the method of bathing. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if transport was requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. The Activity Supervisor (AS) interviewed on 07/05/16 at 12:19 p.m., said staff got residents out of bed in the morning for care and staff assisted those residents to activities. With further inquiry, the AS voiced she did not provide a list of residents targeted for an activity. The electronic medical record, reviewed on 07/05/16 at 1:17 p.m., revealed an annual minimum data set (MDS) with an assessment reference date (ARD) of 06/20/16 which indicated Resident #51 preferred bed baths and sponge baths. Showers and religious practices were not noted as preferences. Additionally, the MDS indicated the resident did not utilize a wheelchair. The admission MDS with an ARD of 08/25/16 had indicated Resident #51 preferred a shower and that religious activities or practices were significant to the resident, as did the care plan, reviewed on 07/05/16. Registered Nurse Assessment Coordinator (RNAC) #97, interviewed on 07/06/16 at 11:17 a.m., confirmed no information was evident in the medical record as to why Resident #51's preference was changed from showers to a bed bath and sponge bath. He reviewed the documentation report entered by the nurse aides and confirmed it indicated the resident received all of her showers as ordered, and no information was present to indicate the resident exhibited behaviors indicating she did not want a shower. The RNAC also related he did not know why religious activities or practices was not listed as an activity of preference, as indicated by the care plan. RNAC #97 also indicated Resident #51 utilized a wheelchair and voiced the MDS with an ARD of 06/20/16 had been coded inaccurately. b) Resident #127 A stage one observation of the Quality Indicator Survey (QIS) on 06/28/16 at 9:08 a.m. revealed a dressing on Resident #127's right inner leg above the ankle and a scab on her left inner leg above the dressing. The leg was swollen and reddish in color. A wound care observation of the right inner leg, on 06/30/16 at 11:58 a.m. revealed a small open wound. The minimum data set (MDS) with an assessment reference date (ARD) of 06/15/16, reviewed on 07/05/16 at 11:30 a.m., revealed no evidence the resident's had a wound or aquired one on admission. Further review of the medical record revealed a Wound Assessment - Initial Assessment of Lower Extremity Wound dated 06/09/16, present on admission (06/08/16). The assessment noted a wound on the medial aspect of the right ankle. Another assessment, dated 06/17/16 also noted an assessment of the right inner ankle wound, noted as present on admission, and vascular in description. An interview, on 07/05/16 at 11:41 a.m. with Registered Nurse Coordinator (RNAC) #97 voiced the areas should have been captured and confirmed the MDS was inaccurate.",2019-10-01
4524,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,278,D,0,1,8SXB11,"Based on medical record review and staff interview, the facility failed to ensure the individual completing and certifying the accuracy of Resident #119's quarterly Minimum Data Set (MDS) assessment completed the assessment accurately for the area of falls. Resident identifier: #119. Facility census: 79. Findings include: A review of Resident #119's medical record revealed the resident experienced falls on 04/01/16, 04/04/16, and 04/28/16. The quarterly Minimum Data Set (MDS) assessment with an Assessment Reference Date (ARD) of 5/27/16, did not identify the resident experienced any falls since admission or the last assessment, whichever was more recent. On 07/06/16 at 10:47 a.m., the Director of Nursing agreed the quarterly assessment did not accurately reflect the resident's falls. On 07/06/16 at 11:45 a.m., Registered Nurse-Minimum Data Set Coordinator (RN-MDS) #97 stated the quarterly assessment concerning falls for Resident #119 was incorrect.",2019-10-01
4525,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,279,D,0,1,8SXB11,"Based on observation, resident interview, medical record review, and staff interview, the facility failed to develop a comprehensive care plan for one (1) of fifteen (15) Stage 2 sample residents. The facility did not develop a comprehensive care plan for a resident who leaned on the siderail. Facility census: 79. Resident identifier: Resident #98 Findings include: a) Resident #98 During an observation on 07/05/16 at 1:03 p.m., Resident #98 was leaning toward the left on the side rail. No support device was present. The resident related she was uncomfortable. Additionally, she was seated in a reclined position attempting to eat her lunch meal. Resident #98 voiced she preferred to sit up and eat, and she was unable to see her food very well and was uncomfortable. Upon request, Registered Nurse (RN) #101 completed an interview and observation with Resident #98 at 1:08 p.m. on 07/05/16. The resident expressed she preferred to eat sitting up, and said leaning on the siderail was uncomfortable. No padding or support device was present. The RN then informed the resident, We straighten you up, but you always lean back over that way. Do you want repositioned? Upon request, the RN visualized the residents arm against the side rail, which was pressing into Resident #98's arm. The nurse confirmed the resident should have a support device in place. Review of the medical record, on 07/05/16 at about 3:50 p.m., revealed no evidence a care plan had been devised to address Resident #98 leaning left and/or leaning into the siderail. A follow-up interview with the RN confirmed a care plan should have been developed to address positioning related to leaning.",2019-10-01
4526,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,280,D,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview the facility failed to revise the plan of care for one (1) of fifteen (15) Stage 2 sample residents. The care plan related to medication administration was not revised for a [MEDICAL TREATMENT] resident to ensure medications were administered as ordered. Resident #98 did not receive medications scheduled for 9:00 a.m. on days she received [MEDICAL TREATMENT]. Resident identifier: Resident #98. Facility census: 97. Findings include: a) Resident #98 A medical record review related to unnecessary medication, reviewed on 07/06/16 at 3:00 p.m., revealed Resident #98 received [MEDICAL TREATMENT] treatments on Monday, Wednesday and Friday weekly. The medication administration records (MAR), reviewed for the months of April, May, (MONTH) and (MONTH) (YEAR) indicated the resident did not receive medications scheduled for 6:00 a.m. and 9:00 a.m., which included acidophilus, [MEDICATION NAME] (for [MEDICAL CONDITION]), gabepentin (for [MEDICAL CONDITION]), [MEDICATION NAME] Solution (elevated blood sugar), [MEDICATION NAME] (for [MEDICAL CONDITION]), Rena-Vite tablet (for end stage [MEDICAL CONDITION]), Vitamin C for wound healing, and [MEDICATION NAME] (for [MEDICAL CONDITIONS]). b) The care plan addressed [MEDICAL TREATMENT] and medications, but did not address the omission of medication on [MEDICAL TREATMENT] days. c) During an interview with Physician #1, on 07/06/16 at 4:06 p.m., the doctor related she was not aware Resident #98 did not receive her morning medications on [MEDICAL TREATMENT] days. The physician said it was important for the resident to have the medications and immediately reviewed them with Registered Nurse (RN) #97, changing times of administration, with the exception of [MEDICATION NAME].",2019-10-01
4527,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,282,D,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to implement the care plan for two (2) of fifteen (15) Stage 2 sample residents. Resident #51 was not afforded the opportunity to participated in an activity of significance to the extent possible and Resident #46's feet were not elevated to relieve pressure. Facility census: 79. Findings include: a) Resident #51 During Stage 1 observations of the Quality Indicator Survey, Resident #51 did not attend out of room activities. Observations on 06/28/16 at 9:17 a.m. and 12:30 p.m., revealed the resident in bed. Family Member (FM) #1, interviewed at 4:20 p.m., said the resident did not get out of bed until 2:00 p.m. During observations on 06/29/16 at 10:26 a.m., 11:23 a.m. and 11:52 a.m., Resident #51 was still in bed. On 07/05/16 at 12:15 p.m., observation revealed Resident #51 in bed. A family member (FM) #1 interview on 06/28/16 at 4:23 p.m., indicated Resident #51 hardly ever went to church, and related it was probably because she was not aware. FM #1 related the resident had enjoyed church services in the past. Nurse Aide (NA) #44, interviewed on 06/29/16 at 1:22 p.m., said Resident #51 understood some things and would follow directions such as to open her mouth if brushing teeth. The NA related the resident did not usually attend activities. Upon inquiry regarding religious activities, the NA related she would sometimes go to church and listen to them sing. The nurse aide said the facility had services on Sundays. NA #44 voiced residents would be assisted to activities if transport was requested. Upon inquiry as to how it was known who should attend which activity, the NA related she did not know who should attend. The resident was seated in the rock-n-go wheelchair and NA #44 said Resident #51 would sometimes propel herself. Nurse Aide (NA) #52, interviewed on 06/30/16 at 8:14 a.m., voiced Resident #51 was sometimes up early and sometimes slept in late. The nurse aide related the resident did not usually attend activities, but the daughter would visit and take Resident #51 outside. NA #52 related the resident liked church and would sometimes attend. The activity supervisor (AS), interviewed on 07/05/16 at 12:19 p.m., said staff got residents out of bed for morning care and staff assisted those residents to activities. With further inquiry, the AS voiced she did not provide a list of residents targeted for an activity. The admission MDS with an ARD of 08/25/15 indicated it was important to the resident to participate in religious activities or practices. The care plan, reviewed on 07/05/16 at 2:24 p.m., noted Resident #51 was dependent upon staff for activities, cognitive stimulation, social interaction related to cognitive deficits. The goal indicated the resident would maintain involvement in cognitive stimulation, and social activities as desired. Interventions included staff would escort Resident #51 to activity functions, honor her preference to participate in (Denomination) church services; and indicated the resident enjoyed church regardless of denomination. Activity records, reviewed on 07/05/16 at 3:30 p.m., revealed no evidence Resident #51 had participated in a religious service during the month of (MONTH) or (MONTH) (YEAR). Entries were either blank, indicated the resident was in therapy, or that she was in bed. Upon exit of the facility on 07/07/16 at 10:30 a.m., no evidence had been presented to indicate the facility had implemented Resident #51's care plan related to the preference to attend religious activities. b) Resident #46 Medical record review on 06/29/16 at 9:00 a.m., revealed a physician's orders [REDACTED]. The order stated Float heels while in bed. On 06/29/16 at 9:20 a.m., review of the care plan in use at the time of the survey, dated 09/25/15, addressed floating heels while in bed as an intervention to prevent potential skin breakdown. An observation on 06/29/16 at 9:58 a.m. revealed the resident in bed with the heels not floated. An interview with Licensed Practical Nurse #18 on 6/29/16 at 10:06 a.m. revealed the resident's heels are to be floated at all times while in bed. An observation on 6/30/16 at 7:35 a.m. revealed the resident in bed with the heels not floated. An interview with the Director of Nursing on 6/30/16 at 8:00 a.m. revealed the resident's heels are to be floated at all times while in bed.",2019-10-01
4528,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,309,E,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, and staff interview, the facility failed to provide the necessary care and services to obtain or maintain the highest practicable well-being for four (4) of fifteen (15) Stage 2 sampled residents. The facility did not follow physicians orders related to parameters for holding insulin administration for Resident #104. The facility did not assess the abdomens or bowel sounds of Residents #104 and #64, both of whom went greater than three (3) days without having a bowel movement. The facility did not follow physician's orders [REDACTED].#46's heels while in bed. The facility failed to promote a comfortable environment and positioning for Resident #98. Resident identifiers: #104, #64, #46, #98. Facility census: 79. Findings include: a) Resident #104 1) Insulin Administration Medical record review for Resident #104 on 06/30/16 at 9:00 a.m. found physician's orders [REDACTED]. The physician directed to hold the insulin, and not administer the insulin at noon or 5:00 p.m., when the blood sugar level was less than 150 deciliters per milliliter (dl/ml). Review of the Medication Administration Record [REDACTED] -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]with either lunch or dinner eleven (11) times when the blood sugar was less than 150 dl/ml. This includes the following dates for the noon doses: 12/02/15, 12/04/15, 12/05/15, 12/06/15, 12/10/15, and 12/20/15. This includes the following dates for the 5:00 p.m. doses: 12/01/15, 12/15/15, and 12/16/15. This also includes the noon and 5:00 p.m. doses on 12/25/15. -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]either at lunch or dinner eight (8) times when the blood sugar was less than 150 dl/ml. This includes the following dates for the noon doses: 01/01/16, 01/09/16, 01/12/16, adn 01/23/16. This includes the following dates for the 5:00 p.m. doses: 01/08/16, 01/10/16, 01/14/16, and 01/31/16. -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]at dinner six (6) times when the blood sugar was less than 150 dl/ml. This includes the following dates for the 5:00 p.m. doses: 02/01/16, 02/06/16, 02/07/16, 02/08/16, 02/15/16, and 02/17/16. -- In (MONTH) (YEAR), he received five (5) units of [MEDICATION NAME]either at lunch or dinner three (3) times when the blood sugar was less than 150 dl/ml. This includes the following date for the noon doses: 03/04/16. This includes the following dates for the 5:00 p.m. doses: 03/01/16 and 03/05/16. An interview conducted with the Director of Nursing on 06/30/16 at 11:15 a.m., revealed the insulin should have been held those days when the blood sugar result was less than 150 dl/ml., but it was not. 2) Bowel Assessment Further medical record review found Resident #104 had a bowel movement on 02/12/16. He had no further bowel movements for three (3) consecutive days. On 02/16/16 nursing initiated step one (1) of the facility's bowel protocol. Nursing administered thirty (30) milliliters of Milk of Magnesia to the resident. The physician's orders [REDACTED]. The medical record was silent for assessment of the resident's abdomen, or for bowel sounds. During an interview with the director of nursing on 06/30/16 at 11:15 a.m., she said although it is not a facility policy to assess the resident's abdomen or listen for bowel sounds when a resident goes three (3) days without a bowel movement, she would expect a nurse to do so as a standard of practice. She agreed there was no evidence of a nursing assessment of the abdomen, or of the resident's bowel sounds, prior to the administration of Milk of Magnesia on 02/16/16. b) Resident #64 Review of the bowel movement record for Resident #64 revealed no bowel movements from 06/09/16 thru 06/17/16. Continued review of the nursing notes for this period of time revealed no monitoring of bowel sounds. On 06/30/16 at 11:15 a.m., the director of nursing (DON) agreed that monitoring bowel sounds is a standard of practice and she would expect nursing staff to monitoring and document bowel sounds for a resident who is not having bowel movements. c) Resident #46 Medical record review on 06/29/16 at 9:00 a.m., revealed a physician's orders [REDACTED]. The order stated Float heels while in bed. The care plan in use at the time of the survey, dated 09/25/15, reviewed on 06/29/16 at 9:20 a.m. included floating heels while in bed as an intervention to prevent potential skin breakdown. An observation on 06/29/16 at 9:58 a.m. revealed the resident in bed with the heels not floated. An interview with Licensed Practical Nurse #18 on 6/29/16 at 10:06 a.m. revealed the resident's heels are to be floated at all times while in bed. An observation on 6/30/16 at 7:35 a.m. revealed the resident in bed with the heels not floated. An interview with the Director of Nursing on 6/30/16 at 8:00 a.m. revealed the resident's heels are to be floated at all times while in bed. d) Resident #98 During an observation on 07/05/16 at 1:03 p.m., Resident #98 was leaning toward the left on the side rail. No support device was present. The resident related she was uncomfortable. Additionally, she was seated in a reclined position attempting to eat her lunch meal. Resident #98 voiced she preferred to sit up and eat, and she was unable to see her food very well and was uncomfortable. Upon request, Registered Nurse (RN) #101 completed an interview and observation with Resident #98 at 1:08 p.m. on 07/05/16. The resident expressed she preferred to eat sitting up, and said leaning into the siderail was uncomfortable. No padding or support device was present. The RN then informed the resident, We straighten you up, but you always lean back over that way. Do you want repositioned? Upon request, the RN visualized the residents arm against the side rail, which was pressing into Resident #98's arm. The nurse confirmed the resident should have a support device in place. During a follow-up interview at 1:30 p.m. on 07/05/16, Resident #98 voiced comfort after being repositioned and provided support. Pillows had been placed to the resident's left and provided a cushion/barrier between the resident and the siderail. Review of the medical record, on 07/05/16 at about 3:50 p.m., revealed no evidence a care plan had been devised to address Resident #98 leaning left and/or leaning into the siderail. A follow-up interview with the RN confirmed a care plan should have been developed to address positioning related to leaning.",2019-10-01
4529,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,329,E,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to provide indications for withholding medications, administering medications beyond paremeters, and clearly identify the the indications for use of medications with care delivered and/or ordered by diverse sources such as consultants/providers/suppliers for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifer: Resident #98. Facility Census: 79. c) Resident #98 A medical record review, on 06/28/16 at 2:27 p.m., revealed Resident #98 received [MEDICATION NAME] 3.5 milligrams (mg) orally at bedtime on Monday, Wednesday, and Friday for [MEDICAL CONDITION] and [MEDICATION NAME] 2.5 mg orally every Sunday, Tuesday, Thursday and Saturday for [MEDICAL CONDITION] Fibrillation (irregular heartbeat), and Humalog 100 units/milliliter (ml) subcutaneously per sliding scale coverage (ssc) before meals and at bedtime. Further review of the medical record, on 07/06/16 at 3:00 p.m., indicated Resident #98 also received [MEDICATION NAME] 125 micrograms (mcg) by mouth (po) one time a day for [MEDICAL CONDITION], [MEDICATION NAME] 25 mg (give one half tablet to equal 12.5 mg) twice daily for atheroosclerotic [MEDICAL CONDITION] with instructions to hold the medication if the systolic blood pressure (b/p) was less than 100, diastolic b/p was less than 65 or the pulse was less than 60 beats per minute (bpm); [MEDICATION NAME] 75 mg po daily in the morning for [MEDICAL CONDITION], and [MEDICATION NAME] for low blood pressure. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview with Registered Nurse (RN) #97, at 3:50 p.m. on 07/06/16, the RN reviewed the medical record and voiced it provided no indication as to why the resident did not receive 9:00 a.m. medications on [MEDICAL TREATMENT] days. Physician #1, interviewed on 07/06/16 at 4:06 p.m., said she was not aware Resident #98 was not receiving medications on [MEDICAL TREATMENT] days. Upon inquiry as to whether the resident should receive the medications, the physician related the medications should be administered, reviewed the medication list with RN #97, and gave directions for administration of medications after [MEDICAL TREATMENT] for [MEDICATION NAME], and [MEDICATION NAME]. Physician #1 also reviewed administration times of [MEDICATION NAME], related it was administered for rate rather than blood pressure, and made no adjustments. During a follow-up interview, at 4:20 p.m., the physician related an awareness the resident received both [MEDICATION NAME] and [MEDICATION NAME], but had made no adjustments due to both medications ordered by physician consultants, and thought one may have been administered related to a stroke and one for the use of [MEDICAL CONDITION]. Further review of the Medication Administration Record, [REDACTED] -- 06/01/16 blood pressure was 100/62 -- 06/02/16 blood pressure was 107/63 -- 06/04/16 blood pressure was 104/64 -- 06/05/16 blood pressure was 108/60 -- 06/09/16 blood pressure was 104/64 -- 06/10/16 blood pressure was 100/50 -- 06/11/16 blood pressure was 110/67 -- 06/12/16 blood pressure was 110/63 -- 06/13/16 blood pressure was 102/56 -- 06/14/16 blood pressure was 114/56 -- 06/15/16 blood pressure was 102/56 -- 06/16/16 blood pressure was 118/62 -- 06/19/16 blood pressure was 99/62 -- 06/23/16 blood pressure was 112/62 -- 06/24/16 blood pressure was 102/60 -- 06/25/16 blood pressure was 110/61 -- 06/27/16 blood pressure was 104/64 -- 06/28/16 blood pressure was 110/58 -- 06/30/16 blood pressure was 122/60 Additionally, the MAR indicated [REDACTED]. The consultant pharmacist records, reviewed on 07/06/16 at 4:25 p.m. noted a recommendation dated 01/26/16, to adjust medication administration times related to [MEDICATION NAME] (for low blood pressure). Subsequent reviews indicated no irregularities or recommendations. No evidence was present to indicate the facility had identified the relationship between the administration [MEDICATION NAME] and low blood pressures, or the omission of [MEDICATION NAME] ([MEDICATION NAME] treats [MEDICAL CONDITION] and slows the heart rate in patients with [MEDICAL CONDITION].) The director of nursing (DON), interviewed on 07/07/16 at 7:30 a.m., confirmed the facility had not identified the need to adjust medication administration times on [MEDICAL TREATMENT] days, and had administered medications outside of physician paremeters. Additionally, no evidence was presented to indicate clarification had been obtained to ensure the resident required the use of concommitant use of [MEDICATION NAME] and [MEDICATION NAME] (both controlled heart rate), or concommitant use of [MEDICATION NAME] and [MEDICATION NAME] (both prevent the blood from clotting with an increased risk of bleeding.)",2019-10-01
4530,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,371,F,0,1,8SXB11,"Based on observation and staff interview the facility failed to store, distribute and serve food under sanitary conditions. The kitchen equipment was visibly soiled. This practice has the potential to effect all residents who are served food from the kitchen. Facility census: 79. Findings include: On 06/27/16 at 11:15 a.m., observation of the the facility's kitchen revealed the following visibly soiled areas on kitchen equipment, and doorways. -- Fingerprints on the clear top of the storage bins for sugar, flour and beans. -- Four (4) two (2) shelf carts were visibly soiled and waiting to be used by the kitchen staff. -- Interior of exit doors to enter into the dining area were visibly soiled. -- Three (3) large garbage cans were visibly soiled on the exterior. -- The wall and baseboard behind the large garbage cans were visibly soiled. -- A vent in the ice machine and a ceiling vent near the ice machine was observed with visible dust. On 07/06/16 at 2:45 p.m., the dietary services supervisor, stated the kitchen is deep cleaned about every two months and that he had staff off sick and as soon as he has a full staff the kitchen will be deep cleaned.",2019-10-01
4531,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,428,E,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to act upon a consultant pharmacist recommendation for three (3) of five (5) residents reviewed for the care area of unnecessary medications during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #81, #64, #98. Facility census: 78. Findings include: a) Resident #81 Review of medical records for Resident #81 on 07/06/16 revealed a consultant pharmacist communication to the physician of the resident being prescribed both Bentyl and [NAME]anechol. The pharmacist went on to state these two (2) medications work against each other. The only response from the nurse practitioner was continue. There was no rationale to continue the medications. b) Resident #64 Review of medical records for Resident #64, on 06/30/16, revealed a consultant pharmacist communication to the physician with directions on how to prescribe Midodrine and a recommendation to decrease an antianxiety medication. The only response from the nurse practitioner on both medications was continue current dose. There was no rationale to continue the medication. On 7/6/16 at 10:10 a.m., the Director of Nursing (DON) agreed the nurse practitioner should have wrote a rationale for continuing the medications. c) Resident #98 A medical record review, on 06/28/16 at 2:27 p.m., revealed Resident #98 received coumadin 3.5 milligrams (mg) orally at bedtime on Monday, Wednesday, and Friday for deep vein thrombosis prophylaxis and coumadin 2.5 mg orally every Sunday, Tuesday, Thursday and Saturday for [DIAGNOSES REDACTED](irregular heartbeat), and Humalog 100 units/milliliter (ml) subcutaneously per sliding scale coverage (ssc) before meals and at bedtime. Further review of the medical record, on 07/06/16 at 3:00 p.m., indicated Resident #98 also received digoxin 125 micrograms (mcg) by mouth (po) one time a day for congestive heart failure, metoprolol tartrate 25 mg (give one half tablet to equal 12.5 mg) twice daily for atheroosclerotic heart disease with instructions to hold the medication if the systolic blood pressure (b/p) was less than 100, diastolic b/p was less than 65 or the pulse was less than 60 beats per minute (bpm); plavix 75 mg po daily in the morning for coronary artery disease, and midodrine for low blood pressure. The (MONTH) (YEAR) Medication Administration Record [REDACTED]. During an interview with Registered Nurse (RN) #97, at 3:50 p.m. on 07/06/16, the RN reviewed the medical record and voiced it provided no indication as to why the resident did not receive 9:00 a.m. medications on dialysis days. Physician #1, interviewed on 07/06/16 at 4:06 p.m., said she was not aware Resident #98 was not receiving medications on dialysis days. Upon inquiry as to whether the resident should receive the medications, the physician related the medications should be administered, reviewed the medication list with RN #97, and gave directions for administration of medications after dialysis for digoxin, and plavix. Physician #1 also reviewed administration times of metoprolol, related it was administered for rate rather than blood pressure, and made no adjustments. During a follow-up interview, at 4:20 p.m., the physician related an awareness the resident received both plavix and coumadin, but had made no adjustments due to both medications ordered by physician consultants, and thought one may have been administered related to a stroke and one for the use of atrial fibrillation. Further review of the Medication Administration Record, [REDACTED] -- 06/01/16 blood pressure was 100/62 -- 06/02/16 blood pressure was 107/63 -- 06/04/16 blood pressure was 104/64 -- 06/05/16 blood pressure was 108/60 -- 06/09/16 blood pressure was 104/64 -- 06/10/16 blood pressure was 100/50 -- 06/11/16 blood pressure was 110/67 -- 06/12/16 blood pressure was 110/63 -- 06/13/16 blood pressure was 102/56 -- 06/14/16 blood pressure was 114/56 -- 06/15/16 blood pressure was 102/56 -- 06/16/16 blood pressure was 118/62 -- 06/19/16 blood pressure was 99/62 -- 06/23/16 blood pressure was 112/62 -- 06/24/16 blood pressure was 102/60 -- 06/25/16 blood pressure was 110/61 -- 06/27/16 blood pressure was 104/64 -- 06/28/16 blood pressure was 110/58 -- 06/30/16 blood pressure was 122/60 Additionally, the MAR indicated [REDACTED]. The consultant pharmacist records, reviewed on 07/06/16 at 4:25 p.m. noted a recommendation dated 01/26/16, to adjust medication administration times related to midodrine (for low blood pressure). Subsequent reviews indicated no irregularities or recommendations. No evidence was present to indicate the facility had identified the relationship between the administration metoprolol and low blood pressures, or the omission of digoxin (Digoxin treats congestive heart failure and slows the heart rate in patients with atrial fibrillation.) The director of nursing (DON), interviewed on 07/07/16 at 7:30 a.m., confirmed the facility had not identified the need to adjust medication administration times on dialysis days, and had administered medications outside of physician paremeters. Additionally, no evidence was presented to indicate clarification had been obtained to ensure the resident required the use of concommitant use of metoprolol and digoxin (both controlled heart rate), or concommitant use of plavix and coumadin (both prevent the blood from clotting with an increased risk of bleeding.)",2019-10-01
4532,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2016-07-07,441,E,0,1,8SXB11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and Centers for Disease Control and prevention guidelines, the facility did not maintain an effective infection control program to the extent possible. Staff did not use gloves when cleaning up unknown fluids from the floor, did not utilize proper handwashing technique and transported a bag of wound treatment items and bag of soiled items in the same hand. This practice had the potential to affect more than a limited number of residents. Facility census: 79. Findings include: a) Personal Protective Equipment A random observation, on 06/28/16 at 3:31 p.m., revealed a liquid substance on the floor beside the bed of Resident #96. Upon inquiry, Nurse Aide (NA) #78 related she did not know whether it was urine or water. The nurse aide obtained paper towels from the bathroom, placed them on the floor, then stepped on them with her right foot and began to wipe up the fluid by rubbing back and forth with her foot. She then bent down and with ungloved hands continued wiping the areas with the saturated towels. b) Resident #127 During an observation of a wound dressing change, on 06/30/16 at 11:58 a.m., Licensed Practical Nurse (LPN) #69 placed a plastic bag which contained wound care supplied on the over-the-bed table. The nurse washed her hands for a count of ten (10) seconds, donned gloves, placed a clean plastic garbage bag on the table as a barrier, then placed wound supplies on the barrier. The LPN removed the soiled dressing, which contained another dressing beneath, related she had done something wrong, removed the gloves and washed her hands for a count of four (4) seconds, turned off the faucet with bare hands, then obtained paper towels from the dispenser to dry her hands. The nurse donned a new pair of gloves, obtained a new garbage bag for soiled items, and placed it on the bed. The LPN sprayed the wound bed with wound cleanser, removed her gloves, started to apply new gloves, threw them away before donning them, washed her hands for a count of five (5) seconds, turned off the water faucet with her bare hands, then obtained paper towels from the dispenser and donned new gloves. LPN #69 cleaned the wound, wiping over the same area multiple times with the same area of gauze. The nurse washed her hands, donned new gloves, applied skin prep to the peri wound area, applied [MEDICATION NAME] to the wound bed using her gloved fingers, labled the dressing, removed the soiled gloves, without sanitizing hands, donned new gloves, and applied the new cover dressing. Upon completion of the dressing change at 12:08 p.m., LPN #69 disposed of the soiled items into the garbage can, donned new gloves without sanitizing hands, cleaned items from the over-the-bed table and disposed of all with the exception of wound cleanser and peri-wipes. The nurse removed her gloves, and washed her hands for a count of seven (7) seconds. The nurse transported the bag of soiled garbage and bag of clean items (wound cleanser, peri wipes), in the same hand. c) Resident #51 During a random observation on 06/29/16 at 11:52 a.m., Nurse Aide (NA) #44 was in the room of Resident #51. The bed was raised to waist height and the NA was removing the resident's nasal cannula. The nurse aide asked the resident if she wanted to get up and wash off. The NA removed her gloves, lowered the bed, and exited the room without using hand hygiene. The nurse aide walked down the hallway to the clean linen room and obtained linens for the resident's bath. Upon request of the infection control guidelines, on 06/29/16 at 10:41 a.m., the Director of Nursing (DON) related the guidelines were the Centers for Disease Control and Prevention guidelines (CDC). The CDC guidelines indicated the procedure for handwashing required staff to wash hands and wrists for at least 15-20 seconds with soap and water, or an alcohol-based sanitizer, covering all surfaces of the hands and fingers.",2019-10-01
5486,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2015-06-04,272,D,0,1,OF8Y11,"Based on observation, medical record review, family interview, and staff interview, the facility failed to ensure the accuracy of a comprehensive annual Minimum Data Set (MDS) assessment for one (1) of three (3) residents reviewed for dental status. Resident identifier: #62. Facility census: 81. Findings include: a) Resident #62 Observation of the resident on 06/01/15 at 3:55 p.m., found the resident's bottom teeth appeared to be chipped and discolored. Medical record review at 1:00 p.m. on 06/02/15, found the resident's last annual comprehensive assessment MDS, with an assessment reference date of 12/18/14, Section L entitled oral/dental status indicated the resident was assessed as having no dental issues. Further medical review found a nursing assessment, completed on 12/18/14, by Registered Nurse (RN), Clinical Care Supervisor #39. RN #39 documented the resident had missing, decayed or broken teeth. At 4:15 p.m. on 06/02/15, the resident's oral cavity was observed with RN #39, who verified the resident had at least two (2) teeth on the bottom left side and two (2) teeth on the bottom right side that were black and decayed. The resident's daughter was also present during the exam. The daughter stated she was aware of the decayed teeth, but her mother was ninety-four (94) years old and she probably would not do anything about the resident's dental needs. RN #105, Quality Standards Coordinator, was interviewed at 4:36 p.m. on 06/02/15 regarding the conflicting documentation on the MDS and the documentation on the nursing assessment. Employee #105 provided no additional comments or information. At 4:50 p.m. on 06/02/15, the MDS coordinator, RN #8, was interviewed because she had completed the 12/18/14 annual MDS. She stated, I could have put the wrong information in, I did look at her. I will see if I can find my notes. At the close of the survey on 06/05/15, no further information had been provided.",2019-01-01
5487,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2015-06-04,329,D,0,1,OF8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure one (1) of five (5) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) for the care area of unnecessary medications, had a drug regimen free from unnecessary medications. The physician failed to provide additional documentation to clarify the rational and benefits for the use of multiple medications (duplicate therapy) of the same pharmacological class. Resident identifier: #149. Facility census: 81. Findings include: a) Resident #149 On 06/04/15, medical record review at 9:30 a.m. found Resident #149 was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED] -- [MEDICATION NAME] XR (extended release) 37.5 mg. (milligrams) three (3) times a day for a [DIAGNOSES REDACTED]. -- [MEDICATION NAME] HCI 50 mg at bedtime for a [DIAGNOSES REDACTED]. -- [MEDICATION NAME] 15 mg. at bedtime for a [DIAGNOSES REDACTED]. On 04/10/15, the pharmacist addressed the use of duplicate antidepressants and provided the following report to the physician: Re: CMS (Centers for Medicare and Medicaid Services) F329; duplicate antidepressant drugs [MEDICATION NAME] and [MEDICATION NAME] Use of two or more antidepressants simultaneously may increase the risk of side effects, and require additional documentation concerning the rationale under CMS F-329. Please address the following: (Please check the appropriate response) { } Duplicate agents are being used due to differing mechanisms of action that result in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs (verses) benefit has been considered. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Duplicate agents with similar mechanisms are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Duplicate agents are being used for different indications. (please specify below) ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Other rational (Please describe below) The pharmacist's report had not been completed or signed by the physician. At 2:21 p.m. on 06/04/15, the director of nursing (DON) stated the physician addressed the pharmacist's concerns in a progress note. The DON provided a copy of the physician's progress. The progress note, dated 05/04/15, was reviewed with the DON. The note included: C/O (complaints of) lethargy. Daughter in law in to visit with pt. (patient) and reports to this provider that pt. is sleeping more. Pt. denies pain Assessment/plan: 1. chest wall pain-managed on [MEDICATION NAME]-well managed. 2. Dementia with behaviors - decrease trazadone 25 mg. PO (by mouth) BID (two times a day) x (times) 1 week then q (every) day notify provider if pt. still lethargic. At 3:55 p.m. on 06/04/15, Registered Nurse (RN), Quality Standards Coordinator #105 was interviewed regarding the use of duplicate medications. RN #105 stated the physician had addressed the use of the anti-depressant, medication [MEDICATION NAME] by adding the [DIAGNOSES REDACTED]. She was advised the pharmacist did not ask for a dose reduction, but asked for the rational for the use of duplicate antidepressant use. RN #105 was unable to provide any further information to verify the physician had addressed the pharmacist's recommendations to provide additional documentation concerning the rational for duplicate antidepressants.",2019-01-01
5488,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2015-06-04,428,D,0,1,OF8Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to act upon pharmacy recommendations for one (1) of five (5) residents reviewed for unnecessary medications. The physician failed to provide a clinical rational for the use of duplicate medications from the same pharmacological class when the pharmacist made recommendations. Resident identifier: #149. Facility census: 81. Findings include: a) Resident #149 On 06/04/15, medical record review at 9:30 a.m., found Resident #149 was admitted to the facility on [DATE]. Review of the Medication Administration Record [REDACTED] -- Effexor XR (extended release) 37.5 mg.(milligrams) three (3) times a day for a [DIAGNOSES REDACTED]. -- Trazodone HCI 50 mg at bedtime for a [DIAGNOSES REDACTED]. -- Remeron 15 mg. at bedtime for a [DIAGNOSES REDACTED]. On 04/10/15, the pharmacist addressed the use of duplicate antidepressants and provided the following report to the physician: Re: CMS (Centers for Medicare and Medicaid Services) F329; duplicate antidepressant drugs Effexor, Remeron and Trazodone Use of two or more antidepressants simultaneously may increase the risk of side effects, and require additional documentation concerning the rationale under CMS F-329. Please address the following: (Please check the appropriate response) { } Duplicate agents are being used due to differing mechanisms of action that result in augmentation in managing symptoms of depression. Usage is based on clinical experience or medical literature and the risk vs (verses) benefit has been considered. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Duplicate agents with similar mechanisms are being used in an attempt to use lower dosages of each individual agent. Usage is based on clinical experience or medical literature and the risk vs benefit has been considered. ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Duplicate agents are being used for different indications. (please specify below) ---------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- { } Other rational (Please describe below) The pharmacist's report had not been completed or signed by the physician. At 2:21 p.m. on 06/04/15, the director of nursing (DON) stated the physician addressed the pharmacist's concerns in a progress note. The DON provided a copy of the physician's progress note. The progress note, dated 05/04/15, was reviewed with the DON. The note included: C/O (complaints of) lethargy. Daughter in law in to visit with pt. (patient) and reports to this provider that pt. is sleeping more. Pt. denies pain Assessment/plan: 1. chest wall pain-managed on fentanyl patch-well managed. 2. Dementia with behaviors - decrease trazadone 25 mg. PO (by mouth) BID (two times a day) x (times) 1 week then q (every) day notify provider if pt. still lethargic. At 3:55 p.m. on 06/04/15, Registered Nurse (RN) Quality Standards Coordinator #105 was interviewed regarding the use of duplicate medications. RN #105 stated the physician had addressed the use of the anti-depressant medication Trazodone by adding the [DIAGNOSES REDACTED]. She was advised the pharmacist did not ask for a dose reduction, but asked for the rational for the use of duplicate antidepressant use. RN #105 was unable to provide any further information to verify the physician had addressed the pharmacist's recommendations to provide additional documentation concerning the rational for duplicate antidepressants.",2019-01-01
5489,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2015-06-04,514,D,0,1,OF8Y11,"Based on medical record review and staff interviews, the facilities failed to ensure one (1) of twenty-seven (27) medical records reviewed during Stage 2 of the Quality Indicator Survey were accurate. Resident #142 required the extensive assistance of one (1) to two (2) staff members for transfers. However; Activities of Daily Living (ADL) flow sheets for Resident #142 consistently reflected Resident #142 was totally dependent on staff for transfers, which was inaccurate. Resident Identifier: #142. Facility Census: 81. Findings Include: a) Resident #142 A review of Resident #142's medical record at 11:26 a.m. on 06/04/15, found a Lift/Transfer Screening dated 05/07/15. A review of this screening found Resident #142 was able to safely stand and pivot and was able to transfer with the assistance of one (1) person. Review of Resident #142's ADL flow sheets, related to transferring, from 05/01/15 through 06/03/15 found Resident #142 was marked as being totally dependent for transfers on the following dates and times: -- 05/01/15 at 3:16 a.m. -- 05/01/15 at 11:53 p.m. -- 05/02/15 at 3:58 p.m. -- 05/03/15 at 4:04 p.m. -- 05/04/15 at 12:32 a.m. -- 05/05/15 at 10; 20 p.m. -- 05/06/15 at 4:01 p.m. -- 05/07/15 at 12:14 a.m. -- 05/07/15 at 3:24 p.m. -- 05/09/15 at 4:09 a.m. -- 05/09/15 at 11:19 p.m. -- 05/10/15 at 11:55 p.m. -- 05/11/15 at 3:18 p.m. -- 05/12/15 at 12:38 a.m. -- 05/12/15 at 03:35 p.m. -- 05/13/15 at 2:36 a.m. -- 05/15/15 at 1:49 a.m. -- 05/16/15 at 05:05 p.m. -- 05/17/15 at 12:46 a.m. -- 05/17/15 at 6:11 p.m. -- 05/17/15 at 11:44 p.m. -- 05/19/15 at 1:14 a.m. -- 05/20/15 at 2:30 a.m. -- 05/20/15 at 5:31 p.m. -- 05/21/15 at 12:05 a.m. -- 05/21/15 at 1:56 p.m. -- 05/21/15 at 10:26 p.m. -- 05/24/15 at 1:19 p.m. -- 05/25/15 at 12:07 a.m. -- 05/26/15 at 1:32 p.m. -- 05/26/15 at 11:39 p.m. -- 05/29/15 at 1:24 a.m. -- 05/29/15 at 10:48 p.m. -- 05/30/15 at 3:26 p.m. -- 05/31/15 at 1:18 a.m. -- 05/31/15 at 3:08 p.m. -- 06/01/15 at 3:54 a.m. -- 06/01/15 at 10:19 p.m. -- 06/03/15 at 1:43 a.m. An interview with Registered Nurse (RN) #39 at 2:14 p.m. on 06/04/15, found Resident #142 transferred well with the assistance of one (1) person. When asked if Resident #142 participated in the transfer process, RN #39 stated, She can stand and pivot with the assistance of one staff member. Nurse Aide (NA) #59, during an interview at 2:56 p.m. on 06/04/15, stated, Resident #142 does help with her transfers. She stated, She helps a little bit, but not a lot. When asked what she would code on the ADL flow sheet in regards to Resident #142's need for assistance with transfers, NA #59, stated, I would code that as an extensive assist because she helps a little bit. NA #52, during an interview at 3:05 p.m. on 06/04/15, stated that she would consider Resident #142 totally dependent for transfers. When asked how she assisted Resident #142 with transfers, she stated, When she is in the bathroom she will grab the bar and will pull up. She stated that when the resident was already up in her chair, it only took one (1) person to transfer Resident #142. NA #52 stated that when she was transferring Resident #42 from her bed to her wheelchair, she would usually get another staff member to help with the transfer because the resident was not able to help as much. She stated when transferring from the bed, Resident #142 would use the side rail to help with the transfer a little bit. The director of nursing (DON) was interviewed at 3:20 p.m. on 06/04/14. When asked to explain the difference between total dependence and extensive assist as it related to transfers, the DON indicated the NAs should only code total dependence if a mechanical lift was used. She indicated total dependence meant the resident was not able to help at all in the transfer process. She stated if the resident participated at all in the transfer process, it should not be coded total dependence. The DON was then asked if Resident #142 required the use of a mechanical lift for transfers. She stated, No, she is able to be transferred safely with the assistance of one (1) to two (2) staff members. When asked to review the ADL flow sheets which indicated Resident #142 was totally dependent for transfers, she stated, We have some new staff and it appears they are coding this wrong. She agreed Resident #142's transfer documentation on the ADL flow sheets was not accurate.",2019-01-01
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
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
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
6892,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,226,E,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the facility's reported allegations of abuse / neglect to State authorities, policy review, medical record review, and staff interview, the facility failed to ensure the implementation of their policy for investigation and reporting of allegations of abuse / neglect for five (5) of eighteen (18) allegations reviewed. The facility did not ensure the immediate notification of the supervisor and the administrator or director of nursing. The incidents and/or allegations were not immediately reported as required by State and federal regulations. The facility did not complete a prompt and thorough investigation of each allegation of abuse and/or neglect. Resident identifiers: #145, #26, #151, and #77. Facility census: 85. Findings include: a) Review of the facility's policy for Abuse, Neglect and Exploitation, dated 07/01/09, found the following information: -- Purpose To prevent abuse, neglect or exploitation of resident, to the extent possible and ensure proper investigation and reporting of suspected cases, in compliance with applicable state and federal regulations. -- Procedure . When abuse, mistreatment, exploitation or neglect is suspected, the person who suspects the abuse will immediately notify the Supervisor. Supervisor will notify the administrator or Director Of Nursing, who will complete an incident report immediately and initiate an investigation. In addition, appropriate state authorities will be immediately notified Further review of the facility's Policy Interpretation and Implementation, entitled investigations, found: 1. The facility will thoroughly investigate all allegations and take appropriate actions. 2. Investigation will be prompt, comprehensive and responsive to the situation. b) The facility failed to operationalize their policies for the following five (5) allegations of abuse / neglect: 1) 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 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 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 withe 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 involves 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) hand written 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. Neither was there evidence the employee 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 9-6-9, the APS the reporting form should be received by APS within 48 hours. Submission of the form does not relieve the facility of the responsibility to complete the immediate reporting form. 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 hand written 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 proper state authorities. On 01/20/14, after intervention during the survey, the facility's administrator reported the incident to the proper 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
6893,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,241,E,0,1,ONTQ11,"Based on observation, resident interview, and staff interview, the facility failed to ensure eight (8) randomly observed residents were treated with dignity and respect. During medication pass, the nurse entered the rooms of Residents #77, #156, and #150 without knocking or otherwise asking permission to enter. Resident #77 was not provided prompt toileting assistance, resulting in soiling herself. During meal service, Residents #58, #36, and #41 were not served meals at the same time as all the other residents seated at their tables. Resident #19, who was eating in her room, was not served at the same time as her roommate. Resident #4 was not provided a meal substitution in a timely manner. Resident identifiers: #77, #156, #150, #4, #19, #58, #36, #41. Facility Census: 85. Findings include: a) Resident #77 On 01/16/14 at 12:40 p.m., a Licensed Nurse (Employee #68) was observed administering medications to Resident #77. The nurse walked into the resident's room without knocking, announcing herself, or otherwise asking for permission to enter the resident's room. 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 her was another story. She stated, They do not care anyway, because they tell you to just go ahead and use your diaper. b) Resident #156 During a medication administration observation on 01/15/14 at 10:35 a.m., Employee #68 (a licensed nurse) was observed entering the resident's room. The nurse walked into the resident's room without knocking, announcing herself, or otherwise asking for permission to enter the resident's room. c) Resident #150 During a medication administration observation on 01/15/14 at 8:50 a.m., Employee #68 (a licensed nurse) was observed entering the room of Resident #150. The nurse walked into the resident's room without knocking, announcing herself, or otherwise asking for permission to enter the resident's room. During an interview with the corporate nurse (Employee #94), on 01/16/14 at 3:30 p.m., she was made aware of the observations of staff not treating residents with dignity. After the observations were discussed, Employee #94 agreed staff should knock on the doors prior to entering residents' rooms and provide toileting when it was requested. d) Resident #4 Observation of the noon meal, on 01/13/14, found Resident #4 was served his noon meal, consisting of pizza and pasta, in his room. At 12:25 p.m., the resident told the nursing assistant, Employee #64, he did not like the meal he was served. The resident requested a bologna sandwich for lunch. Observation found Employee #64 delivered a sandwich at 1:20 p.m., fifty-five (55) minutes after the resident's request. Further observation found the milk and coffee from the original meal were not replaced with fresh beverages when the sandwich was provided. The resident was interviewed at 1:20 p.m. on 01/13/14. He said he asked for a bologna sandwich, but had received a ham and cheese sandwich. The resident stated he could not eat cheese, which was why he requested a sandwich in the first place. He said he would just remove the cheese and eat the ham. The resident stated he would just have to drink the cold coffee and the warm milk. This incident was discussed with Employee #64, the nursing assistant serving trays on the unit, at 1:20 p.m. on 01/13/14. Employee #64 stated he asked the kitchen for a sandwich when the resident requested it, and he served it to the resident when it was delivered by the kitchen. He said he was told the kitchen was serving ham and cheese sandwiches and not bologna sandwiches. e) Resident #19 Observation of the noon meal at 12:35 p.m. on 01/13/14 found Resident #19 and Resident #1 having the noon meal in their room. The residents did not receive their meals at the same time. Resident #1 received her meal at 12:35 p.m.; however, Resident #19 did not receive her meal until 1:00 p.m. Employee #64, the nursing assistant serving trays on the unit, was asked why both residents were not served their meals at the same time. He stated, Her tray (indicating Resident #19) was on another cart. At 1:00 p.m. on 01/13/14, this observation was discussed and verified with Employee #68, a licensed nurse who was serving trays on the unit. f) On 01/21/14 at 1:42 p.m., a discussion was held with the administrator and the director of nursing regarding the observations of the facility's failure to promote dignity for Residents #4 and #19 on 01/13/14. No additional information was provided. Surveyor: Settle,(NAME)F. g) Residents #58 Observation of the noon meal, in the main dining area on 01/13/14 beginning at 12:15 p.m., found Resident #58 seated at a table with Residents #53, #97, #44, #35, #64 and #69. Residents #53, #97, #44, #35, #64 and #69 were served their meals. Resident #58 waited for approximately twenty (20) minutes after her tablemates were served, before she was served her meal. h) Resident #36 During the noon meal observation, at 12:15 p.m. on 01/13/14, in the main dining room, Residents #36, #106, #115, #39, #94, #50 and #45 were seated together at a table. Residents #106, #115, #39, #94, #50 and #45 received their meals. Resident #36 did not receive her meal for approximately eight (8) minutes after everyone else at her table had already been served. i) Resident #41 Residents #41, #33, #78, #61 and #90 were seated together at a table in the main dining room on 01/13/14 at 12:15 p.m. Resident #41 waited for his tray for approximately ten (10) minutes after the other residents seated at his table had already been served their meals. j) Employee #90, a licensed practical nurse, was in the dining room during the noon meal observations at noon on 01/13/14. Upon inquiry, she stated they tried to serve all residents at the same table before serving residents at another table, but were unable to do so. She said, It depends on how the trays come out from the kitchen.",2017-11-01
6894,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,242,D,0,1,ONTQ11,"Based on resident interview, observation, and staff interview, the facility failed to ensure two (2) of five (5) residents, who triggered the care area of choices, were afforded the right to exercise autonomy regarding an important aspect of their lives. Neither were given a choice regarding what time they wished to get up in the mornings. Both were gotten up earlier than they desired and/or was necessary to receive ordered care and services. Resident identifiers: #59 and #144. Facility census: 85. Findings include: a) Resident #59 During Stage 1 of the Quality Indicator Survey, at 11:07 a.m. on 01/14/13, the resident was asked, Do you choose when to get up in the morning? The resident replied, They get me up at 5:00 in the morning. I would like to sleep. They get me up and get me ready for therapy and make me sit around here and wait for breakfast. They say I have to be ready for therapy. The resident explained he received speech therapy because he had difficulty swallowing his food. He said the speech therapist watches him eat his breakfast in his room around 7:30 a.m. The resident was observed resting in his bed at 7:30 a.m. on 01/15/14. He was dressed in sweat pants, shirt, socks, and tennis shoes that were laced and tied. He said staff woke him up very early to assist him with getting up and getting dressed. He stated he thought it was around 5:00 a.m. The resident said, When they weren't looking, I went back to bed. He added he was supposed to ring the light for assistance, but if he was up in the wheelchair and the wheelchair was beside his bed, he could get in bed by himself. The resident said, Getting up so early wouldn't be bad if they actually gave you therapy when they got you up. At 8:00 a.m. on 01/15/14, the resident was observed being taken to the therapy room by wheelchair. On 01/15/14 at 11:52 a.m., the physical therapy assistant, Employee #107, stated he thought the resident did not mind getting up early for therapy. He said the resident went to physical therapy around 8:30 a.m. to 9:00 a.m. Employee #107 said he did not know what time the resident was awakened and dressed for therapy. At 11:52 a.m. on 01/15/14, the speech therapist, Employee #105, stated she thought the resident did not mind having speech therapy at approximately 7:30 a.m. She stated he went to physical therapy around 8:00 a.m. to 9:00 a.m. Employee #105 said she was unaware of the time the resident was actually up and dressed, she only knew he was up when she arrived for work. Employees #1 and #65, both nursing assistants providing care for the resident, were interview at 2:30 p.m. on 01/15/14. Both staff members stated the resident was usually up when they arrived for their shift at 7:00 a.m. Both employees stated the resident was on the, get up list for night shift. At 2:31 p.m. on 01/15/13, Employee #36, the registered nurse on the resident's unit, stated, They hang out a list every night as to who gets up by midnight shift. She said she did not know who was on the list to get up the previous night as the list had been removed. Employee #36 stated, The list contained several residents and the night shift leaves at 7:00 a.m., so they probably do start around 5:00 a.m. getting people up who go to therapy. On 11/16/14 at 7:45 a.m., Employee #46, the night shift licensed nurse was interviewed. She said she gets a list of people who need to be up. She stated, We get up about 5 or so people on this unit, who go to therapy. She stated staff start getting up residents up around 5:00 a.m. You have to or you won't have the residents up and ready. b) Resident #144 Resident #144 was interviewed at 2:23 p.m. on 01/15/14. The resident stated staff made her get up around 5:00 a.m. every morning. She told staff she did not want up at this time but was told, If you want therapy you have to get up and get dressed. When asked how the resident knew what time of the morning she was made to get up, she pointed to her cell phone and stated, I just flip this up and the time is right there, plus I could always look at the television to see what time it is. The resident then stated, My butt gets sore sitting up all the time. She said she gets up at 5:00 a.m. but did not receive therapy until later in the mornings, around 8:00 a.m. or 8:30 a.m. She further explained she was unable to get out of her wheelchair once she got up. The resident pointed to her feet, one of which had a therapeutic boot applied, and stated, Do you think you could get up with all this stuff on your feet? I can't walk. Employees #1 and #65, the resident's assigned nursing assistants, were interviewed at 2:30 p.m. on 01/15/14. Both employees stated the resident was up in her wheelchair and dressed when they arrived that day at 7:00 a.m. Both employees stated the resident had been complaining about being up all morning. According to Employees #1 and #65, Resident #144 was on the get up list for the night shift workers. On 01/15/14 at 2:31 p.m., Employee #36, a registered nurse on the resident's unit, verified several residents were on a list every night to be gotten up by the midnight shift. The resident was again observed up in her wheelchair in her room at 7:50 a.m. on 01/16/14. She expressed anger at being up and said, I had to get up bright and early and I am still sitting here. This isn't right. She again said she did not want to get up, but was told she had to be up. At 7:55 a.m. on 01/16/14, Employee #46, the night shift licensed nurse, was interviewed. She said she got a list of people who need to be up. Employee #46 said they got up about 5 people or so who went to therapy. She stated staff started getting residents up around 5:00 a.m. Employee #46 said, You have to or you won't have the residents up and ready. She provided a list of residents who were gotten up, and Resident #144 was on the list. This information regarding Residents #59 and #144 was provided and discussed with the director of nursing and the administrator on 01/21/14 at 1:42 p.m. No further information was provided.",2017-11-01
6895,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,246,D,0,1,ONTQ11,"Based on observation, medical record review, and staff interview, the facility failed to provide a reasonable accommodation of needs for one (1) of twenty (20) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). The facility did not ensure the resident's mattress accommodated his height. The resident was 73 inches tall and his mattress was 72 inches long. Resident identifier: #145. Facility census: 85. Findings include: a) Resident #145 During Stage 1 of the QIS, the resident was observed in bed at 8:42 a.m. on 01/14/14. The soles of his feet were resting against the bed's footboard. Employee #105, the speech therapist, was present during this observation. She stated, The resident is a wiggle-worm at times. Medical record review, on 01/14/14, found the resident's height was recorded as 73 inches. At 4:20 p.m. on 01/14/14, the resident was observed in bed. The physical therapy assistant, Employee #107, was at the resident's bedside. Employee #107 said the bed was not too short for the resident, He just scoots himself down in bed, he is the one who gets on the footboard. Observation of the resident, with the DON, on 01/16/14 at 11:45 a.m., found the resident was in bed with protective boots over his feet. A foam padding (which was not present before) was placed against the foot board of the resident's bed. The resident's feet were resting against the padding. The DON was asked to measure the resident's mattress. On 01/20/14 at 10:03 a.m., the resident was again observed with the soles of his feet resting against the footboard. Employee #48, a nursing assistant, was present for the observation and agreed the resident's feet were against the footboard. On 01/21/14 at 9:46 a.m., the maintenance supervisor, Employee #38, was asked to measure the resident's mattress. Employee #38 measured the mattress and stated it was 72 inches long. When asked if he was aware the resident was 73 inches tall, he stated, I can fix that right now. The footboard extends and we can lengthen the bed to keep his feet off the footboard. We have extenders to put in the gap between the mattress and the footboard. The DON was interviewed again on 01/21/14 at 10:01 a.m. She was advised of the measurement of the mattress, which was 72 inches long, and the recorded height of the resident in the medical record, which was 73 inches tall. She was aware the maintenance supervisor had extended the footboard. The administrator was advised of these findings at 1:43 p.m. on 01/21/14. No further information was provided.",2017-11-01
6896,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,248,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to utilize the comprehensive minimum data assessment (MDS), which identified the resident's interests and preferences, to develop an individualized program to meet the needs and interests for two (2) of three (3) Stage 2 residents reviewed for the care area of activities. Resident identifiers: #93 and #145. Facility Census: 85. Findings include: a) Resident #93 At each observation during Stage 1 of the QIS (Quality Indicator Survey), on 01/13/14 and 01/14/14, Resident #93 was observed in bed sleeping. She was only observed awake during meal service while being fed by staff in her room, and during her treatment observation when care was being provided. She was observed sleeping the rest of the time. A review of this resident's medical record revealed she had a terminal [DIAGNOSES REDACTED]. Resident #93's most recent comprehensive MDS assessment, dated 09/18/13, Section F titled Preferences for Customary Routine and Activities, indicated this resident was interviewed about her activity preference. Resident #93 indicated it was very important to her to listen to the music she liked. She also indicated it was very important to her to participate in religious services, and to keep up with the news. The resident's care plan was reviewed. There was no evidence this resident's preferences were included in her care plan for activities. The activity participation records were reviewed for November 2013, December 2013, and January 2014. There was no evidence the resident was involved in or offered any of the activities she expressed were important to her. During an interview with the Activity Director (Employee #21), on 01/15/14 at 8:45 a.m., it was verified Resident # 93's care plan did not include a specific activity plan. Employee #21 also verified was no evidence in the participation records the resident had been involved in the activities she expressed interest in, or those which were identified as being very important to her. She stated this resident's condition had declined and she was not up much anymore. The director was made aware there was no radio or music player in the resident's room and this was one thing in which the resident had expressed interest. The activity director stated they have a player and will play some music for the resident in her room. b) Resident #145 Observation of the resident on the morning of 01/14/14, from 8:30 a.m. until 11:41 a.m., found the resident was in bed and did not participate in any facility activities. The same observation was made at 3:30 p.m. on 01/14/14. Review of the admission activity services evaluation, completed on 12/29/13, found the resident's activity pursuit patterns and preferences were: animals/pets, computer / Internet, farming, gardening / plants / flowers arranging, household chores, reading and travel / camping. The resident's admission MDS, with an assessment reference date (ARD) of 12/30/13, indicated it was very important for the resident to have books, newspapers and magazines to read, very important to listen to music, very important to be around animals such as pets, very important to keep up with the news, and very important to go outside to get fresh air when the weather was good. A review of the resident's current care plan on the morning of 01/14/14 found the resident's activities of interest were not addressed on the care plan. Observation of the resident's room on 01/14/14 found no evidence of any reading material or any evidence the resident was given the opportunity to listen to music. The resident had a television in his room, but the television was not turned on. On 01/14/14 at 4:00 p.m., the activity director was interviewed regarding the activity plan for Resident #145. The activities director stated the resident had not attended any activities since his admission. She was also unable to provide any evidence activities had been offered. The activities director stated the resident had asked for a visit from the priest. She stated she had called the priest but she did not know if the priest had visited the resident. At 5:00 p.m. on 01/14/14, the activity director provided a care plan for Resident #145. It had been formulated on 01/14/14. The goals on the new care plan were: resident will agree to recreational visits or programs, show physical sign of enjoyment following at least on activity, maintain appropriate interaction with others and will express satisfaction with a new independent / individual activity pursuit. On 01/21/14 at 1:42 p.m. the administrator and director of nursing were made aware of the observations, record review, and the interview with the activity director regarding Resident #145. No further information was provided.",2017-11-01
6897,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,250,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, job description review, policy review, staff interview, and resident interview, the facility failed to provide medically-related social services for three (3) of three (3) residents reviewed for the care area of social services during Stage 2 of the Quality Indicator Survey. The facility failed to ensure these residents were afforded the opportunity to exercise their rights to autonomy regarding their lives. When Resident #125 was admitted to the facility, she was noted to not have capacity to make medical decisions. She was later determined to have capacity to make medical decisions. The resident voiced a desire to go home; however the facility did not promptly initiate discharge planning. The resident was angry and saddened by the way she was treated and the fact she was still at the facility. The facility's lack of prompt discharge planning resulted in psychological harm to this resident. Resident #53 had capacity to make medical decisions when she was admitted to the facility; however, the facility allowed someone else to sign a Physician order [REDACTED]. The facility failed to afford the resident the right to formulate her own advance directive. Resident #32 had capacity when she was admitted to the facility; however the facility allowed someone else to sign a POST form which indicated the resident was to be a Do not resuscitate (DNR). The facility failed to afford the resident the right to formulate her own advance directive. Resident identifiers: #125, #53, and #32 Facility Census: 85. Findings Include: a) Resident #125 Resident #125's medical record was reviewed at 8:22 a.m. on [DATE]. This review revealed the resident was admitted to the Lighthouse Unit (Dementia Care Locked Unit) at the facility on [DATE]. Upon her admission, the resident lacked capacity to make medical decisions. She had a determination of incapacity which was completed on [DATE] at an acute care hospital. This determination was in effect until [DATE], when the resident's physician reviewed the resident for capacity and determined the resident had regained capacity to make medical decisions. Further review of the medical record revealed the following progress notes written by Employee #28, Lighthouse Unit Director: Note dated [DATE]: 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. This staff member explained that (Resident Name) is going to have to go through the adjustment period, and she will probably be unhappy at first. This staff member assured her that we would continue to monitor her, and also provide positive reinforcement to help her adjust to her new environment. I encouraged her to attend family support group meeting because it will also be an adjustment for the family as well. Note dated [DATE]: Resident has adjusted well to the Lighthouse Unit thus far. She has been cooperating with therapies, and is much more social now than when she first got here. She does believe she is going home soon, and states she is going to work hard to get there. Mood is greatly improved from admission, and she is very active with activities and word games. She enjoys drinking Coca-Cola and reading magazines. Family is supportive and visits often. Note dated [DATE]: (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 [DATE]: Quarterly Review: Resident has adjusted very well to the Lighthouse Unit. (Resident Name) is very social and enjoys spending time with the other residents. She enjoys reading books, and is active with activities. 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 [DATE]: (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 [DATE]: (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 [DATE]: (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 The medical record review revealed the only progress notes regarding discharge planning, by Employee #88, the Social Service Director, were on [DATE] and [DATE]: Note dated [DATE]: 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. Note dated [DATE]: 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. Note dated [DATE]: 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, ,[DATE], 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. Note dated [DATE]: 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 At 10:41 a.m. on [DATE], 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. Employee #116, the physician, was interviewed at 1:45 p.m. on [DATE]. He stated the resident did not belong in the nursing home and especially did not belong on a locked unit. He stated he has told Resident #125 on previous occasions she does not belong in the nursing facility. An additional interview with Employee #116 was conducted on [DATE] at 11:00 a.m. During this interview he stated, Discharge planning should have began sooner for this resident and he did not know why they did not begin working on her discharge sooner. Employee #28, Lighthouse Unit Coordinator, was interviewed at 10:00 a.m. on [DATE]. She stated the resident was not appropriate for the Lighthouse unit currently. She stated this was a recent change and the resident was not appropriate for the unit. She confirmed Resident #125's discharge planning did not start until [DATE], because this is when the resident became very vocal about wanting to go home. At 2:54 p.m. on [DATE], Employee #88, the Social Service Director was interviewed. The Social Service Director agreed Resident #125 was not appropriate for the Alzheimer's Unit. Employee #88 confirmed she began discharge planning for this resident on [DATE]. The Social Service Director stated, This was when her strong vocalizations about going home began. The Social Service Director confirmed 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 [DATE], [DATE], [DATE], and [DATE]. Employee #88, offered no explanation as to why discharge planning had not begun sooner for Resident #125. She just said she was not aware of the resident's desire to return home until [DATE], when the resident had been upset and crying for two (2) days over her desire to go home. The facility's policy titled Discharge Planning was reviewed at [DATE] at 9:00 a.m. This review revealed the following policy statement: Discharge plans will be discussed with resident and/or family/guardian upon admission and will be reviewed and updated at least quarterly and with any significant change. Social Services are responsible for assisting with discharge to home. The procedures for discharge planning included: 1. The social worker or designee will be responsible for discussing discharge plans with each resident (and/or family/guardian) admitted to the facility during the admission process. 2. During the admission process the Social Worker or designee will document the discharge plan on the social services history in the Electronic Medical Record. 3. Social Services will review discharge plans with residents and/or family/guardian at least quarterly and document these quarterly on the Social Services Quarterly Review in the Electronic medical record. 4. Updates and changes in discharge plans can occur at any time, due to change of condition ore resident changing plans. These changes will be documented in the general notes of the Electronic Medical Record. 5. Social Services responsibilities for assisting resident to discharge to home may include, but not limited to: setting up follow-up appointments, setting up home health, and assist in acquiring health related equipment, etc. The Social Service Director job description was reviewed on [DATE] at 9:15 a.m. This review revealed the following key responsibilities related to discharge planning under the heading, Key Responsibilities: .6. Ascertains potential and develops discharge plans when clients are admitted . 7. Arranges for post discharge services and follow-up care. The Social Service Director said she was under the assumption, until [DATE] when she began discharge planning, Resident #125 was going to remain in the facility for long term care. The social worker said she was not aware of Resident #125's desire to go home until Employee #28 told her about it on [DATE]. b) 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 was completed on [DATE], indicating 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 cardiopulmonary resuscitation (CPR) should she need it. The form was signed by the resident's appointed Medical Power of Attorney on [DATE], not the resident who had capacity to make this decision. Since Resident #53 had capacity to make medical decisions, the MPOA was not in effect at the time the appointed MPOA signed the form. Resident #53 was interviewed at 11:30 a.m. on [DATE]. When asked if she would want CPR if she should 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 at [DATE] at 11:00 a.m. This review revealed: 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 ensure the resident is knowledgeable in and exercises his/her rights Employee #88, the Social Service Director, was interviewed at 02:24 p.m. on [DATE]. She stated if the resident had capacity then she should have signed her own POST form. The Social Worker confirmed Resident #53 was not afforded her right to formulate an advance directive regarding whether or not to have CPR. The Social Service Director stated she was aware it was Resident #53's right to formulate an advance directive, but was not aware Resident #53 had not signed her POST form. The Social Service Director stated, To my recollection, I have never talked to this resident about CPR. c) 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 Cardiopulmonary Resuscitation (CPR). The form was signed by the Resident's appointed Medical Power of Attorney on [DATE]. Since Resident #32 had capacity to make medical decisions, the MPOA was not in effect at the time the appointed MPOA signed the form. Employee #88, Social Service Director, was interviewed at 12:13 p.m. on [DATE]. She stated if the resident had capacity then she should have signed her own POST form. The Social Worker confirmed Resident #32 was not afforded the right to formulate an advance directive regarding whether or not to receive CPR. The social worker 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 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 Service Director stated, The practice is typically if the resident seems with it they will allow the resident to sign the forms otherwise they will try to wait until the Doctor determines the resident's capacity.",2017-11-01
6898,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,279,E,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, observation, and policy review, the facility failed to develop a care plan based on the comprehensive assessment for six (6) of twenty (20) residents reviewed during Stage 2 of the Quality indicator Survey (QIS). There was no care plan for an individualized activity program for Resident #145. A comprehensive care plan was not developed regarding [MEDICAL TREATMENT] services or nutritional needs for Resident #97. Specific interventions were not developed related to the potential for dehydration for Resident #17. The care plan for Resident #93 did not specify how the facility would implement the approaches for use of a diuretic medication and did not contain a plan for an individualized activity program. Dental needs were not addressed in the care plan for Resident #35. Resident #77's care plan did not address urinary incontinence. The care plan for Resident #147 did not address the resident's Foley catheter. Resident identifiers: #145, #97, #17, #93, #35, #77, and #147. Facility census: 85. Findings include: a) Resident #145 Review of the resident's admission activity services evaluation, completed on 12/29/13, found the resident's activity pursuit patterns and preferences were: animals/pets, computer / Internet, farming, gardening / plants / flowers arranging, household chores, reading and travel / camping. The admission minimum data set (MDS), with an assessment reference date (ARD) of 12/30/13, found the MDS identified it was very important for the resident to have books, newspapers and magazines to read, very important to listen to music, very important to be around animals such as pets, very important to keep up with the news, and very important to go outside to get fresh air when the weather is good. Observation of the resident on 01/14/14, from 8:30 a.m. until 11:41 a.m., found the resident was in bed. The same observation was made at 3:30 p.m. on 01/14/14. Observation of the resident's room revealed no evidence of any reading material or any evidence the resident was given the opportunity to listen to music. The resident had a television in his room but the television was not turned on. A review of the resident's current care plan on 01/14/14 found activities were not addressed. On 01/14/14 at 4:00 p.m., the activity director, Employee #21, was interviewed and asked what activities the resident had attended since his admission to the facility on [DATE]. The activities director stated the resident had not attended any activities since his admission. She was also unable to provide any evidence activities had been offered. She stated the resident had asked for a visit from the priest, and she called the priest, but she did not know if he had visited the resident. At 5:00 p.m. on 01/14/14 at 5:00 p.m., the activity director provided a new care plan for Resident #145. The goals on the new care plan were: resident will agree to recreational visits or programs, show physical sign of enjoyment following at least on activity, maintain appropriate interaction with others and will express satisfaction with a new independent / individual activity pursuit. On 01/21/14 at 1:42 p.m. the administrator and director of nursing were made aware of the observations, record review, and the interview with the activity director regarding Resident #145. No further information was provided. b) Resident #97 Medical record review found the resident was receiving [MEDICAL TREATMENT] via an arteriovenous (AV) fistula in the left forearm, three (3) days a week on Tuesdays, Thursdays and Saturdays. It was provided at an offsite [MEDICAL TREATMENT] center. The resident had resided at the facility since 03/14/13, and had been receiving [MEDICAL TREATMENT] since admission. Review of the resident's current care plan, dated 01/23/13 found the following problem: (Resident name) requires [MEDICAL TREATMENT] due to end stage [MEDICAL CONDITION]. (Resident name) has a left arm fistula. The goal associated with this problem was, (Resident name) will have no unidentified complications related to [MEDICAL TREATMENT]. This goal was developed on 01/18/14. There were several approaches associated with the problem; however, the care plan did not address the following: -- The [MEDICAL TREATMENT] center's full name, phone number and contact person, -- Transportation plan and contact information, -- The time the resident goes to [MEDICAL TREATMENT], -- The laboratory values, and who would be responsible for obtaining the laboratory work and how the laboratory values would be communicated, --How vascular access care would be provided which would include assessing the resident both before and after [MEDICAL TREATMENT], -- Who will obtain the resident's pre and post weights, and --How information would be communicated between the facility and the [MEDICAL TREATMENT] center. Interviews were conducted with the director of nursing (DON) and the corporate registered nurse, Employee #94, on 01/15/14 at 3:51 p.m., regarding the resident's care plan. Employee #94 said the the [MEDICAL TREATMENT] center did the laboratory work and the facility did not need copies of their work because, [MEDICAL TREATMENT] just flushes everything out and the lab work would not be beneficial. At that time, the DON agreed the care plan needed to be more specific regarding [MEDICAL TREATMENT] care. The resident's care plan had a problem noted, Resident is at risk for significant changes in weight due to chronic disease process and [MEDICAL TREATMENT]. The goal associated with this problem was: Resident will not experience any significant weight changes through next review. The approaches included: --Monitor intake and output, --Provide diet as ordered --Weigh resident per protocol and as indicated At 10:13 a.m. on 1/20/14, the registered dietitian, Employee #95, and the dietary manager, Employee #83, were interviewed regarding the resident's nutritional care plan. Employee #95 confirmed the resident's specific diet orders for no added salt, no bananas, oranges or orange juice, and reduced concentrated sweets was not included in the care plan. Upon inquiry, the dietitian was unaware of the facility's protocol regarding weights for pre and post [MEDICAL TREATMENT], and who would obtain those weights. c) Resident #17 Medical record review, on 01/22/14 found the physician had prescribed [MEDICATION NAME] 20 milligrams, 1 tablet daily. Review of the resident's care plan found a problem: Resident is at risk for dehydration due to diuretic therapy. The goal associated with the problem was, Resident will have no signs or symptoms/ of dehydration through next review. The approaches for this goal included: --Evaluate hydration status daily or as ordered, --Evaluate electrolytes, --Observe for changes in Resident's symptoms that may indicate worsening of condition and notify the physician, --Provide diet and liquids as ordered. The DON was interviewed on 1/22/14 at 9:22 a.m. She was asked how the facility would evaluated the resident's hydration status, how staff would evaluate electrolytes, what symptoms would the resident exhibit that may indicate worsening of condition and what diet was ordered for the resident. The DON said the company trained staff to write the care plan this way, without being specific. d) Resident #93 A review of this resident's medical record revealed she had a terminal [DIAGNOSES REDACTED]. The activities section in her most recent comprehensive MDS, dated [DATE], identified it was very important to her to listen to the music she liked, to participate in religious services, and to keep up with the news. The resident's care plan was reviewed. The resident's preferences were not included in her care plan for activities. The activity participation records were reviewed for November 2013 , December 2013 , and January 2014. There was no evidence the resident was involved in, or offered, any of the activities she expressed were important to her. During an interview with the Activity Director (Employee #21) on 1/15/14 at 8:45 a.m., it was verified Resident #93's care plan care did not include a specific activity plan. It was also verified there was no evidence in the participation records the resident had been involved in the activities she expressed interest in or that were identified as being very important to her. e) Resident #35 During Stage 1 of the QIS survey, 01/14/14 at 9:22 a.m., Resident #35 was observed with broken front teeth and dark black areas on her teeth. Review of the dental care area revealed the medical record did not contain any evidence this resident's teeth had any abnormalities. Employee #90, a licensed nurse, was interviewed about the resident's oral status on 01/15/14 at 3:15 p.m. She stated the resident had never complained and did not have any chewing problems. The nurse said she was not aware of any dental issues. She confirmed there was no evidence of any type of dental consult or dental evaluation. Employee #90 verified there was nothing relative to the resident's oral status, other than the admission assessment, on 05/20/13, which noted no abnormalities were identified. Review of the resident's care plan, on 01/16/14, revealed it did not address the oral problems the resident was experiencing. The care plan contained an intervention which stated dental consult as needed. The care plan did not reflect the resident's poor dental condition or how the condition of the resident's teeth impacted her abiilty to chew food. During an interview on 01/20/14 at 2:00 p.m. with another nurse (Employee #31), she was asked about Resident #35's dental status. She stated Employee #90 had called the resident's son and was working on making this resident a dental appointment. The nurse was asked to do an oral exam on this resident to determine if she had dental issues. The oral cavity of Resident #35 was observed, verifying she had teeth missing, one (1) tooth on the bottom was very loose, there were two (2) black areas of decay on the back bottom teeth, and two (2) broken front teeth. The resident was interviewed about her teeth on 01/20/14 at 2:15 p.m. She stated a nurse had visited her and looked at her teeth. The resident said arrangements were being made to have something done with them. When asked about eating, she stated her teeth bothered her, but she just chewed on one side or the other when she was having problems. When asked about her last dental appointment, she said it was a very long time ago, and she could not recall. . f) Resident #77 Observation on 01/16/14 at 12:40 p.m., found the resident was calling out for assistance and said, Could you get me the bedpan? The nurse (Employee # 68) informed the resident she had not been using the bedpan, but had been getting up and going to the bathroom. The resident then told the nurse, I do not want to get up and go to the bathroom, I want the bedpan. The resident was interviewed at 1:00 p.m. on 1/16/14. When asked about the amount of toileting assistance she required, she stated she had a hurt foot and did not want to get back up after she lays down just to use the bathroom, because it was a lot of trouble. The resident expredded she knew when she needed to urinate. A review of the medical record found this resident was admitted from an acute care hospital on [DATE]. She had an indwelling catheter present at that time. A physician's orders [REDACTED]. The resident's care plan was reviewed. It indicated the catheter was discontinued (yellow highlighted) on the care plan. There was no care plan established for toileting or to restore as much of the resident's bladder function as possible. This resident's urinary incontinence was further explored. A review of the sixty (60) day MDS, with an ARD of 01/06/14, revealed the resident was frequently incontinent during the seven (7) day look back period. During an interview with the Registered nurse who completes the MDS assessments ( Employee #27), she verified she writes the care plans and updates them. She said this resident should have had a care plan to address her incontinence. Employee #27 verified there was no evidence a toileting care plan was established for this resident. The resident's Care Plan Kardex was reviewed. The Kardex is based upon the care plan. It is what the nursing assistants use to implement the care plan. The resident's Kardex stated the resident used the bed pan. The Kardex contained nothing relative to a toileting plan, or a plan to go to the bathroom instead of using the bedpan. During an interview, on 01/16/14 at 4:00 p.m., with a nursing assistant (Employee #1), she verified Resident #77 used the bedpan, and was not on a toileting program. g) Resident #147 Review of medical records for Resident #147, on 01/16/14 at 10:00 a.m., revealed the resident was admitted to the facility on [DATE], with a Foley catheter in place. The Foley catheter was identified on the discharge summary which was sent to the facility from an area hospital. There were no assessments regarding the need for a catheter, no plan for the physician to evaluate its continued use, and/or no plan to consider discontinuation of the catheter. Review of the admission orders [REDACTED]. In addition there were no orders for care and maintenance of the indwelling Foley catheter. On 01/07/14, review of the policy for Catheter (Indwelling Utilization Policy) revealed, A resident admitted with an indwelling catheter in place shall have documentation demonstrating medical justification or shall be evaluated for removal as soon as clinically warranted. Rationale for catheter use shall be documented in the clinical record. Other Essential Points of this policy were: Physician must order utilization as well as any follow-up (e.g. changes, irrigations, etc.) Meticulous peri-care or catheter care must be performed. Review of the Initial/Admission At Risk Care Plan, which was a printed check off type form, revealed no checkmarks under the section which said, At risk for infection related to indwelling catheter. This form gave no indication Resident #147 had an indwelling Foley catheter. Review of nurses' notes, dated 01/07/14 through 01/16/14, found no assessments or evidence the resident was provided Foley catheter care. During a Stage 1 interview on 01/14/14, Employee #9, a licensed practical nurse (LPN), said Resident #147 had a Foley catheter due to [MEDICAL CONDITION]. Interviews with Employee #9 and Employee #51, the director of nursing (DON), on 01/16/14 at 12:30 p.m., confirmed the resident had an indwelling Foley catheter on admission. They verified the medical record contained no justification for, or assessments of the Foley catheter. In addition, Employees #9 and #51 verified there were no directions for care and maintenance of the Foley catheter. It was verified the Foley catheter should have had orders written on admission for the justification for the use and also orders for the care and maintenance of the catheter. They further confirmed the initial/admission care plan should have been completed. After interview with Employee # 51, DON it was revealed the resident had an indwelling Foley catheter due to [MEDICAL CONDITION] and had a follow-up scheduled with the urologist for 01/22/14 for voiding trials in which the facility was unaware. Based on medical record review, observation, policy review, and staff interview, the facility failed to identify, assess and manage an indwelling Foley catheter for Resident #147 upon admission to the facility. For Resident #77, the facility failed to attempt to restore as much normal bladder function as possible. Resident identifier: Resident #147 and Resident #77. Facility census: 85. Findings include: a) Resident #147 Review of this resident's medical records, on 01/16/14 at 10:00 a.m., revealed the resident was admitted to the facility on [DATE]. According to the hospital discharge summary and nurses' report dated 01/07/14, the resident had an indwelling Foley catheter due to [MEDICAL CONDITION]. A follow-up was scheduled with the urologist for 01/22/14 for voiding trials. The admission orders [REDACTED]. The orders contained no reason for the catheter and no orders for care and maintenance of the indwelling Foley catheter. Further review of the record found n Review of the policy for Catheter (Indwelling Utilization Policy) on 01/07/14 , revealed, A resident admitted with an indwelling catheter in place shall have documentation demonstrating medical justification or shall be evaluated for removal as soon as clinically warranted. Rationale for catheter use shall be documented in the clinical record. Essential Points of this policy included: --Resident/Responsible party educated to potential risks and benefits. --Physician must order utilization as well as any follow-up (e.g. changes, irrigations, etc.) --Meticulous peri-care or catheter care must be performed. The Initial/Admission At Risk Care Plan, a printed check-off form, revealed the no checks in the section that said, At risk for infection related to indwelling catheter. Review of nurses notes, for the time period of 01/07/14 through 01/16/14, found no notes concerning the indwelling Foley catheter. A Stage 1 interview was conducted with Employee #9, licensed practical nurse (LPN), on 01/14/14. When asked Is there use of an indwelling Foley catheter, the nurse responded Yes. When asked What is the reason for the resident's catheter, the nurse responded [MEDICAL CONDITION]. During interviews with Employee #9 and Employee # 51, the director of nursing (DON), on 01/16/14 at 12:30 p.m., they both verified the resident had an indwelling Foley catheter on admission to the facility. Both confirmed the orders contained no justification for use and no orders for care and maintenance of the Foley catheter. They further verified the initial/admission care plan did not address the Foley catheter.",2017-11-01
6899,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,280,D,0,1,ONTQ11,"Based on medical record review and staff interview, the facility failed to ensure the care plan, for one (1) of twenty (20) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey, was updated to reflect current interventions. A sensor alarm, which was implemented after the resident fell , was not added to the care plan. Resident identifier: #77. Facility census: 85. Findings include: a) Resident #77 Medical record review found the resident fell , on 01/06/14, while transferring from the wheelchair to the bed. After the fall, the facility added a sensor alarm to the resident's wheelchair. On 01/15/14, the resident's care plan was reviewed. The care plan addressed the resident's risk of falls, but did not include the sensor alarm to the wheelchair. At 10:47 a.m. on 01/15/14, the care plan was reviewed with Employee #94, a corporate registered nurse. She verified the sensor alarm, which was implemented after the fall on 01/06/14, was not added to the resident's care plan.",2017-11-01
6900,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,282,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to implement the interventions established in care plans for two (2) of twenty (20) residents whose care plans were reviewed in in Stage 2 of the survey. Resident #35 did not have anti-tippers on her wheelchair and was not walked with her walker every day as directed by her care plan. Resident #17 did not have chair and bed alarms, landing strips on both sides of her bed, and the bed was not maintained in the lowest position as directed by her care plan. Resident identifiers: # 35 and #17. Facility Census: 85. Findings include: a) Resident #35 Medical record review revealed this resident fell back into her wheelchair and hit her hip on the side of the chair on 12/27/13. Review of the care plan identified the resident had a potential for falls due to decreased functional and cognitive status. The goal regarding this was for her to have no fall with injury requiring hospitalization . An intervention was, Anti-tippers to WC (wheelchair). This was also written on the nursing assistant care card as an intervention for the resident. On 01/20/13 at 1:45 p.m. observation revealed no anti-tippers on the resident's wheelchair. This was verified at that time by a nurse, Employee #31. Further review of the resident's care plan identified a problem stating, Weakness when ambulating short distances. The goal was to increase strength when ambulating. The approach was to ambulate the resident seventy five (75) feet with FWW (front wheel walker) and one (1) assist every day. Review of the medical record for January 2014 found the resident was not ambulated, as directed by the care plan, on thirteen (13) days of twenty (20) days reviewed. During an interview with Resident #35, on 01/20/14 at 3:00 p.m., she stated staff hardly ever walked her down the hall with her walker. She said there was one boy who always walked her when he worked with her, but he was the only one. The resident stated she became weak when she did not walk much. Employee #61, a registered nurse, was interviewed on 01/21/14 at 2:00 p.m. He stated he was the nurse responsible for the restorative nursing program. The nurse was asked about the evaluation of established interventions, and how the facility ensured the interventions were implemented. Employee #61 stated the nurses were supposed to monitor staff to ensure the established care plan was implemented. He verified there were thirteen (13) days in January 2014 this resident was not ambulated as directed in her care plan. b) Resident #17 Review of the medical record found the resident fell on [DATE]. The resident was found on the floor in front of her wheelchair. The resident told staff she got out of bed, walked to the wheelchair, and missed her seat. Review of the POS [REDACTED]. Further review of the medical record found a care plan for falls, initiated on 11/03/14. It contained interventions for landing strips on each side of the bed at all times, and for the bed to be in the lowest position at all times. At 8:20 a.m. on 01/22/14, the resident was observed in her bed. Observation with Employee #16, a licensed nurse, found the bed was not in the lowest position, only one (1) landing strip was on the left side of the bed, and the resident did not have a bed alarm. At that time, Employee #16 lowered the resident's bed to the lowest position. At 9:32 a.m. on 01/22/14, an observation was made with the director of nursing (DON). The resident's bed had been raised and was no longer in the lowest position, only one (1) landing strip was on the left side of the bed, and the resident did not have a bed alarm. The DON verified the resident's care plan had not been implemented.",2017-11-01
6901,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,309,E,0,1,ONTQ11,"**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 four (4) of twenty (20) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS) received care and services to attain or maintain the highest practicable physical, mental and psychosocial well- being in accordance with the comprehensive assessment. The facility failed to ensure Resident #97, who received [MEDICAL TREATMENT], was assessed at the nursing facility before and after [MEDICAL TREATMENT]. There also was no evidence the dressing over the site was checked and removed as required after the resident received [MEDICAL TREATMENT]. In addition, the facility failed to correlate the resident's care with the [MEDICAL TREATMENT] center, failed to follow facility policy for care of a resident receiving [MEDICAL TREATMENT], and failed to develop a comprehensive care plan that included nutritional needs and management of the resident's end stage [MEDICAL CONDITION]. The facility failed to flush Resident #18's peripherally inserted central catheter (PICC) line according to physician's orders [REDACTED]. The facility failed to administer insulin according to physician's orders [REDACTED]. The resident was to receive [MEDICATION NAME] 35 units twice daily in the morning and at bedtime. The insulin was only administered at bedtime. For Resident #60, the resident had physician's orders [REDACTED]., at bedtime, by mouth as needed for anxiety. The [MEDICATION NAME] was administered on 01/13/14 at 5:20 p.m. and again on 01/14/14 at 1:47 a.m. Resident identifiers: #97, #18, #148 and #60. Facility census: 85. Findings include: a) Resident #97 Medical record review found the resident was receiving [MEDICAL TREATMENT] via an arteriovenous (AV) fistula in the left forearm, three (3) days a week on Tuesdays, Thursdays and Saturdays at an offsite [MEDICAL TREATMENT] center. The resident had resided at the facility since 12/23/13 and had been receiving [MEDICAL TREATMENT] since admission. The medical record contained copies of a [MEDICAL TREATMENT] communication record, shared by the facility and the [MEDICAL TREATMENT] center. The facility was required to complete the top half of the form which included the resident's vital signs before leaving the facility for [MEDICAL TREATMENT] and examination of the shunt site. The [MEDICAL TREATMENT] center was to complete the bottom half on the form which also included obtaining vital signs and monitoring the shunt site for location, condition of dressing, ports, pain and any other problems. Neither the facility or the [MEDICAL TREATMENT] center had consistently recorded the resident's pre and post [MEDICAL TREATMENT] weights. Review of twenty-nine (29) [MEDICAL TREATMENT] communication forms dated 10/01/13 to 01/11/14 found the resident's pre and post [MEDICAL TREATMENT] weight was not recorded on twenty-five (25) of the twenty-nine (29) days: 10/01/13, 10/03/13, 10/05/13, 10/15/13, 10/22/13, 10/24/13, 10/29/13, 10/31/13, 11/05/13, 11/07/13,11/09/13, 11/12/13, 11/14/13, 11/21/13, 11/25/13, 12/05/13, 12/12/13, 12/19/13, 12/21/13, 12/23/13, 12/26/13, 12/28/13, 01/02/14, 01/09/14, and 01/11/14. On 10/31/13, 11/05/13, 11/14/13, 12/09/13, and 12/23/13, the [MEDICAL TREATMENT] center failed to complete / supply any information on the [MEDICAL TREATMENT] communication record. The medical record contained no evidence the facility was checking for the patency of the resident's fistula by listening for bruits and / or palpating for thrills. There was no evidence the fistula was monitored for bleeding after the resident returned from [MEDICAL TREATMENT]. The resident was returned to the facility after [MEDICAL TREATMENT] with a dressing over the fistula which was to be removed after four (4) hours. There was no medical record documentation regarding removal of the dressing and observation of the fistula. There was no evidence the skin over the vascular access was checked for color, warmth, [MEDICAL CONDITION], drainage, bleeding or infection. The medical record / [MEDICAL TREATMENT] communication form contained no information regarding laboratory values obtained by the [MEDICAL TREATMENT] center. Review of the resident's current care plan on 01/15/14 found a problem: Resident is at risk for significant changes in weight due to choric disease process and [MEDICAL TREATMENT]. The approach for obtaining the resident's weight was, Weigh (name of resident) per protocol and as indicated and monitor (name of resident) intake / output. A second problem on the care plan was: Resident requires [MEDICAL TREATMENT] due to end stage [MEDICAL CONDITION]. Resident has a left arm fistula. The approaches associated with this problem were: --Coordinate transportation to [MEDICAL TREATMENT] as scheduled --Labs as ordered --[MEDICAL TREATMENT] frequency: three times a week Tuesday, Thursday and Saturdays. --[MEDICAL TREATMENT] center is (Initials of the center). --Monitor for changes in level of consciousness, assess skin turgor, oral mucosa, heart and lung sounds PRN (as needed). Report any changes to MD. --Assess for [MEDICAL CONDITION]. If noted contact MD promptly. --Monitor for dry skin and apply lotion as needed. --No lab draws or BP (blood pressure) in left arm. --Check left arm fistula for bruit and thrill every shift and as indicated. --Provide emla cream topically to left arm before [MEDICAL TREATMENT]. --Administer medication as ordered. Review of the facility's policy for [MEDICAL TREATMENT] Services found the purpose of the policy was, To provide continuation of necessary care and services to those residents receiving [MEDICAL TREATMENT] from a community based [MEDICAL TREATMENT] center. It is the facility responsibility to develop a plan of care for the resident that includes a means of communication between the resident, the center and the facility staff. The policy also contained the following procedures: The facility staff will complete the [MEDICAL TREATMENT] Resident Communication Report to include the information required by the [MEDICAL TREATMENT] center prior to the resident leaving for treatment. The communication form will provide a means of useful communication between the facility and [MEDICAL TREATMENT] center. The resident care plan that includes care of the shunt / fistula, including complications, i.e. bleeding infections, etc, nutritional needs, emotional and social well being, management of [MEDICAL CONDITION] and monitoring aspects will be reviewed per the facility policy for care plan review and on as needed basis. The [MEDICAL TREATMENT] Resident Communication Report will be completed by the licensed nurse prior to the resident transfer. Upon return from the [MEDICAL TREATMENT] center, the resident will be evaluated by the licensed nurse including vital signs, shunt / fistula observation and the results of the evaluation will be documented in the medical record . Essential points / required elements: .A completed communication sheet. -What meals, nutritional supplements or snacks should be sent with the resident. -What documentation items should be returned with the resident from the [MEDICAL TREATMENT] center, if more that the completed communication form. -Need to have a contact number and emergency contact for a nurse at the [MEDICAL TREATMENT] center clearly posted and / or included in the resident's medical record. -There needs to be staff education on [MEDICAL CONDITION] and [MEDICAL TREATMENT] complications, documentation, care planning and management. -Licensed staff needs to know what to do in case of an emergency. On 01/15/14 at 3:14 p.m., Employee #90, a licensed nurse, was interviewed regarding the completion of the [MEDICAL TREATMENT] communication form. She stated, We just fill out the top of the form, the [MEDICAL TREATMENT] center usually doesn't fill out the bottom. We don't call if they are not complete. The assistant director of nursing (ADON), Employee #14, was interviewed at 3:22 p.m. on 01/15/14. She was asked who was responsible for obtaining the pre and post [MEDICAL TREATMENT] weights. She stated, Well I would think it would be [MEDICAL TREATMENT]. She was asked if the care plan discussed who was responsible for the pre and post weights. She stated, The care plan just says to follow protocol. She was then asked, What is the protocol? The ADON replied, I don't know, I will get (name) to answer your questions. The person provided to answer the questions was Employee #61, a registered nurse and staff development coordinator. He was interviewed at 3:25 p.m. on 01/15/14. Employee #61 stated the [MEDICAL TREATMENT] center did not always record the pre and post weights, or if they did the facility did not always get them. He said, They don't do it and we don't follow up on it. Filling out the form is simple, they can't grasp it. When asked if he had knowledge about lab work preformed at the [MEDICAL TREATMENT] center, he said he did not know the protocol, but if any lab work was critical, the [MEDICAL TREATMENT] center would notify the facility. On 01/15/14 at 3:51 p.m., the director of nursing (DON) was interviewed. She agreed the [MEDICAL TREATMENT] center should supply the facility with pre and post weights. She said she did not know which laboratory values the facility would obtain and what laboratory values the [MEDICAL TREATMENT] center should obtain. The DON said she was unaware the facility did not have any orders for, or documentation the fistula was monitored for bruit and thrill. She was also unaware there was no evidence the skin over the vascular access was checked for color, warmth, [MEDICAL CONDITION], drainage or bleeding. The DON stated the facility should have a physician's orders [REDACTED]. She added, We did have an order but it was discontinued in June 2013 and I don't know why. The resident's care plan was also discussed with the DON, who agreed the care plan did not include who would weigh the resident pre and post [MEDICAL TREATMENT], the complete name of the [MEDICAL TREATMENT] center, the telephone number and the [MEDICAL TREATMENT] contact person, who was responsible for obtaining laboratory values, how the skin over the vascular assess would be checked after the residents return from [MEDICAL TREATMENT] which included removal of the resident's dressing and assessing for color, warmth, [MEDICAL CONDITION], drainage or bleeding. On 01/15/14 at 4:20 p.m., Employee #94, a corporate registered nurse, stated, Well, we never get that stuff from [MEDICAL TREATMENT] and I just interviewed the resident who explained everything. The resident knows when she gets [MEDICAL TREATMENT] and they (the [MEDICAL TREATMENT] center) do its own labs. [MEDICAL TREATMENT] just flushes everything out anyway so their labs wouldn't be any good. [MEDICAL TREATMENT] does their own work and we don't need to know everything that goes on over there. At 4:49 p.m. on 01/15/14, Employee #52, the medical records director, stated, I just called the [MEDICAL TREATMENT] center and they agreed they need to communicate better. On 01/20/14 at 9:39, Employee #31, the resident's licensed nurse, was asked how the facility monitored the resident's intake and output as directed by the care plan. She stated, The resident is independent and we can't monitor her input and output regularly. She will ask for fluid. She is not compliant. Observation of the resident's fluid intake form, dated 01/19/14 midnight to 01/20/14 at 4:42 a.m., found the resident had consumed 3980 cc of fluid. The resident's care plan, which directed staff to monitor the resident's intake and output, was discussed with the DON again at 10:30 a.m. on 01/20/14. She stated the resident's intake and output is not being monitored as the resident is non-compliant with her diet. She said this approach should have never been on the resident's care plan. During the discussion at 10:30 a.m. on 01/20/14, the DON stated, The administrator has contacted the [MEDICAL TREATMENT] center to set up a meeting. At 3:31 p.m. on 01/20/14, the resident was interviewed regarding her treatment for [REDACTED]. She demonstrated how she checked for the thrill by placing her fingers over the fistula. She stated, You can feel it and I check it everyday. The resident said she monitored the site for any redness, swelling or infection. c) Resident #18 Medical record review found the resident returned to the facility from the hospital on [DATE]. Upon return, a physician's orders [REDACTED]. Review of the facility's Medication Administration Record [REDACTED]. (The PICC line was not being used to administer medications). Further review of nursing notes revealed an entry dated 11/15/13, Resident was worried about her picc line. Resident then called her husband and her husband then called the facility and said that someone needed to check on (name of resident) that her arm was hurting where the picc line was and that her hand was swollen. This nurse went to check on the resident and found her hand was swollen. Resident told this nurse that her hand nor her arm had any pain. This nurse elevated residents right arm. Resident is currently resting in bed call light within reach. Will continue to monitor. The next nursing note was made on 11/16/13 at 2:29 a.m., Resident right arm elevated on pillows. Right arm continues to have [MEDICAL CONDITION]. Will continue to monitor, No distress noted. Call light within reach, No behaviors noted thus far. On 11/16/13 the assistant director of nursing (ADON), Employee #14, made an entry in the nurse's note, Lateral lumen of PICC line flushed as ordered, Medial lumen will not flush. Continued review of the medical record found the PICC line was discontinued on 11/20/13. On 01/16/14 at 10:54 a.m., an interview was conducted with Employee #61, a registered nurse, who verified the PICC line was not flushed every shift until 11/16/13. He stated the PICC line was not flushed on 11/15/13 when the order was obtained because the licensed practical nurse (LPN) who wrote the order was not certified to flush the PICC line. He stated it was his understanding LPNs could only flush a PICC line if there were certified. On 01/16/14 at 11:00 a.m., Employee #14, the ADON, was interviewed. She was asked what she did when the medial lumen of the PICC line would not flush on 11/16/13. She stated, I imagine I called the doctor, but I didn't write anything about it. This situation was discussed with the DON and the administrator at 1:43 p.m. on 01/21/14. No further information was provided. d) Resident #148Resident #148's medical record was reviewed at 9:30 a.m. on 01/15/14. This review revealed the resident was admitted to the facility on [DATE]. The list of discharge medications from the hospital, with the date of 01/10/14, indicated the resident was to receive 35 units of [MEDICATION NAME] twice daily every morning and at bedtime. The copy of the physician's orders [REDACTED]. The orders were signed by the facility's physician.The resident's Medication Administration Record [REDACTED]. The MAR indicated [REDACTED]. Employee #36, a registered nurse (RN), was interviewed at 11:30 a.m. on 01/15/14. She confirmed the discharge summary from the hospital, dated 01/10/14, indicated the resident should have received [MEDICATION NAME] 35 units twice a day and not just [MEDICATION NAME] 35 units at bedtime. She said the dose for the [MEDICATION NAME] was clearly marked 35 units twice a day every morning and at bedtime on the discharge information, as well as on the hand written physician orders. According to the nurse, this was where MEDICATION ORDERS FOR [REDACTED]. The RN confirmed the orders were inaccurately placed in the computer and the resident received the wrong dose of [MEDICATION NAME] from 01/10/14 through 01/14/14. The DON reviewed the resident's medical record at 12:00 p.m. on 01/15/14. The DON confirmed the resident should have been receiving 35 units of [MEDICATION NAME] twice a day instead of the 35 units only at bedtime, as the resident received from 01/11/14 through 01/14/14. The DON confirmed the dosage of the [MEDICATION NAME] on the discharge medications from the hospital was 35 units twice daily, but the facility transcribed the wrong dose onto the MAR indicated [REDACTED]. e) Resident #60 During a review of the medical record for Resident #60, on 01/16/14 at 10:05 a.m., a physician's orders [REDACTED]. Review of the Medication Administration Record [REDACTED] An interview was conducted with a registered nurse (RN), Employee #60, on 01/16/14 at 12:30 p.m. Employee #60 confirmed the [MEDICATION NAME] was ordered to be given at bedtime, and should not have been given at 5:20 p.m. on 01/13/14 and 1:47 p.m. on 01/14/14.",2017-11-01
6902,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,311,D,0,1,ONTQ11,"Based on record review, resident interview, and staff interview, the facility failed to provide maintenance and/or restorative services to prevent a decline or achieve improvement in ambulation for one (1) of one (1) resident reviewed in Stage 2 for the care area of Activities of Daily Living. The resident had a restorative nursing care plan to address weakness and to increase strength when she was ambulating. There was no evidence the restorative plan was consistently implemented. Resident identifier: #35. Facility Census: 85. Findings include: a) Resident #35 Review of this resident's medical record for accidents revealed the resident had a nursing rehabilitation/restorative care plan which stated a problem with Weakness when ambulating short distances. The goal was to Increase strength when ambulating. The intervention for reaching this restorative goal was to ambulate the resident seventy-five (75) feet with a front wheeled walker and one (1) assist every day. Further review of the medical record, on 01/20/14, revealed during the first twenty (20) days of January 2014, the resident only ambulated seven (7) days with restorative nursing. The other days were not initialed as not occurring, and there were nothing recorded regarding ambulation on those days. The December 2012 ambulation record was reviewed. During thirty-one (31) days, the record indicated the resident ambulated only fourteen (14) of those days. Nothing was recorded for the other days, they were left blank. Resident #35 was interviewed on 01/22/14 at 2:00 p.m. Her restorative ambulation was discussed. The resident said there was only one (1) nursing assistant who walked her. She said if he was working, she always knew she would get to walk. The resident verified she walked with her walker and one (1)staff member in the hall only on occasion, and not daily. When asked if she would walk every day if it was offered, she relied, Certainly I want to walk, they just do not have time. She stated that she only walked about three (3) times a week and her legs were weak. During an interview with a registered nursing, Employee #61, 01/22/14 at 2:00 p.m., he stated he was in charge of the Restorative Nursing Program. Employee #61 verified the data for December 2013 and January 2014 and confirmed there was no evidence ambulation services were provided daily for Resident #35. He stated the nursing assistants did Restorative. He said the instructions on the forms they use for documentation indicated they were to document a W for withheld, R for refused, or D for discharged . Employee #61 stated if there was nothing in the box, there was no evidence the service was provided. An inquiry was made regarding monitoring for restorative services to ensure residents were provided restorative services. Employee #61 said he did not evaluate this. He said the nurses were supposed to make sure the restorative services were getting done.",2017-11-01
6903,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,315,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, policy review, and staff interview, the facility failed to ensure one (1) of three (3) residents reviewed for incontinence was assessed and provided treatment and services to restore as much normal urinary function as possible after a catheter was removed. The resident was not assessed and no plan was established or attempted to assist the resident to attain or maintain normal bladder function after the catheter was removed. In addition, the resident was not assisted with toileting in a timely manner when she requested assistance. Resident #77. Facility census: 85. Findings include: a) Resident #77 On 01/16/14 at 12:40 p.m., a Licensed Nurse (Employee #68) was observed entering Resident #77's room to administer her medications. The resident's call light was on and the resident was calling out for assistance. The resident asked the nurse, Could you get me the bedpan? The nurse informed the resident that she had not been using the bedpan and had been getting up instead and going to the bathroom. The resident then told the nurse I do not want to get up and go to the bathroom I want the bedpan. The nurse informed the resident she would get someone to take her to the bathroom after she gave the resident her medications. The resident again stated I do not want to go to the bathroom, I want the bedpan. The nurse said, Your daughter wants you to get up and go to the bathroom and does not want you to use the bedpan. The resident then told the nurse, I will just use my depends then. Employee #68 administered the resident's medication. It took seven (7) minutes. When medication administration was completed, the nurse said, 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) entered 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 (staff) have told her before to just use her diaper anyway, so it should not matter. The resident was interviewed at 1:00 p.m. on 0/16/14. When asked about the amount of toileting assistance she required, she said she had a hurt foot and did not want to get back up after she lays down just to use the bathroom, because it was a lot of trouble. She said she knew when she needed to go, but getting someone to take you is another story. She stated, They do not care anyway, because they tell you to just go ahead and use your diaper. Resident #77's medical record was reviewed. The resident was admitted from an acute care hospital on [DATE]. She had an indwelling catheter at the time of admission. The catheter was removed on 01/01/14. There was no evidence the resident was assessed and provided services to restore or improve normal bladder function after the catheter was removed. The resident's care was reviewed. The care plan for the indwelling catheter was discontinued (yellow highlighted) on the care plan. No care plan was established for toileting or an evaluation for necessary interventions to restore as much normal bladder function as possible. Further exploration of the resident's urinary incontinence revealed the sixty (60) day minimum data set (MDS), with an assessment reference date of 01/06/14, noted the resident was frequently incontinent during the seven (7) day look back period. During an interview with Employee #27, the registered nurse who completes the MDS assessments, revealed she also writes and updates the care plans. She stated Resident #77 should have had a care plan to address her incontinence. Employee #27 verified there was no plan to assess and/or provide services to restore or improve normal bladder function for this resident, such as a plan for toileting. The resident's Care Plan Kardex was reviewed. It was verified the Kardex was what nursing assistants use to provide care, instead of reading the care plan. The information relater to Bladder on Resident #77's Kardex stated,She uses the bed pan and is incontinent. During an interview on 01/16/14 at 4:00 p.m., with a nursing assistant (Employee #1), she verified Resident #77 was not on a toileting program. She stated although the Kardex indicated the resident used the bedpan, the resident's family told staff the resident was to use the bathroom and not the bedpan. Employee #1 verified there were some shifts the resident was not incontinent at all, but there was not a real toileting plan. She stated the resident just told staff when she needed to go. The facility's Policy titled, Bladder Continence Program, policy number N-B-007 dated 08/01/12 was reviewed. This policy did not contain measures to attempt to restore bladder function after the removal of a catheter. It also did not contain measures to implement after removal of a catheter to evaluate what toileting method would be appropriate after the catheter removal.",2017-11-01
6904,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,318,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, resident interview, and staff interview, the facility failed to ensure one (1) of one (1) resident reviewed in Stage 2 for the care area of Range of Motion (ROM) was provided services to maintain the highest level of ROM and to prevent an avoidable decline in ROM. These services were not consistently provided daily as ordered and care planned. The resident developed contractures and limited range of motion in her lower extremities which were not addressed by the facility. Resident identifier: #93. Facility Census: 85. Findings include: a) Resident #93 Review of the medical record revealed Resident #93 was admitted to the facility on [DATE]. She was ambulatory at that time. Physical Therapy last treated her in June 2013. Her status of her lower extremities at that time were recorded as WFL (within functional limits). The resident's condition changed. She had a significant change minimum data set (MDS) assessment completed on 09/18/13. Section S of the MDS noted the resident had no contractures present. The resident experienced a decline in condition and started receiving Hospice Services. During an observation of the treatment of [REDACTED]. The nurse completed the treatment on the resident's feet. The resident's legs remained bent the entire time. Resident #93 was interviewed during her dressing change on 01/16/13 regarding her legs. She was asked if she could straighten out her legs. She said not very good and straightened them out a little with the assistance of Employee #94, a registered nurse. The knee joint moved only a little and would not straighten. the resident's knees remained bent. The most recent quarterly MDS, an assessment reference date (ARD) of 12/13/13, was reviewed. This assessment did not identify any range of motion impairment to the resident's lower extremities. Review of the December 2013 nursing rehabilitation / restorative care plan revealed the resident had weakness in her bilateral lower extremities (BLE).The goal established was, Increase strength in BLE. The interventions were: 1. Provide PROM (passive range of motion) to LLE (left lower extremity) for fifteen (15) minutes everyday. 2. Provide PROM( passive range of motion) to RLE (right lower extremity) for fifteen (15) minutes everyday. There were twelve (12) days in December 2013 on which the resident did not receive range of motion (ROM) services as stated in her care plan. At the end of the month, when the monthly review was done, the resident's care plan was noted as appropriate. There were no changes recommended, and documentation said the resident was tolerating the ROM services well, with no complaints of pain during the activity. The monthly review did not indicate the resident did not receive ROM services for nearly 1/2 the month of December. The resident's ROM care plan also included the same goals for the resident's upper extremities. These were to be done fifteen minutes to each extremity daily, for a total was one (1) hour of range of motion daily to the resident's upper and lower extremities. The MDS nurse, Employee #27, was interviewed on 01/16/14 11:50 a.m. She was asked about Resident #93's range of motion and contractures. Employee #27 said she would go look at the resident. At 1:30 p.m. on 01/16/14, after the nurse evaluated the resident, she was again interviewed. Employee #27 confirmed the resident could not straighten out her legs and had contractures. She said the resident could straighten her arms out straight on command. Employee #27 confirmed the the resident was receiving range of motion services, but the resident's limitations,contractures, and restorative services were not captured on her MDS. she said she would need to do a correction of that assessment. When asked if she found anything in the medical record to reflect a decline in this resident's range of motion, Employee #27 verified she did not find anything. The Occupational Therapy Assistant, Employee #108, was interviewed at 2:00 p.m. on 01/16/14. She stated nursing informed them know if there was a decline. Employee #108 verified therapy had not been notified of a decline for this resident. When asked about working with residents who receive Hospice, she said they treated Hospice residents for staff education, positioning, and to prevent further contractures. Employee #108 provided the most recent evaluations and treatments received for Resident #93. The last treatment the resident received from Physical Therapy was June 2013. There was no evidence the resident had contractures or limited range of motion in her legs at that time. During an interview with a licensed nurse, Employee # 90, on 01/16/14 at 11:45 a.m., she was asked how the facility identified a decline in joint mobility. She stated the facility did an evaluation of joint mobility on admission and then quarterly to identify if there was a decline in that quarter. When asked to provide these evaluations for Resident #93, Employee #90 reviewed the resident's medical record. She confirmed she was unable to find any contractures/range of motion evaluations.",2017-11-01
6905,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,323,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide an environment as free as possible from accident hazards over which it had control for two (2) of three (3) residents reviewed for the care area of accidents. Resident # 35 did not have anti-tippers applied to her wheelchair as stated in her care plan. Resident #17 did not have landing strips to both sides of her bed, her bed was not kept in a low position, and there was not an alarm in place to alert staff of unassisted ambulation as stated in her care plan. Resident identifiers: #35 and #17. Facility Census: 85. Findings include: a) Resident #35 Review of this resident's current care plan revealed she was identified with a potential for falls due to decreased functional and cognitive status. A goal established for this problem was for the resident to have no fall with injury requiring hospitalization . An intervention was added on 09/24/13, that stated Anti-tippers to WC (wheelchair). This intervention was also written on the nursing assistant care card for this resident. An observation on 01/20/13 at 1:45 p.m. revealed there were no anti-tippers on the resident's wheelchair. An interview was conducted with a licensed nurse, Employee #31, on 01/20/13 at 1:45. She verified there were no anti-tippers present on the resident's wheelchair. b) Resident #17 Review of the medical record found the resident fell on [DATE]. The resident was found on the floor in front of her wheelchair. She told staff she got out of bed, walked to the wheelchair and missed her seat. Review of the post - incident actions taken by the facility after the resident fell included adding an alarm to her bed and chair. Further review of the medical record found a care plan for falls, which was initiated on 11/03/14. It included landing strips on each side of the bed at all times, and for the bed to be in the lowest position at all times for prevention of falls. A second fall occurred on 12/27/13. The incident was described as, Housekeeping notified nursing staff that resident was on the floor. Upon entering the room this nurse observed resident sitting on the landing matt that was on floor beside the bed The resident told the nurse, My butt hurts. The nurse examined the resident and found no injury. Review of the resident's incident report, post - incident actions form, and the fall RCA (abbreviation unknown) worksheet found no documentation referencing the bed alarm, or if the bed was in the lowest position. At 8:20 a.m. on 01/22/14, the resident was observed in her bed. Observation with Employee #16, a licensed nurse, found the bed was not in the lowest position, only one (1) landing strip was on the left side of the bed, and the resident did not have a bed alarm. At that time, Employee #16 lowered the resident's bed to the lowest position. At 9:32 a.m. on 01/22/14, an observation of the resident was made with the director of nursing (DON). The bed had been raised and was no longer in the lowest position, only one (1) landing strip was on the left side of the resident's bed, and the resident did not have a bed alarm. The DON verified the resident's care plan had not been implemented. On 01/22/14 at 10:43 a.m., Employee #63, the resident's nursing assistant was interviewed. She stated she did not know anything about an alarm or putting the resident's bed in the lowest position. She stated these instructions should have been listed on the nursing assistant care card, but the care card did not include these interventions. Employee #63 stated, If it isn't on my card, I don't know what to do. The resident's licensed nurse, Employee #90, was interviewed at 11:00 a.m. on 01/22/14. Employee #90 stated, She (meaning the resident) has never had an alarm that I know about. Employee #90 said if the facility was using an alarm, then there should be a physician's orders [REDACTED]. We would have a physician's orders [REDACTED]. We have them for other residents here. The DON was interviewed again on 01/22/14 at 11:00 a.m. She reviewed the nursing assistant care card and verified the card contained no instruction to the nursing assistants for landing mats on both sides of the bed, no directive for the bed to be in the lowest position, and nothing regarding a chair / bed alarm. The DON verified the facility used the care cards to communicate interventions for fall prevention to the nursing assistants. The DON could not explain why nursing staff were unaware of the fall interventions outlined in the resident's care plan.",2017-11-01
6906,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,328,D,0,1,ONTQ12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to deliver the proper care and treatment for [REDACTED]. A resident receiving oxygen did not have her oxygen saturation levels checked or oxygen tubing changed as ordered by a physician. This affected one (1) of three (3) sampled residents. Resident identifier: #143. Facility census: 81. Findings include: a) Resident #143 A review of the physician's orders [REDACTED]. saturation to be checked on room air and documented every Monday night. The medication administration record (MAR) was reviewed on 04/08/14 at 9:45 a.m. The oxygen saturation level ordered every Monday night was not obtained and documented on the MAR on 03/17/14 and 03/31/14. Additionally, the MARs had the oxygen saturation level on room air to be obtained at 2:00 a.m. on Mondays. This would make the oxygen saturation being obtained on Monday morning, not night, as ordered by the physician. An observation of Resident #143 on 04/08/14 at 10:45 a.m. revealed the resident's oxygen tubing was dated 03/29/14. According to the physician's orders [REDACTED]. Employee #42 (Licensed Practical Nurse-LPN) witnessed the date on the tubing of 03/29/14. In an interview with Employee #42 (LPN), on 04/08/14 at 10:50 a.m., the employee stated the tubing was changed by night shift on the weekends. The LPN stated the tubing must have been overlooked and not changed the previous weekend, but would have it changed immediately. Employee #118 (Director of Nursing-DON) was interviewed on 04/10/14 at 10:00 a.m. The DON stated she had spoken to Employee #44 (LPN) and the employee had not obtained the oxygen saturation levels ordered for Monday night on 03/17/14 and 03/31/14.",2017-11-01
6907,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,364,E,0,1,ONTQ11,"Based on observation, staff interview, food temperature measurement, and resident interviews, the facility failed to ensure food was palatable, attractive, flavorful, and at the proper temperatures. Seven (7) of thirteen (13) residents interviewed had complaints about food quality, flavor, selections, appearance, and/or temperature. Resident identifiers are not provided to protect the anonymity of the residents who wished to maintain their confidentiality. Facility census: 85Findings include: a) Confidential Resident Interviews During Stage 1 of the Quality Indicator Survey (QIS), interviews were conducted with the residents. The residents were asked if the food tasted good and looked appetizing. They were also asked if foods were served at the proper temperature. The answers provided by the residents were: 1) Resident 1 It is kind of hit and miss with the food. I am allergic to egg yolk and have asked for egg white, but I seldom receive it. The food could be a lot better. Half the time the food is cold and not warm enough when it is served . 2) Resident 2 The food is horrible most of the time, but occasionally it is good. They give you food you don't even know what it is. If you complain enough the kitchen will make you something else. 3) Resident 3 The food doesn't have a taste. That is the biggest subject in the building. I don't like the menu. 4) Resident 4 They have the heated plates, but they don't use them. 5) Resident 5 They serve food I have never ate before like Danishes for breakfast and the toast is just dried out bread, it is not even toasted. 6) Resident 6 It is cold a lot of times, but it was warm today and yesterday. 7) Resident 7 They have a new director of food. The food does not look good or appetizing. I used to be able to eat it, but now it is just not good. b) On 01/20/14 at 1:00 p.m., food temperatures were obtained at the time of service by Employee #83, the dietary manager (DM). The hot food temperature were above 120 degrees Fahrenheit (F); however, the milk was 83 degrees F. The DM stated the milk should have been 41 degrees or lower at the time of service. According to professional standards of practice, cold foods should be no greater than 50 degrees F at the point of service. c) Pureed and regular taste test trays were requested on 01/21/14. A white meat was very dry with no discernable flavor. Review of the menu after the meal revealed it was chicken. Tricolor spiral pasta was dry with a bland flavor. After the meal, further investigation revealed the only seasoning in the product was one (1) stick of butter for the entire product to serve all residents who consumed an oral diet in a facility with a census of 85. d) Food Temperature Monitoring At 11:15 a.m. on 01/20/14, Employee #83, the dietary manager (DM), was asked for a copy of the food temperature records for the period of January 1, 2014 through January 16, 2014. Review of the log revealed no evidence food temperatures were measured for the dinner meal on five (5) of the seventeen (17) days provided: 01/02/14, 01/07/14, 01/09/14, 01/10/14, and 01/16/14. An interview was conducted with the DM at 11:15 a.m. on 01/20/14. According to the DM, to ensure proper food temperatures, the cook is required to obtain the temperature of each food at each meal before the food leaves the kitchen.",2017-11-01
6908,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,412,D,0,1,ONTQ11,"Based on observation , record review, resident interview, and staff interview, the facility failed to adequately assess and obtain necessary dental services to meet the needs of one (1) of one (1) resident reviewed for the care area of dental status and services. The resident had broken, missing, loose and decayed teeth. There was no evidence the facility identified these issues and/or made arrangements for dental services for this resident. Resident identifier:# 35. Facility Census 85. Findings include: a) Resident #35 During Stage 1 of the QIS survey, on 01/14/14 at 9:22 a.m., Resident #35 was observed with broken front teeth and dark black areas on her teeth. Review of the medical record revealed no evidence of a dental consult or oral assessment. There was an intervention written on the care plan, dated 09/24/13, that stated, dental consult as needed but nothing else regarding the dental status or needs of the resident. During an interview with a licensed practical nurse, Employee #90, on 01/15/14 at 3:15 p.m.,she was asked about the resident's dental status. Employee #90 said the resident had never complained about her teeth and she was not aware of any dental issues. When asked about the facility's dental assessment, the resident's last dental assessment, dated 05/30/13, was located. It was the admission assessment, and contained the following information: -- Missing teeth from Upper Left Quad (marked yes) -- Condition of Upper Left Quad (marked fair) -- Missing teeth from Upper Right Quad (marked yes) -- Condition of Upper Right Quad (marked fair) -- Missing teeth from Lower Left Quad ( marked yes) -- Condition of Lower left Quad (marked fair) -- Condition of Lower Right Quad (marked fair) Based on the information in the initial assessment, the facility had knowledge the resident had dental issues; however, at the time of the survey, the issues had not been addressed. After the resident's dental needs were brought to the attention of the facility during the survey, a new dental assessment was completed on 01/16/14. The assessment was indicated an an annual assessment. The assessment completed on 01/16/14 was significantly different from the admission assessment completed on 05/30/13. It contained the following information: -- Missing teeth from Upper Left Quad (marked no) -- Condition of Upper Left Quad (marked poor) -- Missing teeth from Upper Right Quad (marked no) -- Condition of Upper Right Quad (marked no) -- Missing teeth from Lower Left Quad (marked yes) -- Missing teeth from Lower Right Quad ( marked yes) -- Condition of Lower Right Quad ( marked no teeth present) An interview was conducted with a nurse, Employee # 31, on 01/20/14 at 2:00 p.m. She stated that the Employee #90 called the resident's son about the resident's teeth and was working on making the resident a dental appointment. Employee #31 was asked to do an oral exam on Resident #35 at that time. She obtained a tongue blade and examined the resident's mouth. Observation revealed: -- Missing bottom teeth, with one (1) tooth on the bottom left loose -- Two black areas of decay on the back bottom teeth -- The top teeth were present, but had multiple black areas on the teeth -- The front two (2) top teeth were broken Resident #35 was asked about her teeth at that time. She stated a nurse came in, looked at her teeth, and told her she was going to have something done with them. The resident said she was checking with her son. She was asked about eating, chewing, and if her teeth bothered her. The resident said she had problems, but she just chewed on one side or the other when she had problems chewing. When asked about her last dental appointment, she said she could not recall when it was , but it was a long time ago. The resident was asked about going to the dentist. She stated, I guess I should have something done before they start causing me problems.",2017-11-01
6909,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,441,E,0,1,ONTQ11,"Based on review of the infection control policy, infection control logs, and staff interview, the facility failed to implement an infection control program designed to investigate, control, and prevent infections in the facility. The infection control tracking logs were not complete and were not utilized as required by facility policy. The logs had multiple incomplete areas and did not identify the number of infections on a particular unit or the residents' room numbers. There was no organism named for most of the infections, and no dates were recorded for the date the infection was resolved. There was no evidence of tracking or trending infections to identify patterns, need for further intervention, and/or employee education. This practice had the potential to affect more than an isolated number of residents. Facility census: 85 In addition, one (1) random observation revealed the facility failed to ensure the prevention of cross contamination and/or spread of infection during meal service. Resident identifier: #145. Findings Include: a) Infection Control log Data The Director of Nursing (DON, Employee #51 ) was interviewed on 01/21/14 at 2:00 p.m. The facility's infection control data was requested. Specifically asked for were the infection control policies, evidence of the tracking and trending, how the facility monitored infections and identified patterns, and the information utilized to monitor and develop plans to decrease the infection rate in the facility. On 01/22/14 at 10:00 a.m., the DON provided the information she had assembled. She was interviewed about the data and the facility's process for identifying, tracking and trending and prevention of infections. The DON verified she was the person who obtained this information. She provided the logs for the three (3) months prior to the survey (October, November and December 2013). These logs contained places to record the resident's name, admitted , onset date, infection related diagnosis, culture, X-ray date, organism, antibiotic, isolation, HAI (healthcare associated infections or nosocomial /facility acquired infection), re-cultured date, and date resolved. Review of the logs revealed they were not competed as designed, or in a manner in which the facility could identify and track infections. There were multiple areas which contained no information. -- No room numbers or units were recorded on the infection control log to identify where the residents resided in the facility. The DON verified she did not utilize a written document to track the data by room or unit. The DON confirmed she had no written evidence of tracking or trending infections to see if there was a pattern. She stated she did not have a written document to show she looked at infections by unit or room number, but she did not feel they had a problem with infections. -- There was no evidence the facility identified the organism identified in the infection and there was no information regarding re-cultures or a dates the infection resolved. When asked about monitoring the specific organisms, the DON stated, The lab sends a report at the end of the month to tell us how many organisms and what kind we had during the month. She again verified the organisms and infections were not monitored by room or unit. b) Policy and Procedure The facility's policy titled Surveillance for Healthcare-Associated Infections last revised August 2012 was reviewed. In number eight (8) of the policy it stated: Organize the data in the healthcare associated infections worksheet. Indicate in the appropriate column the number of infections that correspond to the pathogenic organism and site of the organism. The policy manual contained a worksheet to be utilized to record this data for each unit. If used, the worksheet would track the organisms present and assist with identifying patterns on specific units. The DON verified, on 01/22/14 at 2:30 p.m., she had never utilized this worksheet because she did not know about it. She stated she would start using it now that she had reviewed it in the policy. The DON said she had not been at the facility long and could only speak for what she had done and for what she could find was done prior to her coming to the facility. She confirmed the infection control logs were incomplete. The Infection Control policy referred to monitoring for trends and comparing rates each month and provide the surveillance data to the infection control committee regularly. The monthly infection control report for December 2013 was reviewed. The report listed only the numbers and types of infections. There were no rooms or units identified for monitoring patterns or trends. The DON confirmed, on 01/22/14 at 2:00 p.m., the data she provided was the only data she reviewed with the quality assurance committee. c) Resident #145. Observation of the noon meal, served on 12/31/13 at 12:50 p.m., found Employee #1, a nurse aide, placed a contaminated tray on the clean food cart containing the clean tray for Resident #145. Employee #36, a registered nurse (RN), confirmed the action of Employee #1 was not appropriate. The RN requested a new tray be prepared by the kitchen for Resident #145.",2017-11-01
6910,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,490,F,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility was not administered in a manner that enabled it to use its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and psychosocial well being of its residents. The facility was not administered in accordance with Federal Regulations and/or in accordance with facility policies and procedures. Systems to provide optimum quality of care and/or quality of life were not established and/or implemented. -- The facility failed to thoroughly investigate and/or report allegations of neglect/abuse related to Residents #145, #26, #151, #77, and #18. -- The facility failed to identify and address medically related social service needs for Residents #125, #53, and #132. -- The facility failed to provide assessment and monitoring for Resident #97, who was receiving [MEDICAL TREATMENT] services. -- The facility failed to ensure an effective infection control program to prevent the development and spread of infection for all residents. The failure to identify and address resident needs related to resident behavior and facility practices, quality of life, and quality of care affected nine (9) residents. The failure to ensure an effective infection control program had the potential to affect all residents. Resident identifiers: #145, #26, #151, #77, #18, #97, #125, #53, and #32. Facility census: 85. Findings include: a) Review of the facility's reportable allegations regarding abuse / neglect (for the past three (3) months), medical record review, and staff interview revealed 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 ,[DATE]). Allegations were not reported to the nursing home program and/or Adult Protective Services (APS) in accordance with West Virginia Code [DATE] for five (5) of nineteen (19) reportable allegations reviewed. 1) Resident #145 There was an allegation that this resident wore 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, was not reported to APS in a timely manner, and was not reported on the correct form. The incident was reported to staff at 8:00 a.m. and again at 10:40 a.m. The facility's investigation consisted of obtaining two (2) statements from staff, who did not work on the day the alleged incident occurred, and a third statement was obtained from the resident who was severely cognitively impaired. The incident was not reported immediately to the proper state authorities, and was not reported to Adult Protective Services (APS) on the proper state required reporting forms. 2) Resident #26 This resident was found by a therapist on [DATE] 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 until [DATE]. The facility did not complete a thorough investigation of the incident, as the only statements from staff were from two (2) staff members who did not work on the day the alleged incident occurred. In addition, the allegation was not reported to APS on the state required form. 3) Resident #151 This resident reported she had to wait several hours to get out of bed, and her call light was placed out of reach. She stated she yelled for help and when no one came, she managed to get her cell phone to call her family for assistance. The allegation occurred on [DATE], but was not reported to the nursing home program until [DATE]. The facility substantiated the allegation, but failed to thoroughly investigate the allegation. The nursing assistant who was responsible for the resident's care at the time the alleged incident was not identified and reported to the nurse aide registry as required by law. The facility also failed to report the allegation to APS using the correct mandatory reporting form. 4) Resident #77 This resident's daughter made seven (7) complaints regarding her mother's care on [DATE]. 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 also not reported timely, as it was not reported until [DATE]. 5) Resident #18 On [DATE], a nursing note dated [DATE] at 6:31 p.m. 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 [DATE] at 12:31 p.m., she verified she was unaware of the nursing note. The social services director, Employee #88, verified on [DATE] at 12:34 p.m., she was unaware of the nursing note. She said the situation had not been investigated or reported to the proper state authorities. 6) Review of facility's past CMS-2567 found the facility was cited at F-225 on [DATE], during a complaint investigation, for the failure to ensure a thorough investigation was completed when allegations of neglect were reported to them, and failed to report allegations to the appropriate State agencies. The facility's plan of correction for this deficiency was, Administrator will review any grievance / concern to ensure that the same are investigated fully, reported per regulations . Also, the plan of correction stated, Any concerns with the investigation or outcomes will be brought to the CQI committee for further review and recommendations. The Regional CQI Nurse will conduct a monthly review to confirm that investigations are complete. The administrator was interviewed at 2:52 p.m. on [DATE]. At that time, the administrator stated she had not reviewed the reportable allegations regarding Residents #145, #26, and #151 yet, so that was why the situation had re-occurred. b) Three (3) residents were identified with unmet medically related social service needs. There was no evidence of monitoring to ensure medically related social services were provided each resident as needed. 1) Resident #125 The resident was admitted to the facility on [DATE] at which time she did not have capacity to make medical decisions. On [DATE] the Resident's physician reviewed her capacity and determined she was able to make medical decisions for herself. The resident voiced a desire to go home since her admission to the facility. The facility did not begin discharge planning for this resident until [DATE] after the resident was upset, crying, and adamant she wanted to go home. During an Interview with the resident, at 10:41 a.m. on [DATE], the resident stated being in the facility made her feel confined, like a prisoner and like someone who has lost their freedom. She stated she was angry and saddened by the way she was being treated, and the fact she was still at the facility. The facility had established discharge planning policies which were not followed. The Discharge Planning policy revealed Discharge plans will be discussed with resident and/or family/guardian upon admission and will be reviewed and updated at least quarterly and with any significant change. Social Services are responsible for assisting with discharge to home. The facility's policy titled Discharge Planning was reviewed at [DATE] at 9:00 a.m. This review revealed, Discharge plans will be discussed with resident and/or family/guardian upon admission and will be reviewed and updated at least quarterly and with any significant change. Social Services are responsible for assisting with discharge to home. 2) Resident #53 This resident had capacity to make health care decisions when she was admitted to the facility; however, her appointed medical power of attorney (MPOA) signed a Physician order [REDACTED]. The resident stated no one at the facility had discussed or shared information with her about her right to formulate her own advance directive. She stated she did not want to have CPR, but wanted to discuss it with her son first before making any final decision. 3) Resident #32 This resident had capacity to make health care decisions when she was admitted to the facility; however, a family member signed her POST form which indicated the resident was to be a Do not resuscitate (DNR). At the time of the survey, Resident #32 no longer had capacity to make medical decisions, and was unable to state whether or not she wanted CPR. In the care area of quality of life, the facility failed to ensure medically related social services were provided to a resident determined to have capacity, who was residing on a locked dementia unit. The facility was aware the resident wished to return home, yet discharge planning was not provided in a timely manner. Also, residents, who had capacity to make medical decisions, were not afforded the right to make decisions regarding advance directives. c) The facility failed to ensure a resident receiving [MEDICAL TREATMENT] was assessed and monitored. 1) Resident #97 This resident was receiving [MEDICAL TREATMENT] at an offsite facility. There was no evidence the resident was assessed by a licensed nurse both before and after [MEDICAL TREATMENT]. In addition, there was no evidence the dressing over the site was checked and removed as required four (4) to six (6) hours after the resident received [MEDICAL TREATMENT]. The facility failed to follow their policy for care of a [MEDICAL TREATMENT] resident, and failed to develop a comprehensive care plan that included nutritional needs and management of the resident's end stage [MEDICAL CONDITION]. The administrator and director of nursing (DON) were interviewed on [DATE] at 1:56 p.m. The DON stated the [MEDICAL TREATMENT] center had been contacted and a meeting had been set up between the facility and the [MEDICAL TREATMENT] center. She stated she could not explain why no one noticed the communication sheets between the facility and the center were not completed. The DON confirmed the resident's status related to [MEDICAL TREATMENT] should have been monitored. d) The facility failed to ensure a program was established to prevent the transmission of disease and infection. The facility also failed to have an effective infection control program which encompassed tracking and trending. Review of the facility's infection control logs revealed they were incomplete, did not identify the resident's room number, the unit on which they were located, or the causative organisms associated with the infection. This information was necessary for tracking and trending of infections. There also was nothing which indicated when the infection was resolved. The facility had no evidence of tracking and trending infections, and no evidence measures were initiated to identify patterns. The facility had no written evidence of tracking or trending of infections to determine possible patterns. When asked about monitoring of specific organisms, on [DATE] at 10:00 a.m., the the director of nursing said, The lab sends a report at the end of the month to tell us how many organisms and what kind we had during the month. The monthly infection control report for [DATE] was reviewed. The report listed only the numbers and types of infections present in the facility that month. No rooms or units were identified for monitoring of patterns or trends. There was no evidence of surveillance to identify, address, and or prevent infections in the facility. On [DATE] at 10:00 a.m., the director of nursing stated this was the only data she used for monitoring and evaluating infections in the facility.",2017-11-01
6911,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,514,D,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the medical record for two (2) of twenty (20) Stage 2 sample residents was accurate and complete. The weight record for Resident #1 contained three (3) different weights recorded on the same day. Resident #98 had a handwritten order for [MEDICATION NAME] which was not correctly transcribed to the physician's orders [REDACTED]. Resident identifiers: #1 and #98. Facility census: 85. Findings include: a) Resident #1 The resident's Stage 1 medical record review, on 01/13/14 at 4:15 p.m., revealed three (3) different weights for the resident on the same date. On 07/08/13, recorded weights for the resident were 113.70, 148.20. and 218.40. Interview with the director of nursing, on 01/13/14 at 4:45 p.m., confirmed the weights were inaccurately recorded in the electronic medical record. b) Resident #98 Medical Record review at 10:00 a.m. on 01/15/14 revealed handwritten readmission orders [REDACTED]. The monthly electronic Medication Administration Record [REDACTED]. Employee #28, Lighthouse Unit director was interviewed at 3:14 p.m. on 01/15/14. She confirmed the order carried over to the January monthly orders and MAR indicated [REDACTED].",2017-11-01
6912,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-01-23,520,F,0,1,ONTQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, observations, staff interview, policy review, and review of the facility's previous CMS-2567 (deficiencies and plan of correction), the facility's quality assurance program failed to act upon quality deficiencies during the daily operation of the facility in which it did have or should have had knowledge. During the survey process from [DATE] to [DATE] the following quality deficits were identified: -- In the care area of resident behavior and facility practices, the facility failed to thoroughly investigate and report allegations of abuse / neglect according to State law. Further review found the facility was cited on [DATE], during a complaint investigation, for a failure to thoroughly investigate and report allegations of abuse / neglect according to State law. -- In the care area of quality of life, the facility failed to ensure medically related social services were provided to a resident determined to have capacity, who was residing on a locked dementia unit. The facility was aware the resident wished to return home, yet discharge planning was not provided in a timely manner. Also, residents, who had capacity to make medical decisions, were not afforded the right to make decisions regarding advance directives. -- In the care area of quality of care, the facility failed to ensure a resident receiving [MEDICAL TREATMENT] services was assessed and monitored. -- In the care area of infection control, the facility failed to ensure a program was established to prevent the transmission of disease and infection. The facility also failed to have an effective infection control program which encompassed tracking and trending. These practices affected nine (9) residents; however, the failure to identify and implement corrective action plans in resident behavior and facility practices, quality of life, quality of care, and/or infection control had the potential to affect all facility residents. Resident identifiers: #145, #26, #151, #77, #18, #97, #125, #53, and #32. Facility census: 85. Findings include: a) Review of the facility's reportable allegations regarding abuse / neglect (for the past three (3) months), medical record review, and staff interview revealed 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 ,[DATE]). Allegations were not reported to the nursing home program and/or Adult Protective Services (APS) in accordance with West Virginia Code [DATE] for five (5) of nineteen (19) reportable allegations reviewed. 1) Resident #145 There was an allegation that this resident wore 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, was not reported to APS in a timely manner, and was not reported on the correct form. The incident was reported to staff at 8:00 a.m. and again at 10:40 a.m. The facility's investigation consisted of obtaining two (2) statements from staff, who did not work on the day the alleged incident occurred, and a third statement was obtained from the resident who was severely cognitively impaired. The incident was not reported immediately to the proper state authorities, and was not reported to Adult Protective Services (APS) on the proper state required reporting forms. 2) Resident #26 This resident was found by a therapist on [DATE] 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 until [DATE]. The facility did not complete a thorough investigation of the incident, as the only statements from staff were from two (2) staff members who did not work on the day the alleged incident occurred. In addition, the allegation was not reported to APS on the state required form. 3) Resident #151 This resident reported she had to wait several hours to get out of bed, and her call light was placed out of reach. She stated she yelled for help and when no one came, she managed to get her cell phone to call her family for assistance. The allegation occurred on [DATE], but was not reported to the nursing home program until [DATE]. The facility substantiated the allegation, but failed to thoroughly investigate the allegation. The nursing assistant who was responsible for the resident's care at the time the alleged incident was not identified and reported to the nurse aide registry as required by law. The facility also failed to report the allegation to APS using the correct mandatory reporting form. 4) Resident #77 This resident's daughter made seven (7) complaints regarding her mother's care on [DATE]. 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 also not reported timely, as it was not reported until [DATE]. 5) Resident #18 On [DATE], a nursing note dated [DATE] at 6:31 p.m. 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 [DATE] at 12:31 p.m., she verified she was unaware of the nursing note. The social services director, Employee #88, verified on [DATE] at 12:34 p.m., she was unaware of the nursing note. She said the situation had not been investigated or reported to the proper state authorities. 6) Review of facility's past CMS-2567 found the facility was cited at F-225 on [DATE], during a complaint investigation, for the failure to ensure a thorough investigation was completed when allegations of neglect were reported to them, and failed to report allegations to the appropriate State agencies. The facility's plan of correction for this deficiency was, Administrator will review any grievance / concern to ensure that the same are investigated fully, reported per regulations . Also, the plan of correction stated, Any concerns with the investigation or outcomes will be brought to the CQI committee for further review and recommendations. The Regional CQI Nurse will conduct a monthly review to confirm that investigations are complete. b) Resident #97 This resident was receiving [MEDICAL TREATMENT] at an offsite facility. There was no evidence the resident was assessed by a licensed nurse both before and after [MEDICAL TREATMENT]. In addition, there was no evidence the dressing over the site was checked and removed as required four (4) to six (6) hours after the resident received [MEDICAL TREATMENT]. The facility failed to follow their policy for care of a [MEDICAL TREATMENT] resident, and failed to develop a comprehensive care plan that included nutritional needs and management of the resident's end stage [MEDICAL CONDITION]. c) Medically Related Social Services The QAA committee failed to ensure medically related social services were provided to three (3) of three (3) residents reviewed for the care area of social services during Stage 2 of the Quality Indicator Survey. This practice resulted in actual psychological harm for one (1) of the three (3) affected residents. 1) Resident #125 The resident was admitted to the facility on [DATE] at which time she did not have capacity to make medical decisions. On [DATE] the Resident's physician reviewed her capacity and determined she was able to make medical decisions for herself. The resident voiced a desire to go home since her admission to the facility. The facility did not begin discharge planning for this resident until [DATE] after the resident was upset, crying, and adamant she wanted to go home. The resident stated being in the facility made her feel confined, like a prisoner and like someone who has lost their freedom. She stated she was angry and saddened by the way she was being treated, and the fact she was still at the facility. The facility's lack of discharge planning resulted in psychological harm to the resident. The facility had established discharge planning policies which were not followed. The Discharge Planning policy revealed Discharge plans will be discussed with resident and/or family/guardian upon admission and will be reviewed and updated at least quarterly and with any significant change. Social Services are responsible for assisting with discharge to home. 2) Resident #53 This resident had capacity to make health care decisions when she was admitted to the facility; however, her appointed medical power of attorney (MPOA) signed a Physician order [REDACTED]. The resident stated no one at the facility had discussed or shared information with her about her right to formulate her own advance directive. She stated she did not want to have CPR, but wanted to discuss it with her son first before making any final decision. 3) Resident #32 This resident had capacity to make health care decisions when she was admitted to the facility; however, a family member signed her POST form which indicated the resident was to be a Do not resuscitate (DNR). At the time of the survey, Resident #32 no longer had capacity to make medical decisions, and was unable to state whether or not she wanted CPR. d) Infection Control Review of the facility's infection control logs revealed they were incomplete, did not identify the resident's room number, the unit on which they were located, or the causative organisms associated with the infection. This information was necessary for tracking and trending of infections. There also was nothing which indicated when the infection was resolved. The facility had no evidence of tracking and trending infections, and no evidence measures were initiated to identify patterns. The facility had no written evidence of tracking or trending of infections to determine possible patterns. When asked about monitoring of specific organisms, on [DATE] at 10:00 a.m., the the director of nursing said, The lab sends a report at the end of the month to tell us how many organisms and what kind we had during the month. The monthly infection control report for [DATE] was reviewed. The report listed only the numbers and types of infections present in the facility that month. No rooms or units were identified for monitoring of patterns or trends. There was no evidence of surveillance to identify, address, and or prevent infections in the facility. On [DATE] at 10:00 a.m., the director of nursing stated the data she provided to the quality assurance committee was the comparison of the rates of infection and the comparison to prior months.",2017-11-01
8120,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-10-24,225,B,1,0,0LWM11,"Based on a review of the abuse/neglect reportable allegations, the abuse/neglect reporting policy, staff interview, and review of complaint files, the facility failed to ensure seven (7) of ten (10) complaints were identified as allegations of abuse and/or neglect and reported to the appropriate outside agencies in accordance with state law. The facility investigated the complaints, but did not recognize them as allegations of abuse/neglect which required reporting to outside agencies. Resident identifiers: #59, #21, #84, #66, #37 #6, and #83. Facility census: 77. Findings include: a) Resident # 59 On 06/10/13, a complaint/concern/grievance/request form for Resident #59 stated, Daughter (name) complained that resident does not receive toileting assistance quickly enough. Stated that mom will proceed to the toilet on her own. Also complained that mother is not being offered continental breakfast. Concerned about inadequate staffing. b) Resident #21 A complaint/concern/grievance/request form for Resident #21, dated 08/06/13, stated 1.) Daughter complained that bed/mattress was noticeably dirty with dried food and also smelled of urine. 2.) Daughter also voiced concern about nursing unit being out of basic supplies like wipes, gloves, and disposable briefs. c) Resident #84 On 09/05/13, Resident #84 complained that her p.m. (night) medicines were given at 11:30 p.m., after her son had to call the facility. d) Resident #66 Resident #66 complained of not receiving baths as scheduled; being told by staff too busy. e) Resident #37 The resident's sister complained that Resident #37 is not warm enough in bed, and has told her she gets cold. The resident's sister believes this is because staff will leave Resident #37 in a thin gown instead of putting pants on her every day in bed as requested. She also believes staff does on provide Resident #37 with the use of a bedpan. The facility received the complaint on 10/02/13. f) Resident #6 Resident #6 complained that aides were not changing her at night every two (2) hours and nurses were not giving her anything for her headaches. She made the complaint on 08/13/13. g) Resident #83 On 08/26/13, the resident's wife stated a nurse aide with dark curly hair who took care of the resident on Saturday and Sunday 08/24/13 and 08/25/13 was too touchy - feely with him; calling him baby and getting in his face. She feels this frustrated and angered her husband. The nurse aide was identified as (name). h) On 10/24/13 at 1:00 p.m., the administrator (Employee #95) confirmed the facility did not report the above allegations to the required outside agencies. She said the facility did not recognize the above issues as allegations of abuse/neglect. She said they investigated these issues as complaints. i) A review of the facility's abuse, neglect, and exploitation policy, with an effective date of 05/01/12, revealed the policy contained criteria to help identify victims of abuse, but did not give criteria to identify victims of neglect.",2016-10-01
8170,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2012-06-01,309,D,0,1,5NR311,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation of the medication pass, and staff interview, the facility failed to ensure medications were administered as ordered by the physician. A crushed buffered aspirin was administered to Resident #5, although the physician's orders [REDACTED]. One (1) of three (3) sampled residents observed on medication pass was not provided with medications as ordered by the physician. Resident identifier: #5. Facility Census: 7. Findings include: a) Resident #5 During a medication administration pass, on 05/30/12 at 8:30 a.m., Employee #30 was observed to administer an Aspirin 325 mg tablet. This medication was crushed prior to administering it to the resident. Review of the label on the bottle from which the nurse had poured the medication found it was buffered aspirin, not [MEDICATION NAME] coated aspirin. Review of the Medication Administration Record [REDACTED]. Employee #30 was questioned about this medication. She stated they had changed it to regular Aspirin instead of [MEDICATION NAME] coated because they crushed this resident's medications prior to administering it to him and they could not crush the [MEDICATION NAME] coated. There was no evidence the facility had consulted with the physician before changing the type of aspirin.",2016-09-01
8171,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2012-06-01,371,E,0,1,5NR311,"Based on observation, staff interview, and review of the USDA (United States Department of Agriculture) Food Code, the facility failed to ensure safe and sanitary storage of food items in the resident pantry. Resident personal care items, that required contacting the poison control center if ingested, were stored in the pantry along with food items intended for resident consumption. The resident refrigerator contained fruit cocktail and pudding that was outdated and should have been discarded. This practice had the potential to affect more than an isolated number of residents on the Lighthouse (locked unit) of the facility. Facility census: 7. Findings include: a) Observation of the clean linen/pantry room on the Lighthouse unit of the facility, at approximately 9:00 a.m., on 05/30/12, with Employee #9, the Lighthouse coordinator, found the following potentially hazardous resident personal care items stored in the pantry: antiperspirant deodorant spray, antifungal ointment, hand and body lotion, and instant hand sanitizer. Each of these items, labeled with warnings to contact the physician or the poison control center if swallowed, were stored on a shelf in the pantry which contained food items intended for resident consumption. Review of the guidelines to surveyors for F371 found, It is recommended that chemical products including, but not limited to cleaning supplies, be stored separately from food items. b) Observation of the pantry refrigerator, located in the same room as the personal care items, revealed perishable items were not discarded within seven (7) days. Several bowls of fruit cocktail were dated 05/21/12 (the day prepared) and 06/04/12 (the date to discard). There was also one (1) bowl of vanilla pudding, dated 05/19/12 (the date prepared) and 12/16/12 (the date to discard). The fruit cocktail and the vanilla pudding had exceeded the seven (7) days allowed for keeping a food item as specified by the USDA food code. The vanilla pudding was dated 12/16/12, which was the use by date for the pudding in an unopened can. Employee #10, the dietary supervisor, was interviewed, at approximately 10:00 a.m. on 05/30/12. She thought the use by date on the can could be used on the product after the product was opened. The use by date on the can is only for an unopened product. The dating of the pudding, once the can is opened, is the seven (7) day limit for keeping a food item. The same is true for the fruit cocktail. Once the product is opened, the time to discard is seven (7) days. Hermetically sealed foods in containers (such as canned foods) is a method of food preservation. These foods remain commercially sterile until the container is opened. After they are opened, they become a perishable food. According to the USDA Food Code, Appendix A: Perishable food, is defined as any food of such type or in such condition as may spoil. Once a canned food product is opened, its opened condition makes the food product inside a perishable food which has the potential to spoil. Review of the 2005 and the 2009 Food Codes 3-501.17 found: (A) Except when packaging food using a reduced oxygen packaging method .food prepared and held in a food establishment for more than 24 hours shall be clearly marked to indicate the date or day by which the food shall be consumed .based on the temperature and time combinations specified below . The day of preparation shall be counted as Day 1. (1) 5 degrees C (41 degrees F) or less for a maximum of 7 days . According to this, the fruit cocktail should have been discarded on 05/28/12 and the vanilla pudding on 05/26/12, yet both of these food items remained in the refrigerator on 05/30/12. Employee #10, the dietary supervisor, was interviewed, at approximately 10:00 a.m. on 05/30/12. She stated she was unaware the food items needed to be discarded 7 days after the date of preparation. The administrator, Employee #1, was also interviewed, at approximately 10:00 a.m., on 05/30/12. She stated she would remove the resident personal care items from the pantry.",2016-09-01
8172,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-09-20,280,D,1,0,F3O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and staff interviews, the facility failed to revise the care plans for two (2) of ten (10) sampled residents. Resident #48's care plan was not revised to reflect the restrictions for a [MEDICAL TREATMENT] diet. The care plan for Resident #56 did not indicate a pressure ulcer had healed. Resident identifiers: #48 and #56. Facility census: 79. Findings include: a) Resident #48 A record review was completed for Resident #48 on 09/19/13 at 8:55 a.m. This review found a physician's orders [REDACTED]. A review of the current care plan found no revisions had been completed to include any food restrictions regarding this resident's [MEDICAL TREATMENT] diet. On 09/19/13 at 11: 20 a.m., a review of the diet listing attached to the snack cart for [MEDICATION NAME] Hall identified this resident received a regular diet with no added salt (NAS). This list did not include any food restrictions for this resident. An interview was conducted on 09/19/13 at 11:10 a.m. with Employee #39, the Dietary Supervisor. He provided a copy of the resident's diet card, which indicated this resident was to receive a regular diet, no added salt (NAS), no bananas, oranges or orange juice. He confirmed he did not relate the food restrictions to the staff regarding this resident's diet and the care plan was not revised to address her current food restrictions. b) A review of Resident #56's weekly skin assessment for 06/25/13 was conducted on 09/18/13 at 10:00 a.m. It was revealed the resident's right heel pressure area was resolved on 06/25/13. A review of Resident #56's current care plan was conducted on 09/18/13 at 10:30 a.m. The care plan addressed a pressure area to the right heel with a problem onset date of 12/28/12 and a goal/target date set for 11/30/13. The care plan did not reflect the resolution of the right heel pressure area on 06/25/13. An interview with the Employee #115 (Director of Nursing-DON) was conducted on 09/18/13 at 3:00 p.m. The DON stated Resident #56's right heel pressure area had been resolved since June 2013. The DON verified Resident #56's care plan had not been updated reflecting the resolution of the right heel pressure area. The DON stated the care plan should have been updated the same day the pressure area was resolved.",2016-09-01
8173,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-09-20,356,B,1,0,F3O611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation of the posting of direct care staffing and staff interview, the facility failed to ensure the required information was posted daily at the beginning of each shift. The staffing information sheet on [MEDICATION NAME] Lane was not completed for of 09/16/ 13. This information is to be posted so families and residents will be aware of how many direct care staff members are in the facility at any given time providing care. This had the potential to affect more than an isolated number of residents/families who may want to review this information on each shift. [MEDICATION NAME] Lane Census: 35. Facility Census: 79. Findings Include: a) [MEDICATION NAME] Lane During the initial tour of the facility on 09/16/13 at 7:00 p.m., the staffing available in the facility at that time was checked on each of the facility's three (3) units. The posted form for staffing was observed to be complete for the Lifesteps unit and the Lighthouse unit, but on the [MEDICATION NAME] Lane unit, the form had not been completed. The form posted on [MEDICATION NAME] Lane was blank. At the time of the observation, on 09/16/13, at approximately 7:15 p.m., the form should have been completed for 7-3 shift and 3-11 shift. The Administrator (Employee #116) was made aware of the posting being incomplete on [MEDICATION NAME] Lane on 09/16/13 at 8:30 p.m. She verified the form should be completed at the beginning of each shift.",2016-09-01
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
8364,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,225,D,1,0,3CP611,"Based on a review of the medical record, review of the facility's abuse/neglect files, family interview, and staff interview, the facility failed to ensure a thorough investigation was conducted when allegations of neglect was reported to them. A grievance/concern form filed by the family of Resident #79 alleged multiple care issues and services that were not provided to a resident. The facility failed to thoroughly investigate the allegations and failed to report all of the allegations to the appropriate State agencies. Only one (1) allegation was reported. This was true for one (1) of five (5) complaints reviewed. Resident identifier: #79. Facility Census: 82. Findings include: a) Resident #79 During a review of the abuse and neglect reporting files, it was identified there was a complaint/concern/grievance request form completed for Resident #79 on 07/02/13. This resident's family expressed concerns that were recorded on the complaint form by the facility administrator as follows: 1. No evidence of food eaten today and BS (blood sugar) was over 300 in the hospital today (07/02/13) 2. Hip popped out 3. Sores 4. Dehydrated with IV (intravenous) Foley bag had 100 cc, family has been in and abduction pillow was not in place, no pillow between legs, Ted hose ordered (?) , legs swollen (ordered for Ted hose) why catheter not removed issues with the nurse (name) giving pain meds and was very unprofessional. The facility reported only an allegation regarding the family's concern related to the resident's skin condition. The other allegations of neglect/abuse were not reported. During an interview with the resident's family, on 07/15/13 at 6:30 p.m., it was identified they filed a complaint with the nursing home administrator about multiple issues. A family member said this resident had multiple issues identified when the resident arrived at the hospital. The family member told the administrator it was felt neglect had occurred at the nursing home with regards to the care of their mother. The administrator was shown pictures the family had taken. The investigation documentation gathered by the facility included witness statements, the resident's care plan and clinical notes. The five (5) day follow up report stated these were the documents used to determined the ulcers were not a result of neglect. The witness statements used in the facility's investigation included statements from two (2) nursing assistants, the dementia unit manager, and one (1) licensed practical nurse (LPN). Both of the nursing assistants provided information in their written statements on 07/03/13. They wrote they had worked with the resident on Friday, June 28th. They had observed the resident's heels were soft. They both reported they told the licensed practical nurse (LPN) that was working that day about the resident's heels. They both stated the resident's heels were discolored when they came in three (3) days later, on Monday, 07/01/13 . This was three (3) days after they reported the initial concern about the heels to the nurse. The other nursing assistants who had provided care for this resident during the time frame being investigated were not interviewed. There was no evidence found in the documentation of the facility's investigation to verify the facility had attempted to determine who the LPN was the nursing assistants notified of the resident's heels being soft. The Lighthouse Director was interviewed during the facility's investigation and provided a signed written statement on 07/08/13. She stated she personally witnessed staff providing care, turning and repositioning the resident and had not seen any behavior that would indicate neglect on the part on any employee. The investigation documentation included a witness statement from an LPN who stated on 07/02/13, the resident had a follow up appointment for her left hip. She stated she witnessed the nursing staff performing hygiene care. Two (2) staff members were at her side, she administered medications, did a routine accucheck, administered as needed (PRN) pain medication, and changed all dressings that were ordered. These four (4) statements were the only statements gathered from employees during this investigation conducted by the facility. The Social Worker (SW) was interviewed on 07/23/13 at 10:30 a.m. She was questioned about the documentation she was referring to in the investigation. She stated she was referring to the nursing notes written on 07/02/13. It was confirmed the nurse had documented on 07/02/13 that yesterday it was brought to my attention by the staff . and this had been recorded after the pressure ulcers were discovered. This was also after these pressure ulcers developed. She was asked if she had found any evidence during her investigation to indicate the facility had implemented measures to prevent the pressure ulcers prior to their development. The SW said those notes were what she used to determine there was not neglect. She was questioned about her investigation and if she interviewed other staff, reviewed the schedule to see who had provided care to this resident, had tried to find out who the nurse was the nursing assistants told about the soft heels, or interviewed the nurse who recorded she was notified of the pressure ulcers and did not record them at that time. She stated that she did not. She was asked to provide a procedure that was followed for conducting an investigation. The SW was questioned at this time whether she had investigated the other issues identified by the family on the complaint /concern/grievance form. She confirmed she had not addressed or investigated the other issues in the complaint. She also confirmed she had not reviewed the schedule to see who had worked with this resident, to gather statements from everyone who had cared for the resident during the time frame in question.",2016-07-01
8365,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,278,D,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on a record review and staff interview, the facility failed to ensure the minimum data assessment (MDS) required to be completed at the time of discharge, accurately reflected a resident's skin condition. Resident #79 was transferred to the hospital and her assessment did not reflect the pressure ulcers that were known to be present at the time of her discharge. This was true for on (1) of ten (10) sampled residents. Resident identifier: #79. Facility Census: 82. Findings include: a) Resident #79 A review of the medical record revealed this resident went for a doctor's appointment on 07/02/13. The resident was transferred to the hospital from the appointment and was admitted the same day. An MDS assessment, with an assessment reference date (ARD) of 07/02/13, was coded in Section A to identify the resident was discharged with return anticipated. Further review of this assessment found Section M - Skin Conditions, was coded to indicate the resident had one (1) Stage II pressure ulcer present at the time of her discharge. According to the MDS nurse, the Stage II area was located on the resident's inner thigh. This was also reflected in a nursing entry on 06/27/13 which noted there was an area on the resident's left inner thigh that was a blister, but the surface had come off. Although the areas on her heels had been identified during the look-back period, they were not coded in the skin condition section of the discharge MDS dated [DATE]. An interview was conducted with Employee #26 (MDS Nurse) on 07/17/13 at 2:00 p.m. It was verified this assessment did not include the pressure ulcers that were present at the time of this resident's discharge. She stated this should have been included on this assessment and it would be corrected.",2016-07-01
8366,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,279,D,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a care plan was established to include measures to prevent pressure ulcers from developing following a decline in a resident's mobility status. A resident experienced a [MEDICAL CONDITION] and had surgery resulting in the resident not being able to ambulate. The facility failed to implement measures to prevent skin breakdown following this decline in condition. The resident subsequently experienced skin breakdown. This was true for one (1) of ten (10) sampled residents. Resident identifier: #79. Facility Census: 82. Findings include: a) Resident #79 During a review of the medical record, it was identified Resident #79 had experienced a fall resulting in a [MEDICAL CONDITION]. She was admitted to the hospital on [DATE]. She returned to the facility on [DATE]. A five (5) day minimum data set (MDS) was completed, with an assessment reference date (ARD) of 06/28/13, after the resident returned from the hospital. This assessment reflected the resident required the extensive assist of two (2) staff members with bed mobility and transfers. It also reflected she had not ambulated (coded 8/8 as the activity did not occur) during the look-back period. Locomotion off the unit had also not occurred (coded 8/8). This assessment was compared to the most recent quarterly MDS, with an ARD of 03/25/13. At the time the 03/25/13 assessment was completed, the resident required the limited assistance of one (1) person for bed mobility, transfers, walking, and locomotion both on and off the unit. (These areas were all coded 2/2). The assessment also indicated the resident ambulated with a walker. This was prior to the fall resulting in the [MEDICAL CONDITION]. Review of the facility's abuse /neglect investigation reports revealed there were two (2) nursing assistants (NAs) who identified Resident #79 had impaired skin integrity (the resident's heels were soft) on 06/28/13 and brought this to the attention of the nurse. The NAs also stated the resident's heels were discolored when they came in three (3) days later, on Monday, 07/01/13, three (3) days after they reported the initial concern about the heels to the nurse. The resident's care plan was reviewed. The care plan was dated with a problem onset date of 07/23/12. The goal had been continued after every review for a period of one year. There was no evidence a care plan had been established to prevent skin breakdown when the resident was readmitted with a [MEDICAL CONDITION] on 06/21/13. She was not ambulating at that time and had an abduction pillow (which limits mobility) between her legs. There were some interventions added to the care plan, but it could not be determined when these were added. The only intervention that was relative to preventing complications from occurring with her heels was written on 07/04/13. This was for Prevalon boots to bilateral heels at all times. The MDS nurse (Employee #26) was interviewed on 07/16/13 at 11:00 a.m. She verified the old care plan, established a year before, had been continued and a new care plan had not been developed when the resident returned from the hospital and was no longer ambulating. It was confirmed there were no measures implemented on the care plan until 07/04/13 (after the pressure ulcers developed) to address the resident's heels and the increased risk for pressure ulcers due to her decline in mobility.",2016-07-01
8367,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,314,G,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, review of the facility abuse/neglect files, and family interview, the facility failed to implement measures to prevent the development of pressure ulcers and failed to identify pressure ulcers promptly when they developed. Resident #79 experienced a mobility decline after suffering from a [MEDICAL CONDITION]. Measures were not implemented following the identification of increased risk factors for skin breakdown. She subsequently developed pressure ulcers on her heels and on her coccyx that were determined to be preventable. This was identified for one (1) of ten (10) sampled residents. Resident identifier: #79. Facility census: 82. Findings include: a) Resident #79 During a review of the medical record it was identified this resident had a [DIAGNOSES REDACTED]. The resident experienced a fall on 06/16/13 resulting in a [MEDICAL CONDITION]. The resident was admitted to the hospital 06/17/13 for repair of her hip. She was re-admitted to the facility on [DATE] following the hip repair and had a physician's orders [REDACTED]. The skin assessment completed at the time of her re-admission from the hospital did not reflect the presence of pressure ulcers. According to the medical record, she had a decline in mobility and she was to receive therapy for her mobility decline. A 5-day minimum data set (MDS) assessment, with an assessment reference (ARD) date of 06/28/13, indicated in Section G this resident did not walk in her room or in the corridor during the of seven (7) day look-back period of the assessment. Walking was coded 8/8 meaning it did not occur. The quarterly MDS, with an assessment reference date (ARD) of 03/25/13, completed prior to the resident's hospitalization , indicated the resident only required the limited assistance of one (1) person for ambulation in her room and in the corridor. Review of the medical record, for the period from 06/17/13 to 07/01/13, found no evidence this resident's increased risk for skin breakdown was addressed. It was not evident in the care plan that interventions were put in place at that time to address her decreased mobility and increased risk for skin breakdown. A nursing entry, on 07/02/13 at 6:36 a.m., noted Yesterday evening it was brought to my attention by the staff while they were getting resident ready for bed that she has pressure ulcers on both of her heels. It is said that she did not have the areas the night before and that therapy got her ready for the day and took her to therapy that morning. She did wear shoes, the director of nursing (DON) was here and I brought the areas to her attention also. Will be discussed in the morning meeting. This was the first time the resident's skin breakdown was mentioned in the record. It was also the same day the family filed a complaint about the resident's care. The resident was sent to a scheduled doctor's appointment at 9:30 a.m. on 07/02/13. It was identified the resident's physician's office had called to inform the facility the resident was being sent to the hospital for an evaluation of her left hip. She was subsequently admitted to the hospital where it was determined her hip was fractured. A nursing note, written on 07/02/13 at 11:40 p.m., stated (typed as written) Addendum to note entered by this nurse on 07/02/13 at 6:36 a.m. findings occurred 07/01/13 at 730 p.m. It was brought to my attention by an aid when they were getting resident ready for bed and I observed the areas to both of residents heels, they were soft and did not blanche, suspected deep tissue injury from diabetes. Heels remain elevated and abduction pillow was in place, resident was turned every two hours to prevent breakdown. Immediate treatment to heels was skin prep to both areas, Reported to the DON (director of nursing) and area is awaiting RN's (registered nurse's ) evaluation to stage the areas in question and measure the areas. During a review of the resident's hospital admission records, it was identified the resident had a Stage II pressure ulcer present on her coccyx and a deep tissue injury present to her right and left heels at the time of her admission to the hospital on [DATE]. A review of the facility's abuse/neglect investigation revealed there were two (2) witness statements collected from the nursing assistants who provided care to this resident. During this investigation conducted by the facility it was verified that Resident #79's heels were identified as being soft on 06/28/13 by the nursing assistants. The nursing assistants reported that the LPN (licensed practical nurse) was notified. There was no evidence the nurse observed the resident's heels at that time or implemented any measures to prevent further skin breakdown or communicated to others this resident's heels were soft at that time. During a family interview on 07/16/13 at 6:30 p.m., they confirmed the resident had large purple areas on her heels and an open area on her coccyx when she arrived at the hospital. The family said they had never observed the resident's heels elevated when they visited and had not seen the resident being turned. The first measurements of these wounds were dated 07/04/13, which was approximately two (2) weeks after the resident returned from the hospital. The measurements of the wounds at that time were the left heel - 4.0 cm x 5.0 cm, the right heel was 4.0 cm x 3.0 cm, and the Stage II area present on the coccyx was 5.5 cm x 4.3 cm with necrosis and slough. During an interview with the physician, on 07/17/13 at 10:00 a.m., he was questioned about the pressure ulcers. He verified he was not made aware of these areas until the family informed him. He was asked whether he felt these were preventable ulcers. He stated he felt these areas were preventable. The physician stated he felt the resident returned from the hospital with a mobility decline, had the abduction pillow, and did not have anything to prevent pressure to her heels.",2016-07-01
8368,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,329,D,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain a drug regimen that was free from unnecessary medications for one (1) of ten (10) sample residents. Facility staff administered an antibiotic for an excessive duration. It was given for ten (10) days beyond the date for which it was ordered. This had the potential to result in an adverse medication reaction. Resident identifier: #73. Facility census: 82. Findings include: a) Resident #73 During a medical record review, on 07/17/13 at 11:00 a.m., of the physician's orders [REDACTED]. The order was for one (1) tablet twice a day for seven (7) days. A review of Resident #73's Medication Administration Record [REDACTED]. It should have been discontinued after seven (7) days, which was 07/06/13. The Bactrim DS was administered ten (10) days longer than the medication was prescribed. An interview was conducted with Employee #27, the Assistant Director of Nursing (ADON) on 07/17/13 at 12:00 p.m. This employee verified the medication was used for ten (10) days beyond the directives on the order. He stated it had occurred because the pharmacy sent more of the medication than what was prescribed. The ADON stated he would complete an incident form for a medication error.",2016-07-01
8369,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-07-23,364,F,1,0,3CP611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, and resident interview, the facility failed to serve food at the proper temperatures. The hot foods were below the minimum acceptable temperature, and the cold foods were above the minimum acceptable temperature, as discerned by customary practice for food temperatures at the point of service. In addition, the facility failed to ensure foods were palatable and prepared by methods which ensured a minimum loss of nutrients. These practices had the potential to affect all residents who consumed foods prepared and served from the kitchen. Facility census: 82 Findings Include: a) Observation during the initial tour of the kitchen, on 07/15/13 at 2:30 p.m., revealed the cooking of pork chops for the 5:00 p.m. evening meal, was completed at 2:45 p.m. Excessive holding time of prepared foods contributes to a loss of nutritive value and a loss of palatability. b) On 07/17/13 at 2:30 p.m., on the [MEDICATION NAME] Lane Unit, a temperature check was completed of a test tray from the noon meal. Employee #51 (Dietary Supervisor) was requested to bring the facility thermometer to be used for the test. The last tray of food was selected for review of the quality and the temperatures. The temperature of the vegetables was 72 degrees Fahrenheit (F). The peaches were 70 degrees F. The grilled cheese sandwich was 84 degrees in the middle. The edges of the sandwich bread were very hard and the bread was still white and was not grilled. Customary practice is 120 degrees F for hot foods and 50 degrees F for cold foods at the point of service. Employee #51 was not present at the time of the temperature measurements. He left after he brought the facility thermometer. Observation of the test tray was verified by Employee #83, a Licensed Practical Nurse. c) Resident #60 was observed sitting in the dining room eating her lunch on 07/17/13 at 2:45 p.m She was questioned about her lunch. She stated, This sandwich is as hard as a brick, feel it. She then touched the surveyor's arm with the bread and the surveyor felt the bread crust. The bread was very hard and not edible. d) Employee #51 was made aware, on 07/17/13 at 2:45 p.m., that the resident's sandwich was hard. He told her he would get another one. He was also made aware of the problem with the temperatures of the food at the time of the service of the last tray on the unit at 2:30 p.m. He stated they were working on improving the food quality at the facility. e) An interview with the dietary supervisor was completed on 7/23/13 at 9:45 a.m. When the observation about the pork chops was discussed, he stated that 2:45 p.m. was too early for the pork chops to be prepared before serving them at the scheduled 5:00 p.m. dinner. The dietary supervisor further stated that evening meats would be placed in a steam oven or a convection oven to maintain the proper temperature, but by 5:00 p.m., The pork chops would be dried out and would lose nutritional value.",2016-07-01
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
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
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
8599,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,250,D,1,0,BVS711,"Based on medical record review and staff interview the facility failed to provide medically necessary social services for a resident with behavior problems. The facility failed to care plan for a resident's involuntary discharge from the facility. Behavioral interventions and additional education with staff on providing care to residents with dementia was not provided. This was found for one (1) of eight (8) sample residents. 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 had a care plan which did not have his involuntary thirty (30) day notice of discharge planned. The resident had multiple interventions listed for behaviors and dementia issues the resident may have. An interview was conducted with Employee #13, the social worker, on 05/31/13 during the afternoon regarding the residents discharge planning and staff training. The social worker stated she did not know that she needed to care plan the resident's discharge. When asked about staff training and inservicing for dementia residents she stated she did not do the inservicing or training. When she was asked about the interventions for Resident #16 relating to his behaviors and dementia she stated this is not a psychiatric hospital we are not River Park. An interview was conducted with Employee #2 on 05/31/13 at 10:30 a.m. she stated the corporation had dementia training that staff had to attend. When asked if they did specialized training to deal with behaviors such as Resident #16 has she stated no they had not done anything, but could get that arranged.",2016-05-01
8600,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,280,D,1,0,BVS711,"Based on medical record review, a review of the facility's incident and accident reports, and staff interview, the facility failed to ensure the care plans were revised for two (2) of eight (8)sampled residents when they experienced changes which required a care plan revision. Resident #60 had multiple falls. A new care plan was initiated and dated after each fall; however, the care plans did not reflect any changes or new interventions to address the prevention of falls. In addition, the facility presented a 30-day discharge notice to the responsible party of Resident #16. His plan of care was not revised to reflect this change in the resident's discharge plans. Resident identifiers: #60 and #16. Facility Census: 78. Findings include: a) Resident #60 Review of incident and accident reports revealed this resident had multiple falls. His care plan, initially established on 08/17/12, identified this resident at high risk for falls due to a past history of falls, decreased functioning, and cognitive status. His goal stated he would not have a fall with injury requiring hospitalization through the next review period. This care plan had been continued, without revision, since it was initially established on 08/17/12. The facility initiated a new care plan with each fall, but did not develop interventions to prevent falls for any of the care plans. As of 05/28/13, fourteen (14) care plans for falls had been initiated since March 2013. Review of these care plans revealed they all said the same thing. No changes were made as the resident continued to experience falls. There was no evidence the facility made any attempts to determine the causes of each fall so effective individualized interventions could be put into place to prevent the falls from reoccurring. At 3:00 p.m. on 05/31/13, Employee #2, a licensed practical nurse, was interviewed about the fall care plans for this resident. When asked about the facility's protocol for falls, she stated they initiated these new care plans after each fall. She was asked if there had been any new interventions put in place, as the resident continued to experience falls. Employee #2 confirmed the care plans which were initiated after each fall did not contain revisions or any new interventions to prevent the resident's falls. b) Resident #16 The facility had given this resident a thirty (30) day discharge notice. A medical record review was conducted on 05/30/13 at 2:00 p.m. During the review of Resident #16's care plan, it was discovered the thirty (30) day discharge had not been care planned for the resident. An interview was conducted with Employee #13, the social worker, on 05/31/13. She stated she did not know she had to care plan the resident's discharge. The discharge was added to the resident's care plan after the interview. A review of the facility's policy, Transfer/Discharge and Bedhold, on 05/31/13 at 4:45 p.m., revealed social service staff is to provide interventions to facilitate transition and adjustment when a resident is transferred or discharged .",2016-05-01
8601,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,281,E,1,0,BVS711,"**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 medications were administered in accordance with the facility's administration guidelines. The guidelines for administration, Policy IIA2, stated medications are administered as prescribed in accordance with good nursing principles and practices. The guidelines and procedures set forth in this policy were not followed. Medications were not administered according to the orders given by the physician. This was true for four (4) of eight (8) sampled residents. Resident identifiers: #42, #19, #59, and #60. Facility Census: #78. Findings include: a) Resident #42 This resident was observed during medication pass on 05/28/13. At 1:12 p.m., Employee #25 verified this resident had medications due at 9:00 a.m. which had not yet been administered at 1:12 p.m. On 05/28/13 at 3:00, review of computerized medical records, which indicated the time medications were actually administered, verified morning medications for Resident #42 were not administered until 2:20 p.m. The medications that were scheduled at 9:00 a.m., but not administered until 2:20 p.m., included [MEDICATION NAME] 750 mg which was scheduled twice a day (bid) for [MEDICAL CONDITION], [MEDICATION NAME] 15 mg twice a day for pain control, [MEDICATION NAME] Inhaler one puff four times a day, [MEDICATION NAME] 2.5 mg tablet, [MEDICATION NAME] 40 mg every morning, Senna 8.6 mg tablet every morning, [MEDICATION NAME] sulfate 325 mg tablet daily, [MEDICATION NAME] 20 mg tablet once each morning, KCL 10 meq tablet each day. b) Resident #19 During a medication pass observation on 05/28/13 at 1:15 p.m., the nurse (Employee #25) was observed pulling up the medications for Resident #19. The electronic Medication Administration Record [REDACTED]. During an interview with the nurse at 1:15 p.m., 05/28/13 she verified she had not yet given these medications. Employee #25 stated the times for administering medications was sometimes a problem. It was verified, in the medical record, that the nurse administered the resident's 9:00 a.m. medications at 2:00 p.m. on 05/28/13. The medication, [MEDICATION NAME], was due at 9:30 a.m. and 5:30 p.m. The nurse administered the 9:00 a.m. medication at 2:00 p.m., and again at 5:15 p.m. This resulted in this medication being administered only three (3) hours and fifteen minutes apart. The other medications which were due at 9:00 a.m. and given at 2:00 p.m. included [MEDICATION NAME] 325 mg one tablet by mouth daily due to [MEDICAL CONDITION], Protein Powder 2 scoops, Multivitamin tablet daily, Potassium Chloride ER 20 meq daily, [MEDICATION NAME] 20 mg tablet daily. These medications were administered five (5) hours after the scheduled time. c) Resident # 59 During the medical record review, on 05/29/13 at 3:00 p.m., it was identified Resident #59 had received her medications early. Her medications were scheduled at 11:30 a.m. They were administered at 8:09 a.m. on 5/28/13, more than three (3) hours early. She also received a sedating medication at 8:37 a.m., which was ordered to be given as needed (PRN) at bedtime due to complaints of sleeplessness and anxiety. Medications administered at 8:00 a.m., which were not scheduled until 11:30 a.m., included Aspirin 81 mg, Calcitonin -Salmon 200 units SP 1 puff daily alternating nostrils, [MEDICATION NAME] Tears 0.5% eye drops instill one drop in each eye twice daily for complaints of dry eyes. Calcium with vitamin D tablet one tablet daily, [MEDICATION NAME] 325 mg one daily , Potassium Chloride 10 meq one tablet by mouth daily, [MEDICATION NAME] 20 mg one tablet by mouth every day. The facility's policy and procedures for medication administration indicated, in section B-10, that medications are administered within 60 minutes of the scheduled time. During an interview with the facility's medical director, on 05/29/13 at 11:30 a.m., he verified medications should be administered one hour before or after they were scheduled. He agreed that giving the medications so far from their scheduled time was not a good practice. Review of the medical record also revealed Resident #59 had a physician's order for [MEDICATION NAME] 0.5 mg one tablet by mouth as needed (PRN) at bedtime (HS) due to complaints of increased anxiety and sleeplessness. The MAR indicated [REDACTED]. An interview conducted with the registered nurse (Employee #33), on 05/29/13 at 2:00 p.m., confirmed this medication which was ordered at bedtime should not have been given in the morning. d) Resident # 60 During a review of the medical record, it was identified this resident had a physician's order, written on 04/17/13, for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hours sleep due to [MEDICAL CONDITION] was scheduled, instead of only as needed, on the MAR for each night at 9:00 p.m. The resident began receiving this medication each night. There was no written physician's order found for this change from PRN to every night. The facility's Policy and Procedure for administration of medications in accordance with good nursing principles and practice indicated, in section B.2, that medications are administered in accordance with written orders of the attending physician. During an interview with the physician on 05/31/13/ at 2:15 p.m. he confirmed there was no physician's order to change this medication to schedule it each night because he had wanted it only PRN (as needed). He stated that this medication was not administered as he had ordered it.",2016-05-01
8602,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,329,D,1,0,BVS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications. Two (2) of eight (8) residents received medications for which there was no evidence of necessity to treat their assessed conditions. Resident #60 received a medication for [MEDICAL CONDITION] without adequate indications for use, without adequate monitoring, and administered contrary to physician's orders. Resident #59 received a sedating medication early in the morning, contrary to physician's orders. It was ordered as needed (PRN) for anxiety at bedtime. Resident identifiers: #60 and #59. Facility Census: 78. Findings include: a) Resident #60 During a review of the medical record, it was identified this resident had a physician's order, written on 04/17/13, for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hour of sleep due to [MEDICAL CONDITION] was scheduled, instead of only as needed (PRN), on the MAR for each night at 9:00 p.m. The resident began receiving this medication each night. There was no written physician's order found for this change from PRN to every night. During an interview with the nurse, Employee #12, on 05/30/13 at 3:28 p.m., she was asked to find a physician's order for the [MEDICATION NAME] to be given each night, instead of PRN. She was unable to find such an order. At that time, it was verified with the nurse, that the medical record contained no evidence the resident had [MEDICAL CONDITION] which required this medication every night. This nurse also stated this resident was usually re-directed after calling his family. She stated she was not aware the resident had problems sleeping. Employee #12 was asked if there was a tracking form for [MEDICAL CONDITION], or other means of tracking this resident's [MEDICAL CONDITION]. She verified there was no means for tracking whether or not this resident experienced [MEDICAL CONDITION]. The physician was interviewed on 05/31/13 at 2:15 p.m. He was asked about the use of this medication and the reason it was scheduled every night, although the resident had not required it every night when it was ordered PRN. He verified he did not order the [MEDICATION NAME] to be scheduled. He further stated he had met with the family, and they had decided not to give the [MEDICATION NAME] unless the resident really needed it. He said that was why he ordered it PRN. He verified that he was not sure why it was scheduled each night, there was no physician's ordered this, and the medication was not administered as he had ordered it. b) Resident #59 During a review of the medical record for Resident #59, it was identified she had a physician's order for [MEDICATION NAME] 0.5 mg tablet give one table by mouth as needed (PRN) at bedtime (HS) due to complaints of increased anxiety and sleeplessness. Review of the MAR indicated [REDACTED]. In addition, had the facility assessed the resident for need for this PRN medication,as is required for a PRN medication, nursing personnel should have recognized the PRN medication was ordered for increased anxiety and sleeplessness at night. An interview was conducted with the registered nurse, Employee #33, on 05/29/13 at 2:00 p.m. This conversation confirmed the PRN [MEDICATION NAME] was ordered to be given at bedtime and should not have been given in the morning.",2016-05-01
8603,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,332,D,1,0,BVS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the medication error rate was five percent (5%) or less. Two (2) errors were identified in twenty-five (25) opportunities for medication errors, resulting in a medication error rate of eight percent (8%). The medication [MEDICATION NAME], which is for [MEDICAL CONDITION], and the diuretic medication [MEDICATION NAME] ordered for hypertension, were each ordered by the physician to be given twice daily. These medications were administered in a time span that was too close together, resulting in timing errors. Resident identifiers: #42 and #19. Facility Census: 78. Findings include: a) Resident # 42 During a medication administration observation, on 05/28/13 at 1:15 p.m., Resident #42 was observed receiving his medication. The nurse, Employee #25, was asked why this resident's medications were highlighted in Red in the computer. She stated they were Red because they were past due. The nurse stated she came to administer the resident's medications earlier, but he was asleep. The nurse was observed administering Resident #42's medications. She only gave him two (2) medications. She stated she gave him his pain medication and inhaler, but did not administer the rest of his medications that were highlighted in Red. She said she would not be able to administer those medications because they were so late. During a review of the Medication Administration Record [REDACTED]. This made these medications five (5) hours and twenty (20) minutes past the scheduled administration time. These medications were administered outside the allowable 60 minute time frame as required by facility policy. The medication [MEDICATION NAME] 750 mg one tablet by mouth twice a day was ordered due to [MEDICAL CONDITION]. This medication was scheduled at 9:00 a.m., but was not administered until 2:20 p.m. on 05/28/13. This was more than five (5) hours past the scheduled time for this medication. The evening dose was given at 10:20 p.m., the night before on 05/27/13. It was scheduled for 9:00 p.m. The administration of this medication was fifteen (15) hours from the prior dose at 10:40 p.m. on 05/27/13 and only eight (8) hours from the evening dose on 05/28/13. b) Resident # 19 During the medication observation on 05/28/13, observation revealed Resident #19's medications were highlighted in Red. The nurse, Employee #25,stated that she would not be able to administer the medications because they were late. This resident had six (6) medications that were scheduled to be given at 9:00 a.m. As of 1:15 p.m. (4.25 hours after they were due) the medications had not been administered. Medical record review, at 3:45 p.m. on 05/28/13, revealed the medications omitted during the observation at 1:15 p.m. on 05/28/13 were administered at 2:00 p.m. [MEDICATION NAME] 20 mg, ordered twice daily and due at 9:30 a.m., was not administered until 2:00 p.m. on 05/28/13. The next dose of [MEDICATION NAME] was given at 5:14 p.m. This resulted in the medications being administered only three (3) hours and fifteen (15) minutes apart. This medication was ordered for hypertension. Administering the doses so close together had the potential to result in the blood pressure going too low, as well as excessive diuresis after the administration at 5:14 p.m. During an interview with the facility's medical director, on 05/29/13 at 11:30 a.m., he confirmed medications administered five (5) hours past their scheduled time was not an acceptable practice for medication administration. c) The facility's policy and procedure for medication administration was requested. This policy was last reviewed on 12/18/12. Section B.10 stated, Medications are administered within 60 minutes of the scheduled time. This policy also instructed, in section C6, if a dose was given at other than the scheduled time, the space provided on the front of the MAR indicated [REDACTED]. There was no note written for these medications that were administered five (5) hours or more after their scheduled time.",2016-05-01
8604,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-30,514,F,1,0,BVS711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records for eight (8) of eight (8) sampled residents. In addition, the facility failed to ensure the computerized medical records were readily accessible to staff members and other authorized persons, such as the State certification agency surveyors. Also, pertinent information which was supposed to be computerized was not always available in the computer. Hand written medical records were also incomplete. The information provided to indicate when baths were given did not always contain resident names and no months were written on behavior logs. Resident #16 had been given a thirty (30) day discharge notice by the facility. This resident's medical record did not contain a copy of the discharge notice. Resident identifiers: #58, #60, #61, #59, #65, #42, #19, and #16. Facility Census: 78. Findings include: a) Residents #58, #60, #61, #59, #65, #42, #19, #16 The computerized medical records were reviewed for these residents from 05/28/13 to 05/31/13. The computerized records were not always able to be accessed by surveyors. Access was denied (locked out) after a few minutes of not touching the computer. At the point access was locked out, a facility staff member had to come to log the surveyor back into the system. On more than one occasion, the computer was not even able to be accessed by facility personnel, and information technology employees had to be called for assistance. This process of obtaining access to the medical record extended the length of time required to complete the investigations and obtain the needed information from the records. b) Residents #58, #60, #61, #59, #65, #42, #19, #16 The information for activities of daily living were requested for the above named residents. Employee #2 provided skin sheets that she stated the employees completed each time they did a bath or shower. Review of these skin sheets revealed they did not always have resident names on them to distinguish for which resident the sheets belonged. In addition, these sheets did not always specify whether the resident had a shower or bath, and/or what type of bath was provided. During an interview with Employee #2, a licensed practical nurse, on 05/29/13 at 2:00 p.m., she was not able to determine which sheet belonged to whom, because there were no names on the sheets. c) Residents #58, #60, #61, #59, #65, #42, #19, #16 Review of the medical record revealed the facility did not have a consistent and organized method of recording when residents had a bath or shower. There was no record in the medical record to specifically state whether or not they had a shower or bath. The residents named above were sampled residents. They were observed and were clean, no odor was observed and they appeared to have had a bath. They were well groomed. The staff indicated that they had showers and baths but the documentation was not clear to provide evidence of when and what type of bath was provided. d) Resident #16 - Behavior Monitoring Sheets A review of the resident's medical record, on 05/30/13 at 2:00 p.m., revealed the resident had multiple behavior sheets in the paper medical record. These sheets did not contain documentation of the months for which the documentation was completed. The behaviors for which the facility was monitoring were: 1) socially withdrawn, crying, verbalizing sadness for the medication [MEDICATION NAME] 15 mg by mouth at bedtime. 2) verbally abusive, physically aggressive for [MEDICATION NAME] 75 mg by mouth three times a day 3) monitor hours sleep for [MEDICATION NAME] 15 mg by mouth every bedtime. 4) hitting kicking, shouting for [MEDICATION NAME] 9.5 mg patch every 24 hours. 5) hitting, kicking, aggressive behaviors, refusing care violently for [MEDICATION NAME] 2 mg IM injection every 6 hours. 6) shouting, inappropriate behaviors and statements for [MEDICATION NAME] 50 mg. An interview was conducted with Employee #2, a licensed practical nurse and the staff development coordinator, on 05/31/13 at 10:30 a.m., regarding the date of the behavior monitoring sheets. She stated she was unable to determine for which months the behavior monitoring was completed. e) Resident #16 - Discharge Notice This resident had been given a thirty (30) day discharge notice, Review of the resident's medical record, on 05/30/13, revealed the resident did not have a copy of the thirty (30) day discharge notice in his paper chart. An interview was conducted on 05/31/13 at 1:00 p.m., with the facility administrator, regarding the absence of a copy of the thirty (30) day discharge notice in the resident's chart. She verified there was no copy in the chart, and stated she had a copy of the letter in her office. She said she would place a copy of the notice in the resident's chart.",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
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
8607,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,225,D,1,0,5M3K11,"Based on medical record review, staff interview, family interview, and a review of the facility's complaint policy, the facility failed to identify and investigate occurrences of verbal abuse for two (2) of eight (8) sampled residents. An employee was overheard by a family member talking to Resident #60 in a manner they felt was verbally abusive. This was reported to facility management, but was not investigated or reported to the state agencies. Resident #42 was told by the nurse if he did not act in a civil manner that she would Take his medication and leave the room, when he expressed to the nurse he did not want his medicine, he wanted a cup of coffee. This information was recorded in the nursing notes, but was not investigated or reported. Resident identifiers: #62 and #42. Facility Census: 78. Findings include: a) Resident #60 A review of the medical record revealed a nursing note dated 05/15/13 at 8:27 a.m. It was a late entry for 05/14/13. The note said this resident displayed combative behavior and was verbally abusive to staff. According to the nursing note, the family was called twice. The resident refused his medications from the nurse three (3) times, but said he would take them if someone else gave them to him. The daughter requested to stay on the phone while his medications were given. According to the nursing note, the nursing assistant was encouraging the resident to swallow his medications and not chew them. After the medications were administered, the resident reached the phone to the nurse. According to the nursing note, The daughter proceeded to voice her opinion about this nurse curt and short with her father and she did not appreciate it. The nurse recorded she apologized to the daughter, but informed the daughter that .who she heard was not the writer. The daughter hung up at that point. Another daughter then called, and was inquiring about this resident. According to the note, she proceeded to voice her displeasure with the incident earlier. Daughter then came to the facility and proceeded to confront this writer with the director of nursing present. Apologized to the daughter and she was not receptive to explanations. The facility's abuse and neglect files and complaint files were reviewed. These files contained no evidence this incident was investigated or reported. During a family interview, on 05/31/13 at 4:00 p.m., the family confirmed they discussed with staff that they did not feel their dad received good care. They stated they felt the episode on 05/15/13 was verbal abuse, and they did not feel it was addressed by the facility. This incident was discussed with the social worker (Employee #13) on 05/31/13 at 12:00 p.m. She was asked if she had any further information about this incident. She said she would see if there was anything else. Employee #13 did not present any further information by the end of the survey. Employee #2 (Staff Development Coordinator, Licensed Practical Nurse) presented a complaint/concern/grievance form on 05/31/13 at 2:00 p.m. This form stated that the daughter felt the nurse was being rude and impatient with the father (Resident #60). This form was dated 05/21/13. It was not in the original complaint/grievance forms that were requested and provided when the facility was entered on 05/28/13. The date this was signed by the administrator was 05/31/13. The employee was questioned about the dates and the statements not being dated. She stated she had this complaint on her desk and had not followed up with it. Review of the form revealed statements were obtained from staff, but there was no statement obtained from the family. The director of nursing (DON) was out of the facility during the complaint survey; however, she was interviewed by telephone on 05/30/13 at 9:00 p.m. The DON confirmed she was aware of the allegation that a nurse, Employee #23, had been very impatient and short with Resident #60's father. She also stated the resident's daughter came to the facility in tears and wanted to find the nurse (Employee #23). This statement from the DON was obtained during the survey, after facility staff had already been questioned about the incident recorded in the nursing notes. There was nothing in the complaint or abuse files regarding this incident until 05/31/13. A written witness statement from the nurse present at the time of this occurrence on 05/15/13 (Employee #23) indicted the family approached her in the facility with the DON present. Employee #23's witness statement included, The family believes he is being mistreated which he is not. She states how unhappy the family is with the care he is receiving. There was no evidence the facility investigated this allegation, and there was no evidence the family was interviewed regarding the allegations of abuse/neglect. The facility's policy, Abuse/Neglect and Exploitation, with an effective date of 05/01/12, was reviewed. This policy stated the supervisor was to notify the administrator or director of nursing if abuse, mistreatment, exploitation, or neglect was suspected. At that time an incident report was to be completed, and an an investigation immediately initiated. There was no evidence the policy was initiated to investigate this allegation of verbal abuse. b) Resident #42 A review of nursing notes for Resident #23 revealed a note, dated 05/23/13 at 3:17 p.m., which stated, During medication pass, resident became belligerent stating he didn't want medicine, he wanted coffee. Addressed the issue by offering to get coffee after he took his medication. He became agitated and verbally abusive. According to the nursing notes, the resident cursed the nurse, at which time the nurse responded she would take the medication and leave the room if he did not act in a civil manner. This resident's agitation may have been averted if the nurse had gotten the resident coffee as he requested. The nurse's response was a verbal threat to withhold medication if the resident did not comply with the nurse's demands relative to the resident's behavior. There was no evidence this was identified and investigated related to verbal abuse, threatening behavior toward a resident, and/or potential neglect. As such, no action was taken on this incident. On 05/31/13 at 12:00 p.m., an inquiry was made of the social worker (SW) about the incident. She stated she was not made aware of the incident. She confirmed it had not been identified as verbal abuse, threatening behavior, and/or potential neglect. The SW agreed the incident was a reportable incident which should have been investigated and reported by the facility. .",2016-05-01
8608,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,241,D,1,0,5M3K11,"Based on medical record review, resident interview, and staff interview, the facility failed to promote dignity and respect for one (1) of eight (8) sampled residents. The facility did not promote the resident's self esteem and self worth when the resident's preferences for bathing were not provided as agreed upon between the resident and the facility. Resident #65 expressed she felt bad all day when she did not get her baths and hair washed on the days agreed upon between herself and the facility. Resident identifier: #65. Facility Census: 78. Findings include: a) Resident #65 An interview with this resident, on 05/28/13 at 1:30 p.m., revealed she had not had her bath as scheduled the prior three (3) times it was scheduled (since 05/22/13). According to the resident, she should have had a bath on 05/24/13, 05/26/13, and 05/27/13. She stated she did not get any of these baths. The resident said, When I do not get my bath, it makes me feel bad all day. Resident #65 stated, Needless to say, I feel really bad today. She commented that she did not have much to look forward to, but she loved her baths and they always made her feel better. The resident verbalized she sometimes had problems getting her baths like she wanted them, because it took a while to do her bath. According to the resident, this was discussed with the facility, and a schedule was worked out for a bath on Mondays, Wednesdays, and Fridays. On these days, she would have a total bed bath, which included washing her hair. On Sundays, she was to receive a partial bath, which included all of her bath, but not her hair. She stated she felt so much better when this schedule was followed. She commented she did not have much to look forward to, but loved her baths, and they always made her feel better. The medical record was reviewed to determine when the resident had her bath. There was nothing found in the record which indicated when the resident received her baths. On 05/29/13 at 10:00 a.m., Employee #33, a registered nurse (RN), was asked if there was documentation which indicated when baths were given. He stated it was in the computer, and it could be printed. Upon request, he printed the previous two (2) weeks of documentation for this resident's baths. This data indicated Resident #65 last had a bath on 05/25/13. This was on a Saturday, which was not one of her scheduled bath days. On 05/29/13 at 1:00 p.m., Employee #2, a licensed practical nurse (LPN), presented skin sheets, which she said were to be completed each time a bath was given. The skin sheets were inconsistent with the documentation on the activity of daily living (ADL) sheets, and each was inconsistent with what the resident said she received. The skin sheets contained no evidence a bath was provided the resident since 05/21/13. During the discussion with Employee #33, on 05/29/13, this RN stated the resident had some confusion related to time and day. Employee #33 said the nursing assistant said she gave the resident a bath on 05/25/13. Employee #33 verified this resident's bath schedule was as the resident described. He also verified the bathing records were not complete, and could not be used to determine when the resident actually had a bath. The facility was unable to provide evidence to support this resident was receiving her bath according to the schedule which was agreed upon between herself and the facility. Accompanied by Employee #33, the resident was interviewed on 05/29/13 at 2:15 p.m. Upon inquiry from Employee #33, Resident #65 told him she had not had her bath on the agreed upon scheduled days. He told the resident he would follow up on this issue. The resident was interviewed the next day, on 05/30/13 at 10 :00 a.m. She stated she had her bath after the discussion in her room the prior day. She said she felt much better.",2016-05-01
8609,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,280,D,1,0,5M3K11,"Based on medical record review, a review of the facility's incident and accident reports, and staff interview, the facility failed to ensure the care plans were revised for two (2) of eight (8)sampled residents when they experienced changes which required a care plan revision. Resident #60 had multiple falls. A new care plan was initiated and dated after each fall; however, the care plans did not reflect any changes or new interventions to address the prevention of falls. In addition, the facility presented a 30-day discharge notice to the responsible party of Resident #16. His plan of care was not revised to reflect this change in the resident's discharge plans. Resident identifiers: #60 and #16. Facility Census: 78. Findings include: a) Resident #60 Review of incident and accident reports revealed this resident had multiple falls. His care plan, initially established on 08/17/12, identified this resident at high risk for falls due to a past history of falls, decreased functioning, and cognitive status. His goal stated he would not have a fall with injury requiring hospitalization through the next review period. This care plan had been continued, without revision, since it was initially established on 08/17/12. The facility initiated a new care plan with each fall, but did not develop interventions to prevent falls for any of the care plans. As of 05/28/13, fourteen (14) care plans for falls had been initiated since March 2013. Review of these care plans revealed they all said the same thing. No changes were made as the resident continued to experience falls. There was no evidence the facility made any attempts to determine the causes of each fall so effective individualized interventions could be put into place to prevent the falls from reoccurring. At 3:00 p.m. on 05/31/13, Employee #2, a licensed practical nurse, was interviewed about the fall care plans for this resident. When asked about the facility's protocol for falls, she stated they initiated these new care plans after each fall. She was asked if there had been any new interventions put in place, as the resident continued to experience falls. Employee #2 confirmed the care plans which were initiated after each fall did not contain revisions or any new interventions to prevent the resident's falls. b) Resident #16 The facility had given this resident a thirty (30) day discharge notice. A medical record review was conducted on 05/30/13 at 2:00 p.m. During the review of Resident #16's care plan, it was discovered the thirty (30) day discharge had not been care planned for the resident. An interview was conducted with Employee #13, the social worker, on 05/31/13. She stated she did not know she had to care plan the resident's discharge. The discharge was added to the resident's care plan after the interview. A review of the facility's policy, Transfer/Discharge and Bedhold, on 05/31/13 at 4:45 p.m., revealed social service staff is to provide interventions to facilitate transition and adjustment when a resident is transferred or discharged .",2016-05-01
8610,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,281,E,1,0,5M3K11,"**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 medications were administered in accordance with the facility's administration guidelines. The guidelines for administration, Policy IIA2, stated medications are administered as prescribed in accordance with good nursing principles and practices. The guidelines and procedures set forth in this policy were not followed. Medications were not administered according to the orders given by the physician. This was true for four (4) of eight (8) sampled residents. Resident identifiers: #42, #19, #59, and #60. Facility Census: #78. Findings include: a) Resident #42 This resident was observed during medication pass on 05/28/13. At 1:12 p.m., Employee #25 verified this resident had medications due at 9:00 a.m. which had not yet been administered at 1:12 p.m. On 05/28/13 at 3:00, review of computerized medical records, which indicated the time medications were actually administered, verified morning medications for Resident #42 were not administered until 2:20 p.m. The medications that were scheduled at 9:00 a.m., but not administered until 2:20 p.m., included [MEDICATION NAME] 750 mg which was scheduled twice a day (bid) for [MEDICAL CONDITION], [MEDICATION NAME] 15 mg twice a day for pain control, [MEDICATION NAME] Inhaler one puff four times a day, [MEDICATION NAME] 2.5 mg tablet, [MEDICATION NAME] 40 mg every morning, Senna 8.6 mg tablet every morning, [MEDICATION NAME] sulfate 325 mg tablet daily, [MEDICATION NAME] 20 mg tablet once each morning, KCL 10 meq tablet each day. b) Resident #19 During a medication pass observation on 05/28/13 at 1:15 p.m., the nurse (Employee #25) was observed pulling up the medications for Resident #19. The electronic Medication Administration Record [REDACTED]. During an interview with the nurse at 1:15 p.m., 05/28/13 she verified she had not yet given these medications. Employee #25 stated the times for administering medications was sometimes a problem. It was verified, in the medical record, that the nurse administered the resident's 9:00 a.m. medications at 2:00 p.m. on 05/28/13. The medication, [MEDICATION NAME], was due at 9:30 a.m. and 5:30 p.m. The nurse administered the 9:00 a.m. medication at 2:00 p.m., and again at 5:15 p.m. This resulted in this medication being administered only three (3) hours and fifteen minutes apart. The other medications which were due at 9:00 a.m. and given at 2:00 p.m. included [MEDICATION NAME] 325 mg one tablet by mouth daily due to [MEDICAL CONDITION], Protein Powder 2 scoops, Multivitamin tablet daily, Potassium Chloride ER 20 meq daily, [MEDICATION NAME] 20 mg tablet daily. These medications were administered five (5) hours after the scheduled time. c) Resident # 59 During the medical record review, on 05/29/13 at 3:00 p.m., it was identified Resident #59 had received her medications early. Her medications were scheduled at 11:30 a.m. They were administered at 8:09 a.m. on 5/28/13, more than three (3) hours early. She also received a sedating medication at 8:37 a.m., which was ordered to be given as needed (PRN) at bedtime due to complaints of sleeplessness and anxiety. Medications administered at 8:00 a.m., which were not scheduled until 11:30 a.m., included Aspirin 81 mg, Calcitonin -Salmon 200 units SP 1 puff daily alternating nostrils, [MEDICATION NAME] Tears 0.5% eye drops instill one drop in each eye twice daily for complaints of dry eyes. Calcium with vitamin D tablet one tablet daily, [MEDICATION NAME] 325 mg one daily , Potassium Chloride 10 meq one tablet by mouth daily, [MEDICATION NAME] 20 mg one tablet by mouth every day. The facility's policy and procedures for medication administration indicated, in section B-10, that medications are administered within 60 minutes of the scheduled time. During an interview with the facility's medical director, on 05/29/13 at 11:30 a.m., he verified medications should be administered one hour before or after they were scheduled. He agreed that giving the medications so far from their scheduled time was not a good practice. Review of the medical record also revealed Resident #59 had a physician's order for [MEDICATION NAME] 0.5 mg one tablet by mouth as needed (PRN) at bedtime (HS) due to complaints of increased anxiety and sleeplessness. The MAR indicated [REDACTED]. An interview conducted with the registered nurse (Employee #33), on 05/29/13 at 2:00 p.m., confirmed this medication which was ordered at bedtime should not have been given in the morning. d) Resident # 60 During a review of the medical record, it was identified this resident had a physician's order, written on 04/17/13, for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hours sleep due to [MEDICAL CONDITION] was scheduled, instead of only as needed, on the MAR for each night at 9:00 p.m. The resident began receiving this medication each night. There was no written physician's order found for this change from PRN to every night. The facility's Policy and Procedure for administration of medications in accordance with good nursing principles and practice indicated, in section B.2, that medications are administered in accordance with written orders of the attending physician. During an interview with the physician on 05/31/13/ at 2:15 p.m. he confirmed there was no physician's order to change this medication to schedule it each night because he had wanted it only PRN (as needed). He stated that this medication was not administered as he had ordered it.",2016-05-01
8611,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,309,E,1,0,5M3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, policy review, and staff interview, the facility failed to ensure care and services were provided in a manner to promote the highest practicable physical, mental, and/or psychosocial well-being for four (4) of eight (8) sampled residents. Medications were not administered as ordered by the physician and/or were not administered timely to Residents #60, #19, and #59. Resident #60 also experienced an acute condition change that was not monitored and reassessed. Resident identifiers: #60 , # 59, #42, and #19. Facility Census 78. Findings include: a) 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. The nurse also verified there was no evidence the resident's vital signs were monitored or evidence he was reassessed and monitored after this incident. The next nursing note was not written until 05/06/13 four (4) days after the acute episode was experienced on 05/02/13. Further review of the medical record, also identified this resident had a physician's order written on 04/17/13 for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hours sleep due to [MEDICAL CONDITION] was scheduled on the MAR for every night at 9:00 p.m., instead PRN. The resident began receiving this medication each night. There was no written physician's order found for this change. During an interview with the nurse, Employee #12, on 05/30/13 at 3:28 p.m. she was unable to find a physicians order for the medication [MEDICATION NAME] to be given each night. It was verified that the medical record did not support the resident had [MEDICAL CONDITION] and required this medication to be given every night. The physician was interviewed on 05/31/13 at 2:15 p.m. He was asked about the use of this medication and the reason it was scheduled every night, although the resident had not required it every night when it was ordered PRN. He verified he did not order the [MEDICATION NAME] to be scheduled, and stated it was a medication error. He further stated he had met with the family, and they had decided not to give the [MEDICATION NAME] unless the resident really needed it. He said that was why he ordered it PRN. He verified that he was not sure why it was scheduled each night, but there was no physician's order to support this change. b) Resident #59 During a review of the medical record for Resident #59, it was identified she had a physician's order for [MEDICATION NAME] 0.5 mg tablet give one table by mouth as needed (PRN) at bedtime (HS) due to complaints of increased anxiety and sleeplessness. Review of the MAR indicated [REDACTED]. An interview conducted with the registered nurse, Employee #33, on 05/29/13 at 2:00 p.m., revealed this medication was ordered to be given at bedtime and should not have been given in the morning. c) Resident #19 During a medication pass observation on 05/28/13 at 1:15 p.m., the nurse (Employee #25) was observed pulling up the medications for Resident #19. The electronic Medication Administration Record [REDACTED]. During an interview with the nurse at 1:15 p.m., 05/28/13 she verified she had not yet given these medications. Employee #25 stated the times for administering medications was sometimes a problem. It was verified, in the medical record, that the nurse administered the resident's 9:00 a.m. medications at 2:00 p.m. on 05/28/13. The medication, [MEDICATION NAME], was due at 9:30 a.m. and 5:30 p.m. The nurse administered the 9:00 a.m. medication at 2:00 p.m., and again at 5:15 p.m. This resulted in this medication being administered only three (3) hours and fifteen minutes apart. The other medications which were due at 9:00 a.m. and given at 2:00 p.m. included [MEDICATION NAME] 325 mg one tablet by mouth daily due to [MEDICAL CONDITION], Protein Powder 2 scoops, Multivitamin tablet daily, Potassium Chloride ER 20 meq daily, [MEDICATION NAME] 20 mg tablet daily. These medications were administered five (5) hours after the scheduled time. Further review of the medical record, on 05/28/13. at 3:00 p.m., revealed the nurse had administered this resident's 9:00 a.m. medications at 2:00 p.m. on 05/28/13. This resident had a physician's order for [MEDICATION NAME] 20 mg one tablet by mouth twice a day. The medical record indicated the [MEDICATION NAME] was to be given at 9:30 a.m. and 5:30 p.m. According to the record, the [MEDICATION NAME] was administered on 05/28/13 at 2:00 p.m. and then again at 5:14 p.m. These doses were administered just a little over three (3) hours apart. According to Webmd.com drug information, the use and dosage of this medication requires close supervision from the physician, and the dosage must be individualized according to individual requirements. Giving the doses of this medication so close together had the potential to cause this resident to have a decrease in her blood pressure, which had the potential to result in excess diuresis with water and electrolyte depletion. Since the diuretic effect of this medication lasts six (6) hours following oral administration, providing the medication doses only three (3) hours apart would increase the effects of this medication. A review of the facility's medication administration guidelines policy last revised on 12/18/12, stated in section B.10 stated medications are administered within sixty (60) minutes of the scheduled time. d) Resident #42 This resident was observed during medication pass on 05/28/13. At 1:12 p.m., Employee #25 verified this resident had medications due at 9:00 a.m. which had not yet been administered at 1:12 p.m. On 05/28/13 at 3:00, review of computerized medical records, which indicated the time medications were actually administered, verified morning medications for Resident #42 were not administered until 2:20 p.m. The medications that were scheduled at 9:00 a.m., but not administered until 2:20 p.m., included [MEDICATION NAME] 750 mg which was scheduled twice a day (bid) for [MEDICAL CONDITION], [MEDICATION NAME] 15 mg twice a day for pain control, [MEDICATION NAME] Inhaler one puff four times a day, [MEDICATION NAME] 2.5 mg tablet, [MEDICATION NAME] 40 mg every morning, Senna 8.6 mg tablet every morning, [MEDICATION NAME] sulfate 325 mg tablet daily, [MEDICATION NAME] 20 mg tablet once each morning, KCL 10 meq tablet each day.",2016-05-01
8612,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,323,E,1,0,5M3K11,"Based on observation, medical record review, policy review, and staff interview, the facility failed to provide an environment as free from accident hazards as possible. The medication cart was left unlocked and unsupervised on Whistle Lane. This practice allowed unauthorized access to medications, and was particularly a potential hazard for any confused resident who could reach the cart and its contents This practice had the potential to affect more than an isolated number of residents who resided on Whistle Lane, where the census was 36. In addition, the facility failed to explore causative factors and initiate interventions related to the numerous falls experienced by one (1) of eight (8) residents, Resident # 60. Facility Census: 78. Findings include: a) Medication Cart On 05/28/13 at 12:30 p.m., the medication cart was observed unattended and unlocked in the hallway in front of room #216. No staff members were observed in sight of the medication cart. The cart was observed until a nurse came out of a room in which the door was closed. When informed the medication cart was observed unlocked and unattended, the nurse, Employee #25 stated she knew she was not to leave the medication cart unlocked. She said she must have forgotten to lock it. The facility's medication policy, IIA2: Medication Administration Guidelines, last reviewed 12/18/12, stated in section B-12, During administration of medications, the medication cart is keep closed and locked when out of sight of the mediation nurse or aide. b) Resident # 60 Review of incident and accident reports revealed this resident had multiple falls. His care plan, initially established on 08/17/12, identified this resident at high risk for falls due to a past history of falls, decreased functioning, and cognitive status. His goal stated he would not have a fall with injury requiring hospitalization through the next review period. This care plan had been continued, without revision, since it was initially established on 08/17/12. The facility initiated a new care plan with each fall, but did not develop interventions to prevent falls for any of the care plans. As of 05/28/13, fourteen (14) care plans for falls had been initiated since March 2013. Review of these care plans revealed they all said the same thing. No changes were made as the resident continued to experience falls. There was no evidence the facility made any attempts to determine the causes of each fall so effective individualized interventions could be put into place to prevent the falls from reoccurring. Employee #2, a licensed practical nurse, was interviewed, at 3:00 p.m. on 05/31/13, about the fall care plans for this resident. When asked about the facility's protocol for falls, she stated they initiated these new care plans after each fall. She was asked if there had been any new interventions put in place, as the resident continued to experience falls. Employee #2 confirmed the care plans which were initiated after each fall did not contain revisions or any new interventions to prevent the resident's falls. There was no evidence the facility evaluated the resident's falls in an effort to identify causal factors and/or risks which were resulting in the multiple falls experienced by the resident. This evaluation was essential in the development of appropriate plans to reduce this resident's instances of falls. In addition, the facility had no planned individualized interventions in an effort to reduce hazards and risks which might be causing the resident to fall.",2016-05-01
8613,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,329,D,1,0,5M3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure residents were free from unnecessary medications. Two (2) of eight (8) residents received medications for which there was no evidence of need. Resident #60 received a medication for [MEDICAL CONDITION] without adequate indications for use, without adequate monitoring, and administered contrary to physician's orders. Resident #59 received a sedating medication early in the morning, contrary to physician's orders. It was ordered as needed (PRN) for anxiety at bedtime. Resident identifiers: #60 and #59. Facility Census: 78. Findings include: a) Resident #60 During a review of the medical record, it was identified this resident had a physician's order, written on 04/17/13, for [MEDICATION NAME] 50 mg one tablet by mouth at HS (hour of sleep) PRN (as needed) due to [MEDICAL CONDITION]. This medication was on the Medication Administration Record [REDACTED]. It was noted this medication was not administered for the entire month it was ordered. In addition, there was no indication the resident needed this medication. On 05/13/13, [MEDICATION NAME] 50 mg tablet one by mouth at hour of sleep due to [MEDICAL CONDITION] was scheduled, instead of only as needed (PRN), on the MAR for each night at 9:00 p.m. The resident began receiving this medication each night. There was no written physician's order found for this change from PRN to every night. During an interview with the nurse, Employee #12, on 05/30/13 at 3:28 p.m., she was asked to find a physician's order for the [MEDICATION NAME] to be given each night, instead of PRN. She was unable to find such an order. At that time, it was verified with the nurse, that the medical record contained no evidence the resident had [MEDICAL CONDITION] which required this medication every night. This nurse also stated this resident was usually re-directed after calling his family. She stated she was not aware the resident had problems sleeping. Employee #12 was asked if there was a tracking form for [MEDICAL CONDITION], or other means of tracking this resident's [MEDICAL CONDITION]. She verified there was no means for tracking whether or not this resident experienced [MEDICAL CONDITION]. The physician was interviewed on 05/31/13 at 2:15 p.m. He was asked about the use of this medication and the reason it was scheduled every night, although the resident had not required it every night when it was ordered PRN. He verified he did not order the [MEDICATION NAME] to be scheduled. He further stated he had met with the family, and they had decided not to give the [MEDICATION NAME] unless the resident really needed it. He said that was why he ordered it PRN. He verified that he was not sure why it was scheduled each night, there was no physician's ordered this, and the medication was not administered as he had ordered it. b) Resident #59 During a review of the medical record for Resident #59, it was identified she had a physician's order for [MEDICATION NAME] 0.5 mg tablet give one table by mouth as needed (PRN) at bedtime (HS) due to complaints of increased anxiety and sleeplessness. Review of the MAR indicated [REDACTED]. In addition, had the facility assessed the resident for need for this PRN medication,as is required for a PRN medication, nursing personnel should have recognized the PRN medication was ordered for increased anxiety and sleeplessness at night. An interview was conducted with the registered nurse, Employee #33, on 05/29/13 at 2:00 p.m. This conversation confirmed the PRN [MEDICATION NAME] was ordered to be given at bedtime and should not have been given in the morning.",2016-05-01
8614,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,332,D,1,0,5M3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and staff interview, the facility failed to ensure the medication error rate was five percent (5%) or less. Two (2) errors were identified in twenty-five (25) opportunities for medication errors, resulting in a medication error rate of eight percent (8%). The medication [MEDICATION NAME], which is for [MEDICAL CONDITION], and the diuretic medication [MEDICATION NAME] ordered for hypertension, were each ordered by the physician to be given twice daily. These medications were administered in a time span that was too close together, resulting in timing errors. Resident identifiers: #42 and #19. Facility Census: 78. Findings include: a) Resident # 42 During a medication administration observation, on 05/28/13 at 1:15 p.m., Resident #42 was observed receiving his medication. The nurse, Employee #25, was asked why this resident's medications were highlighted in Red in the computer. She stated they were Red because they were past due. The nurse stated she came to administer the resident's medications earlier, but he was asleep. The nurse was observed administering Resident #42's medications. She only gave him two (2) medications. She stated she gave him his pain medication and inhaler, but did not administer the rest of his medications that were highlighted in Red. She said she would not be able to administer those medications because they were so late. During a review of the Medication Administration Record [REDACTED]. This made these medications five (5) hours and twenty (20) minutes past the scheduled administration time. These medications were administered outside the allowable 60 minute time frame as required by facility policy. The medication [MEDICATION NAME] 750 mg one tablet by mouth twice a day was ordered due to [MEDICAL CONDITION]. This medication was scheduled at 9:00 a.m., but was not administered until 2:20 p.m. on 05/28/13. This was more than five (5) hours past the scheduled time for this medication. The evening dose was given at 10:20 p.m., the night before on 05/27/13. It was scheduled for 9:00 p.m. The administration of this medication was fifteen (15) hours from the prior dose at 10:40 p.m. on 05/27/13 and only eight (8) hours from the evening dose on 05/28/13. b) Resident # 19 During the medication observation on 05/28/13, observation revealed Resident #19's medications were highlighted in Red. The nurse, Employee #25,stated that she would not be able to administer the medications because they were late. This resident had six (6) medications that were scheduled to be given at 9:00 a.m. As of 1:15 p.m. (4.25 hours after they were due) the medications had not been administered. Medical record review, at 3:45 p.m. on 05/28/13, revealed the medications omitted during the observation at 1:15 p.m. on 05/28/13 were administered at 2:00 p.m. [MEDICATION NAME] 20 mg, ordered twice daily and due at 9:30 a.m., was not administered until 2:00 p.m. on 05/28/13. The next dose of [MEDICATION NAME] was given at 5:14 p.m. This resulted in the medications being administered only three (3) hours and fifteen (15) minutes apart. This medication was ordered for hypertension. Administering the doses so close together had the potential to result in the blood pressure going too low, as well as excessive diuresis after the administration at 5:14 p.m. During an interview with the facility's medical director, on 05/29/13 at 11:30 a.m., he confirmed medications administered five (5) hours past their scheduled time was not an acceptable practice for medication administration. c) The facility's policy and procedure for medication administration was requested. This policy was last reviewed on 12/18/12. Section B.10 stated, Medications are administered within 60 minutes of the scheduled time. This policy also instructed, in section C6, if a dose was given at other than the scheduled time, the space provided on the front of the MAR indicated [REDACTED]. There was no note written for these medications that were administered five (5) hours or more after their scheduled time.",2016-05-01
8615,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-05-31,514,F,1,0,5M3K11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to maintain complete and accurate medical records for eight (8) of eight (8) sampled residents. In addition, the facility failed to ensure the computerized medical records were readily accessible to staff members and other authorized persons, such as the State certification agency surveyors. Also, pertinent information which was supposed to be computerized was not always available in the computer. Hand written medical records were also incomplete. The information provided to indicate when baths were given did not always contain resident names and no months were written on behavior logs. Resident #16 had been given a thirty (30) day discharge notice by the facility. This resident's medical record did not contain a copy of the discharge notice. Resident identifiers: #58, #60, #61, #59, #65, #42, #19, and #16. Facility Census: 78. Findings include: a) Residents #58, #60, #61, #59, #65, #42, #19, #16 The computerized medical records were reviewed for these residents from 05/28/13 to 05/31/13. The computerized records were not always able to be accessed by surveyors. Access was denied (locked out) after a few minutes of not touching the computer. At the point access was locked out, a facility staff member had to come to log the surveyor back into the system. On more than one occasion, the computer was not even able to be accessed by facility personnel, and information technology employees had to be called for assistance. This process of obtaining access to the medical record extended the length of time required to complete the investigations and obtain the needed information from the records. b) Residents #58, #60, #61, #59, #65, #42, #19, #16 The information for activities of daily living were requested for the above named residents. Employee #2 provided skin sheets that she stated the employees completed each time they did a bath or shower. Review of these skin sheets revealed they did not always have resident names on them to distinguish for which resident the sheets belonged. In addition, these sheets did not always specify whether the resident had a shower or bath, and/or what type of bath was provided. During an interview with Employee #2, a licensed practical nurse, on 05/29/13 at 2:00 p.m., she was not able to determine which sheet belonged to whom, because there were no names on the sheets. c) Residents #58, #60, #61, #59, #65, #42, #19, #16 Review of the medical record revealed the facility did not have a consistent and organized method of recording when residents had a bath or shower. There was no record in the medical record to specifically state whether or not they had a shower or bath. The residents named above were sampled residents. They were observed and were clean, no odor was observed and they appeared to have had a bath. They were well groomed. The staff indicated that they had showers and baths but the documentation was not clear to provide evidence of when and what type of bath was provided. d) Resident #16 - Behavior Monitoring Sheets A review of the resident's medical record, on 05/30/13 at 2:00 p.m., revealed the resident had multiple behavior sheets in the paper medical record. These sheets did not contain documentation of the months for which the documentation was completed. The behaviors for which the facility was monitoring were: 1) socially withdrawn, crying, verbalizing sadness for the medication [MEDICATION NAME] 15 mg by mouth at bedtime. 2) verbally abusive, physically aggressive for [MEDICATION NAME] 75 mg by mouth three times a day 3) monitor hours sleep for [MEDICATION NAME] 15 mg by mouth every bedtime. 4) hitting kicking, shouting for [MEDICATION NAME] 9.5 mg patch every 24 hours. 5) hitting, kicking, aggressive behaviors, refusing care violently for [MEDICATION NAME] 2 mg IM injection every 6 hours. 6) shouting, inappropriate behaviors and statements for [MEDICATION NAME] 50 mg. An interview was conducted with Employee #2, a licensed practical nurse and the staff development coordinator, on 05/31/13 at 10:30 a.m., regarding the date of the behavior monitoring sheets. She stated she was unable to determine for which months the behavior monitoring was completed. e) Resident #16 - Discharge Notice This resident had been given a thirty (30) day discharge notice, Review of the resident's medical record, on 05/30/13, revealed the resident did not have a copy of the thirty (30) day discharge notice in his paper chart. An interview was conducted on 05/31/13 at 1:00 p.m., with the facility administrator, regarding the absence of a copy of the thirty (30) day discharge notice in the resident's chart. She verified there was no copy in the chart, and stated she had a copy of the letter in her office. She said she would place a copy of the notice in the resident's chart.",2016-05-01
8912,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-03-22,368,E,1,0,RZ9U11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, random resident interviews, facility meal schedule review, and staff interview, the facility allowed more than fourteen (14) hours between a substantial evening meal and breakfast the following day. There was no evidence that a nourishing snack was offered every evening to all residents or the residents' group had discussed this meal span. This practice resulted in more than fourteen (14) hours between meals for some residents, and more than sixteen (16) hours between meals for others. Random Resident Identifiers: # 37, #55, #49, #2, and #9. This practice had the potential to affect all residents in the facility who did not receive a continental breakfast or bedtime snack. Facility Census: 59. Findings Include: a) Resident # 37 An observation was made at 6:30 a.m. on 03/21/13 on the long term care unit. Only one (1) resident was observed eating the continental breakfast. This was Resident #37. He was sitting in the small dining room, eating a piece of toast. When questioned about breakfast, he said this is not much of a breakfast. He stated that he just gets some coffee and toast. His real breakfast is about 10:00 a.m. He stated he was a farmer and he liked bacon and eggs early of the morning. He stated he does not get a snack at night. b) Resident # 55 During breakfast observation, on 03/21/13 at 8:00 a.m., Resident #55 was asked about the food. She stated she was not crazy about the hours of food service. She stated the facility does not serve breakfast until around 10:00 a.m., and she was an early riser. She was questioned about the continental breakfast and if she liked what came out on that cart. She stated she had never seen this cart. She was not aware of anything available at 7:00 a.m. and no one had ever offered her anything earlier than breakfast at 10:00 a.m. When asked about bedtime snacks, she stated she never has a bedtime snack. She was sure they would get you one if you ask for it, but they do not ask you if you want one. She said, it is a long time between dinner and breakfast here. c) Resident # 49 During an interview with this resident, at 7:50 a.m. on 03/21/13, she was asked if she had anything to eat this morning. She said you do not get anything to eat until around 10:00 a.m. When asked what time she ate dinner, she stated 6:00 p.m. (this was correct because she had been observed eating at 6:00 p.m. on 03/20/13). She said, if you want something to eat before 10:00 a.m., you can ask them; and if they have it, they will get it for you, but it is usually just crackers or something like that. She was asked about bedtime snacks. She said, If they have something, they will get it for you if you ask them, but they do not keep much available. She stated, They do not bring you a snack automatically or offer you something. d) Resident #2 During an interview with this resident, on 03/21/13 at 8:20 a.m., when asked about the food, she said she eats whatever and whenever they bring it to her. She never tells them she wants something to eat. She was asked when she ate last and she said, dinner yesterday, probably 6:00 or so. She woke up at 4:30 a.m. this morning and verified at 8:30 a.m. she had not had anything to eat this morning. She was asked about bedtime snacks and replied, They will get you some crackers or something if you ask them. She stated that she hates to bother them because they are so busy. e) Resident #9 This resident was interviewed at 8:30 a.m. on 03/21/13. She stated, You have to wait a long time between dinner and breakfast. She was asked about bedtime snacks last night and she said she did not have one. She said she would like to have some cottage cheese and fruit or something. She said. They would probably get it if you ask them, but she has never asked them for anything. When asked about the Continental Breakfast this morning. She said, no one had asked her if she wanted anything. She did not know about an earlier breakfast. f) During a review of the meal documentation in the medical records, it was identified the staff did not record the intake of the morning continental breakfast. There was no way to determine if a resident had the continental breakfast. Also, it was noted the record reflected if the snack was accepted or snack refused, not the amount that was consumed. This was not a true reflection of the residents' meal intake. g) The facility's meal service schedule was reviewed. [MEDICATION NAME] Lane was the long term care unit. The schedule for that unit indicated Continental Breakfast was served at 6:30 a.m., Brunch was served at 9:30 a.m., Siesta Fiesta was served at 1:45 p.m., and dinner was served at 5:45 p.m. There was a night cap snack served at 7:30 p.m. There was no evidence that the intake of the continental breakfast and the night cap snack was monitored and recorded. It was verified through interviews with random residents, everyone was not offered a night time snack or the continental breakfast. Therefore, for these residents it was 16.5 (sixteen and one half) hours between meals. During an interview with a nurse (Employee #65), on 03/21/13 at 11:00 a.m., she verified there were no intake records to reflect the intake of the continental breakfast or the amount of the night cap snack taken. The Dietary Manager (Employee #66) was interviewed at 11:30 a.m. and verified there was no menu for the continental breakfast or the night snack. She said they have a variety of foods they offer on the halls. She stated she was not aware that everyone was not being offered the Continental Breakfast or the snack at night. The Resident Council Minutes were reviewed for the last four (4) months. There was no evidence the residents had agreed or discussed the meal service, or the lapse between the dinner and breakfast meal. The administrator (Employee #100) was interviewed 03/21/13 at 11:30 a.m. The meal service was discussed. She verified all residents should be offered the Continental Breakfast and the bedtime snack, not just those who ask for it. She agreed that without these times, it was a long time between the dinner and brunch meals.",2016-03-01
8913,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-03-22,441,F,1,0,RZ9U11,"Based on observation and staff interview, the facility failed to provide a sanitary environment while serving food. The staff members wore gloves throughout the entire meal service. They touched both food items and non food items without changing their gloves. The practice of wearing gloves inappropriately resulted in no handwashing and also created a potential for spreading potentially infectious microorganisms. This was observed on the Alzheimer's Unit and had the potential to affect thirteen (13) residents eating in the dining area. Facility Census: 56. Findings include: a) During a meal observation, on 03/20/13 from 5:00 p.m. to 5:40 p.m. on the Alzheimer's Unit, Employee #31 and Employee #21 were assisting residents in the dining area. They were both observed to have gloves on their hands. Throughout the entire meal service, they did not wash their hands, use hand sanitizer, or change gloves. Employee #31 and #21 were observed during the meal touching chairs, picking up cups residents were drinking from, getting trays from the cart with food on them, pouring drinks from a pitcher, and getting items residents needed. One (1) employee moved a walker and helped a resident sit down. She was then observed removing cookies from a plastic bag with her gloved hand after touching other items in the dining area. She assisted a resident with garlic bread and held it using this same gloved hand. She had not changed gloves throughout the meal service. The Alzheimer's Unit Director (Employee#101) was questioned about why the staff wore gloves during the meal services. She said because they were touching the residents' food with their hands. She was made aware of the inappropriate use of the gloves and the observation of the staff touching many other items in the dining room and then handling the residents' food with the same contaminated gloves. The Administrator (Employee #100) was interviewed on 03/21/13 at 11:30 a.m. and the inappropriate use of gloves was discussed. She agreed this was not appropriate. She stated she had watched many meals on that unit and has never seen them wear gloves before.",2016-03-01
9982,CABELL HEALTH CARE CENTER,515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2014-04-10,328,D,0,1,ONTQ12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observation, record review, and staff interview, the facility failed to deliver the proper care and treatment for [REDACTED]. A resident receiving oxygen did not have her oxygen saturation levels checked or oxygen tubing changed as ordered by a physician. This affected one (1) of three (3) sampled residents. Resident identifier: #143. Facility census: 81. Findings include: a) Resident #143 A review of the physician's orders [REDACTED]. saturation to be checked on room air and documented every Monday night. The medication administration record (MAR) was reviewed on 04/08/14 at 9:45 a.m. The oxygen saturation level ordered every Monday night was not obtained and documented on the MAR on 03/17/14 and 03/31/14. Additionally, the MARs had the oxygen saturation level on room air to be obtained at 2:00 a.m. on Mondays. This would make the oxygen saturation being obtained on Monday morning, not night, as ordered by the physician. An observation of Resident #143 on 04/08/14 at 10:45 a.m. revealed the resident's oxygen tubing was dated 03/29/14. According to the physician's orders [REDACTED]. Employee #42 (Licensed Practical Nurse-LPN) witnessed the date on the tubing of 03/29/14. In an interview with Employee #42 (LPN), on 04/08/14 at 10:50 a.m., the employee stated the tubing was changed by night shift on the weekends. The LPN stated the tubing must have been overlooked and not changed the previous weekend, but would have it changed immediately. Employee #118 (Director of Nursing-DON) was interviewed on 04/10/14 at 10:00 a.m. The DON stated she had spoken to Employee #44 (LPN) and the employee had not obtained the oxygen saturation levels ordered for Monday night on 03/17/14 and 03/31/14. .",2015-08-01
7976,"CABELL HEALTH CARE CENTER, LLC",515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-12-19,272,D,1,0,WD6M11,"Based on record review and staff interview, the facility failed to conduct accurate admission comprehensive assessment. A resident's comprehensive assessment did not accurately reflect the status of the resident's skin condition for one (1) of six (6) residents whose assessments were reviewed. Resident identifier: #20. Facility census: 87. Findings include: a) Resident #20 The admission nurse's note was reviewed on 12/17/13 at 4:30 p.m. Registered nurse, Employee #4, completed a skin assessment upon the resident's initial admission to the facility. She addressed an open area to the coccyx, and excoriation to the perineum and to the buttocks. On 12/17/13 at 4:45 p.m., the care plan was reviewed. According to the care plan, the resident was admitted with excoriated, denuded buttocks c (symbol for with) stage II. The admission minimum data Set (MDS) assessment, with an assessment reference date (ARD) of 10/23/13, was reviewed on 12/17/13 at 5:00 p.m Item M0100A was coded as the resident not having a Stage 1 or greater pressure ulcer. Item M0210, regarding unhealed pressure ulcers was coded as the resident not having one (1) or more unhealed pressure ulcer(s) at Stage 1 or higher. An interview was conducted with the wound nurse, Employee #69, on 12/17/13 at 5:15 p.m. She said this resident did have a Stage 2 pressure ulcer upon admission. She acknowledged the admission MDS was incorrectly coded as the resident having no pressure ulcers.",2016-12-01
7977,"CABELL HEALTH CARE CENTER, LLC",515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-12-19,278,D,1,0,WD6M11,"Based on record review and staff interview, the health professional who completed Section M, the skin status, of the minimum data set (MDS) assessments for one (1) of six (6) sampled residents certified the accuracy of this portion. However, Section M did not accurately reflect the resident's pressure ulcers. Resident identifier: #20. Facility census: 87. Findings include: a) Resident #20 The admission nurse's note was reviewed on 12/17/13 at 4:30 p.m Registered nurse, Employee #4, completed a skin assessment upon the resident's initial admission to the facility. She addressed an open area to the coccyx, and excoriation to the perineum and to the buttocks. On 12/17/13 at 4:45 p.m., the care plan was reviewed. According to the care plan, the resident was admitted with excoriated, denuded buttocks c (symbol for with) stage II. The 5-day and 14-day minimum data set (MDS) assessments were reviewed on 12/17/13 at 5:00 p.m. Review of Section M of the minimum data sets, with assessment reference dates (ARD) of 10/23/13 and 10/30/13, found Item M0100A was coded as the resident not having a Stage I or greater pressure ulcer. Item M0210 addressed unhealed pressure ulcers. It was coded as the resident not having one (1) or more unhealed pressure ulcer(s) at Stage I or higher. An interview was conducted with the wound nurse, Employee #69, on 12/17/13 at 5:15 p.m. She said this resident did have a Stage II pressure ulcer present upon admission. She acknowledged the 5-day and 14-day MDSs were incorrectly coded as the resident having no pressure ulcers. On 12/19/13 at 10:00 a.m., an interview was conducted with a registered nurse, Employee #70. She acknowledged having coded Section M of the 5-day MDS, and Section M of the 14-day MDS. She did not observe the wound prior to completing those MDSs. Instead, she said she had reviewed notes, and was under the impression that the opened wound on the sacral area was denuded due to moisture. She said she did not realize it was a Stage II pressure ulcer.",2016-12-01
7978,"CABELL HEALTH CARE CENTER, LLC",515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-12-19,285,D,1,0,WD6M11,"Based on medical record review and staff interview, the facility failed to complete the Pre-Admission Screening (PAS) required for this resident to continue to receive the services provided under the State Medicaid program. One (1) of three (3) sample residents reviewed for completion of the pre-admission screening was affected. Resident identifier: #76. Facility census: 87. Findings include: a) Resident #76 A record review was completed on 12/18/13 at 9:35 a.m The review revealed the PAS for this resident to receive ongoing Medicaid services was not valid. The PAS was approved on 04/03/13 for a period of 90 days. There was no evidence an updated PAS had been completed on or before 07/02/13, to determine whether this resident was eligible to continue to receive services provided under the State Medicaid program. On 12/18/13 at 11:05 a.m., staff interviews were conducted with Employee #95, Administrative Bookkeeper, and Employee #89, Social Worker. They verified a new PAS had not been completed for this resident to determine the resident's eligibility to be covered by Medicaid past the first 90 days of admission. The resident had not been authorized for Medicaid benefits since July 2013.",2016-12-01
7979,"CABELL HEALTH CARE CENTER, LLC",515192,30 HIDDEN BROOK WAY,CULLODEN,WV,25510,2013-12-19,441,D,1,0,WD6M11,"Based on observation and staff interview, the facility failed to ensure proper sanitation during food handling while delivering snacks to residents. Staff directly touched food items that were delivered for consumption with their bare hands. This was identified for two (2) of five (5) residents observed. Resident identifiers: #51 and #9. Facility census: 87. Findings include: a) Resident #51 On 12/19/13 at 11:15 a.m., licensed nurse, Employee #25, was observed delivering a snack to Resident #51 in her room. Employee #25 peeled a banana with her bare hands, then handed the peeled fruit to the resident to eat for a snack. The employee then washed her hands and continued delivering snacks to other residents. b) Resident #9 Delivery of a snack to Resident #9 was observed on 12/19/13. Employee #25 opened a sealed package of cookies at 11:26 a.m. She removed two (2) cookies from the package with her bare hands and delivered them to Resident #9. She placed the cookies on a napkin on the resident's overbed tray. An interview was conducted with the director of nursing (DON) on 12/19/13 at 11:45 a.m. She said staff should not touch a resident's food items, such as the banana and the cookies, with bare hands.",2016-12-01
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
6796,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,272,D,0,1,6TWN11,"Based on review of minimum data set (MDS) assessments and through staff interview, it was determined the MDS assessment did not identify one (1) resident who had a urinary tract infection within the past 30 days and had required antibiotic therapy to treat the infection. This was evident for one (1) of fourteen (14) residents reviewed in the Stage 2 portion of the survey. Resident identifier: #22. Facility census: 11. Findings include: a) Resident #22 A review of the MDS, with an assessment reference date of 04/23/14, found the resident was admitted to the unit on 04/17/14. The admission assessment did not indicate the resident had experienced a urinary tract infection in the past 30 days or that she had received an antibiotic in the look back period. Additional review of the medical record found the resident had a catheter and urinary tract infection prior to admission. The resident continued to have the catheter for three (3) more days after admission to the unit. Antibiotics were administered after admission until the infection was cleared. This was confirmed with Registered Nurse (RN) MDS Coordinator, Employee #2 at 2:15 p.m. on 08/05/14. She verified the MDS was not coded correctly to identify the urinary tract infection and antibiotic therapy.",2017-11-01
6797,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,279,D,0,1,6TWN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of medical records and staff interview, it was determined the facility had not developed care plans for the treatment of [REDACTED].#11 or Resident #22's urinary tract infection and treatment. This was evident for two (2) of fourteen (14) residents reviewed in the Stage 2 sample of the survey process. Resident identifiers: #11 and #22. Facility census: 11. Findings include: a) Resident #11 This resident was admitted to the unit from the hospital with an infection in her pacemaker. This was noted on the history and physical of 06/10/14. She had been ordered an antibiotic beginning on 06/04/14. The Minimum Data Set (MDS) assessment identified the resident had [MEDICAL CONDITION], wound infection, and endocarditis. There had been no care plan developed to address the use of antibiotics or the infections as identified on the MDS. b) Resident #22 The resident was admitted to the unit on 04/17/14. At the time of admission, the resident did not have a urinary tract infection [MEDICAL CONDITION]. On 04/20/14, the resident was found to have a UTI and was treated with antibiotics, ([MEDICATION NAME]) for 7 days [MEDICATION NAME] 5 days. The most current care plan did not address the UTI nor the use of antibiotics. c) This was addressed with the Registered Nurse (RN) MDS Coordinator, Employee #2, on the afternoon of 08/05/14. On the morning of 08/06/14, she confirmed there were no care plans addressing these concerns.",2017-11-01
6798,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,356,B,0,1,6TWN11,"Based on observation and staff interview, the facility failed to post, in a prominent place and in a clear and readable format, the information regarding the total number of staff and the actual hours worked by licensed and unlicensed staff directly responsible for resident care each shift. This had the potential to affect all residents and/or visitors. Facility census: 11. Findings include: a) Observations on 08/04/2014 at 11:30 a.m. did not find the posting of staff members for this date. At 11:45 a.m., Employee #20, a licensed practical nurse (LPN), was asked where the staff posting might be located. The LPN pulled the posting off of a cabinet to which it had been taped. The cabinet was behind the desk of the nursing station where it could not easily be seen by residents or families. Additionally, the posting did include the total number of hours worked by each category of staff. b) Interview with Employee #1, Registered Nurse (RN) Manager, at 12:05 p.m. on 08/04/14, revealed the posting should be on the wall across from the nursing station in plain view. c) Further observations did not find the posting on 08/04/2014 at 3:00 p.m. or on 08/05/2014 at 08:30 a.m., 10:30 a.m., or 3:30 p.m. d) Observation on 08/06/2014 at 8:30 a.m., found the posting in place with the correct information regarding the number of licensed staff members, hours worked, and the facility census. At 8:40 a.m. on 08/06/14, Employee #1 confirmed the required information had not been posted on 08/04/14 or 08/05/14.",2017-11-01
6799,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,441,E,0,1,6TWN11,"Based on observation and staff interview, the facility failed to ensure a safe and sanitary environment regarding the handling of ice distribution. This practice had the potential to affect all residents receiving ice from the communal ice container. Facility Census: 11. Finding include: a) During an observation on 08/04/2014 at 12:00 p.m., Employee #16, a nurse aide (NA) was observed in the hallway preparing ice for the residents' pitchers. Employee #16 obtained ice from the bucket with a scoop and placed the ice in a resident's pitcher while holding the pitcher above the ice container. She then placed the ice scoop back into the ice bucket. When asked about the usual method of passing ice, she stated, This is the way we always pass the ice. b) Interview with Employee #1, the nurse manager, she states Oh no, that's not right and immediately left the room and Employee #16 was educated regarding the proper use and care of the ice scoop. The container was emptied and sanitized prior to use. c) Later observation of the ice pass revealed Employee #16 placing the ice scoop in a container when not in use.",2017-11-01
6800,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2014-08-08,514,D,0,1,6TWN11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure care area assessments (CAA) were dated to indicate when they were completed. There was no evidence the assessments were completed when a resident was readmitted to skilled nursing unit ensure the assessments reflected the residents' current status. This was found to be true for one (1) of fourteen (14) assessments reviewed. Resident identifier: #85. Facility Census: 11. Findings include a) Resident #85 A review of this resident's medical record on 08/06/14, found she was discharged from the facility on 06/24/14. She was then readmitted as a new admission on 07/15/14. The five (5)-day minimum data set (MDS) was completed on 07/22/14. This assessment was utilized to develop the resident's care plan. The care area assessments (CAA) were reviewed and it was noted they were dated 05/12/14 and were the notes from the resident's prior admission. There were no new care area assessments completed for the minimum data set assessment completed 07/22/14. The Registered Nurse Unit Coordinator ( Employee #2) was interviewed 08/06/14 at 11:00 a.m. about the care area assessments for this resident. She stated that she utilized the care area assessments from 05/12/14 for the MDS completed on 07/22/14. She stated she reviewed these and the same areas triggered and all of the information was the same so she used the care area assessments from the prior admission to develop the residents care plan. The care area assessments were reviewed and the information was the same information with no changes in the resident's condition from the assessment completed on 05/12/14. Employee #2 verified on 08/06/14 at 11:15 a.m. she reviewed each of these care areas and put these with the new minimum (MDS) data set [DATE], but she did not date the CAA notes when she reviewed them. There was no evidence she reviewed them or recorded these care area assessments were to be used to develop the care plan for 07/22/14.",2017-11-01
6801,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2015-10-22,272,D,0,1,291G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to complete an accurate comprehensive assessment for one (1) of twelve (12) residents reviewed. The assessments were coded inaccurately related to [DIAGNOSES REDACTED].#7. Facility census: 6. Findings include: a) Resident #7 Review of the resident's medical record, on 10/22/15 at 8:27 a.m., revealed an admission wound evaluation dated 05/08/15. The evaluation indicated Resident #7 had an abrasion on her medial back, pink in color, with a scant amount of serous drainage (normal drainage from a healing wound or incision). Another assessment, dated 05/19/15, identified the abrasion as a Stage 3 pressure ulcer with yellow/white necrotic tissue (black, brown or tan tissue that adheres firmly to the wound bed or ulcer edges and may be either softer or firmer than surrounding skin), that measured 1 centimeter (cm) wide by one centimeter long (1 cm L x 1 cm W). The surrounding tissue was noted as macerated (skin that is moist, soft and in a state of deterioration). A history and physical, dated 05/19/15 indicated Resident #7 had a [DIAGNOSES REDACTED]. Review of the comprehensive minimum data set (MDS), with an assessment reference date (ARD) of 05/26/15, noted in Section M, the most severe type of tissue as [MEDICATION NAME] (new pink or shiny tissue (skin) that grows in from the edges or as islands on the ulcer surface), not necrotic. Additionally, impaired renal function was not identified as a diagnosis. An interview, with the MDS coordinator, on 10/22/15 at 10:15 a.m., confirmed the MDS was inaccurately coded related to the pressure ulcer and [MEDICAL CONDITION].",2017-11-01
6802,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2015-10-22,282,D,0,1,291G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement an intervention established in the care plan for one (1) of the twelve (12) residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #16 did not have weekly weights completed to monitor nutritional status. Resident identifier: #16. Facility Census: 6. Findings include: a) Resident #16 Medical record review, completed on 10/20/15 at 11:14 a.m., found a physician's orders [REDACTED]. The comprehensive care plan, written on 05/07/15, included weekly weights as an intervention for monitoring this resident's nutritional status. There was no evidence the weekly weights had been completed. An interview on 10/20/15 at 3:47 p.m., with Care Coordinator #25, verified weekly weights were not completed as an intervention for monitoring this resident's nutritional status.",2017-11-01
6803,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2015-10-22,287,E,0,1,291G11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** .` Based on medical record review and staff interview, the facility failed to complete a discharge minimum data set (MDS) assessment for six (6) of twelve (12) residents reviewed who had been discharged from the transitional care unit. As the discharge assessments were not completed, they had not been encoded and transmitted to the Centers for Medicare and Medicaid System (CMS) as required. Resident identifiers: #86, #79, #16, #68, #7, and #92. Facility census: 6. Findings include: a) Resident #86 A review of the medical record for this resident found she was discharged from the unit on 09/28/15. No discharge MDS assessment was completed. b) Resident #79 The medical record for this resident was reviewed and revealed Resident #79 was discharged on [DATE] from the unit. On 10/22/15 the MDS staff confirmed an MDS discharge assessment was not completed. c) The MDS Coordinator verified on 10/22/15 at 11:10 a.m., the discharge assessments for Residents #86 and #79 had not been completed within 14 days of the residents' discharges and consequently, had not been submitted to the CMS system as required. d) Residents #16 and #68 On 10/20/15 at 10:15 a.m., a review of MDS assessments revealed that Section A had no discharge assessments for Resident #16, who returned home on 06/07/15, and Resident #68, who returned home on 07/24/15. There was no evidence a discharge (MDS) had been completed for either resident to record their discharge from the facility. e) An interview on 10/20/15 at 3:30 p.m. with Transitional Care Unit Care Coordinator #25, verified there were no discharge MDSs completed to record these residents' (#16 and #68) discharge from the facility. Consequently, the discharge assessments for these two (2) residents had not been submitted to the CMS system. e) Resident #92 A medical record review, on 10/22/15 at 10:22 a.m., revealed a discharge summary dated 10/04/15 which indicated Resident #92 was discharged to home. Review of the minimum data sets (MDS) found no evidence the resident was discharged from the facility. d) Resident #7 Resident #7's medical record contained a discharge summary dated 06/04/15, indicating the resident was discharged to home. Review of the MDS revealed no evidence the resident had been discharged . e) An interview with the MDS coordinator, on 10/22/15 at 12:30 p.m., confirmed the discharge MDSs had not been completed for either Resident #92 or Resident #7.",2017-11-01
6804,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,246,E,0,1,NN4R11,"Based on resident interview, observation and staff interview, the facility failed to individualize and accommodate the needs and preferences related to over bed lights. No mechanism was in place for residents to turn on and off over bed lights. This had the potential to affect more than a limited number of residents. Resident identifier: #93. Resident census: 13. Findings include: a) Resident #93 In an interview with Resident #93, on 01/24/17 at 3:13 p.m., this resident stated lights (over bed) could not be turned off and were out of the reach. Resident #93 stated she wanted to go to sleep but could not turn off the lights (overbed). Additionally, this resident stated she had tried to have the staff turn off the lights but failed to have staff that would respond to the request. In a tour with the minimum data set (MDS) Coordinator, on 01/24/17 at 3:13 p.m., the MDS coordinator stated the resident could turn off the overbed lights by a switch on the bed siderails. The MDS Coordinator attempted to turn the lights on and/or off on three (3) different beds. She stated that two (2) of these beds were not the beds purchased specifically for this unit and would not turn on or off the overbed lights. When she attempted to turn on or off the lights from a bed specially purchased and programmed with this capability, the lights could not be turned on or off. In addition, she stated the mechanism did not work. She also stated the only way the overbed lights could be turned on or off was to call the nursing staff to perform this task for the resident. In addition, the Unit Manager agreed the beds purchased for this unit had been moved, replaced with beds that did not allow the residents to operate the overbed lights and the unit beds had not been properly programmed to perform the function of turning on or off the overbed lights.",2017-11-01
6805,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,247,D,0,1,NN4R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, medical record review and staff interview, the facility failed to provide notice of a change in roommates. Resident #95 had two roommate changes with no evidence this resident was given a notice of the roommate change. This was true for one (1) of one (1) residents reviewed for admission, transfer and discharge during Stage 2 of the survey. Resident identifier: #95. Facility census: 13. Findings include: a) Resident #95 During an interview with Resident #95, on 01/24/17 at 4:15 p.m., this resident responded to the question have you been moved to a different room or had a roommate change in the last nine (9) months as a Yes. An additional question of were you given a notice before a room change or a change in roommate as No. A review of the medical record during the survey from 01/24/17 through 01/30/17 revealed Resident #95 was admitted on [DATE] and had a roommate change on 01/11/17 and 01/21/17. A review of the record found no evidence this resident had been notified of the roommate changes. In an interview with the minimum data set (MDS) coordinator, on 01/26/17 at 9:59 a.m., she confirmed Resident #95 had roommate changes on 01/11/17 and 01/21/17. The MDS Coordinator stated the resident is informed verbally about a room change and/or roommate change but could not provide any written evidence to support the notification of a roommate change for Resident #95.",2017-11-01
6806,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,279,D,0,1,NN4R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan regarding urinary tract infections (UTIs) and urinary incontinence for two (2) of three (3) residents reviewed for urinary tract infections. Residents #33 and Resident #6 did not have a care plan regarding UTIs and/or urinary incontinence. Resident identifiers: #33 and #6. Facility census: 13. Findings include: a) Resident #33 A review of the minimum data set (MDS) for Resident #33, on 01/26/17 at 1:34 p.m., found Resident #33's admission MDS with an assessment reference date (ARD) of 10/12/16 assessed as having occasional incontinence. The 14 day MDS with an ARD of 10/19/16 assessed the resident as frequently incontinent. Additional MDSs with ARDs of 11/04/16 and 12/05/16 respectively assessed Resident #33 as continent and then occasionally incontinent. A continuing review of the medical record revealed Resident #33 was admitted in October of 2016 with a [DIAGNOSES REDACTED]. On 10/11/16 [MEDICATION NAME] (antibiotic) was ordered for a UTI. On 11/09/16 [MEDICATION NAME] was ordered intravenously (IV) for a UTI. Again on 11/30/16 Resident #33 received [MEDICATION NAME] for a UTI with a final culture report on 12/02/16 of [MEDICATION NAME] in the urine. During the review of the medical record, a review of the care plan revealed interventions of monitor intake and output, pericare after incontinence and encourage fluids. There was no goal for the problem of alteration in patterns of urinary elimination or goal(s) and/or interventions regarding UTI's. In an interview and review of Resident's #33 records, on 01/26/17 at 12:17 p.m., with the MDS Coordinator, she verified the care plan did not address the issues of incontinence and/or UTI's. b) Resident #6 A review of the minimum data set (MDS) for Resident #6, on 01/26/17 at 1:34 p.m., found Resident #33's admission MDS with an assessment reference date (ARD) of 10/21/16 assessed as having a UTI on admission. The 14 day MDS with an ARD of 10/26/16 and 30 day MDS with an ARD of 11/10/16 assessed the resident as having a UTI in the past thirty (30)days with each assessment. A continuing review of the medical record revealed Resident #6 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 10/26/16 Keflex (antibiotic) was ordered for a UTI. On 11/02/16 [MEDICATION NAME] (antibiotic) was ordered intravenously (IV) for a UTI with altered mental status (AMS). Again on 11/02/16 Resident #33 received [MEDICATION NAME] orally for a UTI with AMS. During the review of the medical record, a review of the care plan revealed interventions of monitor intake and output, pericare after incontinence and encourage fluids. There was no goal for the problem of alteration in patterns of urinary elimination or goal(s) and/or interventions regarding UTI's. In an interview and review of Resident's #6 records, on 01/26/17 at 12:17 p.m., with the MDS Coordinator, she verified the care plan did not address the issues of UTI's.",2017-11-01
6807,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,314,G,0,1,NN4R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed medical record review and staff interview, the facility failed to provide care and services to prevent the development of an unstageable pressure ulcer. This was true for one (1) of three (3) residents reviewed for pressure ulcers. Resident #76 developed an unstageable pressure ulcer related to a suspected deep tissue injury (SDTI) on the left heel. Resident identifier: #76. Facility census: 13. Findings include: a) Resident #76 A review of Resident #76's medical record on 01/27/17 at 12:28 p.m. revealed this resident, admitted on [DATE], had [DIAGNOSES REDACTED]. The Skin Impairment Site/Location Documentation form dated 11/23/16 identified Resident #76 had a Stage II pressure ulcer on her coccyx measuring 1.0 x 1.0 centimeters (cm) on admission. An additional assessment on 11/25/16 noted a 1 cm suspected deep tissue injury (SDTI) to the resident's left heel. On 11/28/16 there was an assessment of the coccyx wound, but no mention of the SDTI. On 12/04/16, again there was an assessment of the coccyx area, but no assessment of the left heel. On 12/06/16 and 12/13/16, the assessment noted the coccyx area and the SDTI, which measured 2 x 1 x 0 cm. An additional assessment on the Skin Assessment Transfer Form External form, dated 12/17/16, assessed the SDTI of the left heel with measurements of 2 x 1 x 0 cm. Included in the assessment was the order for the left heel to have a dressing change every three (3) days with Marathon and [MEDICATION NAME] for SDTI. A physician's orders [REDACTED]. On 12/04/16, the physician added an order to apply Marathon (a liquid skin protectant) and [MEDICATION NAME] (a foam dressing) every three (3) days to the SDTI of the resident's left heel. Additional orders included an order on 11/23/16 for a therapeutic waffle overlay for her bed. The overlay was changed to a pressure reduction mattress on 12/04/16. There was no evidence of off-loading pressure of the resident's heels found in the resident's medical record. The admission minimum data set (MDS) with an assessment reference date (ARD) of 11/29/16 identified Resident #76 had a Stage II pressure ulcer on her coccyx when admitted and was at risk for the development of pressure ulcers. The 14-day MDS with an ARD of 12/05/16 identified the resident also had 1 unstageable pressure ulcer related to SDTI not present on admission. In addition, Resident #76 was assessed as needing extensive assistance with bed mobility and was totally dependent for transfers. In an interview and review of the resident's medical record with the MDS Coordinator on 01/27/17 at 12:30 p.m., she confirmed the assessment of the heel was not completed on admission and Resident #76 had acquired an unstageable pressure related to SDTI after being admitted to the facility. Neither she nor the Clinical Coordinator had an explanation of why the assessment was missed. The Clinical Coordinator stated Resident #76 was dark skinned and could explain the missed assessment. When asked if there were other assessment skills to identify SDTI injuries with dark skin such as palpating the area for boggy tissue and darker areas of the skin, the Clinical Coordinator stated, of course there are. When asked why treatment measures were not put in place until nine (9) days after the SDTI was found, the Clinical Coordinator stated, We just missed this one. The Clinical Coordinator stated the facility had developed a pressure ulcer program and the number of pressure ulcers had drastically reduced. She said she could not understand how this happened.",2017-11-01
6808,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,315,D,0,1,NN4R11,"**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 is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections [MEDICAL CONDITION] and to restore continence to the extent possible. This was true one (1) of three (3) residents reviewed for urinary incontinence. Resident identifier: #33. Facility census: 13. Findings include: a) Resident #33 A review of the minimum data set (MDS) for Resident #33, on 01/26/17 at 1:34 p.m., found Resident #33's admission MDS with an assessment reference date (ARD) of 10/12/16 assessed as having occasional incontinence. The 14 day MDS with an ARD of 10/19/16 assessed the resident as frequently incontinent. Additional MDS with ARDs of 11/04/16 and 12/05/16 respectively assessed Resident #33 as continent and then occasionally incontinent. Resident #33 was discharged on [DATE]. A continuing review of the medical record revealed Resident #33 was admitted on [DATE] with a [DIAGNOSES REDACTED]. On 10/11/16 [MEDICATION NAME] (antibiotic) was ordered for a UTI. On 11/09/16 [MEDICATION NAME] was ordered intravenously (IV) for a UTI. Again on 11/30/16 Resident #33 received [MEDICATION NAME] for a UTI with a final culture report on 12/02/16 of [MEDICATION NAME] in the urine. During the review of the medical record, a review of the care plan revealed interventions of monitor intake and output, pericare after incontinence and encourage fluids. There was no goal for the problem of alteration in patterns of urinary elimination or goal(s) and/or interventions regarding UTI's. In an interview and review of Resident's #33 records, on 01/26/17 at 3:27 p.m., with the MDS Coordinator, she verified Resident #33 was not assessed the issue of incontinence and/or UTI's. In addition, the MDS Coordinator stated an assessment for urinary incontinence had not been completed for a long time because residents are admitted to this unit for such a short time. When asked if residents are admitted who are incontinent there is no assessment for treatment and/or services to achieve or maintain as much normal urinary function as possible improving or maintaining as much normal urinary function as possible answered Yes.",2017-11-01
6809,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,441,E,0,1,NN4R11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** d) room [ROOM NUMBER] On 01/25/17 at 11:15 a.m., an observation revealed a fracture pan sitting on a shower chair, urinal sitting on the commode, neither of these items were marked or placed into bags. Also observed was a wash basin sitting on the floor, this item was not marked or bagged. In the resident room compression leg devices were found laying on the floor under the bed. Resident #93 stated they had been there for two (2) days, they just sweep around them. After speaking with Nursing Coordinator #2, about the problems found she confrimed the items should have been marked with the residents name and and put into a clear plastic so it could been seen through the bag. She also agreed that the leg compression devices should not be placed on hte floor. An order was obtained to discontinue the leg compression devices and they were removed from the resident room. Based on observations and staff interview the facility failed to implement, and maintain an Infection Prevention and Control Program in order to prevent, recognize, and control, to the extent possible, the onset and spread of infection. Resident personal care equipment was found un-bagged and unlabeled. In addition tube feeding supplies were found undated. This practice had the potential to affect more than an isolated number of residents. Resident identifiers: #98, #97, and #94. Room identifiers: #102, #106, and #116. Facility census: 13. Findings include: a) room [ROOM NUMBER] On 1/24/17 at 02:58 p.m., three bedpans were observed unlabeled and unbagged in shared resident bathroom [ROOM NUMBER]. On 01/27/17 at 8:28 a.m., compression leg devices were observed touching the floor in resident room [ROOM NUMBER]. b) room [ROOM NUMBER] On 01/26/17 at 8:49 a.m., compression leg devices were observed touching the floor in resident room [ROOM NUMBER]. c) Resident #98 On 01/2717 at 8:33 a.m., multiple, undated feeding tube flush supplies were observed for Resident #98. On 01/27/17 at 8:47 am, the Clinical Coordinator stated that it was the facility's expectation that bedpans are bagged and labeled. She also stated supplies used to flush feeding tubes were to be labeled and changed daily and compression leg devices should not touch the floor.",2017-11-01
6810,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,497,E,0,1,NN4R11,"Based on staff interview and personnel record review the facility failed to ensure they completed a performance evaluation for 2016 for one (1) of three (3) nurse aides whose personnel files were reviewed. Nurse Aide (NA) #24 did not have a performance evaluation completed in 2016. In addition one (1) of three (3) nurse aides did not receive the annual abuse prevention training in 2016. Nurse Aide #22 did not have the annual abuse prevention training in 2016. These practices had the potential to affect more than a limited number of residents. Staff identifiers: #24 and #22. Facility census: 13. Findings include: a) Nurse Aide #24 At 12:55 p.m. on 01/30/17 the personnel file review revealed Nurse Aide #24 did not have a performance evaluation which evaluated the nurse aides demonstrated competencies in 2016. Nurse Aide #24's hire date was listed as 03/30/09. b) Nurse Aide #22 At 12:57 p.m. on 01/30/17, a review of personnel flies revealed NA #22 did not receive the patient abuse prevention in service training for 2016. NA #22's hire date was listed as 11/18/15. An interview with Nurse Manager (NM) #25 on 01/30/17 at 1:30 p.m., revealed the facility had not completed an inservice education for patient abuse prevention training for NA #22 in 2016. NM #25 also confirmed that NA #24 did not receive a performance review of demonstrated nurse aide competencies in 2016.",2017-11-01
6811,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2017-01-30,520,F,0,1,NN4R11,"Based on staff interviews, medical record reviews and review of personnel files, the quality assessment and assurance committee (QAA) failed to identify and/or act upon quality deficiencies within the facility's operations of which it did have (or should have had) knowledge. The facility failed to complete a criminal background check for Nurse Aide #10. This practice had the potential to affect all residents. Employee identifier: #10. Facility census: 13. Findings include: a) Criminal Background Checks On 01/25/17 at 9:30 a.m. a record review of personnel files revealed Nurse Aide (NA) #10 did not have a fingerprint based criminal background check performed prior to working on the skilled nursing unit. The employee roster revealed this employee came to work on the unit on 12/18/16. On 11/27/17 at 11:48 a.m. Nurse Manager (NM) #25 said the employee worked as float on the unit in 2014. The NM said she had sent the NA for fingerprints in 2014. The NM said she did not have the results from those fingerprints. On 01/27/17 she contacted the agency that took the finge prints in 2014 and was told they could not release the results because the account had never been paid. On 01/27/16 at 11:45 a.m. the NM said she did not enter an application for this employee into the West Virginia Clearance for Access: Registry and Employment Screeeing (WV CARES) system at that time. She said she completed the application but did not submit it to WV CARES. This was confirmed by a representative from WV CARES who was contacted by telephone on 11/17/16.",2017-11-01
7547,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,241,D,0,1,SJUJ11,"Based on observation and staff interview, the facility failed to ensure residents were treated with dignity and respect. During a medication administration observation, a resident was asked questions about his bowel functions in front of other residents. This had the potential to cause embarrassment for the resident and was not treating the resident with dignity and respect. This was observed for one (1) of three (3) residents during medication administration pass observations. Resident identifier: #100. Facility census: 15. Findings include: a) Resident #100 During a medication pass observation on 03/27/13 at 9:30 a.m., Employee #4 was observed preparing medications for Resident #100. The resident was in the physical therapy room so the nurse stated he (the nurse) would go into the therapy room to administer a resident's medications. The resident was sitting in the room with four (4) female residents. The nurse proceeded to administer Resident #100's medications. The nurse asked how have your bowel movements been?. The resident looked at the nurse and said What?. The nurse then adjusted his voice a little louder and said, Is your bowel movements formed?. The resident then told the nurse that everything was good and the nurse gave him his medications. During an interview with Employee #4, on 03/27/13 at 10:45, the practice of administering medications and asking residents questions in a public area was discussed. The nurse agreed he could see how this might not be treating the resident with dignity and was not a good practice.",2017-04-01
7548,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,272,E,0,1,SJUJ11,"Based on record review, staff interview, and a review of the Minimum Data Set assessments, the facility failed to complete OBRA (Omnibus Budget Reconciliation Act) required assessments using the specified assessment instrument (RAI). Care Area Assessments (CAA) were not completed for areas that were triggered as potential problems and required additional assessment. This was found for seven (7) of seventeen (17) residents reviewed in Stage 2 of the survey. Resident identifiers: #56, #52, #5, #13, #87, #94, and #69. Facility census: 15. Findings include: a) Resident #56 This resident had a comprehensive minimum data set (MDS) assessment completed on 11/13/12. Section M, item M0300C1 was coded to indicate this resident had a Stage III pressure ulcer. Section V of this assessment indicated the care area for Pressure Ulcers had triggered and required further assessment. The location of the Care Area Assessment (CAA) information was identified as being in her POC (plan of care). The date was 11/05/12. Further review of the medical record revealed there was no care plan for this resident's pressure ulcer as indicated and no pressure ulcer documentation could be located in the medical record. b) Resident #52 A comprehensive MDS was completed on 12/03/12. Section M, item M0300B1 indicated this resident had a Stage II pressure ulcer present at the time of the assessment. Section V identified the care area for pressure ulcers triggered from the MDS and required further assessment. According to Section V, the location of the care area assessment documentation (CAA) on pressure ulcers was the plan of care (POC) dated 12/03/12. Further review of the record found this resident did not have a care plan for the presence of a pressure ulcer. There was no evidence this care area had been assessed as required and there was no care plan located for this resident's pressure ulcer as indicated. c) Resident # 5 A comprehensive MDS was completed for this resident on 10/19/12. Item M0300B1 was coded to indicate the resident had a Stage II pressure ulcer. Section V of the MDS, identified the care area for pressure ulcers had triggered and required further assessment. According to Section V, the location of the CAA assessment documentation for pressure ulcers was the POC dated 10/13/12. Further review of the record did find a POC for this resident who had impaired skin integrity, but there was no assessment of this care area and the required documentation of additional assessment of this area was not recorded. d) Resident #13 A comprehensive MDS was completed for this resident on 02/06/13. This assessment revealed in Section V the resident had triggered for pressure ulcers and required further assessment of this care area. According to the Section V information, the location of the CAA assessment documentation on pressure ulcers would be in the POC dated 01/31/13. The plan of care dated 01/31/13 was reviewed. There was no further assessment included in this plan. There were directions for skin assessments every shift and a comprehensive assessment every Tuesday. There was no evidence that a further assessment had been completed. The transitional care unit coordinator (Employee #2) was interviewed 03/26/13 at 2:00 p.m. regarding Section V of the MDS and the care area assessment (CAA) documentation required for the triggered areas. She verified the care area documentation was not in the POC as indicated on the assessments. She stated that they did not think the CAA documentation was required for their facility and did not do further assessments. They proceeded directly to the care plan. The Resident Assessment Instrument (RAI) Users Manual, Version 3.0, dated 2012, specifies in Section 2.3 that an RAI (resident assessment instrument) including the MDS, CAA process, and utilization guidelines, must be complete for all residents of Medicare Skilled Nursing facilities (SNF) and Medicaid (Title 19) Nursing Facilities (NFs). This includes SNFs and NFs in hospitals, regardless of payment source. This manual also specifies in Section 2.7 that the CAA completion, after completing the MDS portion of the comprehensive assessment, is the next step to evaluate the strengths, problems, and needs through use of the CAA process and further investigation of resident specific issues. e) Resident #87 The medical record review for Resident #87, completed on 03/27/13 at 4:00 p.m. revealed the facility had not completed the CAAs (care area assessment) for Resident #87. The admission MDS (minimum data set) assessment, target date of 02/04/13, revealed eight (8) areas triggered and required a CAA for a more thorough understanding of the area. This assessment aids in the development of a care plan. The areas of pressure ulcers, urinary incontinence/catheter use, falls, nutrition, dehydration/fluid maintenance, pain, activities of daily living, and psychoactive medications had triggered for further assessment. f) Resident #94 The medical record review for Resident #94 completed on 03/28/13 at 11:00 a.m. revealed the facility had not completed the CAAS for Resident #94. The admission MDS assessment, target date of 02/27/13, revealed seven (7) areas triggered and required a CAA for a more thorough understanding of the area. The areas of activities of daily living/functional rehabilitation, pain, pressure ulcers, tube feeding, dehydration/fluid maintenance, and psychoactive medications required a CAA. g) Resident #69 The medical record review for Resident #69, completed on 03/28/13 at 3:30 p.m., revealed the facility had not completed the CAAs for triggered areas. The admission MDS assessment, target date of 02/20/13, revealed seven (7) areas triggered and required a CAA for a more thorough understanding of the area. The triggered areas of falls, nutrition, dehydration/fluid maintenance, pain, psychoactive medications, pressure ulcers, and urinary incontinence required a CAA. The transitional care unit coordinator (Employee #2) was interviewed on 03/26/13 at 2:00 p.m. regarding Section V of the MDS and the care area assessment (CAA) documentation required for the triggered areas. She verified that the care area documentation was not in the POC as indicated on the assessments. She stated they did not think that the CAA documentation was required for their facility and did not do further assessments. They proceeded directly to the care plan.",2017-04-01
7549,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,278,D,0,1,SJUJ11,"Based on medical record review and staff interview, the facility failed to ensure the completion of an accurate minimum data set (MDS) assessment. The facility had not correctly assessed two (2) of fifteen (15) Stage II residents. The facility had incorrectly recorded Resident #87' s weight. The facility had not captured a pressure ulcer on an MDS assessment for Resident #13. Resident identifiers: #87, and #13. Facility census: 15. Findings include: a) Resident #87 The medical record review for Resident #87 conducted on 03/27/13 at 4:00 p.m. revealed the area of nutrition reflected the resident had sustained a weight loss. The admission assessment with a target date of 02/04/13 revealed the resident was 74 inches tall and weighed 184 lbs. The 14-day assessment with a target date of 02/11/13 indicated the resident weighed 160 lbs. On 03/27/13 at 4:30 p.m., the transitional care unit care coordinator (Employee #2) said the weight recorded on 02/11/13 was inaccurate. The medical weight was entered which was not the resident's actual weight. b) Resident #13 A review of the comprehensive minimum data set assessment, dated 02/06/13, indicated in Section M0210 that this resident did not have a pressure ulcer present. It was recorded, on admission, on 01/31/13, that this resident had a Stage II area to her coccyx present on admission. It was again noted on 02/03/13 that she had a Stage II area on her coccyx and a Stage I area on her heel. The next assessment was 02/10/13. This assessment indicated she had a Stage II pressure ulcer to her coccyx and a Stage I pressure area to her left heel. There was no evidence this pressure area had healed between the resident's admission and the assessment reference date. The State II ulcer was recorded as being present until 03/16/13. An interview with the unit coordinator, on 03/27/13 at 3:00 p.m., confirmed she had not coded this pressure ulcer on the assessment. She verified this assessment did not reflect the resident's skin condition.",2017-04-01
7550,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,279,E,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan with measurable goals for each resident to describe the services that were to be furnished according to the resident's needs and assessments. The facility failed to ensure care plans were developed for the care areas of pressure ulcers for Residents #56, #13, #52, and #5 and there was no care plan developed for the area of toileting for Resident #57. The care plans were not complete for five (5) of seventeen (17) residents reviewed in Stage II of the Quality Indicator Survey. Facility Census: 15 Findings include: a) Resident # 56 This resident's admission assessment, dated 11/05/12, indicated the resident had a Stage III pressure ulcer on her coccyx with drainage/exudate. She also had a Stage I pressure ulcer to her left heel with no measurements recorded and a Stage I pressure ulcer above the coccyx that was 1 cm x 5 cm. The skin impairment sheet also contained documentation of a Stage III area on her coccyx that measured 1 cm x 3 cm. This assessment noted there was a [MEDICATION NAME] dressing in place. Further review of the medical record revealed there was no written care plan established for these areas. There were no instructions for treatment or interventions to prevent further breakdown. During an interview with the Unit Care Coordinator (Employee # 2) on 03/27/13 at 4:00 p.m., it was verified there was no care plan established for the care of the pressure ulcers that had been assessed on admission. b) Resident #13 This resident's admission assessment, dated 01/31/13, indicated she had a Stage II pressure ulcer present to her coccyx. The assessment noted this area had a [MEDICATION NAME] dressing dry and intact. The care plan for this resident, dated 01/31/13, and revised on 02/19/13, did not reflect this resident had a pressure ulcer present at that time. This care plan noted a problem of Impaired skin integrity, decreased mobility due to bilateral ankle fractures. There was no measurable goal established for this problem. The approaches included skin assessments every shift, comprehensive skin assessment every Tuesday, [MEDICATION NAME] cream to denuded peri area, and magic butt paste as needed. The resident developed a Stage I area on her left heel, first evident on 02/03/12. There were no interventions included on the care plan to prevent skin breakdown on the resident's heels. The unit manager (Employee #2) was interviewed on 03/27/13 at 4:00 p.m. She verified this care plan did not include the necessary components. c) Resident #52 This resident was admitted on [DATE]. According to her admission assessment, she had a Stage II pressure ulcer present on admission. There was no evidence in the resident's medical record a care plan had been established to describe the services to be provided for this resident's skin care. The unit manager (Employee #2) was interviewed on 03/27/13 at 4:00 p.m. She stated she was not able to find a care plan for this resident's skin impairment. d) Resident #5 This resident was admitted to the facility on [DATE]. According to the resident's admission assessment, she had blisters present on her coccyx and an intact dressing. This was noted as a Stage II area. A care plan was established on 10/13/12. There were no measurable goals included on the care plan. The interventions included: turn and reposition every three (3) hours while awake (this was discontinued on 10/22/12), weekly wound assessments, good skin care, and [MEDICATION NAME] to the posterior calf right side and change every three (3) days. The care plan did not address the Stage II area on the resident's coccyx, only the area on her leg. The area that was a blister area on her coccyx, became a 4 cm x 1 cm x 0.5 cm depth Stage II ulcer on 11/20/12. This area was not included in the resident's care plan. The unit manager (Employee #2) was interviewed on 03/27/13 at 4:00 p.m. She provided a care plan and confirmed it was the only care plan. This plan did not address the Stage II area on her coccyx with goals or interventions for improvement. e) Resident #87 The medical record review for Resident #87, completed on 03/27/13 at 4:00 p.m., revealed the resident came to the unit for rehabilitation after undergoing a total hip arthroplasty (surgical joint repair) to the left hip. The admission minimum data set (MDS) assessment revealed a target date of 02/04/13. The assessment triggered for urinary incontinence. The unit coordinator (Employee #2) indicated this area triggered due to the resident's immobility. The facility had not addressed this issue in the resident's care plan.",2017-04-01
7551,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,281,E,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, resident interview, observations, and a review of the National Pressure Ulcer Advisory Panel (NPUAP) standards, the facility failed to provide services to residents with pressure ulcers to meet professional standards of quality. The facility did not adequately assess pressure ulcers and did not develop or implement an individualized program for the prevention and treatment of [REDACTED]. This was true for 4 (four) of 4 (four) residents with pressure ulcers reviewed in Stage II. Resident identifiers: #56, #13, #52, and #5. Facility Census: 15. Findings Include: a) Resident # 56 This resident was admitted on [DATE] . According to the resident's admission assessment, there was a Stage III pressure ulcer on her coccyx at that time. Documentation identified she had drainage/exudate present. The assessment included a [MEDICATION NAME] dressing on the area. The measurements recorded on the skin impairment sheet identified this area as 1 cm x 3 cm (no depth measurement recorded). This skin impairment sheet also indicated the resident had a Stage I area above her coccyx that measured 1 cm x 5 cm. It was also recorded she had a red left heel (which was not measured) . Further review of the record revealed there was no care plan for this resident's skin condition that provided instructions and direction to the staff for the care of the pressure ulcers that were present on admission. There were no physician orders or guidance for use of the dressing, to ensure consistency in the treatment of [REDACTED]. The documentation of the care provided to this pressure ulcer was inconsistent and incomplete. The skin assessments for this resident's wounds were not done some days and there was no evidence to show when treatments were done. According to the Unit Care Coordinator (Employee #2), on 03/26/13, the Integumentary Detailed Assessment in the computer was included in the head to toe assessment that was completed each shift. (There were two (2) twelve (12) hour shifts each day.) The skin questions include an area that asked if there was a wound, the location, description, color, length, width depth, drainage, surrounding tissue, cleansing or irrigation, wound dressing. She verified these areas on the assessment were rarely completed, and there was no evidence the wound was assessed and treated consistently. The resident was discharged on [DATE] to the acute care hospital. According to her skin impairment sheet, completed and reviewed and signed by 2 (two) nurses the day of discharge, this wound was a stage IV pressure ulcer with black eschar and tendon visible. Measurements were recorded as 4.5 length x 4 cm width (no depth was recorded). There was no evidence this wound had been assessed for two (2) days prior to her being transferred, at which time it was noted the wound was black and purple with drainage. A review of the facility's practice guidelines for Stage III wounds provided the nursing care standard for treating the wound. This guidance provided the process guidelines for the wound care, but the facility could provide no evidence this care was done. There were also preventative strategies listed in the guidelines, but there was no evidence these were implemented for this resident. b) Resident #13 The admission assessment for this resident indicated she had a Stage II pressure ulcer to her coccyx with a [MEDICATION NAME] dressing present on 01/31/2012 at 19:26 (7:26 p.m.). This was also recorded on her skin impairment site documentation sheet as a one (1) cm x one (1) cm area. There was no evidence this wound was fully assessed and no treatment plan was established for this area. The assessments were inconsistent with no impairments for a few days in a row, then assessments revealed she had a pressure ulcer to her coccyx that was a Stage II and Stage I to her heel. The dressing documentation was also inconsistent; some days she had a [MEDICATION NAME] dressing on her heel, other days the dressing was on her coccyx. No other documentation was presented. The care plan was not updated to reflect her condition. There was no evidence this area was measured or consistently treated to know what kind of skin impairment the resident actually did have. When there was a Stage II area on assessment, no description or measurements of the area were included. The inaccurate skin assessments and inconsistent treatments had the potential for this resident to have skin impairments that were not treated. Resident #13 was interviewed and she was questioned about her skin. She stated she did not have any skin breakdown currently. She stated she did have a place on her bottom and on her heel but they are not there anymore. Permission was obtained from the resident to observe her skin. The nurse (Employee # 4) was observed when he did his skin integumentary assessment and the resident's skin was viewed. There was no redness or open areas and the resident had no impairments observed. She had braces to her ankles and feet bilaterally due to her recent ankle fractures. These braces were removed and her heels were observed. There were no current issues with her skin. c) Resident #52 An admission assessment, dated 12/03/12, for this resident revealed a Stage II pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing intact. There were no measurements recorded to indicate the size of this area, and no description of the wound was recorded. There was no evidence in the medical record on 12/04/13 and 12/05/13 of a pressure ulcer. The skin integumentary assessment completed each shift did not indicate a dressing was in place. It was not evident that the dressing, present on 12/03/12, was still present or if it had been removed. On 12/06/12 it was recorded the resident had a pressure ulcer on her buttocks with serous drainage and a [MEDICATION NAME] dressing in place. The assessment on 12/07/12 revealed she had a pressure ulcer on her buttocks, but no evidence of a dressing or wound was assessment. On 12/08/12, the assessment revealed no skin impairment. On 12/10/12, the record revealed the resident had a pressure ulcer on her coccyx with [MEDICATION NAME] dressing. The description was documented as well healed. No skin integrity issues were recorded again until 12/15/12. The skin assessment completed on day shift noted a Stage II pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing in place. This was not recorded on the skin assessments again until 12/20/12. There was no evidence this dressing had been changed or discontinued. On 12/20/12, the integument assessment listed under skin abnormality, buttocks redness. There was no evidence that any interventions were initiated. The resident was discharged home on[DATE]. d) Resident # 5 This resident was admitted on [DATE]. Her admission skin integumentary detailed assessment listed a skin abnormality described as an ulcerated buttocks. No further description of this area was recorded on the admission assessment. The skin impairment site/location documentation, where skin issues present on admission were recorded, noted a Stage II area recorded as present on the resident's bottom. It was described as blisters with a dressing intact. There were no measurements recorded and the exact location of this area could not be determined. The integumentary assessment was completed each shift twice a day. There were many discrepancies in the resident's skin condition from shift to shift. The documentation was inconsistent with no description or measurements of this resident's pressure ulcer. It was not evident daily that the pressure ulcer was present, or whether a dressing was present and/or changed. The care plan was established on admission on 10/13/12 and reviewed weekly. This care plan reflected a dressing present on the resident's posterior calf, but never addressed any issues relative to the resident's pressure ulcer. The Registered Nurse (Employee # 4) working on the unit on 03/28/13, was questioned about the continuity of care and how they communicate the presence of pressure ulcers and the treatments that were to be done. He said they pass this information in report each shift. He verified they do not write orders for the skin treatments, or have a place that tells you that you need to do the dressing changes you just know to do it. e) The National Pressure Ulcer Advisory Panel (NPUAP) is a reputable national organization that serves as an authoritative voice for improved patient outcomes in pressure ulcer prevention and treatment through public policy, education, and research. The guidelines provided by the NPUAP include the facility must develop and implement an individualized program of skin care depending on the patient's abilities and needs. The clinical practice guidelines also refer to skin assessments being accurately documented and prevention strategies implemented. Accurate documentation of skin assessments is essential for monitoring the progress of the assessments.",2017-04-01
7552,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,314,G,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, resident interview, observations, and staff interview, the facility failed to ensure residents with pressure ulcers received the necessary treatment and services to promote healing and prevent new pressure ulcers from developing. The facility did not have a process that was consistent for assessing, care planning, and implementing individualized interventions for each resident to ensure that pressure ulcers were being treated in a manner to promote healing. Resident #56 was admitted with a Stage III pressure ulcer that worsened after admission and became a Stage IV with tendons visible within one (1) week. There was no evidence this wound assessment, daily treatments, or a care plan was initiated to promote healing and prevent worsening of the ulcer. Resident #52, Resident #5, and Resident #13 had wounds not accurately assessed. Care plans had not been developed for treatment of [REDACTED]. Additionally, it could not be determined whether or not pressure ulcers healed and recurred or had never healed. Failure to adequately assess and treat pressure ulcers resulted in actual harm to one (1) resident and a potential for harm existed for three (3) of the four (4) residents sampled for pressure ulcers in Stage 2 of the survey. Resident identifiers: #56, #52, #5, and #13. Facility Census: 15. Findings include: a) Resident #56 According to this resident's admission assessment, she had a Stage III pressure ulcer on her coccyx on 11/05/12. Her integumentary assessment listed drainage/exudate as being present. The assessment noted she had a [MEDICATION NAME] dressing on this area. The measurements recorded on the skin impairment sheet, on 11/05/12, identified this area as 1 cm x 3 cm (no depth measurement was recorded). This skin impairment sheet also indicated a Stage I area above her coccyx that measured 1 cm x 5 cm and a red left heel (with no measurements noted). There was no care plan for this resident's skin condition to provide direction to the staff for the care of the pressure ulcers present on admission. There were no physician orders for treatment or guidance for the use of a dressing to ensure consistency in the treatment of [REDACTED]. Some shifts there were no skin assessments completed, some shifts the assessments were completed only partially, and some assessments were not accurately completed. During an interview with Employee #4, on 03/28/13 4:00 p.m., it was verified the [MEDICATION NAME] dressing was what the facility typically used for wounds. This treatment was described as an absorbent soft foam dressing. The following were the results recorded in the Integumentary assessments completed for this resident after her admission on 11/05/12: -- 11/05/12, the admission assessment indicated a Stage III area on her coccyx. Drainage /Exudate present. 1 cm x 3 cm. -- 11/06/12 at 16:22 (4:22 p.m.) the Integumentary Detailed Assessment noted the skin was impaired. There was no further description of the impairment and no evidence a dressing was in place or changed. -- 11/06/12 at 19:51 (7:51 p.m.) - an Integumentary Detailed Assessment revealed the resident had a pressure area on her coccyx. The description of the area noted drainage /exudate was present. There were no measurements. The surrounding tissue was noted to be normal. This assessment included there was a [MEDICATION NAME] dressing on the area. The location on the form to record cleansing or irrigation was not completed. There was no evidence of a dressing change. -- There was no skin assessment completed on 11/07/12 on day shift. There was no evidence of a dressing change. -- 11/07/12 at 19:54 (7:54 p.m.) - A pressure ulcer on the coccyx was identified on the integumentary skin assessment. There was no description, measurements, or cleansing of the wound noted. The assessment did reveal a [MEDICATION NAME] dressing was in place, but it was not noted as being changed or just in place. There was no evidence the wound was cleansed. -- There was no evidence a skin assessment was completed on 11/08/12 on the day shift. -- 11/08/12 at 19:35 (7:35 p.m.) - The Integumentary assessment indicated No skin Impairment -- 11/09/12 at 07:35 (7:35 a.m.) - The Integumentary assessment noted the resident had a pressure area on her coccyx with drainage/exudate and a [MEDICATION NAME] dressing was in place. It was not noted if the wound was cleansed or the dressing was changed or just in place. -- 11/09/12 at 22:03 (10:03 p.m.) - it was indicated on the Integumentary Assessment there was no skin impairment. -- There was no assessment completed for day shift on 11/10/12. -- 11/10/12 at 23:24 (11:34 p.m.) it was indicated on the Integumentary Assessment the resident had a pressure ulcer on her coccyx with drainage/exudate, the color of the area was black/ purple, the drainage was brown, and there was a [MEDICATION NAME] dressing on the wound. Again, no evidence if this wound was cleansed and the [MEDICATION NAME] dressing was changed or just present. -- 11/11/12 at 23:03 (11:03 p.m.) - It was indicated on the skin assessment the resident had a pressure ulcer on her coccyx. Drainage/exudate were present. The color was black purple and she had a [MEDICATION NAME] dressing to the wound. The area regarding cleansing/irrigation was not completed. It could not be determined if the wound dressing was changed or just intact. -- 11/12/12 at 18:22 ( 6:22 p.m.) - The integumentary assessment had no pressure ulcers recorded and no dressing noted. There were no skin impairments recorded on this assessment. -- 11/12/12 at 20:01 - The Integumentary assessment indicated there was no impairment. The resident was discharged on [DATE] to the acute care hospital. According to her skin impairment sheet, completed and reviewed and signed by 2 (two) nurses the day of discharge, this wound had progressed to a Stage IV pressure ulcer with black eschar with tendon visible. Measurements were recorded as 4.5 length x 4 cm width. No depth was recorded. A copy of the facility's policy and practice guidelines for Stage III wounds was provided by the unit manager. These guidelines provided the nursing care standard for treating these wounds. This guidance also provided the process guidelines that should be followed for wound care, but there was no evidence this care was done. (The guidelines addressed how wounds should be cleansed; a self-adherent soft silicone foam dressing was to be applied and left undisturbed for 3 days unless nursing practice dictated otherwise; the resident should be turned frequently, but at least every 2 hours; pillows were to be use to prevent direct contact between bony prominences and to elevate heels to offload pressure; not to position immobile patients directly on their trochanters; to maintain the head of the bed at the lowest degree of elevation to avoid shearing; to consider obtaining a physician's order for a therapeutic bed/overlay; and consider obtaining a physician's order for a dietary consult.) The policy/guideline did not address a description of any pressure ulcer stage other than a Stage II. It did not address documentation, physician notification if there was deterioration, or the many other issues relative to pressure ulcers. The Registered Nurse (Employee #4), working on the unit on 03/28/13, was questioned about the facility's process, how they communicated the presence of pressure ulcers, and the treatments that were to be done. He said they pass this information in report each shift. He verified they do not write orders for the skin treatments. He stated there was not a location that told you that you need to do the dressing changes, you just know to do it when you get your report and when you do the head to toe assessment. He stated they do have written guidelines they follow. According to Unit Care Coordinator (Employee # 2), during an interview on 03/28/13 at 4:00 p.m., this was all of the assessments that were done on the skin during the resident's stay on this unit. She was questioned about the facility's process and stated, they should do the skin assessment each shift and there were 2 (two) shifts. She stated, they do measurements weekly on Tuesday (the day she was transferred to the hospital was a Tuesday). She verified there were several shifts the assessment were not completed, shifts where the assessment was inaccurate, and the wound progressed during her time in this facility to a Stage IV. There was no evidence of the depth of the wound, but the skin impairment sheet, dated 11/13/12, noted tendon visible. It was also verified there was no evidence this wound was assessed or treated two (2) days prior to her discharge and prior to it being noted that it had progressed from a Stage III to a Stage IV. ====== b) Resident #13 The admission assessment for this resident, on 01/31/13, indicated she had a Stage II pressure ulcer to her coccyx with a [MEDICATION NAME] dressing present. The size of this area was recorded as one (1) cm x one (1) cm. There was no evidence this wound was fully assessed and no treatment plan was established for this area. The skin assessments were inconsistent; no impairments for a few days in a row, then the assessments revealed a pressure ulcer to her coccyx that was a Stage II and a Stage I to her heel. The dressing documentation was also inconsistent; some days she had a [MEDICATION NAME] dressing on her heel, and other days the dressing was on her coccyx. Her assessments were inconsistent and the care she received to the area could not be determined. The shift assessments for the skin integrity were as follows: -- The Admission skin assessment of 01/31/13 indicated the resident had a Stage II pressure ulcer on her coccyx with a [MEDICATION NAME] dressing. -- 02/01/13 - Shift Integumentary Assessment indicated she had a Stage I Ulcerated Buttocks with [MEDICATION NAME] dressing intact. -- There were no impairments noted on the shift reports for 02/02/13, and no impairment noted on the 02/03/13 assessment for the day shift. -- During the 7:00 p.m. shift, on 02/03/13, it was noted this resident had a Stage I area on her left heel with a [MEDICATION NAME] dressing intact. She also had a pressure ulcer present to her coccyx with paste/powders used. -- There were no impairments noted and no further mention of a dressing on the resident's heel 02/04/13, 02/05/13,02/06/13, 02/07/13, 02/08/13, or 02/09/13, and no impairment noted on the day shift on 02/10/13. -- 02/10/13, on the 7:00 p.m. shift, it was recorded the left heel had a Stage I area with no dressing and the coccyx had a Stage II area that they were using paste/powders on. -- It was noted there were no impairments on both shifts on 02/11/13, 02/12/13, and 02/14/13. There were no skin assessments recorded at all on 02/15/13, 02/16/13, or 02/17/13. There were no impairments recorded daily until 02/22/13. -- 02/22/13, the assessment indicated the resident had a Stage I area on her left heel and they were using paste/powder on this area. It also noted a Stage II area on her coccyx and a [MEDICATION NAME] dressing for that area. -- 02/23/13 - assessments had no documentation concerning skin care. There was no evidence the dressing noted the previous day, was intact or observed. -- It was then noted on 02/24/13 and 02/25/13 the resident had no impairments. -- On 02/26/13 - the assessment stated that the resident had a Stage I area on her left heel and a Stage II area on her coccyx. No dressing in place at that time. -- On 02/27/13 - the Integumentary assessment noted the resident had a Stage II area on her coccyx with a [MEDICATION NAME] dressing in place. There was no mention of an area on her heel. -- There was no impairment recorded on the skin assessment on 02/28/13 on either shift. -- On 03/01/13, on the day shift, there was no documentation concerning the skin care. Then on 03/01/13 on the evening shift, it was noted she had a Stage II area on her coccyx with dressing dry and intact and a Stage I area on her left heel with treatment of [REDACTED]. -- On 03/02/13 - the day shift assessment revealed a Stage II area present on her coccyx with a [MEDICATION NAME] dressing dry and intact. There was no mention on the skin assessment that morning about the resident's heel. On the evening shift assessment, on 03/02/13, it was noted the resident had a Stage I on her heel with [MEDICATION NAME] dressing in place, and a Stage II on her coccyx with paste and powders. -- On 03/03/13 there was a Stage II area on her coccyx with [MEDICATION NAME] dry and intact. -- There was no impairment noted again until 03/10/13, when it was recorded she had a Stage II area on her coccyx. -- The documentation reflected no further impairment on 03/16/13. The assessment noted a pressure ulcer on her heel that was red, ecchymotic, and Stage I. This was the last impairment recorded. The assessments all reflected that there was no impairment since that time. There was no evidence this area was ever measured, consistently assessed, treated, or to determine what kind of skin impairment the resident actually did have. When there was a Stage II area on her assessment, there was no detailed assessment to describe the area. There was no evidence to show when she had dressings applied or removed. The inaccurate skin assessments and inconsistent treatments had the potential for this resident to have skin impairments that did not get properly treated. Additionally, the response to treatment could not be identified to determine whether or not the treatment was effective. The Registered Nurse (Employee #4) was questioned, on 03/28/13 at 1:00 p.m., about Resident #13's skin condition. He stated the resident did not have any areas on her skin currently. He said she had some redness at one time, but it was better now. Resident #13 was interviewed and asked about her skin on 03/28/13 at 11:00 a.m. She stated she did not have any skin problems currently. She said she did have a place on her bottom and on her heel but they are not there anymore. Permission was obtained from the resident for the surveyor to observe her skin. The nurse (Employee # 4) was observed 03/28/12 at 3:00 p.m. when he did his skin integumentary assessment and viewed the resident's skin. There was no redness or open areas with no impairments observed. She had braces to her ankles and feet bilaterally due to her recent fractures of her ankles. These braces were removed and her heels were observed. There were no current issues with her skin observed at that time. During an interview with the Unit Care Coordinator (Employee #2) on 03/28/13 at 3:00 p.m., she confirmed the Integumentary Detailed Assessment in the computer was included in the head to toe assessment. This assessment, completed each twelve (12) hour shift, but was incomplete and inconsistent for this resident. ====== c) Resident # 52 An admission assessment for this resident, dated 12/03/12, revealed a Stage II pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing intact. No measurements were recorded indicating size of the area, and no description of the wound was recorded. The daily Integumentary Detailed Assessments were reviewed. These assessments contained discrepancies and were inconsistent. The assessments were recorded as follows: -- 12/04/12 and 12/05/13 - No indication recorded of a pressure ulcer or problem area on her skin. -- 12/06/12 - day shift skin assessment indicated a pressure area on the right buttock with a small amount of serous drainage and [MEDICATION NAME] dressing in place. -- 12/06/12 - night shift documentation indicated no issues and her skin was intact - no abnormalities. There was no evidence of the presence of a dressing or a pressure ulcer. -- 12/07/12 - The day shift assessment indicated a pressure ulcer on her buttocks. There was no evidence of a dressing and no description of the area. -- 12/07/12 - night shift assessment indicated a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. There was no description of the area. -- 12/08/12 and 12/09/12 - on both day shift and evening shift, the Integumentary Assessment indicated the resident had no skin impairments; There was no evidence of a pressure ulcer or the presence of a dressing. -- 12/10/12 - The day shift assessment revealed nothing, but the evening shift assessment included a pressure ulcer on the coccyx, well healed with a [MEDICATION NAME] dressing. -- 12/11/12 to 12/14/12 - the daily skin assessments did not indicate skin impairments on these days. -- 12/15/12 - The day shift skin assessment noted a Stage II pressure ulcer on her coccyx with a [MEDICATION NAME] dressing in place. There were no measurements of the area or new orders to indicate this area had reappeared after being healed for five (5) days. -- 12/15/12 - The night shift skin assessment indicated no impairment of the skin. -- 12/16/12 - Redness on the buttocks was recorded, but no dressings or evidence of an area on her coccyx as indicated on 12/15/12. -- 12/17/12 to 12/19/12 - There were no skin abnormalities recorded. -- 12/20/12 - The day shift skin assessment indicated the resident had redness to her buttocks. This was the day the resident was discharged from the facility. There was no evidence this resident had a care plan to address her skin impairments. The assessments were inconsistent and it could not be determined what was actually present on the resident's skin and what treatment she received. The Unit Care Coordinator (Employee #2), on 03/26/13 at 3:30 p.m., verified this was all the assessments that were completed on this resident. She also verified there was no care plan developed for this resident's Stage II pressure ulcer and the assessments were inconsistent. ====== d) Resident #5 The admission assessment, completed 10/13/12, indicated this resident had a Stage II pressure ulcer with an intact dressing present at the time of admission. There were no measurements and no evidence this area was assessed. The daily Integumentary Assessments, completed every shift, were inconsistent and did not provide evidence that this resident's wounds were adequately assessed and treated. The assessments were as follows: -- 10/14/12 - Day shift skin assessment, for the day following the resident's admission, reflected there were no skin impairments. The night shift assessment revealed two (2) pressure areas. One (1) area on each buttock. The indicated areas were warm, red, with no evidence of a dressing in place. -- 10/15/12 - The day shift assessment did not indicate any pressure areas present. The evening shift indicated a pressure ulcer on her coccyx with a [MEDICATION NAME] dressing . -- 10/16/12 - The skin assessment for both shifts indicated no skin issues. -- 10/17/12 - The day shift skin assessment indicated a pressure ulcer present to right and left buttocks with a [MEDICATION NAME] dressing in place. However, the evening shift assessment reflected a pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing in place. -- 10/18/12 - The skin assessment for day shift did not indicate skin impairments. Evening shift skin assessment did indicate a pressure ulcer present to her coccyx with a [MEDICATION NAME] dressing in place. -- 10/19/12 - The skin assessment for day shift indicated a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. The evening shift assessment indicated a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. -- 10/20/12 - The day shift did not record a skin assessment and the evening shift noted a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. -- 10/21/12 - The day shift did not record a skin observation, but the evening shift indicated a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. -- 10/22/12 - The day shift assessment did not reveal any skin impairments. The evening shift assessment noted a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing in place. -- 10/23/12 -10/27/12- No skin impairments were documented until evening shift on 10/27/12. The evening shift assessment identified a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. -- 10/28/12 to 11/16/12 (19 days) - There were no skin impairments documented. -- 11/16/12 - Day shift recorded no skin issues. The evening shift recorded redness on the buttocks. -- 11/17/12 and 11/18/12 - There was no skin impairment recorded. -- 11/19/12 - The day shift skin assessment reflected redness on her buttocks. The evening shift assessment indicated an area on her coccyx with a [MEDICATION NAME] dressing. -- 11/20/12-11/22/12 - No skin impairment was recorded again until 11/22/12. During the evening shift assessment, a pressure ulcer on her coccyx with a [MEDICATION NAME] dressing was indicated. -- 11/23/12 - There was no documentation on the skin assessment for day shift. The evening shift skin assessment revealed a pressure ulcer on the coccyx with a dressing that was dry and intact. -- 11/24/12 - Day shift assessment included stated there was a pressure ulcer present on the coccyx., a description of serosanguinous drainage, and a dressing of 4 x 4 's that was dry and intact. The evening shift assessment reflected no skin impairment and no mention of a dressing. -- 11/25/12 - The day shift skin assessment indicated there were no skin impairments. The evening shift assessment indicated a pressure ulcer present on her coccyx and no dressing present. -- 11/26/12 - The skin assessments for both shifts indicated no skin impairment. -- 11/27/12 and 11/28/12 - There was no evidence of skin impairment. -- 11/29/12 - The day shift assessment indicated no skin impairment. The evening shift assessment reflected a Stage II dressing intact, and the resident was encouraged to position on sides. -- 11/30/12 - Day shift did not indicate any skin impairment, but evening shift revealed a Stage II pressure ulcer with a [MEDICATION NAME] dressing in place. -- 12/01/12 - Both day shift and evening shift skin assessments indicated a pressure ulcer to her coccyx with no dressing. -- 12/02/12 - There was no skin impairment noted on day shift. Evening shift noted a pressure ulcer present on her coccyx that was described as red/yellow in color. Paste was applied. -- 12/03/12 - The day shift skin assessment revealed a Stage II pressure ulcer on her buttocks. No dressing was mentioned. -- 12/04/12, 12/05/12, and 12/06/12 - skin assessments completed on these days did not indicate any skin impairments. -- 12/07/12 - day shift did not note any issues with the skin, but the evening shift assessment indicated a Stage II pressure ulcer to her coccyx, treated with paste/powders. This resident was discharged home on[DATE]. There was no evidence the resident's skin condition was adequately assessed when it was noted she had a pressure ulcer present. There were no measurements or descriptions recorded in the record. The care plan, dated 10/13/12, was reviewed. This care plan was reviewed each week during the resident's stay on this unit. Her care plan did not have goals and the interventions were not implemented. There was no evidence weekly skin assessments were done or that the measurements were ever completed of this residents wounds. Her care plan did not contain interventions to help resolve the area of breakdown to her bottom . In an interview with the Unit Care Coordinator (Employee #2), on 03/26/13 at 3:30 p.m., she verified this was all of the assessments completed on this resident. She also verified there was not a care plan developed for this resident's Stage II pressure ulcer. She confirmed the assessments that were completed were inconsistent.",2017-04-01
7553,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,371,F,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure foods were prepared and stored under sanitary conditions. Food items were present on the floor of the cooler, foods were unsecured in the freezer and the preparation area for baking was not clean. This had the potential to affect all residents. Facility census: 15. Findings include: a) On 03/25/13 at 1:00 p.m., a tour of the facility's kitchen area revealed various sanitation issues. 1) In the coolers: onion peelings, an orange, a container of yogurt, and a potato were on the floor. 2) A refrigerator contained: -- a bucket of maraschino cherries that were not dated to indicate when they were opened and/or by when they should be used -- a serving tray with a brown substance stuck to it, and -- a bucket labeled mushrooms with contents that resembled brown sugar. 3) In the freezer a package of chicken tenders and a package of french fries were not labeled, dated or sealed. 4) In the baking preparation area, -- a mixer was stored in a clear plastic container with two opened boxes of baking powder. The powder had spilled out into the container. -- A container of [MEDICATION NAME] sulfate suspension was also in the container with the mixer. The [MEDICATION NAME] sulfate was open and able to spill out into the container. -- A takeout pizza carton was sitting on the baking preparation counter. Employee #31 (kitchen supervisor) accompanied the tour of the kitchen area, and agreed that all the undated, unlabeled, and unsealed items needed to be discarded. He also agreed the items in the baking preparation area needed cleaned and opened, items that were unsecured or not dated/labeled needed to be discarded. On 03/26/13 at 11:50 a.m. - Employee #31 (assistant food service director) became aware of the above sanitation issues. She agreed the items needed cleaned from the cooler floors as soon as they are identified. She also agreed food items needed to be dated when opened.",2017-04-01
7554,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,441,E,0,1,SJUJ11,"Based on observation and staff interview, the facility failed to provide a sanitary environment that prevented cross contamination and transmission of organisms to residents. The nurse was observed to don gloves, then have contact with multiple environmental objects, and touch the medications with the contaminated gloves, before administering the medications. This was observed for two (2) of three (3) residents observed on medication administration pass. This had the potential to affect seven (7) of fifteen (15) residents on the unit where this nurse administered medications. Resident identifier: #101 and #100. Facility census: 15. Findings include: a) Resident # 101 Employee #4 was observed during a medication administration pass observation, on 03/27/13 at 9:30 a.m. He reviewed the orders on the computer at the nurses' station. While still at the nurses' station he put on a pair of gloves and retrieved the resident's medications from the medication cart. He took the entire drawer with the medications for Resident #101 out of the cart with his gloved hands and carried them to the resident's room. He also picked up the electronic device used for medication administration and carried it to the room. When the nurse reached the resident's room, he touched various items on the bedside table with his gloved hands while holding the electronic device. He then proceeded to administer the resident's medications by opening the packages and placing the medications into his gloved hand, then giving them to the resident. After he administered the resident's medications, he removed his gloves and left the room without washing his hands. b) Resident #100 Employee #4 was observed at 9:45 a.m. to administer medications to Resident #100. This resident was in the Therapy Room at the time of this observation. The nurse proceeded to don a pair of gloves while at the nurses' station. He then retrieved the medications from the cart by taking out the drawer containing the resident's medications and carried them with his gloved hands to the therapy room. He had the hand held electronic device, used to record the medications, in his gloved hand. He obtained a cup of water for the resident and touched the chair in the therapy room. The nurse proceeded to prepare the resident's medications: he took them out of the package and placed the medications into his gloved hand, then put them in a medicine cup. He administered the medications to the resident after he had touched them with contaminated gloves . c) The Unit Nurse Manager (Employee #1) was questioned about the practice of donning gloves at the nurses' station, then administering medications, and touching the pills with the gloved hand that had touched the unclean things. She agreed this was not an acceptable infection control practice. She stated the nurses should not put their gloves on at the nurses' station and should not touch the resident's medication with the contaminated gloved hands.",2017-04-01
7555,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,514,E,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, policy review, and staff interview, the facility failed to maintain clinical records that were complete and accurately documented. The documentation in the medical records was inconsistent, inaccurate, and the services provided to the residents with pressure ulcers could not be determined. There was no documentation to show when a dressing was changed, there was no description or measurements of pressure ulcers, and there were days the facility did not complete assessments according to its own policy. This was true for four (4) of four (4) records reviewed in Stage II of residents with pressure ulcers. Resident identifiers: # 56, #13, #52, and #5. Facility Census: 15. Findings include: a) Resident #56 According to this resident's admission assessment, she had a Stage III pressure ulcer on her coccyx at the time of admission on 11/05/12. Her integumentary assessment indicated drainage/exudate present and a [MEDICATION NAME] dressing on this area. The measurements recorded on the skin impairment sheet dated 11/05/12, identified this area as 1 cm x 3 cm (no depth measurement was recorded). This skin impairment sheet also indicated a Stage I area above her coccyx that was 1 cm x 5 cm. and a red left heel with no measurements noted. The documentation recorded in the daily assessments for this resident were incomplete and inconsistent. It could not be determined: what skin issues were present, the appearance of the pressure ulcers, the treatment provided, or if the dressing was changed. The following were recorded in the integumentary assessments completed for this resident after her admission on 11/05/12: -- Admission assessment 11/05/12 indicated a Stage III area on her coccyx. Drainage/exudate present, area measured 1 cm x 3 cm. -- 11/06/12 at 16:22 (4:22 p.m.) the Integumentary Detailed Assessment indicated skin was impaired. There was no further description of the impairment and no evidence that a dressing was in place or changed. -- 11/06/12 at 19:51 (7:51 p.m.) an Integumentary Detailed Assessment revealed pressure area on her coccyx. The description of the area included drainage/exudate present. There were no measurements. The surrounding tissue was noted as normal. This assessment indicated a [MEDICATION NAME] dressing was on the area. The location on the form to record cleansing or irrigation was not completed, so it was not evident if this dressing was in place or changed. -- There was no skin assessment completed on 11/07/12 on day shift. There was no evidence of a dressing change. -- 11/07/12 at 19:54 (7:54 p.m.) - revealed a pressure ulcer on the coccyx on the Integumentary skin assessment. No description, measurements or cleansing were noted. The assessment revealed a [MEDICATION NAME] dressing but, did not identify if it was changed or in place. There was no evidence the wound was cleansed. -- There was no evidence a skin assessment was completed on 11/08/12 on the day shift. -- 11/08/12 at 19:35 (7:35 p.m.) The Integumentary assessment indicated No skin Impairment -- 11/09/12 at 07:35 (7:35 a.m.) The Integumentary assessment indicated a pressure area on her coccyx with drainage/exudate, and a [MEDICATION NAME] dressing was in place. This sheet did not included if the wound was cleansed, the dressing was changed or just in place. -- 11/09/12 at 22:03 (10:03 p.m.) No skin impairment was noted on the Integumentary Assessment. -- There was no assessment completed for day shift on 11/10/12. -- 11/10/12 at 23:24 (11:34 p.m.) the Integumentary Assessment indicated there was a pressure ulcer on her coccyx with drainage/exudate. The color of the area was black/ purple, the drainage was brown, and a [MEDICATION NAME] dressing was on the wound. Again, there was no evidence whether this wound was cleansed, or whether the [MEDICATION NAME] dressing was changed or just present. -- 11/11/12 at 23:03 (11:03 p.m.) - it was indicated on the skin assessment the resident had a pressure ulcer on her coccyx. Drainage/exudate was present. Color was black purple with a [MEDICATION NAME] dressing to the wound. The area of the assessment regarding cleansing/irrigation was not complete. It could not be determined if the wound dressing was changed or just intact. -- 11/12/12 at 18:22 ( 6:22 p.m.) - the integumentary assessment had no pressure ulcers recorded and no dressing noted. No skin impairments were recorded on this assessment. -- 11/12/12 at 20:01 - The integumentary assessment indicated there was no skin impairment. The resident was discharged on [DATE] to the acute care hospital. According to her skin impairment sheet, completed, reviewed and signed by 2 (two) nurses the day of discharge, this wound had progressed to a Stage IV pressure ulcer with black eschar and tendon visible. Measurements were recorded as 4.5 length x 4 cm width. No depth recorded. No progress note or assessment was recorded for two (2) days to this date. b) Resident #13 The admission assessment for this resident, on 01/31/13, indicated a Stage II pressure ulcer to her coccyx with a [MEDICATION NAME] dressing present. The size of this area was noted as one (1) cm x one (1) cm. The documentation recorded in the daily assessments was incomplete and inconsistent. It could not be determined what skin issues were present, the description of the pressure ulcers, the treatment being provided, or if the dressing was being changed. The shift assessments for the skin integrity were as follows: -- Admission skin assessment 01/31/13 indicated a Stage II pressure ulcer on her coccyx with a [MEDICATION NAME] dressing. -- 02/01/13 Shift Integumentary Assessment indicated a Stage I ulcerated buttocks with [MEDICATION NAME] dressing intact. -- No skin impairments were noted on the shift reports for 02/02/13, and no impairments were noted on the 02/03/13 assessment for the day shift. -- During the 7:00 p.m. shift, on 02/03/13 it was noted this resident had a Stage I area on her left heel with a [MEDICATION NAME] dressing intact. The pressure ulcer was noted as present to her coccyx with paste/powders used. -- There were no skin impairments noted and no further mention of a dressing on the resident's heel for the following dates: 02/04/13, 02/05/13,02/06/13, 02/07/13, 02/08/13. 02/09/13, and no impairment on day shift on 02/10/13. -- 02/10/13 - on the evening shift, it was recorded the left heel had a Stage I area with no dressing, and the coccyx had a Stage II area they were using paste/powders on. -- No impairments on both shifts were noted on 02/11/13, 02/12/13, and 02/14/13. No skin assessments were recorded on 02/15/13, 02/16/13, or 02/17/13. No skin impairments were recorded daily until 02/22/13. -- 02/22/13 - skin assessment revealed a Stage I area on her left heel, using paste/powder on this area, and a Stage II area on her coccyx, using [MEDICATION NAME] dressing. -- 02/23/13 - assessments had no documentation concerning skin care. The dressing was noted intact on 02/22/13. -- 02/24/13 and 02/25/13 - It was noted the resident had no skin impairments. -- On 02/26/13 - the assessment indicated the resident had a Stage I area on her left heel and a Stage II area on her coccyx. There was no mention of any dressing in place at that time. -- On 02/27/13 - the integumentary assessment indicated a Stage II area on her coccyx with a [MEDICATION NAME] dressing in place. There was no mention of an area on her heel. -- No impairment was record on the skin assessment on 02/28/13 for either shift. -- On 03/01/13 day shift - no documentation concerning the skin care. On 03/01/13, evening shift, the assessment revealed a Stage II area on her coccyx with dressing dry and intact; and a Stage I area on her left heel with treatment of [REDACTED]. -- On 03/02/13 - The day shift assessment indicated a Stage II area present on her coccyx with a [MEDICATION NAME] dressing dry and intact. There was no mention on the skin assessment that morning of the resident's heel. The evening shift assessment of 03/02/13, indicated a Stage I on her heel with a [MEDICATION NAME] dressing in place, and a Stage II area on her coccyx with paste and powders. -- On 03/03/13 - there was a Stage II area on her coccyx with a [MEDICATION NAME] dressing that was dry and intact. -- No impairment was noted until 03/10/13 when the skin assessment indicated a Stage II area on her coccyx. -- The documentation reflected no further impairment until 03/16/13, when the assessment indicated a pressure ulcer on her heel that was red, ecchymotic , Stage I. This was the last impairment recorded. The assessments had all reflected there was no impairment since that time. There was no evidence these areas were measured, consistently assessed, or treated to determine what kind of skin impairment the resident actually did have. When there was a Stage II area on her assessment, there was no detailed assessment to describe the area. There was no evidence to show when she had dressings applied or removed. The inaccurate skin assessments and inconsistent treatments had the potential for this resident to have skin impairments that did not receive treatment. c) Resident # 52 An admission assessment, dated 12/03/12, for this resident revealed she had a Stage II pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing intact. No measurements were recorded to indicate the size of this area and no description of the wound was recorded. The daily assessments for this resident were incomplete and inconsistent. It could not be determined what skin issues were present, the description of the pressure ulcers, the treatment that was being provided, or if the dressing was being changed. The daily Integumentary Detailed Assessments were reviewed and found to contain discrepancies and inconsistencies. The assessments were recorded as follows: -- 12/04/12 and 12/05/13 - there was nothing recorded to indicate there was a pressure ulcer or problem area on her skin. -- 12/06/12 - day shift skin assessment indicated a pressure area on her right buttock with a small amount of serous drainage and a [MEDICATION NAME] dressing in place. -- 12/06/12 - night shift indicated no issues and skin was intact, no abnormalities. There was no evidence of the presence of a dressing or a pressure ulcer. -- 12/07/12 - The day shift assessment indicated a pressure ulcer on her buttocks. No evidence of a dressing and no description of the area. -- 12/07/12 - Night Shift assessment indicated a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. No description of the area. -- 2/08/12 and 12/09/12 - both Day shift and Evening Shift, the Integumentary Assessment reflected no impairments. There was no evidence of a pressure ulcer or presence of a dressing. -- 12/10/12 - day shift assessment reflected no impairment, but the evening shift assessment indicated the pressure ulcer on the coccyx was well healed with a [MEDICATION NAME] dressing. -- 12/11/12 to 12/14/12 - the daily skin assessments reflected no impairment on these days. -- 12/15/12 - The day shift skin assessment indicated a Stage II pressure ulcer on her coccyx with a [MEDICATION NAME] dressing in place. No measurements or orders were found to address this area's reappearance after being healed for five (5) days. -- 12/15/12 - The night shift skin assessment indicated no impairment of the skin. -- 12/16/12 - The skin assessment indicated redness on the buttocks, but no dressings, or evidence of an area on her coccyx as indicated on 12/15/12. -- 12/17/12 to 12/19/12 - There were no skin abnormalities recorded. -- 12/20/12 - The day shift skin assessment indicated redness to her buttocks. The resident was discharged from the facility on this date. d) Resident #5 The admission assessment, completed 10/13/12, indicated a Stage II pressure ulcer with dressing intact and present on admission. There were no measurements and no evidence of any wound assessment. The daily assessments for this resident were incomplete and inconsistent. It could not be determined what skin issues were present, the description of the pressure ulcers, the treatment provided, or if the dressing was changed. The daily Integumentary Assessments completed every shift, two (2) times a day, were inconsistent and did not provide evidence this resident's wounds were adequately assessed and treated. The assessments were as follows: -- 10/14/12 - Day Shift, skin assessment the day following the resident's admission, reflected no skin impairments. The night shift assessment indicated two (2) pressure areas - one (1) area on each buttock. It indicated the areas were warm, red, and had no dressing in place. -- 10/15/12 - The day shift assessment did not indicate any pressure areas present. The evening shift indicated a pressure ulcer on her coccyx with a [MEDICATION NAME] dressing . -- 10/16/12 - The skin assessment for both shifts indicated no skin issues. -- 10/17/12 - The skin assessment on day shift revealed the resident had a pressure ulcer present to both buttocks with a [MEDICATION NAME] dressing in place. The evening shift assessment revealed a pressure ulcer present on her coccyx with a [MEDICATION NAME] dressing in place. -- 10/18/12 - The skin assessment for day shift reflected no skin impairments. The evening shift skin assessment indicated a pressure ulcer present to her coccyx with a [MEDICATION NAME] dressing in place. -- 10/19/12 - The skin assessment for day shift indicated the resident had a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. The evening shift assessment revealed a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. -- 10/20/12 - The day shift did not record a skin assessment. The evening shift revealed a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. -- 10/21/12 - Day shift did not record a skin observation, but the evening shift indicated a pressure ulcer on her left and right buttocks with a [MEDICATION NAME] dressing. 10/22/12 - The day shift assessment did not reveal any skin impairments, and the evening shift assessment indicated a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing in place. -- 10/23/12 -10/27/12 - There was no skin impairment documented until evening shift on 10/27/12. The assessment indicated a pressure ulcer on her buttocks with a [MEDICATION NAME] dressing. -- 10/28/12 to 11/16/12 (19 days) - No skin impairments documented. -- 11/16/12 - Day shift recorded the resident had no skin issues. The evening shift indicated there was redness on the buttocks. -- 11/17/12 and 11/18/12 - No skin impairment recorded. -- 11/19/12 - The day shift skin assessment identified redness on her buttocks. The evening shift assessment indicated an area on her coccyx with a [MEDICATION NAME] dressing. -- 11/20/12 - 11/22/12 - No skin impairment was indicated until 11/22/12. The evening shift assessment noted a pressure ulcer on her coccyx with [MEDICATION NAME] dressing. -- 11/23/12 - No documentation on the skin assessment for day shift. The evening shift skin assessment revealed a pressure ulcer on the coccyx with dressing dry and intact. -- 11/24/12 - Day shift assessment indicated a pressure ulcer present on the coccyx. The description revealed serosanguinous drainage, 4 x 4 dressing was dry and intact. The evening shift assessment revealed no skin impairment with no mention of a dressing. -- 11/25/12 - The day shift skin assessment indicated no skin impairments. The evening shift assessment indicated a pressure ulcer present on the coccyx and no dressing present. -- 11/26/12 - The skin assessments for both shifts indicated no impairment. -- 11/27/12 and 11/28/12 - No evidence of skin impairment. -- 11/29/12 - The day shift assessment indicated no skin impairment. The evening shift assessment indicated a Stage II dressing intact. Resident encouraged to position on sides. -- 11/30/12 - Day shift, no indication of a skin impairment, but evening shift indicated a Stage II pressure ulcer with a [MEDICATION NAME] dressing in place. -- 12/01/12 - Both day shift and evening shift skin assessments revealed a pressure ulcer to her coccyx with no dressing. -- 12/02/12 - No skin impairment noted on day shift, and evening shift indicated a pressure ulcer present on her coccyx described as red/yellow in color. Paste applied. -- 12/03/12 - The day shift skin assessment revealed a Stage II pressure ulcer on her buttocks. No dressing was mentioned. -- 12/04/12, 12/05/12, and 12/06/12 - Skin assessments did not reveal any skin impairments. -- 12/07/12 - day shift did not reveal any issues with skin, but evening shift assessment indicated a Stage II pressure ulcer to her coccyx, treated with paste/powders. According to the Unit Care Coordinator (Employee #2), on 03/26/13 at 11:00 a.m., she agreed there were documentation issues in the records with pressure ulcers. She was asked to provide evidence of assessments and treatments on the pressure ulcers. The assessments as listed above, included all of the pressure ulcer documentation located in the record. There was not sufficient information to determine the services that were provided to the resident's wounds.",2017-04-01
7556,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2013-03-29,520,G,0,1,SJUJ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview, medical record review, and policy review, the facility failed to ensure their program improvement (PI) committee had identified quality care related issues in the area of pressure ulcers. The facility had no means of monitoring the methodology, established by policy, to determine whether treatments were provided to residents with pressure ulcers or what the status of the pressure ulcer was. Therefore, the response to treatment could not be determined. Additionally, documentation regarding the location of the pressure ulcers for an individual varied. It could not be determined whether pressure ulcers healed and recurred, or whether an area persisted, although it was documented to have healed. Four (4) of four (4) residents with pressure ulcers were affected. Resident identifiers: #56, #52, #13, and #5. Facility census: 15. Findings include: a) Resident #56 On 03/26/13 the medical record review for Resident #56, revealed the facility did not thoroughly assess and reassess this resident's pressure ulcer. There was no evidence the facility had monitored and consistently provided treatments for this pressure ulcer. There was no evidence the physician was informed of the changes occurring with the wound. Therefore, an avoidable decline occurred, and the ulcer increased in stage. The resident was admitted on [DATE] with a Stage III pressure ulcer on her coccyx. At that time, the area was 1 cm x 3 cm with no depth noted. Drainage and exudate were documented as being present. During her stay on the unit, no further measurements or descriptions of the wound were noted. The application of a dressing and any other treatment were inconsistently documented. When she was discharged to an acute hospital on [DATE], two (2) nurses assessed the wound. At that time, the wound was 4.5 cm x 4 cm and identified as a Stage IV pressure ulcer as there was black eschar and tendon was visible. b) Residents #13, #52, and #5 Further record reviews, conducted on 03/26/13 and 03/27/13, for Resident #13, #52, and #5 revealed the facility had not fully assessed, monitored, and treated the residents' pressure ulcers, nor was there evidence they had implemented measures to prevent the development of pressure ulcers. The documentation of treatments and the location and status of pressure ulcers was inconsistent. For example, Resident #13 was noted to have a Stage II on her coccyx at the time of her admission on 01/31/13. A Stage I was documented on the resident's buttocks on 02/01/13. On 02/02/13 and 02/03/13 (day shift), no skin impairment was identified. Then on 02/03/13, a pressure ulcer on her coccyx was again noted. From 02/04/13 through day shift on 02/10/13, no skin impairment was noted. Then on 02/10/13, evening shift again charted a Stage II area on her coccyx. Then again on 02/11/13 through 02/17/13, either no skin impairments were documented or no skin assessments were completed. On 02/22/13, the area on her heel that had previously be noted to be a Stage I was noted to be a Stage II and a Stage II was also noted on her coccyx. This inconsistent monitoring/assessment did not allow for evaluation of response to treatment. It could not be ascertained whether the wounds were healing, or whether they healed, then recurred. On 03/29/13 at 10:00 a.m., the nurse manager (Employee #1) verified the facility did not routinely track the pressure ulcers on the unit. She indicated they had no method established to ensure nursing staff were assessing, treating, and monitoring the pressure ulcers. The nurse manager provided a copy of the policy for the treatment of [REDACTED]. The policy indicated the facility would document the assessment of the pressure ulcer at admission, and any time a new pressure ulcer is identified. The policy also indicated the assessment of the pressure ulcer was to include location, stage, size, length, width, sinus tracts, undermining, tunneling, necrotic tissue and the presence of granulation tissue and [MEDICATION NAME]. There was no evidence the facility had implemented its own policy.",2017-04-01
9266,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,278,D,0,1,0IGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete an accurate an assessment for one (1) of fourteen (14) sampled residents, by failing to identify the use of a psychoactive medication ([MEDICATION NAME]) during the assessment reference period for a minimum data set (MDS) assessment. Because the MDS was not accurate, the care area for [MEDICAL CONDITION] drug use was not triggered for further assessment, and no care plan was developed to address the drug's use. Resident identifier: #131. Facility census: 14. Findings include: a) Resident #131 Medical record revealed a physician's orders [REDACTED]. This medication is classified as an antianxiety medication. Review of the Medication Administration Record [REDACTED]. This resident's MDS assessment, with an assessment reference date of 06/21/11, indicated in Section N that she had not received any antianxiety medications during the seven (7) day look-back period from 06/15/11 - 06/21/11. During an interview on 07/07/11 at 1:00 p.m., the MDS nurse (Employee #5) confirmed that Resident #131 did receive this antianxiety medication during the look-back period of this assessment on two (2) occasions and that this MDS was coded incorrectly. She also confirmed that, had this been coded correctly, the care area for [MEDICAL CONDITION] drug use would have triggered for additional assessment and a care plan would have been developed for its use.",2016-01-01
9267,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,279,E,0,1,0IGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to develop a comprehensive care plan to address resident-specific needs for four (4) of fourteen (14) sampled residents, to address falls, psychoactive drug use, and urinary catheter use. Resident identifiers: #133, #125, #134, and #131. Facility census: 14. Findings include: a) Resident #133 Record review revealed Resident #133 experienced a fall in the community and, subsequently, a [MEDICAL CONDITION] which required surgical repair. During that hospitalization , she fell again and fractured the other hip, which also required surgical repair. During an interview with Resident #133 in the early afternoon on 07/06/11, she stated her second fall occurred while she was a patient in the hospital and it was caused, in part, by a reaction to a medication; she is now recuperating with two (2) [MEDICAL CONDITION] repairs. Record review revealed a fall risk assessment was completed at the facility upon admission. Her fall risk score was 10, indicating she was at risk for falls. Record review revealed her admission care area assessment summary (CAAS) triggered for falls, and the person completing this section indicated that decision was made to develop a care plan for falls. During an interview with the minimum data set (MDS) nurse (Employee #5) on 07/07/11 at 3:45 p.m., she stated this resident did trigger on the CAAS for fall risk, and she should have been care planned for falls, but was not. -- b) Resident #125 Record review found that, upon admission, Resident #125 was prescribed an antidepressant and an antianxiety medication for daily use. Record review revealed the MDS triggered for [MEDICAL CONDITION] medication use, and a decision was made to develop a care plan for [MEDICAL CONDITION] medications. During interview with Employee #5 on 07/07/11 at 11:00 a.m., she stated Resident #125 should have been care planned for [MEDICAL CONDITION] medications and was not. -- c) Resident #134 Observation of Resident #134 revealed the presence of an indwelling urinary catheter connected to bedside drainage. Review of Resident #134's medical record found no physician's order for the use of [REDACTED]. Review of the care plan (interim care plan on the computer) revealed no mention of the urinary catheter. During interview on 07/07/11 at 2:00 p.m., Employees #1 and #5 agreed Resident #134's Foley catheter was inserted while in the hospital's acute care unit prior to being transferred to the facility, and they confirmed there are no physician orders for the catheter; for this reason, it was not addressed on his care plan. -- d) Resident #131 Medical record revealed a physician's order, dated 06/19/11 at 7:30 p.m., for [MEDICATION NAME] 0.5 mg by mouth at bedtime as needed for sleep. This resident's admitted was 06/16/11, and record review verified she was not receiving this medication at that time. There was no documentation describing any problems sleeping prior to this medication being started. The care plan dated 06/16/11 was reviewed. It was copied by Employee #5, who verified this was the resident's complete and most current care plan. This care plan did not address that this resident was receiving a medication to promote sleep, and there were no evidence of any non-pharmacologic interventions that had been attempted to resolve the issue of sleeplessness (if it existed). There was no evidence in the medical record that this alert and oriented resident was complaining of sleeplessness prior to this medication being started. During an interview on 07/07/11 at 1:00 p.m., Employee #5 confirmed that Resident #131 did not have a care plan for the use of this antianxiety medication to treat [MEDICAL CONDITION]. Employee #5 confirmed there was no record of any non-pharmacologic interventions that had been provided prior to using medication to promote sleep and no attempts to identify the issues surrounding the residents sleeplessness. Employee #5 also confirmed that, according to the documentation, the resident was not having problems sleeping.",2016-01-01
9268,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,315,D,0,1,0IGF11,"**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 fourteen (14) sampled residents with indwelling urinary catheters present were not catheterized unless each resident's clinical condition demonstrated that catheterization was necessary. Resident identifiers: #134 and #135. Facility census: 14. Findings include: a) Resident #134 Observation of Resident #134 revealed the presence of an indwelling urinary catheter connected to bedside drainage. Review of Resident #134's medical record found no physician's order for the use of [REDACTED]. Review of the care plan (interim care plan on the computer) revealed no mention of the urinary catheter. During an interview on 07/07/11 at 2:00 p.m., the nurse manager (Employee #1) and the minimum data set assessment (MDS) nurse (Employee #5) agreed Resident #134's Foley catheter was inserted while in the hospital's acute care unit prior to being transferred to the facility, and they confirmed there were no physician orders for the catheter or documented rationale for its use. -- b) Resident #135 Medical record review, on 07/06/11, disclosed this resident was admitted to the facility on [DATE], from the acute care hospital with medical [DIAGNOSES REDACTED]. Observations of the resident, on 07/06/11, found the resident continued to have an indwelling urinary catheter. Review of the current physician's orders for July 2011 found the reason for the indwelling catheter was [MEDICAL CONDITION]. Further review of the medical record found no evidence to reflect the resident's urinary status had been assessed to determine whether an ongoing need for the indwelling urinary catheter existed. During an interview on 07/07/11, at 3:30 p.m., Employee #1 confirmed there had been no assessment to determine whether the need of the indwelling urinary catheter existed, and there was no valid medical [DIAGNOSES REDACTED].",2016-01-01
9269,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,329,D,0,1,0IGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen, for one (1) of fourteen (14) sampled residents, was free of drugs without adequate indications for use. Resident #131 received an antianxiety drug ([MEDICATION NAME]) to promote sleep in the absence of any documented evidence of [MEDICAL CONDITION] and in the absence of any evidence to reflect that non-pharmacologic interventions had been attempted without success prior to medicating the resident. Resident identifier: #131. Facility census: 14. Findings include: a) Resident #131 Medical record revealed a physician's orders [REDACTED]. This resident's admitted was 06/16/11, and record review verified she was not receiving this medication at that time. There was no documentation describing any problems sleeping prior to this medication being started. The care plan dated 06/16/11 was reviewed. It was copied by Employee #5, who verified this was the resident's complete and most current care plan. This care plan did not address that this resident was receiving a medication to promote sleep, and there were no evidence of any non-pharmacologic interventions that had been attempted to resolve the issue of sleeplessness (if it existed). There was no evidence in the medical record that this alert and oriented resident was complaining of sleeplessness prior to this medication being started. During an interview on 07/07/11 at 1:00 p.m., Employee #5 confirmed that Resident #131 did not have a care plan for the use of this antianxiety medication to treat [MEDICAL CONDITION]. Employee #5 confirmed there was no record of any non-pharmacologic interventions that had been provided prior to using medication to promote sleep and no attempts to identify the issues surrounding the residents sleeplessness. Employee #5 also confirmed that, according to the documentation, the resident was not having problems sleeping.",2016-01-01
9270,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,371,F,0,1,0IGF11,"Based on observation and staff interview, the facility failed to prepare and serve food under sanitary conditions. Observations of the food service in the kitchen area, on 07/05/11 at 5:30 p.m., found two (2) kitchen personnel involved in preparing and serving food who were wearing hair restraints that did not adequately cover their hair to prevent contamination of resident foods. The cook serving the food was wearing a net that covered a bun on the back of the head but did not cover the top and front of the hair. A second food service employee was wearing a hair net that did not cover bangs. This practice allows for the physical contamination of food from hair and had the potential to affect all fourteen (14) residents who consume oral diets. Facility census: 14. Findings include: a) During observations of the food service in the kitchen area on 07/05/11 at 5:30 p.m., two (2) kitchen personnel involved in preparing and serving food were wearing hair restraints that failed to adequately cover their hair. The cook, who was serving the food, was wearing a net that covered a bun on the back of the head, but it did not cover the top and front of the hair. Another food service employee was observed wearing a hair net that did not cover the bangs. This practice of failing to cover the hair entirely allows for physical contamination of foods by hair. During an interview on 07/07/11 at 3:00 p.m., the food service director (Employee #29) confirmed and agreed that these two (2) employees were not wearing hair covering as specified in the facility policy and as required by the USDA Food Code.",2016-01-01
9271,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,428,D,0,1,0IGF11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, OBRA's (Omnibus Budget Reconciliation Act) Unnecessary Drugs in the Elderly, the facility's policy on the drug regimen review, and staff interview, the pharmacist failed to recognize and report a drug irregularity to the physician and director of nursing for one (1) of fourteen (14) sampled residents. A [AGE] year old resident (Resident #135) had a physician's orders [REDACTED]. This order, which written on admission to the facility on [DATE], allowed staff to administer Ativan in a daily dose in excess of what was recommended for the elderly. Review of the resident's care plan, which was reviewed by all disciplines on 07/05/11, found the pharmacist had documented there were no issues found with the drug regimen review. Resident identifier: #135. Facility census: 14. Findings include: a) Resident #135 Medical record review, on 07/06/11, disclosed this [AGE] year old resident had been admitted to the facility on [DATE] with an order for [REDACTED]. Review of OBRA's Unnecessary Drugs in the Elderly found the maximum dose of Ativan recommended for use in the elderly was 2 mg per day. Review of the facility's drug regimen review policy / procedure (Policy 6, Section XIII) found on Page 1, the pharmacotherapy of each resident is to be reviewed initially within three (3) days of admission and then at least once monthly thereafter by a licensed pharmacist. Review of the resident's care plan, which was reviewed by all disciplines on 07/05/11, found the pharmacist had indicated there were no issues found in the drug regimen review. During an interview on 07/07/11 at 10:35 a.m., the minimum data set assessment (MDS) nurse (Employee #5) confirmed the pharmacist had not identified the excessive daily dose as an irregularity in the resident's medication regimen and the resident had the potential to receive Ativan in an amount not recommended for the elderly.",2016-01-01
9272,CABELL HUNTINGTON HOSPITAL TCU,515126,1340 HAL GREER BOULEVARD,HUNTINGTON,WV,25701,2011-07-07,431,D,0,1,0IGF11,"Based on observation and staff interview, the facility failed to ensure all opened vials of insulin were labeled with the date opened and disposed of within the specified time period allotted for opened vials of insulin, which was within forty-two (42) days from opening Lantus insulin, according to manufacturer's specifications. This was evident for one (1) opened vial of Lantus insulin found in the medication refrigerator. Facility census: 14. Findings include: a) Lantus insulin Observation of the facility's medication refrigerator, on 07/06/11, found one (1) opened vial of Lantus insulin which was more than half empty. Inspection of the vial revealed there was no date to indicate when it was first opened / accessed and no date to indicate when this vial was to be discarded. During an interview on 07/06/11 at 10:30 a.m., the float nurse (Employee #30) stated this vial of insulin should have been discarded, since it is not labeled when it was opened, and she would dispose of it. When asked, she stated there were no patients in the facility who currently used Lantus insulin.",2016-01-01
9805,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2010-01-13,279,D,0,1,K3WS11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to develop a comprehensive care plan for two (2) of seven (7) sampled residents to meet each resident's assessed medical and nursing needs. Residents #1 and #14 had complained of constipation. Both residents were receiving pain medications that would contribute to the problem of constipation. Physician orders [REDACTED]. Resident identifiers: #1 and #14. Facility census: 20. Findings include: a) Resident #1 Medical record review, on 01/11/10, disclosed this resident was admitted to the skilled nursing unit from the acute care hospital on [DATE], with [DIAGNOSES REDACTED]. Nursing notes, dated 12/14/09, documented this resident complained of constipation. Physician orders [REDACTED]. Review of physician orders [REDACTED]. Review of the resident's current comprehensive care plan found the problem of constipation had not been identified, nor were goals and approaches (both pharmacological and non-pharmacological interventions) developed for the treatment and prevention of constipation. Interview with the director of nursing (DON), on 01/13/10 at 10:00 a.m., confirmed a care plan had not been developed to address the problem of constipation for this resident. b) Resident #14 Medical record review, on 01/11/10, disclosed this resident was admitted to the skilled nursing unit from the acute care hospital on [DATE], with [DIAGNOSES REDACTED]. Nursing notes, dated 12/24/09, documented the resident received a [MEDICATION NAME] rectal suppository due to no bowel movement in over a week. Review of PRN (as needed) Medication Notes, dated 01/01/10, revealed the resident received Milk of Magnesia for constipation. A nursing note, dated 01/06/10, recorded the resident received a Fleets enema for constipation. Review of the PRN Medication Notes revealed the resident had also been given Milk of Magnesia on 01/06/10 and on 01/10/10, for constipation. Review of physician's orders [REDACTED]. physician's orders [REDACTED]. Review of the resident's current comprehensive care plan found the problem of constipation had not been identified, nor were goals and approaches (both pharmacological and non-pharmacological interventions) developed for the treatment and prevention of constipation. Interview with the DON, on 01/13/10 at 10:00 a.m., confirmed a care plan had not been developed to address the problem of constipation for this resident. .",2015-09-01
9806,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2010-01-13,428,D,0,1,K3WS11,"Based on medical record review and staff interview, the facility failed to ensure the physician replied to the pharmacist's recommendation on the Monthly Drug Regimen Review for one (1) of seven (7) sampled residents. During the drug regimen review dated 12/17/09, the consultant pharmacist identified two (2) drug irregularities for Resident #1 and recommended switching to other drugs to treat this resident for osteoporosis and hypertension. The physician had signed the review but failed to document the rationale for not implementing the recommended changes. Resident identifier:#1. Facility census: 20. Findings include: a) Resident #1 Review of the recommendations from the consultant pharmacist to the physician, dated 12/17/09, found the pharmacist had identified two (2) irregularities in this resident's drug regimen and reported them to the physician. The pharmacist identified that Fosamax, a drug for osteoporosis, was contraindicated for patients with CrCl (creatinine clearance) less that 35 ml/min. This resident's CrCl was 27.6 ml/min. The pharmacist recommended switching to another drug. The pharmacist also identified the antihypertensive drug being used for this resident had been discontinued and recommended starting an alternative drug considered advantageous for patients with renal insufficiency. Further review found the physician had signed the recommendations but did not document the rationale for not implementing the recommended changes. When interviewed on 01/13/10 at 10:00 a.m., the director of nursing agreed the physician had not documented any reason for not implementing the recommended changes.",2015-09-01
9807,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2012-06-28,250,D,0,1,8FIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review and staff interview, the facility failed to ensure Resident #132 was involved in making his healthcare decisions, including discharge planning. This resident had lived at home prior to being hospitalized . He was discharged from this skilled unit to a nursing home. There was no evidence this was discussed with the resident, nor was there evidence he had been involved in this decision-making and was prepared for the discharge to the nursing home. This was true for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #132. Facility Census: 23. Findings include: a) Resident #132 Medical record review revealed Resident #132 was admitted on [DATE] from an acute care hospital. This resident was alert and oriented and had been determined by the physician to have the capacity to make his own medical decisions. There was no evidence found in the medical record to indicate this resident had been involved in making his own decisions regarding discharge. There was no evidence the facility had involved him in making the decision about his living arrangements or how he felt about it. The medical record contained a note, dated 01/23/12, that stated, Care plan meeting was on hold as family members not in attendance. The Social Worker to contact the family via telephone to discuss discharge plans. Tentative discharge is to NH (nursing home) vs (versus) 24 (twenty-four) hour care this week. There was no evidence this resident was involved in his care planning or that it was identified how much family involvement he wanted with his care. During an interview with the Director of Nursing (Employee #3), on 06/27/12 at 4:30 p.m., she verified there was no evidence in the medical record that this resident had been involved in the discharge decision to go to a nursing home. She stated they did not have a Social Worker at the time this resident was discharged , and that is why there were no Social Service interventions or notes. The requirement for medically-related social services to be provided does not require these services be provided only by a social worker. It is the responsibility of the facility to identify the medically-related social service needs of the resident and ensure those needs are met. .",2015-09-01
9808,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2012-06-28,279,D,0,1,8FIQ11,". Based on record review and staff interview, the facility failed to ensure Resident #132 had a care plan to reflect his discharge plans after he completed his stay on the Skilled Nursing Unit (SNU). The interdisciplinary care plan did not include the goals for his stay on this unit, nor did it include plans once his stay was completed. This resident had capacity to make healthcare decisions, but there was no evidence a care plan had been established with input from the resident regarding discharge plans. This was identified for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #132. Facility Census: 23. Findings include: a) Resident #132 The interdisciplinary care plan was reviewed for Resident #132. There was no evidence in the care plan this resident had been involved in his care plan development. On 01/23/12, a care conference had been scheduled to discuss discharge plans. It was recorded this meeting was on hold due to the family members not being in attendance. Medical record review revealed the resident's physician had determined Resident #132 had the capacity to make his own decisions. He therefore should have been involved in the care plan meeting to discuss his wishes and to provide input into the development of his care plan. During an interview with the Director of Nursing (Employee #3), on 06/27/12 at 4:30 p.m., she verified there was no evidence in the medical record this resident had been involved in making decisions about his discharge to a nursing home, or that any care had been planned with this resident for his discharge. .",2015-09-01
9809,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2012-06-28,280,D,0,1,8FIQ11,"Based on record review and staff interview, the facility failed to ensure Resident #132 was afforded the right to participate in planning care and treatment. This resident had capacity to make healthcare decisions, but there was no evidence the resident was afforded the right to be involved in the plans regarding his discharge plans. This was identified for one (1) of thirty-three (33) Stage II sample residents. Resident identifier: #132. Facility Census: 23. Findings include: a) Resident #132 Medical record review revealed a care conference had been scheduled for 01/23/12 to discuss discharge plans. It was recorded this meeting was on hold due to the family members not being in attendance. There was nothing to indicate the resident was invited to attend this meeting, or that the resident was involved in his care regarding discharge planning. According to the medical record, the resident's physician had determined Resident #132 had the capacity to make his own health care decisions. He therefore should have been involved in the care conference meeting to discuss his wishes and to provide input regarding discharge plans. During an interview with the Director of Nursing (Employee #3), on 06/27/12 at 4:30 p.m., she verified there was no evidence in the medical record this resident had been involved in making decisions about his discharge to a nursing home, or that any care had been planned with input from this resident for his discharge. .",2015-09-01
9810,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2012-06-28,329,D,0,1,8FIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, record review and staff interview, the facility failed to ensure Resident #92's drug regimen was free of unnecessary medications. There was no evidence of an indication for the use of an antibiotic that had been administered for an excessive duration. Resident # 92 began receiving an antibiotic medication ([MEDICATION NAME]) intravenously (IV) the day after he was admitted to the unit on 06/07/12. As of 06/27/12, he continued to receive this antibiotic. There was no documented rationale of the necessity for the continued use of this medication, and no evidence which indicated why this medication was used for a prolonged period of time. This was true for one (1) of thirty-three (33) Stage II sampled residents. Resident identifier: #92. Facility Census: 23. Findings include: a) Resident #92 Medical record review revealed this resident was admitted to the skilled nursing unit from the acute care hospital on [DATE]. His [DIAGNOSES REDACTED]. A physician's progress note, dated 06/07/12, indicated the resident had a temperature greater than 100 degrees. The physician ordered laboratory tests including a urine culture, blood cultures, a complete blood count (CBC), and a complete metabolic profile (CMP). At that time, the physician also ordered [MEDICATION NAME] 1 (one) gm intravenously (IV). When the results of the urinalysis came back on 06/09/12, the physician ordered another antibiotic, [MEDICATION NAME], 500 mg intravenously for seven (7) days. There had been no order for a stop date on the previous antibiotic ([MEDICATION NAME]), which was ordered two (2) days prior to the [MEDICATION NAME]. The physician progress notes [REDACTED]. A chest x-ray had been done and showed minimal central congestion. The resident continued to have a temperature of 100.7 and was on [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]). His assessment at that time included fractured left arm, fractured left hip, [MEDICAL CONDITION], fever, and fatigue. There were physicians' progress notes on 06/13/12, 06/14/12, 06/15/12, 06/16/12, 06/18/12. 06/19/12, 06/21/12, and 06/22/12. There was no further documentation of the resident's antibiotics. It was noted the [MEDICATION NAME] was discontinued on 06/16/12, after completing seven (7) days as ordered. Observation revealed the resident was still receiving the IV [MEDICATION NAME] on 06/27/12. During an interview with the Director of Nursing (Employee #3), on 06/27/12 at 2:00 p.m., the resident's [DIAGNOSES REDACTED]. It was identified he had been getting the antibiotic [MEDICATION NAME] for twenty (20) days. Employee #3 was unable to specify why the resident was getting this antibiotic, other than it had been ordered for his fever (100.7) on 06/07/12. She stated maybe he was getting it for a urinary tract infection, or maybe for his congestion, she was not sure. She verified there had not been a stop date ordered with this antibiotic and he had been receiving it for twenty (20) days. Employee #3 also could not find a written [DIAGNOSES REDACTED]. Employee #3 verified, on 06/27/12 at 3:30 p.m., a nurse had called the physician to check on this medication, but the physician was out of town. She stated they had called the doctor on call, and the medication had now been discontinued. On 06/28/12, Employee # 3 was questioned about the drug regimen reviews. She stated this resident had not yet had a review. She said she had asked the pharmacy for information about this medication and had verified the usual duration was 4 to 14 days. It was also noted complicated infections could require longer therapy; however, there was no evidence to support the use of this medication for an extended period of time. .",2015-09-01
9811,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2012-06-28,441,F,0,1,8FIQ11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on observations, review of facility policies, review of Centers for Disease Control (CDC) guidelines, and staff interview, the facility failed to ensure staff employed practices to prevent the spread of infection. The activity director was observed assisting a resident with Clostridium difficile (C. diff)) to change clothes wearing only gloves and no gown. Additionally, a registered nurse (RN) was observed using the uncovered medication administration scanner and wearing no gloves or gown when giving medications to a resident with [DIAGNOSES REDACTED]. These practices had the potential to affect all residents residing in the facility as there was a potential for transmission of pathogenic microorganisms. Employee identifiers: #25 and #21. Facility census: 23. a) Employee #25 On 06/25/12 at 12:30 p.m., the activity director was observed to enter an isolation room. The only personal protective equipment (PPE) employed was a pair of gloves. The activity director was observed assisting the resident in the isolation room with a change of clothes. On 06/25/12 at 12:45 p.m., an interview was conducted with the activity director. She stated she had helped the resident to change clothes by putting the resident's feet in her pants and assisting her to stand. The activity director stated she did not wear a gown and did not realize she needed to wear a gown. A review of the facility policy and procedure, entitled C-diff Protocol, revealed under Procedure 3. Contact precautions will be instituted. The DON stated contact precautions consisted of using gloves when entering the room and a gown if there was a potential for direct resident contact. b) Employee #21 On 06/28/12 at 11:30 a.m., a licensed practical nurse (Employee #21) was observed with the medication scanner in an isolation room of a resident who had [DIAGNOSES REDACTED]. Employee #21 was not wearing gloves or a gown. The director of nursing (DON) was informed immediately. The director of nursing interviewed Employee #21. Employee #21 stated she had not worn gloves or a gown and had not covered the medication scanner. The DON stated she had a meeting with the day shift staff, which included Employee #21, and told the staff they were to wear a gown and gloves when entering the room of the resident with [DIAGNOSES REDACTED]. She further stated the staff was informed the medication scanner was to be covered when used in this room. The 2007 guidelines by the CDC include: Contact Precautions are intended to prevent transmission of infectious agents, including epidemiologically import microorganism, which are spread by direct or indirect contact with the patient or the patient's environment . Healthcare personnel caring for patients on Contact Precautions wear a gown and gloves for all interactions that may involve contact with the patient or potentially contaminated areas in the patient's environment. Donning PPE upon room entry and discarding before exiting the patient room is done to contain pathogens, especially those that have been implicated in transmission through environmental contamination (e.g., VRE, difficile, noroviruses and other intestinal tract pathogens; RSV. .",2015-09-01
9812,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2014-02-06,279,D,0,1,MCG211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility's interdisciplinary team failed to develop a comprehensive care plan to address the care needs of a resident taking the medication [MEDICATION NAME], an anticoagulant. The care plan did not identify what measures were to be implemented to prevent and monitor for complications. This was evident for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifiers: #178. Facility census: 17. Findings include: a) Resident #178 A medical record review, on 02/05/14 at 10:55 a.m., revealed Resident #178 was receiving the medication [MEDICATION NAME]. The resident's care plan did not include any interventions for a resident receiving an anticoagulant. In an interview with Employee #1, a registered nurse and clinical nurse manager, on 02/05/14 at 11:05 a.m., she verified there was not a care plan for the anticoagulant. She stated that she had implemented a care plan for the resident after this was brought to her attention. .",2015-09-01
9813,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2014-02-06,325,E,0,1,MCG211,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on staff interview and medical record review, the facility failed to ensure a systematic approach to monitor the effectiveness of nutritional interventions and/or to revise those interventions as needed for five (5) of five (5) residents identified during Stage 1 of the survey. These residents had a physician's orders [REDACTED]. This resulted in an inability to evaluate the effectiveness of the supplement and/or identify the need to modify or revise the nutritional interventions for each resident. Findings include: a) Residents #28, #140, #195, #201, and #283 During Stage 1 of the survey, these residents were identified with a physician's orders [REDACTED]. A review of the system used by the facility for recording intakes of nutritional supplements revealed supplement intakes were not documented separately from the intake of food items consumed at meals. If nutritional supplements were ordered with meals, staff combined the items in determining a total meal consumption percentage. There was no method to determine what part of the total percentage represented food consumption, and what part represented the amount of consumption of the nutritional supplement. This method prevented an assessment of the effectiveness of the nutritional supplement and/or the need to modify or revise the nutritional interventions for each resident. In a discussion with the charge nurse, Employee #23, at 2:30 p.m. on 02/04/14, she said staff did not document the meal intakes and nutritional supplements separately. She said the intake being recorded was the meal and the supplement together. This was verified with dietary staff at 11:00 a.m. on 02/05/14. She indicated she was not aware of any other means of how or where separate information might be recorded. .",2015-09-01
9814,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2014-02-06,371,F,0,1,MCG211,". Based on staff interview and observation, foods were not stored in a manner which ensured safety in their usage. Food items were not labeled and/or dated so they could be monitored for safe consumption. This practice had the potential to affect all residents who were served from this central kitchen area. Census was 17. Findings include: a) On the initial tour of the kitchen, with the dietary manager at 2:15 p.m. on 02/03/14, the following sanitation issues were noted: 1) Packages of provolone cheese were in two (2) different refrigerators. The cheese did not contain a label or date of when opened. They were out of original packaging as well. 2) Chicken pieces were out of the original packaging, and did not contain a label or date of when opened. 3) One refrigerator had a container of an unidentifiable item that had no label regarding what it was, or the date it was opened. .",2015-09-01
9815,CAMDEN CLARK MEM HOSP,515145,800 GARFIELD AVENUE,PARKERSBURG,WV,26102,2014-02-06,441,D,0,1,MCG211,". Based on observation, staff interview, and policy review, the facility failed to maintain a sanitary environment to help prevent the development and transmission of disease and infection. A nurse placed contaminated items directly on Resident #178's bed. The nurse also failed to change gloves and wash her hands after removing a soiled dressing. Facility census: 17 Resident identifier: #178. Findings include: a) Resident #178 During a dressing change observation on 02/05/14 at 11:30 a.m., Employee #27, a registered nurse (RN), gathered dressing supplies and took them into Resident #178's room. The nurse placed the dressing supplies directly on the resident's bed without benefit of a clean barrier. She then washed her hands and donned a pair of gloves. The nurse removed the soiled dressing from the resident's foot and placed it on the bed. After cleaning the wound with cleanser and gauze, the nurse placed the contaminated items on the resident's bed. The RN then applied the clean dressing. The nurse performed the entire procedure while wearing the same pair of gloves. It was not until the nurse picked up the soiled items and put them in the trash can, that the nurse washed her hands again. An interview, on 02/05/14 at 11:45 a.m., with Employee #1, the clinical nurse manager, revealed this process was not correct. She agreed the nurse should not have placed soiled items on the resident's bed and should have changed her gloves and washed her hands during the procedure. A review of the facility's policy for non-sterile dressings, on 02/05/14 at 2:30 p.m., found Step #4 of the procedure directed a trash bag be placed at the end of the bed or within easy reach of working area. Step #9 was Remove soiled dressing, place it in trash bag and Step #10 was Remove gloves, wash hands, and apply new gloves. .",2015-09-01
2007,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2017-01-25,441,F,0,1,GIZY11,"Based on observation, and staff interview, the facility failed to maintain an effective Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Multiple areas of missing and cracked veneer at the nurses' desk with exposed particle board cannot be cleaned, sanitized or disinfected to prevent the direct and/or indirect transmission of infectious agents. This practice has the potential to affect all residents. Facility census: 56. Findings include: a) An observation, on 01/23/17 at 11:00 a.m., revealed multiple areas of chipped veneer along the seams and inner and outer edges of the nurses' station desk. Two drawers fronts were missing all and/or part of the veneer and two large chipped areas were found on the outside corner of the desk exposing particle board. On 01/24/17 at 3:15 p.m., Resident #56 was observed sitting alone behind the nurse's desk, within reach of the exposed particle board. Registered Nurse (RN) #24 confirmed residents are permitted to sit behind the desk during an interview on 01/24/17 at 3:27 p.m. The Director of Nursing (DON) confirmed the nurses' desk was in disrepair and an infection control risk because of the exposed particle board, during an interview on 01/24/17 at 11:00 a.m. During an interview on 01/25/17 at 11:00 a.m., the Administrator presented the facility's temporary fix at the nurses' station desk. The drawer fronts were covered and molding was placed on the outer desk corner. The Administrator stated they were in the process of obtaining replacement veneer to repair the desk.",2020-09-01
2008,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2018-03-14,657,D,0,1,WMLO11,"Based on observation, resident interview, staff interview and record review, the facility failed to ensure one (1) of thirteen (13) comprehensive care plans had been reviewed and revised by the interdisciplinary team. This practice involved needed revisions for medication usage and floating of heels. Resident identifier: 45. Facility census: 50. Findings included: a) Resident #45 1) Medication A review of the physician orders, on 03/13/18 at 9:00 AM, revealed Resident #45 was receiving Aspirin 325 milligrams daily since 01/31/18. A review of Resident #45's Care Plan was conducted on 03/13/18 at 9:45 AM. The Care Plan, with a review date of 03/08/18, contained the intervention Avoid use of Aspirin due to the use of anticoagulants. An interview with the Director of Nursing (DON), on 03/13/18 at 10:30 AM, revealed the Care Plan was wrong and needed updated. The DON stated the resident's care plan should have never stated to avoid the use of Aspirin since the physician wanted the resident to receive it. 2) Floating Heels An observation of Resident #45, on 03/13/18 at 10:15 AM, revealed the Resident was in bed. The Resident's heels were not floated and the Resident was not wearing any boots in bed. An interview with Resident #45, on 03/13/18 at 10:20 AM, revealed the staff rarely put her boots on or placed her feet upon pillows. A review of the physician orders, on 03/13/18 at 10:30 AM, revealed Resident #45 was ordered Heelmedix Boots bilaterally while in bed since 02/16/18. A review of Resident #45's Care Plan was conducted on 03/13/18 at 10:45 AM. The Care Plan, with a review date of 03/08/18, contained the interventions Float heels while in bed and Heelmedix Boots to bilateral feet while in bed due to the potential for skin breakdown. An interview with the DON, on 03/14/18 at 9:00 AM, revealed the resident had an x-ray on 03/13/18 and the staff must have forgotten to put the boots back on. The DON stated Resident #45 does not like having the boots put on. The DON stated she should have updated the care plan and documented the resident's wishes. The DON stated the resident's heels should be floated at all times while in bed due to the high potential for skin breakdown.",2020-09-01
2009,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2018-03-14,684,D,0,1,WMLO11,"Based on observation, resident interview, staff interview, and record review, the facility failed to float a resident's heels as ordered by the physician. This practice affected one (1) of thirteen (13) residents reviewed. Resident identifiers: #45. Facility census: 50. Findings included: a) Resident #45 An observation of Resident #45, on 03/13/18 at 10:15 AM, revealed the Resident was in bed. The Resident's heels were not floated and the Resident was not wearing any boots in bed. An interview with Resident #45, on 03/13/18 at 10:20 AM, revealed the staff rarely put her boots on or placed her feet upon pillows. A review of the physician orders, on 03/13/18 at 10:30 AM, revealed Resident #45 was ordered Heelmedix Boots bilaterally while in bed since 02/16/18. A review of Resident #45's Care Plan was conducted on 03/13/18 at 10:45 AM. The Care Plan, with a review date of 03/08/18, contained the interventions Float heels while in bed and Heelmedix Boots to bilateral feet while in bed due to the potential for skin breakdown. An interview with the DON, on 03/14/18 at 9:00 AM, revealed the resident had an x-ray on 03/13/18 and the staff must have forgotten to put the boots back on. The DON stated the resident's heels should be floated at all times while in bed due to the high potential for skin breakdown.",2020-09-01
2010,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2018-03-14,689,E,0,1,WMLO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to provide an environment free from accident hazards over which the facility had control. A medication was left on the medication cart in the hallway unattended for five minutes. This practice had the potential to affect more than a limited number of residents. Facility census: 50. Findings included: An observation during medication administration, on 03/14/18 at 8:20 AM, revealed Licensed Practical Nurse (LPN) #3 left one (1) tablet of medication in an unmarked cup on the medication cart unattended. The cart was unattended from 8:20 AM to 8:25 AM. An interview with LPN #3, on 03/14/18 at 8:30 AM, revealed the medication left on the cart should have been secured before she stepped away to give a resident their medication. The LPN stated the medication left unattended on the cart was the blood pressure medication [MEDICATION NAME].",2020-09-01
2011,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2018-03-14,757,D,0,1,WMLO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, staff interview and medical record review, the facility failed to address non-pharmacological interventions prior to the administration of pain medications. This practice affected one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #45. Facility census: 50. Findings included: a) Resident #45 A review of the physician orders, on 03/13/18 at 10:50 AM, revealed the following four orders for pain medication since the resident was admitted on [DATE]: -Tylenol 650 milligrams, by mouth, every 12 hours as needed for pain, with a start date of 01/30/18 and a discharge date of [DATE]. -Tylenol 650 milligrams, by mouth, every 6 hours as needed for pain, with a start date of 02/06/18. -[MEDICATION NAME] HCL 50 milligrams, by mouth, one time only for pain, with a start and end date of 03/08/18. -[MEDICATION NAME] HCL 50 milligrams, by mouth, every 8 hours as needed for pain, with a start date of 03/09/18. A review of the Medication Administration Record [REDACTED] Tylenol 650 milligrams: -01/31/18 -02/02/18 -02/03/18 -02/04/18 -02/05/18 -02/06/18 -02/08/18 -02/09/18 -02/16/18 -02/21/18 -02/23/18 -02/24/18 -03/02/18 -03/04/18 -03/06/18 -03/08/18 [MEDICATION NAME] 50 milligrams: -03/08/18 -03/10/18 -03/11/18 -03/12/18 -03/13/18 A review of Resident #45's Care Plan was conducted on 03/13/18 at 11:25 AM. The Care Plan, with a review date of 03/08/18, contained no non-pharmacological interventions for the pain medications. An interview with Resident #45, on 03/14/18 at 8:40 AM, revealed the staff does not provide any non-pharmacological interventions before administering pain medications. Further review of the medical record, on 03/14/18 at 8:55 AM, revealed no non-pharmacological interventions were documented. An interview with the Director of Nursing (DON), on 03/14/18 at 9:15 AM, revealed no non-pharmacological interventions were in place for Resident #45 since admission. The DON stated we must have missed them on this resident.",2020-09-01
2012,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,689,E,0,1,8XJ511,"Based on observation, staff interview, and policy review, the facility failed to provide an environment free from accident hazards over which it had control. The Nursing Supplies Room, located on a resident hallway, was not locked allowing for multiple medications and wound care supplies to be readily accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 59. Findings included: a) Nursing Supplies Room An random observation of the B-Hall, on 04/08/19 at 11:05 AM, revealed the door labeled Nursing Supplies was not locked and was readily accessible to anyone. There were no staff members in the room during this observation. Inside the room, there were shelves that contained the following items: --Sixty (60) plus stock medications --Multiple wound care ointments, sprays, and supplies. An interview with the Clinical Care Supervisor (CCS), on 04/08/19 at 11:10 AM, revealed the door to the room doesn't always latch properly when it is closed. The CCS stated the room is used as the medication storage room for the facility and should always be locked up. Further observation of the B-Hall, on 04/08/19 at 2:05 PM, revealed the Nurse Supply door was unlocked again. An interview with the Director of Nursing (DON), on 04/08/19 at 2:05 PM, revealed the room has medications and should never be unsecured. The DON stated she had no idea why the door was not locking. The DON stated she would ensure the Maintenance Supervisor fixed the door immediately. A review of the facility policy titled Medication Storage in the Facility with an effective date of (MONTH) 1, (YEAR) was conducted on 04/10/19. The policy stated Medication rooms are locked when not attended by persons with authorized access.",2020-09-01
2013,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,695,D,0,1,8XJ511,"Based on observation and staff interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A resident's tubing provided by the facility for breathing treatments was not changed weekly. This practice affected one (1) of three (3) residents reviewed for respiratory care during the Long Term Care Survey Process (LTCSP). Resident identifier: #57. Facility census: 59. Findings included: a) Resident #57 An observation of the Resident, on 04/09/18 at 1:35 PM, revealed the Resident had a nebulizer treatment machine with tubing beside the bed. The tubing had a date of 04/01/19. An interview with the Director of Nursing (DON), on 04/09/19 at 1:45 PM, revealed the tubing used for the nebulizer treatments should be changed every 7 days on Sundays. The DON stated she would ensure the tubing was changed immediately.",2020-09-01
2014,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,761,E,0,1,8XJ511,"Based on observation, staff interview, and policy review, the facility failed to store all drugs and biologicals in a locked room away from unauthorized staff, residents, and visitors. The Nursing Supplies Room, located on a resident hallway, was not locked allowing for multiple medications and wound care supplies to be readily accessible to anyone. This practice had the potential to affect more than a limited number of residents. Facility census: 59. Findings include: a) Nursing Supplies Room An random observation of the B-Hall, on 04/08/19 at 11:05 AM, revealed the door labeled Nursing Supplies was not locked and was readily accessible to anyone. There were no staff members in the room during this observation. Inside the room, there were shelves that contained the following items: --Sixty (60) plus stock medications --Multiple wound care ointments, sprays, and supplies. An interview with the Clinical Care Supervisor (CCS), on 04/08/19 at 11:10 AM, revealed the door to the room doesn't always latch properly when it is closed. The CCS stated the room is used as the medication storage room for the facility and should always be locked up. Further observation of the B-Hall, on 04/08/19 at 2:05 PM, revealed the Nurse Supply door was unlocked again. An interview with the Director of Nursing (DON), on 04/08/19 at 2:05 PM, revealed the room has medications and should never be unsecured. The DON stated she had no idea why the door was not locking. The DON stated she would ensure the Maintenance Supervisor fixed the door immediately. A review of the facility policy titled Medication Storage in the Facility with an effective date of (MONTH) 1, (YEAR) was conducted on 04/10/19. The policy stated Medication rooms are locked when not attended by persons with authorized access.",2020-09-01
2015,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,812,E,0,1,8XJ511,"Based on observation and staff interview, the facility failed to store, prepare, and distribute food in accordance with professional standards for food service safety. The puree machine blade was dropped on a counter and placed back into the machine without being cleaned and a plastic glove was picked up off the kitchen floor and placed on a food preparation counter. These practices had the potential to affect more than a limited number of residents. Facility census: 59. Findings included: a) Puree Machine An observation of the kitchen, on 04/09/19 at 11:15 AM, revealed Dietary Services Assistant (DSA) #1 poured ground pork into the steam table pan from the the puree machine. The blade fell out of the puree machine and landed on the steam table counter. DSA #1 placed the blade back into the puree machine and continued to make pureed ground pork without washing the metal blade. An interview with the Dietary Service Supervisor (DSS), on 04/09/19 at 11:20 AM, revealed the metal blade should have been cleaned before continuing to make more food with the puree machine. b) Protective glove An observation, on 04/09/19 at 11:55 AM, revealed Kitchen Staff #1 with a rubber protective glove, used to transport food containers out of the steamer, dropped on the floor. Kitchen Staff #1 bent down and picked the glove up off the floor and placed it on the clean food prep table. An immediate interview with Dietary Manager #3, on 04/09/19 at 11:55 AM, confirmed that any kitchen item dropped on the floor should not be picked up and placed on the food prep tables.",2020-09-01
2016,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,880,E,0,1,8XJ511,"Based on observation and staff interview, the facility failed to provide a safe and sanitary environment that prevented the development and transmission of communicable diseases and infections. The shower room located on the B-Hall had feces in several places on the floor as well as a bucket. There were also used gloves on the floor. These practices could potentially affect more than a limited number of residents. Facility census: 59. Findings include: a) Observation An observation of the B-Hall Shower Room, on 04/08/19 at 10:55 AM, revealed the room had multiple areas with feces on the floor. The room also contained a bucket of water in a shower stall that contained feces. There were two (2) latex gloves on the floor in the shower stall. The Shower Room was unlocked and accessible to anyone. b) Interview An interview with the Clinical Care Supervisor (CCS), on 04/08/19 at 10:58 AM, revealed the Shower Room should never be left in that condition. The CCS stated she would ensure the room was cleaned and sanitized immediately.",2020-09-01
2017,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2019-04-10,883,D,0,1,8XJ511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, policy and procedure review and review of Centers for Disease Control (CDC) guidelines, the facility failed to ensure each resident received pneumococcal vaccines in accordance with accepted guidelines. The facility failed to educate, offer and/or administer the pneumococcal vaccine in accordance with guidelines for administration for one of five residents reviewed for pneumococcal vaccinations. Resident identifiers: #44 (R#44) Findings included: a) R#44 Record review for R#44 noted the resident had received the Prevnar13 (PCV13) on 10/18/16. There was no documentation noting R#44 and/or the resident's representative, had received information regarding the risks and benefits of [MEDICATION NAME] 23 (PPSV23). Additionally, there was no documentation, R#44 and/or resident's representative had been offered, received or declined the PPSV23 vaccination a year after receiving the PCV13, in accordance with guidelines. b.) Policy and CDC Guideline review Review of the facility's policy and procedure, Influenza and Pneumococcal Vaccination, revision date: 3/1/2018, noted all residents will be offered the pneumococcal vaccines in accordance with CDC guidelines. According to CDC guidelines; if an adult received the PCV13 first, the PPSV23 would be administered one year from when the PCV13 vaccination was received. c.) Staff interview An interview with the Director of Nursing (DON), on 04/09/19 at 03:40 PM, verified R#44 should have been offered the PPSV23 in accordance with CDC guidelines but stated we only have documentation the Prevnar 13 had been discussed with R#44's representative.",2020-09-01
4903,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2015-10-28,279,D,0,1,I3G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to develop a comprehensive care plan which accurately reflected the care required for one (1) of twenty-two (22) resident's whose care plans were reviewed in Stage 2 of the Quality Indicator Survey. Resident identifier: #23. Facility Census: 50. Findings include: a) Resident #23 Review of Resident #23's clinical record, on 10/27/15 at approximately 9:00 a.m., found the resident's [DIAGNOSES REDACTED]. Section G of the resident's annual Minimum Data Set (MDS) assessment, dated 09/04/15, identified the resident was assessed as requiring extensive assistance with transfers. The resident's current care plan, based on the annual MDS assessment dated [DATE], included the resident, Requires assist with activities of daily living d/t (due to) impaired mobility, impaired cognition. The care plan goal was, Will participate in dressing and not become dependent on staff through review period. One (1) of the interventions listed was, Resident to be independent in room and facility with wheeled walker with ambulation and transfers. On 10/27/15 at 12:03 p.m., Resident #23 was observed in the main dining room sitting in a chair with a wheeled walker at her side. At that time, the resident stated she used her walker to independently ambulate. At 10/27/15 at 12:41 p.m., the resident was observed ambulating in her room. The resident used the bed controls to lower the bed and independently transferred herself to a seated position on the side of the bed. A staff member walking by noticed what the resident was doing and assisted the resident by lifting the resident's feet onto the bed. During an interview on 10/27/15 at 12:46 p.m., the resident stated she could get in and out of bed on her own. On 10/27/15 at 12:49 p.m., Nurse Aide #25 stated the resident was able to get in and out of bed on her own, but there were days that the resident would put on her light and ask for assistance getting in and out of the bed. During an interview on 10/27/15 at 1:02 p.m., Registered Nurse Assessment Coordinator #3 verified the comprehensive care plan did not include the resident's fluctuation in transfer ability from independent to extensive assist.",2019-05-01
4904,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2015-10-28,280,D,0,1,I3G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and revise the care plan for one (1) of twenty-two (22) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey. The care plan was not revised after the resident experienced weight loss. Resident identifier: #33. Facility Census: 50. Findings include: a) Resident #33 On 10/27/15, at approximately 8:25 a.m., review of the resident's medical record found the most recent annual minimum data set (MDS) assessment, dated 08/14/15, revealed Resident #33 had severe cognitive impairment and was totally dependent upon staff for all activities of daily living, including eating and drinking. Additionally, the MDS documented the resident received tube feedings and a mechanically altered therapeutic diet. According to the MDS, Resident #33 received 51% or more of his nutrition through tube feedings. Continued review of the medical record on 10/27/15 at 8:25 a.m., revealed the vital sign/weight record dated 09/02/15, indicated resident's weight was 169.4 pounds. The most recent tube feeding care plan, with an admission date of [DATE], revealed a goal for no significant weight change through the review date. Interventions included : 1. See the physician orders [REDACTED]. 2. Provide and serve no-concentrated sweets diet, honey thick fluids 3. Staff to spoon feed the resident all food/drink. Additionally the care plan stated the registered dietitian was to: 1. Evaluate the resident monthly and whenever necessary (PRN) 2. Monitor the resident's nutritional status, caloric intake, and make recommendations for changes for the tube feeding as needed. The target date was 08/20/15. On 10/27/15 at 1:20 p.m., continued review of the resident's medical record revealed [REDACTED]. The noted stated Resident #33 was transferred to the local hospital because the percutaneous endoscopic gastrostomy (PEG) tube was no longer functioning. An interview with the Director of Nursing (DON) on 10/28/15 at 10:38 a.m., revealed the PEG tube blew and was no longer working; therefore, Resident #33 was transferred to the hospital. The progress notes indicated Resident #33 was in the hospital until 10/01/15, when the resident was sent back to the facility with a new PEG tube. The note further stated Resident #33 was not administered food or medication while in the hospital, only intravenous fluids. At 8:10 p.m. on 10/01/15, a progress note was, Nurse found PEG tube displaced, lying in bed beside of resident. The physician was notified the PEG tube was out and ordered arrangements be made in the morning for the resident to be seen by the [MEDICATION NAME] in the emergency room to reinsert the PEG tube. A progress note dated 10/02/15 at 12:10 p.m., revealed the physician was in the facility and was notified of the resident's 10/07/15 appointment with the [MEDICATION NAME]. The note further documented the physician was made aware that Resident #33 was not eating and pocketing (filling his cheeks) his food. The 10/06/15 Speech Therapy Evaluation and Plan of Care recommended alternation of liquids/solids, lingual sweep (movement of the tongue in formation of a bolus) and swallow, and alternation of temperatures and bolus (mass of food ready to be swallowed) size modifications. The vital sign/weight record dated 10/08/15 revealed Resident #33's weight was 158.8 pounds, representing a severe weight loss of 6.3% in 30 days. A progress note, dated 10/08/15, stated the resident was discussed at the weight and nutrition meeting due to a 10.6 pound weight loss in one (1) month and consumption of less than 26% of meals and 900 cc of fluids. The note stated the physician was notified and no new orders were received. In an interview on 10/27/15 at 4:47 p.m., regarding the resident's significant weight loss, Dietary Services Supervisor #23 verified Resident #33 was discussed at the weight and nutrition meeting on 10/08/15. She provided the progress note regarding the meeting and verified there were no new physician orders. She stated Clinical Care Supervisor #2 would be aware of additional interventions. During interview with Clinical Care Supervisor #2 on 10/28/15 at 9:07 a.m., she stated interventions implemented while the PEG tube was out included offering food every shift, starting a nutritional supplement (Magic Cup) three (3) times/day, and ordering a speech therapy evaluation. Many of these interventions were implemented prior to 10/08/15 when the significant weight loss was discussed in the weight and nutrition meeting. There was no revision in the care plan after the severe weight loss was identified. During interview with Registered Nurse Assessment Coordinator (RNAC) #3 on 10/28/15 at 12:30 p.m., he verified there had been no revision in the care plan to include addition interventions to address the significant weight loss identified on 10/08/15.",2019-05-01
4905,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2015-10-28,282,D,0,1,I3G611,"Based on record review, observation, and staff interview, the facility failed to implement the care plan for (1) of twenty-two (22) residents whose care plans were reviewed in Stage 2 of the Quality Indicator Survey. The resident's Velcro waist belt was not released, as directed in the care plan, while resident was being supervised during meals. Resident identifier: #30. Facility Census: 50. Findings include: a) Resident #30 On 10/27/15 at 9:40 a.m., review of the resident's minimum data set (MDS) assessment, dated 09/11/15, found a trunk restraint was used daily for this resident. The MDS further indicated the resident had a Brief Interview for Mental Status (BIMS) score of 4, indicating severe cognitive impairment. Review of the resident's care plan for physical restraints, specifically a Velcro waist belt to the wheelchair, with an effective target date of 09/15/15, found the interventions indicated staff would provide supervision to ensure the restraint was released every 2 hours. An additional intervention was to release the restraint every 2 hours as needed/as requested by the resident for meals. Observations on 10/27/15 at 12:14 p.m., found Resident #30 seated in a wheelchair with a Velcro waist belt. She was seated at a table in the dining room between two (2) nurse aides (NAs). NA #29 was cueing and feeding Resident #30. During the observation, the Velcro waist restraint remained on Resident #30. In an interview at 1:47 p.m. on 10/27/15, NA #29 verified the Velcro waist restraint was not released during the meal. She stated, I guess I should have released it. During an interview with the Director of Nurses (DON), on 10/27/15 at 2:15 p.m., she stated she was aware the Velcro waist belt was not released during meals as it should have been, since Resident #30 was being supervised. On 10/28/15 at 9:58 a.m., NA #5 stated Resident #30 had never requested the Velcro waist belt be removed and she did not think she could.",2019-05-01
4906,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2015-10-28,325,G,0,1,I3G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to provide nutritional care and services to ensure the maintenance of acceptable parameters of nutritional status, to the extent possible, for (1) of one (1) resident who received nutrition through a combination of tube feedings and food by mouth. The resident's feeding tube malfunctioned and the facility failed to ensure timely replacement. In addition, during this time, the resident's food intake and weights were not monitored to ensure interventions were established and/or implemented to prevent avoidable weight losses. Resident identifier: #33. Facility Census: 50. Findings include: a) Resident #33 On 10/27/15, at approximately 3:20 p.m., review of the resident's medical record found the most recent annual minimum data set (MDS) assessment, dated 08/14/15, identified Resident #33 had severe cognitive impairment and was totally dependent upon staff for all activities of daily living, including eating and drinking. Additionally, the MDS documented the resident received tube feedings and a mechanically altered therapeutic diet. According to the MDS, Resident #33 received 51% or more of his nutrition through tube feedings. The vital sign/weight record, dated 09/02/15, documented the resident's weight as 169.4 pounds. The dietitian's note, dated 09/04/15, stated Resident #33 received nocturnal tube feedings of 1000 cc (cubic centimeters) of [MEDICATION NAME] 1.5 at 100 cc/hour. Additionally, he received 150 cc of water before and after feedings as well as 145 cc six (6) times per day. Resident #33 received a protein supplement (Promod) 45 cc every day. He was provided a no-concentrated sweet pureed diet with honey thick liquids during meals. The dietitian further documented weight fluctuations when oral intake increased. The most recent tube feeding care plan, with an admission date of [DATE], revealed a goal for no significant weight change through the review date. Interventions included to: 1. See the physician orders [REDACTED]. 2. Provide and serve no-concentrated sweets diet, honey thick fluids 3. Spoon feed the resident all food/drink. Additionally, the care plan stated the registered dietitian was to: 1. Evaluate the resident monthly and when ever necessary (PRN) 2. Monitor the nutritional status, caloric intake, and make recommendations for changes to tube feeding as needed. Continued review of the medical record, on 10/27/15 at 8:25 a.m., revealed a progress note dated 09/28/15, stating Resident #33 was transferred to the local hospital due to the percutaneous endoscopic gastrostomy (PEG) tube no longer functioning. Interview with the DON on 10/28/15 at 10:38 a.m., revealed the PEG tube blew and was no longer working; therefore, Resident #33 was transferred to the hospital. The progress notes indicated Resident #33 was in the hospital until 10/01/15. The progress note dated 10/01/15, revealed Resident #33 was sent back to the facility with a new PEG tube. The note further stated Resident #33 was not administered food or medication while in the hospital; only intravenous fluids. At 8:10 p.m. on 10/01/15, the progress note documented, Nurse found PEG tube displaced, lying in bed beside of resident. The physician was notified the PEG tube was out and ordered arrangements be made in the morning for the resident to be seen by the [MEDICATION NAME] in the emergency room to reinsert the PEG tube. The progress note dated 10/02/15 at 12:10 p.m. revealed the physician was in the facility and was notified of the resident's 10/07/15 appointment with the [MEDICATION NAME]. The note further documented the physician was made aware that Resident #33 was not eating and was pocketing his food. Review of the progress notes, on 10/27/15 at 1:30 p.m., revealed on 10/06/15; a speech evaluation due to dysphagia (difficulty with swallowing) was ordered. Review of the SLP evaluation and plan of treatment dated 10/06/15 revealed Resident #33 had severe swallowing abilities and was holding foods. The recommendations included a pureed diet, honey-thick fluids, and close supervision. The progress note dated 10/06/15 documented the physician was in and reviewed the speech therapy recommendations. The resident's note by the physician dated 10/06/15 confirmed the resident had many problems with the PEG tube. The physician documented she was going to notify the [MEDICATION NAME] as, This really needs to be addressed on a semi-urgent basis and I feel there has been a slow response to our requests for an evaluation. On 10/07/15, the progress note stated the new appointment with the [MEDICATION NAME] was 10/15/15. The progress note dated 10/07/15 documented the physician was notified and ordered staff to watch intake and outputs and if the resident became dehydrated to call for orders. During an interview with Clinical Care Supervisor #2, on 10/28/15 at 9:07 a.m , she stated the [MEDICATION NAME] refused to insert the PEG tube until the resident was seen in the hospital. The new appointment was scheduled for 10/15/15. The vital sign/weight record dated 10/08/15 revealed Resident #33's weight was 158.8 pounds, indicating a severe weight loss of 6.3% in 30 days. A progress note, dated 10/08/15, indicated the resident was discussed at the weight and nutrition meeting due to a 10.6 pound weight loss in 1 month and consumption of less than 26% of meals and 900 cc of fluids. The note stated the physician was notified and no new orders were received. The note did not indicate the dietitian was notified. An interview was conducted with Dietary Services Supervisor #23 on 10/27/15 at 4:47 p.m., regarding the significant weight loss. She verified Resident #33 was discussed at the weight and nutrition meeting on 10/08/15. She provided the progress note regarding the meeting and verified there were no new physician orders. She stated Clinical Care Supervisor #2 would be aware of additional interventions. During an interview with Clinical Care Supervisor #2, on 10/28/15 at 9:07 a.m., she stated interventions implemented while the PEG tube was out included: offering food every shift, starting a nutritional supplement (magic cup) three (3) times a day, and ordering a speech therapy evaluation. On 10/28/15 at 10:38 a.m., the meal percentages from 10/01/15 through 10/14/15 were reviewed with the DON. During this period, Resident #33 consumed between 5% and 60% of the meals for 26 of 40 shifts. There was no consumption on four (4)shifts and nine (9) meal refusals. The DON stated it was hit or miss when it came to oral consumption. She stated staff should have re-weighed the resident according to the policy since there was greater than 5 pound weight loss. Additionally, she stated she would have expected the resident to receive a nutritional supplement such as [MEDICATION NAME] and increase the number of feedings. On 10/28/15 at 12:00 p.m., review of the Weighing and Measuring the Resident Policy, revised on 07/01/06, revealed staff were to re-weigh the resident if there was a change of five (5) 5 pounds, and to report the change. Additionally, review of the Nutritional Assessment and Documentation Operations policy, effective 03/01/14, indicated the consultant dietitian should review and assess residents experiencing a significant weight change of 5% in 30 days. There was no evidence the dietitian was notified of the significant weight loss. On 10/28/15 at 12:15 p.m., the Dietitian Review Notes, dated 10/22/15 were reviewed. The notes did not mention the significant weight loss. The note stated to continue the tube feedings, oral intake had improved to three (3) meals of varied amounts when the tube was out, and the resident received Magic Cup three (3) times per day. There were no new recommendations. On 10/28/15 at 7:38 a.m., the weight record revealed the resident was weighed on 10/27/15. Resident #33's current weight was 144.7 pounds. This was a loss of 14.1, representing a severe weight loss of 8.88% in 19 days. An observation was made of Resident #33 being fed by Licensed Practical Nurse (LPN) #7 on 10/28/15 at 12:35 p.m. The resident was totally dependent and was being spoonfed. During an interview with LPN #7, at the time of the observation, she verified Resident #33 consumed 1/2 of the Magic Cup and ate a few bites of pureed potatoes and squash. She stated there were no choking episodes and no swallowing difficulty. Corporate Dietitian #67 was interviewed on 10/28/15 at 12:48 p.m. She stated she evaluated Resident #33 and made significant recommendations to the tube feeding schedule and medications for Resident #33 to address the weight loss. Review of the Dietitian Review Notes, dated 10/28/15, revealed Resident #33 was to receive tube feedings for 20 hours/day. Additionally she recommended the administration of Vitamin C and Zinc Sulfate.",2019-05-01
4907,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2015-10-28,441,D,0,1,I3G611,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview, the facility failed to ensure an effective Infection Control Program to prevent, to the extent possible, the development and transmission of disease and infection. Resident #38's nebulizer mask was not protected against contamination when not in use. In addition, isolation rooms were not set up to ensure individuals entering the room did not become contaminated with pathogenic organisms while donning personal protective equipment (PPE). This had the potential to affect more than an isolated number of residents, as well as staff and/or visitors. Resident identifier: #38. Facility census: 50. Findings include: a) Resident #38 On 10/27/15 at 10:40 a.m., Resident #38's medication nebulizer mask was observed lying on a bedside stand uncovered and open to air, exposing the mask to possible contamination from extraneous sources, which the resident might then inhale during a treatment. At the time of the observation, Director of Nursing Services #1 verified the nebulizer mask should be covered when not in use. b) On 10/28/15 at 7:38 a.m., room [ROOM NUMBER] on the B hallway had a nylon isolation caddy hanging over the open door. In order to don the personal protective equipment (PPE), staff and/or visitors had to enter the room. This exposed the individual to possible contamination prior to donning the PPE. During an interview on 10/28/15 at 7:45 a.m., Clinical Care Supervisor (CCS) #2 stated Rooms #8 and #9 were semiprivate rooms used to house residents in need of isolation to prevent the spread of infection. CCS #2 verified in order to don the personal protective equipment when the room door was open, it placed the staff and/or visitor in close proximity to the foot of the bed nearest the door, creating a risk of becoming contaminated while donning the protective equipment.",2019-05-01
6110,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2014-08-20,241,D,0,1,HZJH11,"Based on observation and staff interview, the facility failed to provide care for its residents in an environment that enhanced each resident's dignity. One (1) of nine (9) sampled residents was observed sitting in a wheelchair in the hallway for a prolonged period of time with soiled and wet clothing. This cognitively impaired resident was in full view of other residents and staff. This situation would have caused embarrassment, discomfort, or distress to a cognizant person. Resident identifier: #57. Facility census: 57. Findings include: a) Resident #57 On 08/19/14 at 1:50 p.m., Resident #57 was observed sitting in his wheelchair in the C wing hallway. He wore long pants that were wet in the lower middle abdominal region, the left and right groin areas, and below the groins at the tops of both thighs. Pieces of food were on his shirt. He was observed in this condition for thirty (30) minutes with no staff intervention. Four (4) other residents were also observed outside the first two (2) rooms on the C wing, either sitting in their wheelchairs, or self-propelling in wheelchairs up and down the hallway during this period of time. Resident #57 stayed in the area of the first two (2) rooms on the C wing. He was approximately thirty (30) feet from the nurses' station. Several nursing assistants walked by him as he sat in the wheelchair on the C wing. The activity assistant was observed around the nurses' desk, interacting with other residents who were parked in wheelchairs along the wall across from the nurses' station. Resident #57 was in view of the nurses' station. Numerous offgoing and oncoming staff stood or sat at the nurses' station, or came and left from the nurses' desk during the 2:00 p.m. change of shift period. Four (4) nurses and twelve (12) aides staffed the day and evening shifts. On 08/19/14 at 2:20 p.m., offgoing registered nurse Employee #31 was asked to look at Resident #57 for signs of urinary incontinence and food on his clothing. She went to his wheelchair for a brief assessment. She said she would send staff right away to clean him and change his clothing. The director of nursing (DON) was informed of the incident on 08/19/14 at 4:00 p.m. She had no further information or comments at that time.",2018-05-01
6111,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2014-08-20,309,D,0,1,HZJH11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, policy review, drug handbook review, and manufacturer's literature review, the facility failed to provide care and services to maintain a resident's highest practicable level of well-being. A nurse failed to instruct Resident #63 to rinse his mouth with water and spit following the inhalation of a corticosteroid medication in order to reduce the risk of oral candidiasis, or thrush. This was found for one (1) of two (2) residents observed for inhaled medication administration. Resident identifier: #63. Facility census: 57. Findings include: a) Resident #63 On 08/20/14 at 8:17 a.m., registered nurse, Employee #48, administered an inhalant medication, [MEDICATION NAME] Diskus to the resident. This medication is a corticosteroid used in the treatment of [REDACTED]. The nurse did not instruct the resident to rinse his mouth and spit after use of the inhaler. After using the inhaler, the resident laid down in his bed while awaiting the rest of his medications. He did not rinse his mouth with water and spit out the water following the use of the inhaler. Review of the facility's drug handbook, PharMerica 2014, which is a specialized long term care nursing drug handbook, revealed a directive to, Rinse mouth with water after use and spit to reduce risk of oral candidiasis. The product literature for [MEDICATION NAME] Diskus was reviewed. It included a warning to rinse the mouth with water after use and then spit out the water, to reduce the risk of throat irritation and oral candidiasis. On 08/20/14 at 11:30 a.m., the director of nursing (DON) provided the facility's policy and procedure on oral inhalation of medication. Number fifteen (15) of Section 7.7 of the policy, stated (typed as written) For steroid inhalers, provide resident with cup of water and instruct him/her to rinse mouth and spit water back into cup. The DON agreed that water should be provided to rinse the oral cavity after the use of [MEDICATION NAME] Diskus.",2018-05-01
6112,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2014-08-20,323,D,0,1,HZJH11,"Based on observation, medical record review, and staff interview, the facility failed to ensure an environment as free from accident hazards as possible for one (1) of nine (9) sampled residents. A cognitively impaired resident who had experienced numerous falls in the past, had an intervention for a bed alarm to be used at all times when in bed. The facility failed to implement this intervention. The resident was observed lying in his bed, with the bed alarm in the off position. This created the potential for another fall by not having a means in place to alert the staff of attempts by the resident to transfer unassisted. Resident identifier: #57. Facility census: 57. Findings include: a) Resident #57 Medical record review on 08/19/14 at 1:00 p.m., found the physician had ordered a bed alarm to be used at all times when the resident was in bed. Observation of the resident on 08/19/14 at 4:27 p.m. found him in bed asleep. The bed alarm unit was in the bed, but not showing any indication that it was functioning. At that time, nursing assistants, Employee #68 and Employee #64, entered the room. Upon inquiry, Employee #68 said that if his alarm was on, it would be flashing. She acknowledged that it was not flashing. She confirmed his bed alarm was not turned on at that time. She said the facility had recently obtained new bed alarm units. The older units automatically turned on, but the newer units must be turned on manually. She determined staff had failed to turn on the bed alarm unit when he was assisted into bed about two (2) hours before. Employee #68 turned on the bed alarm unit, and demonstrated that it would function when turned on. A copy of the falls reports for this resident for the past five (5) months was reviewed on 08/20/14 at 10:00 a.m. He sustained falls with no significant injuries on seven (7) occasions between 03/20/14 and 07/26/14. Three (3) of those falls occurred in the resident's room. On 04/27/14, he was found on the floor on his knees beside his bed, and the alarm was not sounding at the time. An interview was conducted with the director of nursing on 08/20/14 at 12:45 p.m. She said she did not know why the alarm was not sounding on 04/27/14, and thought perhaps the batteries had ceased to function. She confirmed there was a difference between the former and the newer bed alarms. She acknowledged that the newer bed alarm was used for Resident #57, and it should have been turned on when he was assisted back into the bed. She said there would be staff education on this subject.",2018-05-01
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
7737,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,253,D,0,1,H1U811,"Based on observation and staff interview, the facility failed to provide maintenance services to maintain and/or repair resident toilet rooms and sink counter tops in a safe and sanitary manner. Observation revealed multiple orange stains on the wall in a toilet room adjoining two (2) resident rooms, from a pipe protruding from the wall. In addition, two (2) sink counter tops were pulled away from the wall and back splash. This allowed water to drain between the counter top and the wall. This was found in three (3) of thirty-one (31) resident rooms observed during the survey. Facility census: 44. Findings include: a) Rooms B2, B4 and C7 On 04/25/13 at 10:18 a.m., observations in the toilet room adjoining rooms B2 and B4, revealed multiple orange stains, running three (3) feet down the wall. These stains came from a pipe protruding from the wall, and disappearing behind a splash board. In addition, in room B4 the sink counter top was pulled away from the wall leaving a gap between the counter top and the back splash. This gap allowed water from the sink to run between the wall and the counter top. The counter top was not level. It was lower on the side which had pulled away from the wall. At 10:23 a.m. of this same day, a counter top in room C7 also revealed the sink counter top was pulled away from the wall, creating a gap between the counter top and the back splash. This allowed water from the sink to run between the wall and the counter top. This counter top was also not level, as it was lower on the side which had pulled away from the wall. A tour was conducted with the maintenance director, on 04/30/13 at 9:00 a.m. By this time, repairs had been made in the toilet adjoining rooms B2 and B4. The maintenance director agreed the stains were still visible and the wall felt damp to the touch. This employee also agreed there was probably a leak at a joint which caused the stains. He stated the pipe needed to be removed. During this tour, the maintenance director confirmed the sink counter tops in rooms B4 and C7 had pulled away from the back splash, allowing water to run between the counter top and the wall. He also confirmed the countertops were uneven and needed to be sealed and made more secure.",2017-02-01
7738,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,272,D,0,1,H1U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, review of incident reports, and staff interview, the facility failed to conduct an accurate assessment for two (2) of nineteen (19) sample residents whose assessments were reviewed. The comprehensive assessments for these residents did not accurately reflect each resident's health status and/or health care needs. The assessment for Resident #37 did not reflect the resident had a pacemaker. Resident #36 had a pressure ulcer that was not accurately described/staged in the assessment. Resident identifiers: #37 and #36. Facility census: 44. Findings include: a) Resident #37 Medical record review revealed this resident was admitted to the facility in May 2009. She had a pacemaker when she was admitted . Review of the resident's medical record, on 04/30/13 at 9:30 a.m., found an annual history and physical (H&P) dictated by the physician. The H&P noted Resident #37 had a past surgical history of a pace maker placement. A chest x-ray, dated 02/01/13, noted a right sided pacemaker was in place. Review of the physician's orders [REDACTED]. The nursing assessment, dated 04/13/13, was reviewed on 04/29/13 at 3:27 p.m. The registered nurse assessment coordinator (RNAC) was interviewed at 3:47 p.m., and confirmed the pace maker was not noted on the nursing assessment or the minimum data set (MDS), dated [DATE]. b) Resident #36 An interview was conducted with Employee #34, a licensed practical nurse (LPN), on 04/22/13 at 3:51 p.m She stated Resident #36 had an unstageable pressure ulcer on her left shoulder. An incident report, dated 02/22/13 at 10:33 p.m., was reviewed on 04/23/13. The report was written at the time the facility discovered an area on the resident's left shoulder. The report described the left shoulder wound as a red non blanchable area. According to the note, the facility determined the area was an abrasion due to rubbing against the back of the shower chair. A wound note, dated 02/24/13, described a red area on the left shoulder. It indicated the surrounding skin was intact and noted staff were monitoring the area. According to the medical record, on 02/26/13 Nutrashield was applied to the left shoulder area, and the resident was repositioned. The wound was described as a small scab with slight redness surrounding the scab. A note dated 03/02/13 indicated the wound bed was, scabbed, surrounding area was red. Another note, dated 03/02/13 at 16:10, indicated the resident was repositioned so the resident was not on shoulder. On 03/04/13 at 22:01 a note was written which noted the scabbed area (L) top shoulder as approximately the size of a nickel in diameter .due to neck distorted and locked in downward position regarding [DIAGNOSES REDACTED] it rubs on the bony prominence of shoulder blade causing friction to area. Review of the medical record, on 04/22/13 at 5:18 p.m., revealed an initial pressure ulcer wound assessment and pressure ulcer note, dated 03/05/13. It described the pressure area as a black scab on the resident's left shoulder. On 04/22/13 at 5:30 p.m., review of the care plan revealed a care plan note, dated 03/6/13 at 8:05 a.m. It indicated a care plan update was completed because Resident #36 had a red area on her left shoulder which was re-evaluated, and determined to be related to pressure. It was noted as unstageable, due to staff's inability to visualize the wound bed. On 04/22/13, the resident's minimum data set (MDS) assessments were reviewed. The most current assessment, an MDS quarterly assessment dated [DATE], noted a Stage I or greater, a scar over bony prominence, or a non-removable dressing/device. It noted no unhealed pressure ulcer(s) at Stage I or higher. During an interview with the director of nursing (DON) and administrator, on 04/30/13, when asked why the area was not identified as a pressure ulcer, the DON said she initially believed the area to be an abrasion due to moisture and to friction related to the [DIAGNOSES REDACTED].",2017-02-01
7739,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,309,D,0,1,H1U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the provision of necessary care and services to maintain the highest level of care for one (1) of nineteen (19) Stage 2 sample residents. The resident had a cardiac pacemaker which was not identified in her assessment. As a result, appropriate care and services, such as monitoring its function, was not provided the resident. Resident identifier: Resident #37. Facility census: 44. Findings include: a) Resident #37 While reviewing the medical record, on 04/30/13 at 9:30 a.m., an annual history and physical, dictated by the physician, noted Resident #37 had a past surgical history of a pacemaker placement. A chest x ray, dated 02/01/13, noted a right sided pacemaker was in place. Review of the physician's orders [REDACTED]. The most recent nursing assessment, dated 04/12/13, was reviewed on 04/29/13 at 3:27 p.m. There was no mention of a pacemaker. The registered nurse assessment coordinator (RNAC) was interviewed at 3:47 p.m. on 04/29/13. She confirmed the pacemaker was not noted on the readmission nursing assessment, dated 04/12/13, nor the minimum data set (MDS), dated [DATE]. During an interview with Employee #59, a registered nurse (RN), she said if a resident had a pacemaker, the resident should have an order for [REDACTED].#37 had a pacemaker. At the time of the survey, there was no evidence the resident's pacemaker was ever monitored. In addition, the facility had no plans in place to monitor this resident's pacemaker for function and/or other potential associated problems.",2017-02-01
7740,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,323,E,0,1,H1U811,"Based on observation, staff interview, family interview, medical record review, material safety data sheets (MSDS) review, and facility policy review, the facility failed to ensure the environment was as free of accident hazards as possible for five (5) of forty-four (44) residents. One (1) of four (4) residents reviewed for accidents in Stage 2 of the survey, Resident #36, incurred an injury due to improper transfer on 09/27/12. A plan was put in place for the resident's safety during transfers. At the time of the survey, the resident remained at risk for injury, as a staff member transferred the resident without implementing the resident's plan for safe transfers. In addition, potentially hazardous chemicals, multiple tubes and bottles of creams and lotions, were stored in the common resident restroom in an unlocked cabinet. This had the potential to affect four (4) cognitively impaired residents (#17, #37, #38, and #99) who were identified with wandering behaviors by the facility. Review of their their minimum data set (MDS) assessments confirmed these residents wandered and were cognitively impaired. Furthermore, handrails were not secured to the wall and/or had a vertical cut which went completely through the handrail, creating a potential for a splinter, pinch, or skin tear. The condition of these handrails had the potential to affect more than an isolated number of residents who used the handrails during ambulation. Resident identifiers: #36, #17, #37, #38, and #99. Facility census: 44. Findings include: a) Resident #36 During a family interview, on 04/23/12 at 10:10 a.m., it was revealed Resident #36 had sustained a bruise across her chest of unknown origin. Review of the incident report, dated 09/27/12 at 1:30 p.m., indicated the origin of this bruise was unknown, but the facility thought it might be related to inappropriate transfers from the bed and chair. A referral was made to therapy. The facility's information indicated education was provided related to inappropriate transfers. Observation of a transfer of this resident, from a geri-chair to the bed, on 04/30/13, revealed Employee #15, a nursing assistant (NA), transferred Resident #36, without assistance of another staff member. Observation revealed the resident bore a little weight on the tips of her toes. The transfer was performed in the presence of Employee #19, a registered nurse (RN). The NA was questioned about any difference in transfer techniques and the resident's status, since the resident was treated by therapy. The NA stated there was no difference. The medical record was reviewed with Employee #19. This RN confirmed the medical record indicated Resident #36 should have been transferred with the assistance of two (2) staff members. The Kardex (NA information for care) was then reviewed. It also noted the resident was to be transferred with assistance of two (2) staff members. Upon inquiry, the director of nursing (DON), indicated no policy was available regarding transfers and safety. Educational records were requested and reviewed on 04/30/13 at 5:00 p.m This review revealed Employee #15 had completed the education regarding transfers and safety on 04/06/13. Review of the resident lifting and transferring educational information revealed a gait belt should be utilized for residents who were partially dependent, could bear some weight, and were cooperative. A gait belt was not used during the transfer of Resident #36, on 04/30/13. The educational information provided employees was reviewed. It encouraged workers to transfer residents with a helper at all times. Employee #15 was not encouraged to ask for assistance during the observation on 04/30/13, even though an RN was present. The education also noted staff were to check the Kardex, care plan, care card, or assignment sheet before transferring a resident. Had the Kardex been checked, the staff members would have realized Resident #36 was supposed to be transferred with assistance of two (2) staff members. b) Residents #17, #37, #38, and #99 On 04/24/13 at 11:20 a.m., a random observation in the resident restroom, across from the nurses' station, revealed an unlocked cabinet containing the following items: -Remedy with olivamine (six (6) tubes) -Skin Repair cream (four (4) tubes) -Remedy Cleansing body lotion (four (4) bottles) Each of the above products contained the warning: Keep out of reach of children and avoid eye contact. A review of the Material Safety Data Sheet (MSDS) for all of the above items revealed, under the section Emergency and First Aid Procedures, Eye contact: FLUSH WITH WATER, GET MEDICAL ATTENTION IF IRRITANCY PERSISTS. Ingestion: IF LARGE QUANTITIES ARE INGESTED, GET MEDICAL ATTENTION. The easy access to these potentially hazardous products had the potential to affect, at a minimum, the four (4) cognitively impaired residents who wandered in the facility. At 11:30 a.m. on this same day, the director of nursing (DON) agreed there were warnings on the lotions and creams which were observed in an unlocked cabinet. She further agreed any resident had ready access to this room and the products in the unlocked cabinet. c) A random observation of the handrail beside the water cooler, on 04/24/13 at 10:04 a.m., revealed a vertical cut which went completely through the handrail. A small gap was observed between the two (2) pieces of wood. This gap created a potential for a splinter, pinch, or skin tear. In addition, the handrail was freely movable at least one-third (1/3) of an inch. The administrator agreed, at this time, the handrail was not secure and was freely movable. On 04/24/13 at 10:12 a.m., a random observation of the handrail in the rehabilitation hallway revealed this handrail was freely movable. The maintenance director was in the rehabilitation hallway during the observation and agreed the handrail was loose. He stated he would fix it immediately. The disrepair of these handrails had the potential to cause resident injury.",2017-02-01
7741,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,356,B,0,1,H1U811,"Based on record review and staff interview the facility failed to post accurate nurse staffing information on a daily basis. The numbers of licensed and unlicensed staff posted did not represent the actual number of staff available for direct resident care for each shift. This practice had the potential to affect more than a limited number of residents. Facility census: 44. Findings include: a) On 04/24/13, a review of staffing information postings dated 04/01/13 through 04/07/13 was conducted. The postings were compared with the facility's staffing worksheet. There was a discrepancy in the number of direct care staff listed. Four (4) of seven (7) actual staffing postings revealed one (1) less direct care staff member on duty, than the information posted for that day. During an interview with the administrator, on 04/24/13 at 2:15 p.m., it was revealed Employee #79 begins the the shift after the day shift staffing is posted. He stated the staffing posted is not updated upon arrival of Employee #79. The administrator presented an individual employee time card for Employee #79 which paralleled the noted inconsistency. The facility did not update the number of available licensed and unlicensed staff when the number of staff members changed.",2017-02-01
7742,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,364,B,0,1,H1U811,"Based on observation and resident interview, the facility failed to ensure hot foods were served at preferable temperatures as discerned by the resident and customary practice. Two (2) residents expressed concerns with the temperature of hot foods. The facility did not implement practices to ensure foods were hot enough when received by the residents. This affected two (2) residents, but had the potential to affect more than an isolated number of residents. Resident identifiers: #6 and #29. Facility census: 44. Findings include: a) Residents #29 and #6 During a Stage 1 interview, on 04/22/13 at 1:31 p.m., Resident #29 stated hot foods were not hot enough upon receipt. Resident #6, during a Stage 1 interview on 04/22/13 at 1:56 p.m., said The hot food is just barely warm. b) The meal tray line was observed, on 04/24/13 during the lunch meal. The meal service was observed from the beginning of the meal, until the last trays were served. The first trays were prepared, placed on carts, and sent to the units. The dining room, which was adjacent to the kitchen, was served last. At 12:12 p.m., prior to serving the last trays, Employee #74, a dietary assistant, was requested to obtain the temperatures of the pureed chicken and the chicken patties. The temperature of the chicken patties was 110 degrees Fahrenheit (F) and the temperature of the pureed chicken was 124 degrees F. At these temperatures, the chicken patties (which were 110 degrees) could not be received by the residents at the customary temperature of 120 degrees for hot foods. In addition, the pureed chicken (which was 124 degrees) was very likely to have fallen below 120 degrees F by the time of receipt by the residents.",2017-02-01
7743,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,371,E,0,1,H1U811,"Based on observation, food temperature measurement, and staff interview, the facility failed to ensure critical operational steps, to prevent or eliminate food safety hazards during the holding of foods for service, were implemented. The facility failed to ensure hot foods were held for service at temperatures which prevented the rapid and progressive growth of organisms which contribute to food borne illnesses. This practice had the potential to affect more than an isolated number of residents who received nourishment from the dietary department. Facility census: 44. Findings include: a) The meal tray line was observed, on 04/24/13 during the lunch meal. The meal service was observed from the beginning of the meal, until the last trays were served. The first trays were prepared, placed on carts, and sent to the units. The dining room, which was adjacent to the kitchen, was served last. At 12:12 p.m., prior to serving the last trays, Employee #74 was requested to obtain the temperatures of the pureed chicken and the chicken patties. Using the facility's thermometer, Employee #74 measured the temperatures. The chicken patties were 110 degrees Fahrenheit (F), and the temperature of the pureed chicken was 124 degrees. To ensure food safety, hot foods must be held for service on the steam table at a temperature no less than 135 degrees F. Employee #24, the dietary supervisor, was present during the temperature check at this meal. Employee #24 questioned the functioning of the steam table. Employee #74 raised a pan on the steam table, and said the water was not reaching the pan as required to maintain the temperatures of foods. After lunch, the administrator, in the presence of Employee #24, questioned the food temperatures He was informed Employee #74 had obtained the temperatures with the facility's thermometer. At that time, the food service supervisor confirmed the temperatures reported by Employee #74.",2017-02-01
7744,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,456,F,0,1,H1U811,"Based on observation and staff interview, the facility failed to maintain electrical equipment in safe operating condition. Observation of the ice machine, located in the pantry behind the nurses' station, revealed the external and internal air filters were filled with brown debris. This had the potential to affect all residents. Facility census: 44. Findings include: a) During an observation of the pantry located at the nurses' station, on 04/24/13 at 12:00 p.m., a sign on the outside of the ice machine stated, Clean air filter twice a month. The exterior grill contained brown debris. Further observation revealed the interior filter also contained brown debris. At 12:10 p.m. on this same day, the administrator was shown the ice machine filters and agreed the filter was dirty and needed to be cleaned. The maintenance director was shown the filter at 12:20 p.m. on this same day. He was in agreement both the interior and exterior filters needed to be cleaned. He stated the filters were cleaned monthly. He stated he had never noticed the sign above the filter stating, Clean filter twice a month. The maintenance director immediately removed the filters and stated he would clean the filters as soon as he removed items from the sink.",2017-02-01
7745,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,468,E,0,1,H1U811,"Based on observation and staff interview, the facility failed to ensure handrails in hallways were securely affixed to the wall. During a random observation, a handrail in the rehabilitation hallway was found moveable when pulled. An additional rail, located by the water cooler at the nurses' station, revealed a freely moving rail. This handrail also had a vertical cut through it. The condition of these handrails had the potential to affect more than an isolated number of residents who used the hand rails during ambulation. Facility census: 44. Findings include: a) A random observation of the handrail beside the water cooler, on 04/24/13 at 10:04 a.m., revealed a vertical cut which went completely through the handrail. A small gap was observed between the two (2) pieces of wood. This gap created a potential for a splinter, pinch, or skin tear. In addition, the handrail was freely movable at least one-third (1/3) of an inch. The administrator agreed, at that time, the handrail was not secure and was freely movable. On 04/24/13 at 10:12 a.m., a random observation of the handrail in the rehabilitation hallway revealed this handrail was freely movable. The maintenance director was in the rehabilitation hallway during the observation and agreed the handrail was loose. He stated he would fix it immediately.",2017-02-01
7746,CAMERON NURSING AND REHABILITATION CENTER,515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2013-05-01,502,D,0,1,H1U811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on medical record review and staff interview, the facility failed to obtain physician ordered laboratory services for one (1) of nineteen (19) Stage 2 sample residents. Resident #50 did not receive a liver function test as ordered. resident identifier: #50. Facility Census: 44. Findings include: a) Resident #50 When reviewed on 04/24/13 at 3:30 p.m., this resident's medical record revealed a physician's orders [REDACTED]. The test was ordered due to the [DIAGNOSES REDACTED]. Further review of the medical record revealed the most recent liver function test available for this resident was dated 09/16/11. On 04/24/13 at: 4:05 p.m., the director of nursing stated she could not find evidence of a liver function test being completed after 09/16/11. She confirmed the resident had remained a resident at the facility since 09/16/11, and the liver function test should have been completed as ordered in July 2012.",2017-02-01
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
9261,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,225,D,0,1,JZU011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, facility record review, policy review, and staff interview, the facility failed to immediately report an incident involving possible neglect to the appropriate State officials and/or to investigate the incident which involved a fall resulting in a resident sustaining a fracture. This affected one (1) of thirty-two (32) Stage II sample residents. Resident identifier: #42. Facility census: 55. Findings include: a) Resident #55 Medical record review revealed Resident #42 was an [AGE] year old female admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. This resident had been determined to lack capacity to form her own medical decisions and had a court-appointed guardian for several years. A review of the physician's orders [REDACTED]. The following was added on 12/28/10: Transfer order: transfer with two assist and gait belt, wheelchair for mobility w/i (within) facility. A new order was written on 07/26/11, stating: Transfer order: transfer with two assist and sit to stand lift. The ambulation order was discontinued except for physical therapy, and she was to be turned every two (2) hours. The resident's physical status had deteriorated, and the physical therapy record stated that, during the treatment period from 07/25/11 through 08/11/11, the resident had poor balance and was unable to stand at all on several occasions during this treatment period. The notes attributed this to weakness caused by a recent bout of pneumonia. At the time of her fall on 08/11/11, she had met none of her therapy goals. A review of the quarterly minimum data set assessment (MDS) with an assessment reference date of 07/21/11 found the assessor indicated the resident required physical assistance from 2 + persons for transfers, she was not steady getting on and off the toilet, and she could only stabilize with assistance. The resident sustained [REDACTED]. The incident report completed by the licensed practical nurse (LPN - Employee #7) read: Resident climbed out of bed insisting that she needed to walk to the bathroom with her walker, tried to encourage not to walk and use stand up lift but she became very agitated and angry so staff proceeded to walk her to the bathroom. After toileting tried to stand up and pivot into w/c (wheelchair) she yells 'I am too weak and I can't stand' and just let herself fall to the floor with knees underneath her taking all the weight and a 'popping' sound was heard and resident started screaming out 'my knee my knee' 'I broke my kneecap'. The occurrence note by the same LPN stated: fell on to floor in bathroom when trying to transfer off of toilet in w/c with walker. The resident was transferred to the hospital via ambulance and found to have a [MEDICAL CONDITION] tibia. She was readmitted to the facility on [DATE], with a knee immobilizer to the right leg. The resident was assisted out of bed to the bathroom without the use of the sit-to-stand lift, although the ADL (activities of daily living) records revealed the resident had not ambulated since 06/30/11. This was in violation of the physician's orders [REDACTED]. During an interview with the administrator and the director of nursing (DON - Employee #74) at 10:30 a.m. on 10/04/11, they were asked why this incident had not been reported as an allegation of neglect, to which they responded that it was because the resident had insisted on transferring / ambulating without a mechanical lift. They both admitted they were aware she was weak and had not been ambulating. The DON stated she had investigated the incident and the LPN involved had been counseled. During a follow-up interview with the administrator at 11:05 a.m. on 10/05/11, he stated he would report the incident and the LPN, although there was no evidence that an investigation had taken place.",2016-01-01
9262,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,226,D,0,1,JZU011,"Based on record review and staff interview, staff did not follow the Reporting / Response section of the facility's policy for reporting allegations of abuse or neglect by not indicating in their Five Day Follow-Up - Nursing Home Program either the outcome of the investigation or the complete corrective action taken by the facility for one (1) of three (3) reports reviewed. Resident identifier: #29. Facility census: 55. Findings include: a) Resident #29 Review of the facility's self-reported allegations of abuse / neglect found that, on 05/17/11, the daughter of Resident #29 reported the following, which was recorded on a grievance / concern report form (quoted as written): daughter stated that while resident was out to appointment 'that girl lifted my mom into the seat of the van without a gait belt. I don't think she knows how bad my mom's arms are. If she whines tonight that her arms hurt that is why.' On 05/18/11, the facility submitted the following allegation to the State survey agency on a form titled Immediate Fax Reporting of Allegations - Nursing Home Program: While transferring patient from wheelchair to facility van sent nurse did not use gait belt as ordered by physician. Patient complained of Left arm pain on 5/18/11. On 05/18/11, the facility submitted a form titled Five Day Follow-Up - Nursing Home Program stating the following under the heading Outcome / Results of Investigation (quoted as written): X-rays of Left arm were negative for any fracture or dislocation. Heat wrap applied to left shoulder. Under the heading titled Corrective Action By Facility was written: Nurse reeducated to use of gait belt and following physician orders. In an incident summary, the reporter noted the alleged perpetrator stated (quoted as typed) . she wrapped she did not pull or move patient's arms during the transfer . she wrapped her arms around patient's waist and with patient's help completed the transfer. She stated that during transport resident was complaining of seatbelt strap was hurting her arm. The facility's investigation verified the nurse had not used a gait belt during this transfer, but there was no documentation on the Five Day Follow-up form indicating the allegation had been substantiated. Additionally, although documentation on the form stated that education had been provided to the nurse, there was no mention of whether or not the nurse had been reported to the appropriate licensing board. During an interview with the administrator at 11:05 a.m. on 10/04/11, he acknowledged the facility's policy required this missing information be included in the report, and he stated he would file an amended report.",2016-01-01
9263,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,280,D,0,1,JZU011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interview, the facility failed to review and revise the care plan for one (1) of thirty-two (32) Stage II sample residents, who sustained multiple falls since her admission to the facility on [DATE], including falls with injuries, in an effort to promote resident safety. Resident identifier: #66. Facility census: 55. Findings include: a) Resident #66 1. A review of the clinical record revealed Resident #66 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed on admission as being at high risk for falls due to wandering and altered safety awareness. - 2. Review of the resident's comprehensive admission minimum data set (MDS) with an assessment reference date (ARD) of 02/18/11 found these responses to the following questions related to falls (J1700 and J1800): - Did the resident have a fall any time in the last month prior to admission? - No - Did the resident have a fall any time in the last 2-6 months prior to admission? - No - Did the resident have any fractures related to a fall in the 6 months prior to admission? - No - Has the resident had any falls since admission or the prior assessment , whichever is more recent? - Yes According to the assessor, the resident one (1) fall since admission or the prior assessment, for which no injury was sustained. - Review of the results of the brief interview for mental status (BIMS) completed as part of the 02/18/11 MDS found the resident scored 04 out of 15, indicating the resident's cognitive status was severely impaired (C0500). As part of the BIMS, the resident was asked to recall three (3) words that had been said to her earlier in the interview (C0400); she was unable to recall two (2) of the words and was only able to recall the third word with cuing. (Review of the resident's most recent quarterly MDS with an ARD of 07/28/11 found her BIMS score was 06 out of 15, again indicating her cognitive status was severely impaired (C0500). As part of this BIMS, she was able to recall one (1) word with no cuing and one (1) word with cuing and was not able to recall the third word.) - Review of the assessment of her functional status completed as part of the 02/18/11 MDS found her balance (G0300) when moving from a seated position to a standing position was not steady and she was only able to stabilize with human assistance; her balance while walking and while turning around and facing the opposite direction while walking was not steady but she was able to stabilize without human assistance. - 3. Her comprehensive admission care plan included the following problem statement: (Resident #66) is High risk for falls r/t wandering. (initiated on 02/14/11) Interventions to promote Resident #66's safety with respect to her risk of falling (all of which were initiated on 02/14/11) included (quoted as typed): HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT (physical therapy) evaluate and treat prn (as needed). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate patient / family / IDT (interdisciplinary team) as to cause. (These were the same routine interventions found on all the records records reviewed for falls during the survey, and there were no interventions that reflected the unique needs of the individual residents.) - Additional problem statements (P) and their associated interventions (I) included (quoted as typed): P - (Resident #66) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia / occassional aggressive behaviors. (initiated on 02/14/11) I - 1/2 side rails up on both sides of bed to enhance bed mobility and transfer ability TRANSFER: Independent. DRESSING: Assist of 1. Wears Glasses. TOILET USE: Independent. TOILETING SCHEDULE: . PERSONAL HYGIENE/ORAL CARE: Assist of 1. BATHING: Assist of 1. (all initiated 02/17/11) P - Patient is at risk for elopement due to Hx (history) of elopements from home, increased confusion. (initiated on 02/09/11) I - Secure Care Alarm to right ankle at all times. Check alarm device every shift to ensure functionality. Allow patient to wander freely within safe and secure environment. Involve patient in 1:1 (one-on-one) recreational activities. Encourage socialization with other appropriate residents. Encourage family support / involvement. (all initiated on 02/09/11) - 4. Her admission orders [REDACTED]. Following her admission to the facility on [DATE], Resident #66 sustained falls on the following dates, as documented in her progress notes (quoted as typed): - 02/13/11 at 7:20 p.m. - Resident was found sitting beside of foot of bed on buttocks. - 02/20/11 at 8:20 a.m. - found sitting on floor beside bed in room (number), merriwalker in hallway . - 02/24/11 at 3:27 p.m. - fall, found on the floor beside merry-walker sitting, leaning up against the . - 02/27/11 at 2:00 p.m. - resident observed sitting on buttocks beside of bed . - 03/02/11 at 9:09 p.m. resident sat down on floor from merry walker . - 03/06/11 at 11:47 a.m. - resident was found on floor in room (number) on buttocks in front of merry walker. - 04/08/11 at 7:50 p.m. - Nursing assistants reports to me resident was on floor beside of bed . - 07/29/11 at 3:45 p.m. - CNA (certified nursing assistant) walking down B hall, observed resident sitting on floor beside bed . Hematoma 6cm x 6cm x 3cm protrusion observed to left forehead . - 07/29/11 at 10:39 p.m. - Fall out of bed with no apparent injury. - 08/27/11 at 3:58 a.m. - . Resident found lying on back on floor.Denies hitting head. - 10/02/11 at 7:10 a.m. - patient found on floor lying on rt (right) side in front of lt (left) side of bed, 1cm laceration and 2cm laceration rt side of rt eyebrow and 3cm hematoma under lacerations. - 10/03/11 at 12:52 a.m. - Fall this morning . The resident sustained [REDACTED]. [REDACTED]. - 5. The resident was observed at 2:30 p.m. on 09/26/11, walking aimlessly in the hallway, asking staff members if they would help her find her cane. A nurse (Employee #56) led her back to her room and got her quad cane for her. The resident was observed again on 09/27/11, 09/28/11, and 09/29/11, walking about either with or without her cane. She would ask about it, and staff would get it for her. Sometimes she would carry the cane with her while she walked, and sometimes she would use it for support. - 6. Although the initial (and still active) care plan stated that all falls were to be reviewed and evaluated to identify root cause(s) with resulting changes made to the care plan, there was no evidence in the record (nursing notes, progress notes, incident reports, CAA Worksheets, care plans, etc.) to reflect this was being done. The care plan for falls remained, on 10/05/11, exactly as it was at its initiation. There had been no revisions to the care plan (to include use of the quad cane) and/or any evidence that additional / different interventions had been attempted in an effort to promote the resident's safety even after she sustained falls with injuries requiring medical intervention. - 7. The director of nurses (DON - Employee #74), when asked at 11:00 a.m. on 10/04/11 if the resident's falls were being reviewed, stated they always talked about them, but she acknowledged, after reviewing Resident #66's medical record, that there had been no revisions to the care plan and no documentation reflecting an effort to identify causal or contributing factors to the falls. She had no answer when asked when and why the use of the cane was started. - 8. A review of the physical therapy (PT) evaluation and notes from 02/10/11 through her discharge from PT services on 04/08/11 found that, although she had improved and had less ataxia with her gait, she did not meet her rehabilitation goals. She continued a second course of therapy from 04/09/11 through 04/22/11, and at discharge was noted to have less unsteadiness. A review of subsequent therapy screens dated 07/15/11, 08/01/11, and 08/30/11 failed to find any proposed interventions or comments except for recommending the use of a bed alarm on 08/30/11, which was not adopted. There was also no evidence that therapy staff had assessed the resident for or instructed her in the use of a quad cane. This was verified by the physical therapist (Employee #76) at 9:30 a.m. on 10/05/11. - 9. During an interview with Employee #75 (the nurse who was responsible for developing the care plans) at 11:15 a.m. on 10/05/11, she acknowledged there had been no entries into the care plan regarding the use of the quad cane and no revisions to the care plan interventions after any of the falls. When asked about the lack of individuality in the care plan addressing Resident #66's falls, she stated that, usually after they know the resident better, they address individual needs, but she acknowledged this had not occurred for Resident #66.",2016-01-01
9264,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,323,G,0,1,JZU011,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, facility policy review, and staff interview, the facility failed to provide a safe environment and/or adequate supervision to prevent falls for three (3) of thirty-two (32) Stage II sample residents, one (1) of whom sustained injuries requiring medical intervention. Resident #66, whose cognitive status was severely impaired and who had been assessed as having unsteady gait, was identified as being at high risk for falls. She sustained twelve (12) falls in the facility since her admission on 02/09/11, two (2) resulting in injuries requiring medical attention, with no evidence of root cause analysis of the falls (which was identified as an intervention in her falls care plan) and no revisions made to her care plan to promote her safety. Resident #43 sustained seven (7) falls between the middle of July 2011 and the beginning of October 2011, with no consistent, documented evidence that the facility's falls and fall risk policy was being followed (which was to include a re-evaluation of interventions after each fall) or that all recommended measures to minimize falls had been implemented (e.g., the application of a non-slip material to the resident's chair). Resident #54 sustained one (1) fall in September 2011, with no evidence that the facility's falls and fall risk policy was followed after the fall occurred. Resident identifiers: #66, #43, and #54. Facility census: 55. Findings include: a) Resident #66 1. A review of the clinical record revealed Resident #66 was a [AGE] year old female admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. She was assessed on admission as being at high risk for falls due to wandering and altered safety awareness. - 2. Review of the resident's comprehensive admission minimum data set (MDS) with an assessment reference date (ARD) of 02/18/11 found these responses to the following questions related to falls (J1700 and J1800): - Did the resident have a fall any time in the last month prior to admission? - No - Did the resident have a fall any time in the last 2-6 months prior to admission? - No - Did the resident have any fractures related to a fall in the 6 months prior to admission? - No - Has the resident had any falls since admission or the prior assessment , whichever is more recent? - Yes According to the assessor, the resident one (1) fall since admission or the prior assessment, for which no injury was sustained. - Review of the results of the brief interview for mental status (BIMS) completed as part of the 02/18/11 MDS found the resident scored 04 out of 15, indicating the resident's cognitive status was severely impaired (C0500). As part of the BIMS, the resident was asked to recall three (3) words that had been said to her earlier in the interview (C0400); she was unable to recall two (2) of the words and was only able to recall the third word with cuing. (Review of the resident's most recent quarterly MDS with an ARD of 07/28/11 found her BIMS score was 06 out of 15, again indicating her cognitive status was severely impaired (C0500). As part of this BIMS, she was able to recall one (1) word with no cuing and one (1) word with cuing and was not able to recall the third word.) - Review of the assessment of her functional status completed as part of the 02/18/11 MDS found her balance (G0300) when moving from a seated position to a standing position was not steady and she was only able to stabilize with human assistance; her balance while walking and while turning around and facing the opposite direction while walking was not steady but she was able to stabilize without human assistance. - According to the care area assessment (CAA) worksheet associated with the above MDS, dated [DATE] (quoted as typed), under the heading Analysis of Findings for Nature of the problem / condition: Resident had a fall 2/13 beside her bed, unsteady on feet, received scheduled xanax for anxiety progress notes, observation, physician's orders [REDACTED]. - 3. Her comprehensive admission care plan included the following problem statement: (Resident #66) is High risk for falls r/t wandering. (initiated on 02/14/11) Interventions to promote Resident #66's safety with respect to her risk of falling (all of which were initiated on 02/14/11) included (quoted as typed): HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT (physical therapy) evaluate and treat prn (as needed). Review information on past falls and attempt to determine cause of falls. Record possible root causes. Alter remove any potential causes if possible. Educate patient / family / IDT (interdisciplinary team) as to cause. (These were the same routine interventions found on all the records records reviewed for falls during the survey, and there were no interventions that reflected the unique needs of the individual residents.) - Additional problem statements (P) and their associated interventions (I) included (quoted as typed): P - (Resident #66) has an ADL (activities of daily living) Self Care Performance Deficit r/t (related to) Dementia / occassional aggressive behaviors. (initiated on 02/14/11) I - 1/2 side rails up on both sides of bed to enhance bed mobility and transfer ability TRANSFER: Independent. DRESSING: Assist of 1. Wears Glasses. TOILET USE: Independent. TOILETING SCHEDULE: . PERSONAL HYGIENE/ORAL CARE: Assist of 1. BATHING: Assist of 1. (all initiated 02/17/11) P - Patient is at risk for elopement due to Hx (history) of elopements from home, increased confusion. (initiated on 02/09/11) I - Secure Care Alarm to right ankle at all times. Check alarm device every shift to ensure functionality. Allow patient to wander freely within safe and secure environment. Involve patient in 1:1 (one-on-one) recreational activities. Encourage socialization with other appropriate residents. Encourage family support / involvement. (all initiated on 02/09/11) - 4. Her admission orders [REDACTED]. Following her admission to the facility on [DATE], Resident #66 sustained falls on the following dates, as documented in her progress notes (quoted as typed): - 02/13/11 at 7:20 p.m. - Resident was found sitting beside of foot of bed on buttocks. - 02/20/11 at 8:20 a.m. - found sitting on floor beside bed in room (number), merriwalker in hallway . - 02/24/11 at 3:27 p.m. - fall, found on the floor beside merry-walker sitting, leaning up against the . - 02/27/11 at 2:00 p.m. - resident observed sitting on buttocks beside of bed . - 03/02/11 at 9:09 p.m. resident sat down on floor from merry walker . - 03/06/11 at 11:47 a.m. - resident was found on floor in room (number) on buttocks in front of merry walker. - 04/08/11 at 7:50 p.m. - Nursing assistants reports to me resident was on floor beside of bed . - 07/29/11 at 3:45 p.m. - CNA (certified nursing assistant) walking down B hall, observed resident sitting on floor beside bed . Hematoma 6cm x 6cm x 3cm protrusion observed to left forehead . - 07/29/11 at 10:39 p.m. - Fall out of bed with no apparent injury. - 08/27/11 at 3:58 a.m. - . Resident found lying on back on floor.Denies hitting head. - 10/02/11 at 7:10 a.m. - patient found on floor lying on rt (right) side in front of lt (left) side of bed, 1cm laceration and 2cm laceration rt side of rt eyebrow and 3cm hematoma under lacerations. - 10/03/11 at 12:52 a.m. - Fall this morning . The resident sustained [REDACTED]. [REDACTED]. - 5. The resident was observed at 2:30 p.m. on 09/26/11, walking aimlessly in the hallway, asking staff members if they would help her find her cane. A nurse (Employee #56) led her back to her room and got her quad cane for her. The resident was observed again on 09/27/11, 09/28/11, and 09/29/11, walking about either with or without her cane. She would ask about it, and staff would get it for her. Sometimes she would carry the cane with her while she walked, and sometimes she would use it for support. - 6. Although the initial (and still active) care plan stated that all falls were to be reviewed and evaluated to identify root cause(s) with resulting changes made to the care plan, there was no evidence in the record (nursing notes, progress notes, incident reports, CAA Worksheets, care plans, etc.) to reflect this was being done. The care plan for falls remained, on 10/05/11, exactly as it was at its initiation. There had been no revisions to the care plan (to include use of the quad cane) and/or any evidence that additional / different interventions had been attempted in an effort to promote the resident's safety even after she sustained falls with injuries requiring medical intervention. - 7. The director of nurses (DON - Employee #74), when asked at 11:00 a.m. on 10/04/11 if the resident's falls were being reviewed, stated they always talked about them, but she acknowledged, after reviewing Resident #66's medical record, that there had been no revisions to the care plan and no documentation reflecting an effort to identify causal or contributing factors to the falls. She had no answer when asked when and why the use of the cane was started. - 8. A review of the physical therapy (PT) evaluation and notes from 02/10/11 through her discharge from PT services on 04/08/11 found that, although she had improved and had less ataxia with her gait, she did not meet her rehabilitation goals. She continued a second course of therapy from 04/09/11 through 04/22/11, and at discharge was noted to have less unsteadiness. A review of subsequent therapy screens dated 07/15/11, 08/01/11, and 08/30/11 failed to find any proposed interventions or comments except for recommending the use of a bed alarm on 08/30/11, which was not adopted. There was also no evidence that therapy staff had assessed the resident for or instructed her in the use of a quad cane. This was verified by the physical therapist (Employee #76) at 9:30 a.m. on 10/05/11. - 9. During an interview with Employee #75 (the nurse who was responsible for developing the care plans) at 11:15 a.m. on 10/05/11, she acknowledged there had been no entries into the care plan regarding the use of the quad cane and no revisions to the care plan interventions after any of the falls. When asked about the lack of individuality in the care plan addressing Resident #66's falls, she stated that, usually after they know the resident better, they address individual needs, but she acknowledged this had not occurred for Resident #66. - 10. During an interview with the administrator (Employee #73) at 1:00 p.m. on 10/04/11, he reported that the fall on 10/02/11 had been reviewed and was attributed to the resident's receiving a newly prescribed pain medication, which was discontinued. When asked about any previous actions, his only remark was that they had the resident screened by physical therapy after the falls and they had carried out their recommendations. -- b) Resident #43 Record review revealed Resident #43 was a [AGE] year old woman who was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. Her comprehensive admission MDS with an ARD of 01/11/11, when reviewed on 10/03/11 at 2:00 p.m., found her BIMS score was 03 out of 15, indicating severe cognitive impairment with no ability to recall three (3) words said to her earlier in the interview (C0500 and C0400). She required the extensive physical assistance of one (1) person to transfer between surfaces and the limited assistance of one (1) person with ambulation and locomotion (G0110). Her balance when moving from a seated to standing position and when transferring between surfaces was not steady but she was able to stabilize herself without human assistance; her balance when walking, turning around, and moving on and off the toilet was not steady and she was not able to stabilize herself without human assistance (G0300). She also used a cane / crutch and a wheelchair as mobility devices (G0600). She had sustained a fall in the last month prior to her admission to the facility (J1700), and she had one (1) fall since admission with no injury (J1900) - Review of her care plan revealed the following problem statement, which was initiated on 01/04/11 (quoted as typed): (Resident #43) is High risk for falls r/t impaired safety awareness, Confusion , Wandering, Hx of frequent falls. The goal associated with this problem was: Patient will not sustain serious injury from falls through 12/21/11. (This goal was initiated on 01/19/11.) Interventions to be implemented to accomplish this goal were: HIGH FALL RISK: Anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of his/her room every shift and correcting any identified issues. PT prn (as needed). All of these interventions were initiated on 01/04/11. Subsequent revisions to the care plan found the following additional interventions: - Added on 04/15/11 - Low bed at all times and fall mat to both sides of bed. - Added on 09/27/11 - FALL RISK: Alarm to bed at all times to alert staff of patient attempts to transfer unassisted. Bed in lowest position except when providing care. - Added on 09/27/11 - FALL RISK: Alarm to chair when not in merrywalker, at all times to alert staff of patient attempts to transfer unassisted. (All of these interventions were found in place through daily observations during the survey event.) - Review of incident reports, on 10/04/11, found Resident #43 had sustained falls on 07/17/11, 08/03/11, 08/12/11, 09/05/11, 09/10/11, 09/29/11, and 10/02/11. Beginning in September 2011, interdisciplinary team (IDT) notes were found to be included at end of the incident reports. The IDT note on the report for the 09/05/11 fall, which was dated 09/06/11, simply recapitulated verbatim a statement of what had happened: Resident sitting in merry walker when she fell asleep and fell on to strap and then onto floor when staff was assisting her back up into merry walker. The IDT note on the report for the 09/10/11 fall, which was 09/13/11, simply recapitulated the current interventions already in place prior to this fall. The IDT note on the report for the 09/29/11 fall, which was dated 10/03/11, discussed the continued use of the Merrywalker (typed as written): IDT reviewed incident report evaluated use of merry walker weighed benefits, safety and risks, the benefits out weight the risks due to the merry walker allowing for independent mobility. resident has poor memory and does (not) remember other assistive devices such as a cane or walker. - Review of fall assessments in the resident's electronic medical record (EMR), on 10/04/11 at 1:00 p.m., found graphs of assessment scores containing the legend fall risk assessments trigger therapy screen. During an interview with the administrator on 10/04/11 at 2:00 p.m., when asked to explain this process, he stated that therapy screens were done after every fall assessment, except for annual assessments. Copies were requested of completed therapy screens for Resident #43 following each of the falls under review (07/17/11, 08/03/11, 08/12/11, 09/05/11, 09/10/11, 09/29/11, and 10/02/11.) On 10/04/11 at 3:10 p.m., the administrator provided the PT screen completed on 09/07/11 for the 09/05/11 fall and the PT screen completed on 10/03/11 for the 09/29/11 fall. He stated Resident #43 was still an active therapy client on 07/17/11. For the remaining falls that occurred on 08/03/11, 08/12/11, and 09/10/11, there was no evidence that therapy screens were ever completed. - The facility's policy and procedure for falls was requested. A policy titled Falls and Fall Risk, Managing (revised 07/01/06) was provided at 3:40 p.m. on 10/04/11. The policy stated, under the heading Monitoring Subsequent Falls and Fall Risk: 1. The staff will monitor and document each resident's response to interventions intended to reduce falling or the risks of falling. 2. If interventions have been successful in preventing falling, staff will continue the interventions or reconsider whether these measures are still needed if a problem that required the intervention (e.g., dizziness or weakness) has resolved. 3. If a resident continues to fall, staff will re-evaluate the situation and whether it is appropriate to continue or change current interventions. As needed, the attending physician will help the staff reconsider possible causes that may not previously have been identified. 4. The staff and/or physician will document the basis for conclusions that specific irreversible factors exist that continue to present a risk for falling or injury due to falls. - A review of Resident #43's physician orders, on 10/04/11 at 3:50 p.m., found the resident was ordered Seroquel 12.5 mg once daily beginning on 06/20/11. This was an increase from the previous dosage of 6.25 mg daily. The current care plan described side effects of Seroquel as dizziness, headaches, and seizures. There is no evidence of any consideration given to possible impact of the psychoactive medication increase on the resident's falls found in the assessments or the care plan. - When reviewed on 10/05/11 at 9:00 a.m., the PT screen completed on 09/07/11, for the fall of 09/05/11, was found to contain a recommendation to use of Dycem (a non-slip material) in the resident's room chair to prevent her from sliding out, as she had on 09/05/11. This intervention was not found in Resident #43's care plan, and it was not found on the daily care instructions for nursing assistants (the resident's Kardex). The DON, when asked about the use of Dycem as a safety measure for Resident #43 on 10/05/11 at 11:40 a.m., stated that Dycem was used on her chair when she is in it. The nursing assistant assigned to provide care for Resident #43 (Employee #46) was interviewed at 11:45 a.m. on 10/05/11. When asked if there was non-skid material to be applied to Resident #43's room chair when she was in it, Employee #46 replied that there was not. An interview was conducted with the administrator on 10/05/11 at 9:35 a.m., during which he voiced understanding that there was not consistent, documented evidence that the facility's falls and fall risk policy was being followed or that all recommended measures to minimize falls had been implemented. -- c) Resident #54 Record review revealed Resident #54 was a [AGE] year old woman who was admitted to the facility on [DATE]. Her [DIAGNOSES REDACTED]. Observations throughout the survey found Resident #54 travelling throughout the facility in her wheelchair. - An abbreviated quarterly MDS with an ARD of 03/03/11, when reviewed on 10/03/11 at 1:30 p.m., revealed Resident #54's cognitive skills for dialing decision making were moderately impaired (C1000), with short-term and long-term memory problems (C0700 and C0800). She walked independently in her room, but she did not walk in the corridor at all during the assessment reference period. Her balance while moving from a seated to standing position, walking, and turning around was not steady, but she was able to stabilize without human assistance (G0300). She used a wheelchair as a mobility device, and she moved independently on the unit with set-up help only and off the unit with the assistance of one (1) person. As of 03/03/11, she had no falls since her prior MDS. A comprehensive annual MDS, with an ARD of 05/26/11, revealed no changes had occurred in her cognitive status since the previous MDS. She walked in her room and in the corridor only once or twice during the assessment period, and when walking in her room she received the assistance of one (1) person. Her balance while walking and turning around was not steady, but she was able to stabilize without human assistance (G0300). She used a wheelchair as a mobility device, and she moved on the unit and off the unit with supervision by one (1) person. As of 05/26/11, she had no falls since her prior MDS. An abbreviated quarterly MDS, with an ARD of 08/25/11, revealed no changes had occurred in her cognitive status since the previous MDS. She walked independently in her room, but she did not walk in the corridor at all during the assessment reference period. She used a wheelchair as a mobility device, and she moved on the unit and off the unit with supervision and set-up help. As of 08/25/11, she had no falls since her prior MDS. - Resident #54's current care plan, when reviewed on 10/03/11 at 1:40 p.m., was found to contain a focus area for High risk for falls r/t (related to) hx (history) of falls, impaired safety awareness, cognitive deficits. This problem statement was initiated on 03/07/11. The stated goal for this focus area was that the resident would not sustain serious injury from falls through 11/30/11. The only two (2) interventions were to be implemented to accomplish the goal were: HIGH FALL RISK: anticipate and meet patient's needs. Provide a safe environment for the patient by observing the condition of her room every shift and correcting any identified issues. These interventions, which were also initiated on 03/07/11, were not specific to this resident's needs and were found in the care plans of other residents reviewed for falls. - During an interview with a licensed practical nurse (LPN - Employee #23) on 09/27/11 at 12:19 p.m., she stated the resident had a fall on 09/02/11. - An incident report recording this fall, when reviewed at 1:00 p.m. on 10/03/11, stated the resident was found in a shower stall on the floor with her wheelchair in front of her on the morning of 09/02/11. A note at the end of the report, dated 09/06/11, stated (typed as written): IDT (interdisciplinary team) review report referral made to PT for screening resident transfers independently. - Further record review found no evidence that the PT screen, which had been requested by the IDT following the fall of 09/02/11, had been completed. During an interview with the administrator at 10:40 a.m. on 10/04/11, a PT screen dated 08/10/11 was provided, which stated: . at this time pt (patient) does not need skilled therapy. The administrator confirmed the facility failed to act upon the recommendation by the IDT for another therapy screening of Resident #54 in an effort to prevent further falls.",2016-01-01
9265,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-10-05,364,F,0,1,JZU011,"Based on observation and staff interview, the facility failed to assure the nutritive value and attractive appearance of food being served, by allowing the food to be held on the steam table for a prolonged period of time prior to service. This had the potential to affect all residents. Facility census: 55. Findings include: a) During an interview with the certified dietary manager (CDM - Employee #19) at 10:15 a.m. on 09/27/11, she informed this surveyor that the food for the noon meal would be placed on the steam table at 10:25 a.m. and that tray service would begin at 11:45 a.m. Observation of resident dining, at 12:15 p.m. on 09/27/11, found the broccoli on the trays was soft and mushy, even that which was served to residents who were to receive regular consistency foods, and it was lacking the full green color of the vegetable. During observation of food service in the kitchen at 11:20 a.m. on 09/28/11, all foods to be served at the noon meal were on the steam table. Holding temperatures, when checked, met and exceeded requirements, but the mashed potatoes were dry and brown at the edges meeting the pan. Plating of the food onto the trays began at 11:50 a.m., and the first cart left the kitchen at 12:00 noon. A second observation of food service took place at 10:30 a.m. on 10/05/11. Upon entry to the kitchen, the pureed carrots and pureed macaroni casserole were observed already on the steam table while Employee #42 was assembling supplies for serving. Holding temperatures were observed being checked by the cook / server (Employee #9) at 10:42 a.m., and the remaining food items to be served (regular consistency carrots and macaroni casserole) was placed on the steam table at that time. Food service for employees began at 10:50 a.m. on 10/05/11. In an interview with the CDM, who was present during the observations, she acknowledged that the food items do remain on the steam table over the allowable holding time of thirty (30) minutes, which is intended to assure that the nutritive value of the food is not compromised and/or destroyed and that the food retains it attractiveness.",2016-01-01
10400,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-12-30,279,D,1,0,2IT511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, observations, and staff interviews, the facility did not ensure that one (1) resident, of a sample of five (5), was provided a comprehensive care plan for being at high risk for aspiration. Resident #55 did not have a comprehensive care plan to include interventions for a high risk for aspiration. The resident's care plan did not provide for the resident to be placed in an upright position after being evaluated as a high risk for aspiration. Resident identifier: #55. Facility census: 54. Findings include: a) Resident #55 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dysphagia Oropharyngeal Phase, and History of Malignant Neoplasm Prostate. The resident, over the years in the facility, had deteriorated related to the [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident had been placed on palliative care. The family did not want gastric tube placement, but wanted the resident to be able to eat. The resident's diet order was for a pureed diet with honey consistency for fluids. The resident's quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], in Section K - Swallowing/Nutritional Status was identified as having coughing or choking during meals or when swallowing medication. This was a change from the annual MDS, with an ARD of [DATE], that had been coded to indicate the resident was not having any difficulty with coughing or choking during meals or when swallowing medication. The resident's care plan indicated, ""Risk of Aspiration r/t [MEDICAL CONDITION]. Resident Goals: Resident will have no s/s (signs / symptoms) of aspiration such as fever, choking, coughing with meals through [DATE]."" The interventions were: -- ""Monitor/document/report to physician PRN any s/s of aspiration or dysphagia, choking, fever, coughing. -- Obtain and monitor labs as ordered. Report results to attending physician. -- Consultation with Registered Dietician in accordance with physicians orders. -- Provide and serve pureed diet with honey thick liquids by spoon as ordered. -- Monitor and document % consumed each meal. -- Swallowing precautions."" The care plan was initiated on [DATE] and continued until the resident's death on [DATE]. The care plan interventions did not address the positioning of the resident during meals to lessen the risk of aspiration. A speech therapy evaluation and plan of treatment for [REDACTED]. Pureed/honey for the current diet order. A description of impairment indicated, moderate/severe for lingual ROM, lingual coordination, lingual strength, bolus cohesion, bolus manipulation, oral clearance, delayed swallowing, and slow elevation hyoLaryngeal excursion. Comments: Resident was re-evaluated related to improvement condition. Resident was made NPO, but family did no want PEG (percutaneous endoscopic gastrostomy, a tube for administering nourishment) tube. Resident was given small sips of honey liquid. A decrease in liquid coordination strength. Resident had cough post swallowing honey liquid. Family made aware of high aspiration risk of eating by mouth, but wanted resident to have meals anyway. Speech to treat for dysphagia."" Nursing notes, beginning on [DATE], and ending with the death of the resident on [DATE], indicated the resident had developed rhonchi (coarse rattling sounds, usually caused by secretions in [MEDICATION NAME] airways) in the lungs and an increase in temperature. The resident's temperature ranged from 98.0 to 100.8. The physician was notified and ordered a Tylenol suppository. A nursing note, on [DATE] at 5:30 p.m., indicated the resident had a choking spell while drinking milk and spit the milk out of his mouth. A chest x-ray was ordered on [DATE] when the resident began to show signs and symptoms of lung congestion. The chest x-ray was negative. An interview with the director of nursing, on [DATE] at 11:30 a.m., revealed the facility's policy ""Assisting the Impaired Resident with In-Room Meals"" explained to the staff how to position a resident during meals. She further stated, ""the staff has been educated on the facility policy for assisting with meals and the facility does not determine the elevation of the resident in degrees such as 90 or 45 degree elevation for eating."" A review of the facility policy ""Assisting the Impaired Resident with In-Room Meals"" revealed, ""the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position."" An interview with the administrator, on [DATE] at 10:40 a.m., revealed an allegation had been reported to the facility concerning a resident not being properly elevated while an aide was feeding the resident a dietary supplement (Magic Cup). The family member reported she had seen an aide feeding the resident while the resident was lying on his back in bed. The facility reported the allegation and during their investigation found that the aide had elevated the bed to a 25 degree only. The aide had not followed the facility's policy to make sure the resident was in an upright position. The facility substantiated the allegation. He determined the policy was all that was needed and that other information concerning the positioning of the resident during a meal was not necessary on the care plan. He further stated, ""Resident #55 received a chest x-ray on [DATE], after the incident with the aide not elevating the resident and later the resident was having trouble breathing. The chest x-ray did not show that anything was wrong with the resident's lungs."" The chest x-ray report, dated [DATE], indicated, ""No acute [MEDICAL CONDITION] process."" An observation of residents' rooms, on [DATE] at 11:10 a.m., revealed signs had been posted behind two (2) residents' beds noting the degree of elevation when eating meals and snacks. Resident #20 had a sign that indicated the resident was to be elevated to 90 degrees when eating meals and snacks. A review of the resident's care plan found it included a problem statement of ""choking episodes."" The interventions included, ""Supervision for resident to be at 90 degrees for all meals/snacks."" Resident #51 had a sign posted behind his bed revealing the resident's head was to be elevated at 30 degrees at all times. The resident was a receiving tube feeding. A review of the resident's care plan found it included ""Resident requires tube feeding r/t (related to) swallowing difficulties/poor po intake r/t [MEDICAL CONDITION]."" The interventions included, ""Aspiration precautions. Head of the bed elevated at all times."" Interviews with facility nursing staff revealed, information that was on each resident's care plan was pulled over to the kardex that was on the care-tracker on each hallway. The tracker was used by the nursing assistants to determine the care needs of the resident. An interview with a registered nurse, Employee #27, on [DATE] at 10:20 a.m., revealed all of the information on the care plan was pulled to the tracker system and a kardex was available for each resident. An interview with Employee #52, a nursing assistant (NA), on [DATE] at 10:50 a.m., revealed the kardex that was on the wall in the tracker allowed them to look up care areas for each resident if they did not know what to do for the resident. If the resident needed to be set up to eat and they did not know how high to raise the resident while in bed, they could look on the kardex and the care plan to find out how to position the resident. An interview with a NA, Employee #68, on [DATE] at 10:55 a.m., revealed, ""We check the computer on the wall if we are not sure of how to set up a resident to eat. "" The facility failed to provide a comprehensive care plan to include an intervention that would ensure nursing staff were aware of a resident needing to be placed in an upright position when eating. The potential for aspiration was evident related to Resident #55's swallowing evaluation performed by the speech therapist. .",2015-04-01
10401,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2011-12-30,309,D,1,0,2IT511,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** . Based on record review, staff interviews, and observations, the facility did not ensure that one (1) resident of a sample of five (5) received care and services to prevent the potential for aspiration. Resident #55 was not placed in an upright position before receiving a dietary supplement. The resident was evaluated by speech therapy and was listed as a high risk for aspiration. Facility census: 54. Findings include: a) Resident #55 The resident was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]., Dysphagia Oropharyngeal Phase, and History of Malignant Neoplasm Prostate. The resident, over the years in the facility, had deteriorated related to the [MEDICAL CONDITION] and [MEDICAL CONDITION]. The resident had been placed on palliative care. The family did not want gastric tube placement, but wanted the resident to be able to eat. The resident's diet order was for a pureed diet with honey consistency for fluids. The resident's quarterly minimum data set (MDS) assessment, with an assessment reference date (ARD) of [DATE], in Section K - Swallowing/Nutritional Status was identified as having coughing or choking during meals or when swallowing medication. This was a change from the annual MDS, with an ARD of [DATE], that had been coded to indicate the resident was not having any difficulty with coughing or choking during meals or when swallowing medication. The resident's care plan indicated, ""Risk of Aspiration r/t [MEDICAL CONDITION]. Resident Goals: Resident will have no s/s (signs / symptoms) of aspiration such as fever, choking, coughing with meals through [DATE]."" The interventions were: -- ""Monitor/document/report to physician PRN any s/s of aspiration or dysphagia, choking, fever, coughing. -- Obtain and monitor labs as ordered. Report results to attending physician. -- Consultation with Registered Dietician in accordance with physicians orders. -- Provide and serve pureed diet with honey thick liquids by spoon as ordered. -- Monitor and document % consumed each meal. -- Swallowing precautions."" The care plan was initiated on [DATE] and continued until the resident's death on [DATE]. The care plan interventions did not address the positioning of the resident during meals to lessen the risk of aspiration. A speech therapy evaluation and plan of treatment for [REDACTED]. Pureed/honey for the current diet order. A description of impairment indicated, moderate/severe for lingual ROM, lingual coordination, lingual strength, bolus cohesion, bolus manipulation, oral clearance, delayed swallowing, and slow elevation hyoLaryngeal excursion. Comments: Resident was re-evaluated related to improvement condition. Resident was made NPO , but family did no want PEG tube (percutaneous endoscopic gastrostomy, a tube for administering nourishment). Resident was given small sips of honey liquid. A decrease in liquid coordination strength. Resident had cough post swallowing honey liquid. Family made aware of high aspiration risk of eating by mouth, but wanted resident to have meals anyway. Speech to treat for dysphagia."" Speech therapy treated the resident until April of 2011. Nursing notes, beginning on [DATE], and ending with the death of the resident on [DATE], indicated the resident had developed rhonchi (coarse rattling sounds, usually caused by secretions in [MEDICATION NAME] airways) in the lungs and an increase in temperature. The resident's temperature ranged from 98.0 to 100.8. The physician was notified and ordered a Tylenol suppository. A nursing note, on [DATE] at 5:30 p.m., indicated the resident had a choking spell while drinking milk and spit the milk out of his mouth. A chest x-ray was ordered on [DATE] when the resident began to show signs and symptoms of lung congestion. The chest x-ray was negative. An interview with the director of nursing, on [DATE] at 11:30 a.m., revealed the facility's policy ""Assisting the Impaired Resident with In-Room Meals"" explained to the staff how to position a resident during meals. She further stated, ""the staff has been educated on the facility policy for assisting with meals and the facility does not determine the elevation of the resident in degrees such as 90 or 45 degree elevation for eating."" A review of the facility policy ""Assisting the Impaired Resident with In-Room Meals"" revealed, ""the resident should be positioned so his or her head and upper body are as upright as possible and with the head tipped slightly forward. If the resident is served his or her meal in bed, use wedges and pillows to achieve a nearly upright position."" An interview with the administrator, on [DATE] at 10:40 a.m., revealed an allegation had been reported to the facility concerning a resident not being properly elevated while an aide was feeding the resident a dietary supplement (Magic Cup). The family member reported she had seen an aide feeding the resident while the resident was lying on his back in bed. The facility reported the allegation and during their investigation found that the aide had elevated the bed to a 25 degree only. The aide had not followed the facility's policy to make sure the resident was in an upright position. The facility substantiated the allegation. He determined the policy was all that was needed and that other information concerning the positioning of the resident during a meal was not necessary on the care plan. He further stated, ""Resident #55 received a chest x-ray on [DATE], after the incident with the aide not elevating the resident and later the resident was having trouble breathing. The chest x-ray did not show that anything was wrong with the resident's lungs."" The chest x-ray report, dated [DATE], indicated, "" No acute [MEDICAL CONDITION] process. "" An observation of residents' rooms, on [DATE] at 11:10 a.m., revealed signs had been posted behind two (2) residents' beds noting the degree of elevation when eating meals and snacks. Resident #20 had a sign that indicated the resident was to be elevated to 90 degrees when eating meals and snacks. A review of the resident's care plan found it included a problem statement of ""choking episodes."" The interventions included, ""Supervision for resident to be at 90 degrees for all meals/snacks."" Resident #51 had a sign posted behind his bed revealing the resident's head was to be elevated at 30 degrees at all times. The resident was a receiving tube feeding. A review of the resident's care plan found it included ""Resident requires tube feeding r/t (related to) swallowing difficulties/poor po intake r/t [MEDICAL CONDITION]."" The interventions included, ""Aspiration precautions. Head of the bed elevated at all times."" Interviews with facility nursing staff revealed, information that was on each resident's care plan was pulled over to the kardex that was on the care-tracker on each hallway. The tracker was used by the nursing assistants to determine the care needs of the resident. An interview with a registered nurse, Employee #27, on [DATE] at 10:20 a.m., all of the information on the care plan was pulled to the tracker system and a kardex was available for each resident. An interview with Employee #52, a nursing assistant (NA), on [DATE] at 10:50 a.m., revealed the kardex that was on the wall in the tracker allowed them to look up care areas for each resident if they did not know what to do for the resident. If the resident needed to be set up to eat and they did not know how high to raise the resident while in bed, they could look on the kardex and the care plan to find out how to position the resident. An interview with a NA, Employee #68, on [DATE] at 10:55 a.m., revealed, ""We check the computer on the wall if we are not sure of how to set up a resident to eat. "" The facility failed to provide a comprehensive care plan to include an intervention that would ensure nursing staff were aware of a resident needing to be placed in an upright position when eating. The potential for aspiration was evident related to Resident #55's swallowing evaluation performed by the speech therapist. .",2015-04-01
10985,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2009-09-02,372,F,0,1,QHU011,"Based on observation and staff interview, the facility failed to properly dispose of garbage and refuse; the outdoor waste storage receptacle was not in good repair, with lids that could not be closed to prevent the harborage and feeding of pests. Facility census: 54. Findings include: a) During a tour of the dietary department with the dietary manager (Employee #70) on 09/01/09 at 4:00 p.m., observation found the facility's Dumpster was not in good repair, with lids that could not be closed to prevent the harborage and feeding of pests. Employee #70 confirmed the lids were broken off but was unable to relate how long the Dumpster had been in this condition. On 09/01/09 at 5:00 p.m., the environmental service supervisor (Employee #76) related the Dumpster had been in disrepair for several months, and they had been trying to get it replaced or fixed. .",2014-10-01
10986,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2009-09-02,225,D,0,1,QHU011,"Based on a review of the facility's complaint reports and staff interviews, the facility did not ensure two (2) of six (6) complaints reviewed, both of which contained allegations of abuse, were immediately reported to the appropriate State agencies as required by State law. Resident #10 alleged a nurse aide was rude and nasty to her. Resident #41 alleged a nurse aide sprayed the resident's neck with cold water. Resident identifiers: #10 and #41. Facility census: 54. Findings include: a) Resident #10 A review of the facility's ""Grievance Complaint Reports"" found the following complaint: ""Resident told me (social worker) that the aide that put her to bed the night before (04/08/09) was very rude and nasty to her."" An interview with the administrator (Employee #78), on 09/01/09 at 1:00 p.m., revealed the social worker would have called the corporate office before making a decision to submit the complaint as an allegation to the appropriate State agencies, and the decision was made to not report this complaint as an allegation of abuse. b) Resident #41 A review of the facility's ""Grievance Complaint Reports"" found the following complaint made on 05/25/09: ""Resident stated, I fell asleep in shower and a certified nursing assistant sprayed my neck with cold water. I'll never get over it."" An interview with the administrator, on 09/01/09 at 1:00 p.m., revealed the corporate office was contacted and determined that, because the event was not willful, the allegation was not submitted to the appropriate State agencies. .",2014-10-01
10987,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2009-09-02,241,E,0,1,QHU011,"Based on an observation and staff interviews, the facility did not ensure one (1) of thirteen (13) sampled residents and four (4) residents of random opportunity were provided care in an environment that would enhance each resident's dignity. Residents #4, #23, #36, #12, and #19 were observed lined up against the wall of the hallway seated in wheelchairs and a reclined geri chair. Each resident was placed by staff behind another resident. Facility census: 54. Findings include: a) Residents #4, #23, #36, #12, and #19 Observation, on 09/01/09 at 3:55 p.m., found five (5) residents parked in transport chairs against the wall of the hallway, with one (1) resident lined up behind another. Facility staff was observed lining the residents up along the length of the hallway. No interaction was observed by the staff with these residents. Interview with two (2) nurses (Employees #69 and #30), on 09/01/09 at 3:55 p.m., revealed the residents were brought out to the hallway by the nursing staff to wait for dinner. They had not thought about taking the residents into the dining room or somewhere else in the facility. In an interview on 09/01/09 at 4:00 p.m., the director of nursing (Employee #73) related she would find somewhere else in the facility to place the residents instead of putting them in the hallway. .",2014-10-01
10988,"CAMERON NURSING AND REHABILITATION CENTER, LLC",515125,"ROUTE 4, BOX 20",CAMERON,WV,26033,2009-09-02,323,D,0,1,QHU011,"Based on an observation and staff interviews, the facility did not ensure one (1) resident of a sample of thirteen (13) was provided an environment free of accident hazards. Resident #5 was observed attempting to go to the bathroom that did not have a functioning light switch. The bathroom was dark, and the resident was not able to see to use the bathroom. Facility census: 54. Findings include: a) Resident #5 Observation, during a tour of the facility on 08/31/09 at 7:00 p.m., found Resident #5 utilizing a walker to walk into the bathroom in the resident's room. The bathroom was dark, and the resident stated the light switch would not turn on the light in the bathroom. Resident #5 reported the light in the bathroom was not working all day, and she indicated she was very upset with trying to use the bathroom without a light. A nurse came into the resident's room and stated the light switch at the opening of the bathroom was not working properly. She walked through the bathroom and used a switch on the other side of the bathroom to turn on the light. An interview with an employee from the maintenance department confirmed the light switch was not working, and he stated he would fix it immediately. .",2014-10-01
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
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
3065,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,226,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, policy review, staff interview and family interview, the facility failed to investigate an injury of unknown origin for one (1) of three (3) residents reviewed for the care area of abuse. Resident #119 had a bruise of unknown origin on his hand. Resident identifier: 119. Facility census: 59. Findings include: a) Resident #119 Review of Resident #119's medical record began on 06/06/17 at 5:35 p.m. Resident #119 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. The physician's progress note dated 05/24/17 noted under Skin, Inspection: No rashes or ulcers. On 06/05/17 at 5:00 PM, an interview was conduced with a family member of Resident #119. The family member stated that she wasn't sure if Resident #119 had been abused. He has a bruise on his hand and we don't know where it came from. I had to show it to the nurse (Nurse #1). He (Resident #119) says they have hit him. He hasn't bruised at home. He said they were tearing his clothes off and roughing him up. (Nurse # 1) called me Saturday morning and said he had pinched someone else. The bruise happened on Saturday night and (Nurse #1) said that she thought he had hit the side rail. On 06/05/17 at 5:40 p.m., the Administrator was made aware of the allegation made by the family member of Resident #119. During an interview 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 asked her if she felt like he was being abused. She said that isn't what she meant, that she just wasn't told about it. She talked to the nurse on Saturday night about the bruise. I told her to see me or a manager if she ever thought there was abuse. I talked to (Nurse #1) on 06/03/17 around 5:00 a.m She stated Resident #119 was awake and combative. (Nurse #1) said she did not see bruising on 6/3/17, but did see it on 6/4. According to the Administrator, the Assistant Director of Nurses (ADON) said when Resident #119 was admitted , he had extensive bruising on his upper arms. It is documented in the admission assessment. On 06/06/17 at 5:10 p.m., an interview was conducted with the ADON #37. She stated she had completed the incident report for Resident #119's hand bruise. She noted in the report that Resident #119 was combative and had fragile skin. Resident #119 was admitted with bruising to both upper extremities. She had then documented the review was complete. The ADON stated that if there was more information related to the bruising, it would have been documented during her review. On 06/06/17 at 5:40 p.m, ADON #37 stated she completed the nursing assessment on admission for Resident #119. He had bruises up both of his arms. I think he just bruises easy. Review of the admission assessment at this time noted that Resident #119 had bilateral upper extremity bruising On 06/06/17 at 5:42 p.m., an observation was completed of Resident #119's arms. Bruising was noted to the back of both hands. The left darker than the right. No significant bruising was noted to his arms. An interview was completed with the Administrator on 06/07/17 at 8:30 a.m. The Administrator said they had collected statements about Resident #119's behaviors around the time of the bruising. However, there was no investigation into how the bruising may have occurred including statements from witnesses about potential causes. On 06/07/17 at 7:55 a.m., a review of progress notes dated 06/04/17 at 6:28 a.m. was completed. The progress note was written by Nurse #1 and documented, A change in condition has been noted. The symptoms include: Other change in condition bruises on both hands/wrist areas 06/03/17 at night. The note also documented the physician and the family were both notified. The facility policy and procedure for abuse was reviewed on 06/06/17 at 4:50 p.m. The policy noted that injuries of unknown origin would be investigated to determine if there was possible abuse.",2020-09-01
3066,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,242,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to provide a choice of bathing. This affected two (2) of three (3) residents reviewed for the care area of choices. Resident identifiers: #118 and #82. Facility census: 59. Findings include: a) Resident #118 Review of the clinical record began on 06/06/17 at 2:30 p.m., and revealed a face sheet indicating Resident #118 was admitted to the facility on [DATE]. On 06/05/17 at 12:20 p.m., an interview was conducted with Resident #118. She stated she had not been to the showerroom yet, but, they haven't asked when I want to go. During an interview, on 06/06/17 at 3:55 p.m., Nurse Aide (NA) #3 said, There is a shower schedule. They (residents) are assigned shower days based room numbers. When they are admitted , they find out when they have their showers. We usually don't go off the schedule. NA #3 showed the shower schedule book that listed bed numbers and days/shifts for showers. During an interview with Assistant Director of Nurses (ADON) #37, on 06/06/17 at 5:13 p.m., she stated that shower days and times are a set schedule based on bed assignment. b) Resident #82 Record review on 06/06/17 at 2:30 p.m. revealed a face sheet indicating Resident #82 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. During an interview with Resident #82 on 06/05/17 at 11:07 a.m. she stated she had no choice in the type of bathing she gets. They tell me what kind of bath to take. An interview conducted on 06/06/17 at 3:55 p.m. with Nurse Aide (NA) #3 . NA #3 said, There is a shower schedule. They (residents) are assigned shower days based room numbers. When they are admitted , they find out when they have their showers. We usually don't go off the schedule. NA #3 showed the shower schedule book that lists bed numbers and days/shifts for showers. The book did not include documentation of the bathing preference. On 06/06/17 at 5:13 p.m., an interview was completed with ADON #37. She stated that shower days and times are a set schedule based on bed assignment.",2020-09-01
3067,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,280,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review and staff interview, the facility failed to review and revise a fall care plan for Resident #77. This affected one (1) of nineteen (19) resident care plans reviewed. Resident identifier: #77. Facility census: 59. Findings include: a) Resident #77 Review of Resident #77's clinical record began on 06/06/17 at 3:00 p.m., and revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident's plan of care dated 05/11/17 included the following identified problem, Resident at risk for falls: impaired mobility, recent hospitalization , impaired vision, [MEDICAL CONDITION] (dizziness) requires help with transfers. The goal was Resident will have no falls with injury every day through review. The interventions were the following: Assist resident getting in and out of bed/wheelchair with use of gait belt and one assist. Assist resident with ambulation with one assist, gait belt using walker. Place call light within reach while in bed or close proximity to the bed. Remind resident to use call light when attempting to ambulate or transfer. When resident is in bed, place all necessary personal items within reach. Remind resident where items are located and not move items due to vision deficit. Monitor for and assist toileting needs. Therapy/Rehab-PT evaluation. Continued review of the medical record revealed the facility Risk Management System documentation identified the resident fell on [DATE] at 10:00 a.m. The documentation included, Resident in shower room transferring from shower chair to wheelchair with GB (gait belt) and walker and knees buckled. CNA (certified nursing assistant) lowered resident to floor on knees. Knees reddened no apparent injury noted. The plan of care was not reviewed or revised on 05/20/17 or thereafter to include the fall that occurred on 05/20/17. During an interview conducted on 06/06/17 at 3:30 p.m., Assistant Director of Nursing #37 verified the plan of care was not reviewed and revised to include the occurrence of the fall on 05/20/17.",2020-09-01
3068,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,281,E,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interviews and review of the Lippincott Manual of Nursing Practice (2014), the facility failed to meet professional standards of quality by not following a physician's orders [REDACTED]. This affected one (1) of five (5) residents reviewed for the medication regimen review. Resident identifier: 108. Facility census: 59. Findings include: a) 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 p.m., the blood sugar was 413 mg/dl --04/08/17 at 8:00 p.m., the blood sugar was 440 mg/dl --04/15/17 at 8:00 p.m., the blood sugar was 377 mg/dl --04/16/17 at 8:00 p.m., the blood sugar was 384 mg/dl --04/29/17 at 8:00 p.m., 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 p.m., the blood sugar was 382 mg/dl --05/07/17 at 8:00 p.m, the blood sugar was 360 mg/dl --05/13/17 at 8:00 p.m., the blood sugar was 356 mg/dl --05/18/17 at 8:00 p.m., the blood sugar was 354 mg/dl --05/19/17 at 8:00 p.m., the blood sugar was 423 mg/dl --05/20/17 at 8:00 p.m., the blood sugar was 387 mg/dl --05/21/17 at 8:00 p.m., the blood sugar was 396 mg/dl --05/22/17 at 8:00 p.m., 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 (ADON) #37 verified the lack of physician notification for the blood glucose levels greater than 350 on the aforementioned dates. On 06/08/17 at 8:43 a.m., an interview was conducted with the Director of Nurses (DON) #44. The DON stated, The order was for calling for a blood sugar for over 350 and we should have called for that. Review of the Lippincott Manual of Nursing Practice (2014), revealed the professional standard of nursing practice includes implementing a physician's orders [REDACTED].",2020-09-01
3069,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,282,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observations, staff interview and family interviews, the facility failed to follow the nutritional care plan for one (1) of residents whose care plans were reviewed. Resident identifier: #72. Facility census: 59. Findings include: On 06/02/17 at 1:20 p.m., the clinical record for Resident #72 was reviewed. Resident #72 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. A physician's orders [REDACTED]. The care plan was reviewed on 06/06/17 at 11:40 a.m. The care plan dated 05/03/17 noted Resident #72 was at risk for altered nutrition. The goal was for Resident #72 to eat at least 50% of her meals each day. Interventions included speech therapy 3 times a week and alert the dietitian and physician of any significant weight loss. Report decreases in meal intake to the physician. On 06/05/17 at 12:40 p.m., an observation of the lunch meal was completed. Resident #72's liquids were noted to be of normal consistency and not thickened as ordered. Her meal tray card on her tray noted she was to have honey thick liquids. A family member was assisting Resident #72 with feeding. Resident #72 was not observed choking. The family member stated that Resident #72 has not eaten well while she was here and has lost, about 20 pounds. An interview was conducted on 06/05/17 at 3:15 p.m. with Nurse Aide (NA) #3. She stated, We mix the thickener. We put in 2 packs per cup. In the dining room, we have a bowl. We use a spoon and eyeball it. They (liquids) all end up the same thickness. On 06/06/17 at 8:30 a.m., Resident #72 was observed eating breakfast. The breakfast tray was noted with thin liquids. There were 2 souffle cups of powdered thickener on the tray labeled honey thick. A family member was noted to be feeding Resident #72. The family member reported that staff usually add thickener when tray is brought in; not always; like this morning and lunch yesterday, but she is doing well with thin liquids. On 06/06/17 at approximately 10:30 a.m., the meal intake documentation for (MONTH) (YEAR) was reviewed. It was noted that for breakfast and lunch on 06/01/17; zero percent was eaten. On 06/05/17, 25% of dinner was eaten. The rest of the form was left blank. The (MONTH) meal intake documentation noted 36 meals with no documentation and 12 meals where no food was eaten. Percentages of food eaten ranged from 25% to 100%. An observation of the lunch meal was completed on 06/06/17 at 12:10 p.m. NA #26 delivered Resident #72's lunch tray and added white powder from a souffle cup labeled honey thick to the resident's lemonade. NA #26 was interviewed and stated that they have souffle cups labeled honey thick and nectar thick and that she adds whatever powder is in the cup to the liquids to get the ordered consistency. She stated that the powder is measured in the kitchen and there are no instructions on how the nursing assistants use the powder. NA #26 stated milk doesn't thicken as well so she adds a honey and a nectar powder to make a honey consistency. On 06/06/17 at 1:55 p.m., an interview was conducted with the Assistant Director of Nurses (ADON) #37. The ADON reported that she was familiar with Resident #72. Resident #72 was on a dysphagia, advanced texture (soft foods) with honey thick liquids. Nurses and nursing assistants thicken liquids on the floor. There are directions on the thickener cups. It says pudding, honey or nectar. They would add that (pre-poured powder) to the liquid and stir it. If they aren't sure, they would ask the nurse. It doesn't take a different amount of thickener to get the consistency, but hotter liquids take longer to thicken. Staff should mix the liquids for the resident. The kitchen staff have directions to oversee how to put the powder in the cups. I'm not sure why we don't buy any pre-thickened liquids. We don't have them. On 06/06/17 at 2:50 p.m, an interview was conducted with NA #2. NA #2 stated she was familiar with Resident #72. (Family member) was always here to feed her. She had thickened liquids. We would get thickener on our carts. We mix the liquids for her. We usually get a bowl with a scoop for the thickener. It comes out on the drink cart. We would use four scoops for honey and let it sit a little longer. It wasn't a measuring spoon, just a scoop. There is also nectar thick. It is two scoops. It isn't as thick. Honey is like a pudding and nectar isn't that thick. Milk doesn't take as much (thickener powder). It gets like ice cream. On 06/07/17 at 10:46 a.m., an interview was completed with the Director of Nurses (DON). The DON said the activities of daily living (ADL) form where food consumption would be documented) sheets are audited sometimes between shifts. I have some nursing assistants who we use to review the sheets. (Resident #72) 's family brought in food. It's hard to know how much she ate. They should have asked how much she ate and written it. She didn't eat much of our food.",2020-09-01
3070,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,323,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on clinical record review, resident interview and staff interview, the facility failed to comprehensively assess for intrinsic and extrinsic factors to provide supervision and prevent accidents. This affected one (1) of three (3) residents (#77) reviewed for the care area of accidents. Resident identifier: #77. Facility census: 59. Findings include: a) Resident #77 Review of Resident #77's clinical record conducted on 06/06/17 at 3:00 p.m. revealed the resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set assessment dated [DATE] indicated in section G0110B that the resident required two-person physical assistance with transfers. Continued review of the clinical record revealed the facility Risk Management System documentation identified the resident had fallen on 05/20/17 at 10:00 a.m. The documentation included Resident in shower room transferring from shower chair to wheelchair with GB (gait belt) and walker and knees buckled. CNA (certified nursing assistant) lowered resident to floor on knees. Knees reddened no apparent injury noted. Review of a Physical Therapy note dated 05/24/17 revealed, resident reported having a fall recently with staff in last 3-4 days when their legs bucked as they were assisting in a transfer to shower. States they went down on knees twice, some bruising noted to left shin. The clinical record did not contain a comprehensive fall assessment to determine any intrinsic and or extrinsic factors that may have led to the fall or to prevent further falls. During an interview conducted on 06/07/17 at 1:00 p.m. the resident stated there were 2 nursing assistants assisting with the shower transfer. She stated that her knees buckled and fell to the floor. She hit her knees twice on the floor. During an interview conducted on 06/06/17 at 3:30 p.m., Assistant Director of Nursing Staff #37 verified the lack of a comprehensive fall assessment to determine any intrinsic and or extrinsic factors that may have led to the fall in order to prevent a future fall.",2020-09-01
3071,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,325,G,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, resident interview, family interview, staff interview and policy review, the facility failed to monitor and intervene to identify weight loss for three (3) of three (3) residents reviewed for the care area of nutrition. Failure to monitor and implement interventions resulted in Resident #72 having an avoidable weight loss resulting in harm. Resident #72 had a 27-pound weight loss in 21 days (22.5% loss of body weight), and a discharge from therapy for lack of progress due to fatigue. Resident identifiers: #72, #2 and #117. Facility census: 59. Findings include: a) Resident #72 Record review began, on 06/06/17 at approximately at 11:32 a.m., revealed Resident #72 was admitted to the facility on [DATE]. [DIAGNOSES REDACTED]. Resident #72's admission weight was noted as 120 pounds. A physician's orders [REDACTED].#72 was to receive honey thick liquids. The nutritional assessment dated [DATE] revealed Resident #72: --Weighed 120 pounds; --Had no swallowing issues; --Was on a regular diet; and --Had a concern noted for intakes to be monitored. Review of the weight log found the following weights: --04/28/17 (admission weight): weight was 120 pounds --05/04/17: weight was 109 pounds; --05/11/17: weight was 104 pounds; and --05/19/17: weight was 93 pounds. Twenty-one (21) days after admission Resident #72 experienced an unexplained 27-pound weight loss or a loss of 22.5% of her total body weight. No weights were documented after 05/19/17. Review of the care plan dated 05/03/17 noted Resident #72 was at risk for altered nutrition with a goal to eat at least 50% of her meals each day. Interventions included: --Speech therapy three (3) times a week; --To alert the dietitian and physician of any significant weight loss; and --To report decreases in meal intake to the physician. Review of the medical record revealed a physician's note dated 05/17/17 specified Resident #72 still weighed 120 pounds which was inaccurate according to the weight log. Resident #72 had two (2) noted weight losses indicating severe weight loss since admission by the date of this physician's note. A discharge note dated 06/01/17 by the physician also noted that Resident #72 still weighed 120 pounds which was inaccurate according to the weight log. Resident #72 had three (3) noted weight losses indicating severe weight loss since admission by the date of this discharge note by the physician. A physician note dated 05/30/17 noted Resident #72 was chronically undernourished. This issue was not addressed by the plan of care. Continued review of the clinical record revealed a progress noted titled Weight Warning written by the Assistant Director of Nursing (ADON) on 06/01/17. The note documented a 27-pound weight loss and that Resident #72 was on calcium and vitamin D as supplements. The record noted, Resident #72 received a dysphagia diet with advanced texture with poor appetite, and the physician and dietician aware of the variance. On 06/05/17 at 12:40 p.m., an observation of the lunch meal was completed. Resident #72 ate approximately 50 percent of her meal. At the time of the observation, a family member was assisting Resident #72 with feeding. Resident #72 was not observed choking. The family member stated that Resident #72 has not eaten well while she was here and has lost about 20 pounds. On 06/06/17 at 8:30 a.m., Resident #72 was observed eating breakfast. The breakfast tray was noted with thin liquids, not honey thick liquids as ordered. Resident #72 ate approximately 50% of her breakfast. An observation of the lunch meal was completed on 06/06/17 at 12:10 p.m. NA #26 delivered Resident #72's lunch tray. Resident #72 ate approximately 50 percent of her lunch. A follow up interview was completed with a family member on 06/06/17 at 12:15 p.m. The family member stated Resident #72 was being discharged home today and stated, Today was her last day in therapy. She wasn't progressing so therapy stopped. We are going to go home and will have people come in there. Review of the Weights and Heights policy found residents are weighed on admission and weekly for 4 weeks, then at the discretion of the interdisciplinary care team. On 06/06/17 at 1:55 p.m., an interview was completed with the Assistant Director of Nursing (ADON) #37. The ADON reported she was familiar with Resident #72. She stated, Residents get weighed monthly after the admission weights unless the registered dietitian (RD) or doctor sign off to do them more often. We would do weights more often if a resident is consistently losing weight. The ADON acknowledged Resident #72 was losing weight. She stated Resident #72 should have been put on weekly weights. She further stated a 5% weight loss in a month would trigger weekly weights. She also stated NAs do the weights. She said, If they see a big discrepancy, they know to get me a follow up weight. If it's a 5-pound weight loss, I would have them re-weigh. The NA's write the weights down on paper and give them to me. I enter them in the computer. I missed putting a request in for weekly weights. I get a weight warning if there is a 5% weight change and then I make a note (with the Weight Warning). Resident #72 was not on a nutritional supplement. Speech was involved with her. We put her on (antidepressant) for weight loss. The only dietary evaluation was on 05/03/17. After the note on (06/01/17 Weight Warning), I would notify the doctor and we would have weighed her again this week. I haven't notified the RD yet. I haven't seen him. She had a problem refusing meals and her appetite wasn't good. I would have told the doctor already. He's here every day. She was on a dysphagia, advanced texture (soft foods) with honey thick liquids. Our system sends out notices after 30 days when weights are put in. It doesn't calculate weight changes with each weight. Weekly weights aren't evaluated as they are entered. Calculations are just done every 30 days. On 06/06/17 at 2:50 p.m., an interview was completed with NA #2. NA #2 stated she was familiar with Resident #72 and (Family member) was always here to feed her. An interview was completed with Therapy Director #81 on 06/06/17 at 3:03 p.m. Therapy Director #81 said, We worked with (Resident #72) in speech, physical and occupational therapy. She didn't progress well. We improved her bed mobility slightly. Services were stopped about a week ago. She wasn't making improvements. She fluctuated, but towards the end declined some. She would fatigue easily. She didn't eat very well. It probably affected her energy level along with her body positioning. On 06/07/17 at 7:05 a.m., an interview was completed with RD #84. RD #84 said There is a weight exception report that can be looked at any time. It should be done monthly. It shows if there has been a significant change. If there is a change in the weekly weights, the nurses would need to let us know. The report looks back 30 days. We make notes on admission and quarterly. If they have a weight issue or a pressure ulcer the system will flag for a monthly note. Reviewed resident's chart. I would have started daily weights with the drops she had. We would start a supplement if we found something that she would like. An interview was completed with Speech Therapist (ST) #79, on 06/07/17 at 9:00 a.m., revealed she was working with Resident #72 on her swallowing. ST #79 said, She came in on thin liquids and nursing downgraded her to honey thick liquids because she was having trouble swallowing. On bad days, she would still have trouble swallowing so I left her on honey thick for the facility staff. Her eating fluctuated. Some days she swallowed well and some days she had a lot of problems where I wouldn't even try to give her anything by mouth. She had a significant decline while she was here. I thought she would be back on thin liquids. At one point, she had to go out for a blood transfusion. By the end of therapy, I think they did a lot in bed because she couldn't get up as much. When I first met her, she was very pleasant and alert. Two weeks ago, she was completely different. She was agitated and wouldn't cooperate. On the last day, she looked better than the last couple weeks. On 06/06/17 at 10:30 a.m., the meal intake documentation for (MONTH) (YEAR) was reviewed. It was noted that for breakfast and lunch on 06/01/17; zero percent was eaten. On 06/05/17, 25% of dinner was eaten. The rest of the form was left blank. The (MONTH) meal intake documentation noted 36 meals with no documentation and 12 meals where no food was eaten. Percentages of food eaten ranged from 25% to 100%. On 06/07/17 at 10:46 a.m., an interview was completed with the Director of Nurses (DoN). The DoN said the Activity of Daily Living (ADL) sheets are audited sometimes between shifts. She stated, I have some NAs who we use to review the sheets. (Resident #72) 's family brought in food. It's hard to know how much she ate. They should have asked how much she ate and written it. She didn't eat much of our food. The facility failed to monitor Resident #72's weight, failed to notify the physician and dietician of the weight loss, failed to consistently document meal intake, failed to order supplements or meal substitutions, failed to continue to monitor weight, failed to follow the facility weight loss policy, and failed to address the weight loss on the care plan. This failure resulted in harm to Resident #72 experiencing an avoidable t27-pound weight loss in 21 days (22.5% loss of body weight), and a discharge from therapy for lack of progress due to fatigue. b) Resident #2 Record review on 06/06/17 at 1:00 p.m. revealed Resident #2 was admitted to the facility on [DATE]. Among the resident's [DIAGNOSES REDACTED]. The resident had a physician order [REDACTED]. Further review of the clinical record at 1:00 p.m. on 06/06/17 revealed the actual recorded weights in the Vital section of the electronic medical record for the resident were as follows: --05/03/17 weight = 152.6 pounds --05/11/17 weight = 152.8 pounds --05/30/17 weight = 134.2 pounds --06/02/17 weight = 139.0 pounds The first recorded weight was 13 days after admission. Subsequent weights did not comply with the ordered weekly weights for the first month following admission. The weight recorded on the initial nutrition assessment was pulled from a previous admission for the resident (09/01/16 = 154.4 pounds). During a 06/06/17 at 2:00 p.m., interview with the ADON #37, she stated the resident had not refused to be weighed per the ordered schedule. On 5/30/17 a Weight Warning was generated by the electronic medical record based on declining weight entries. ADON #37 responded to the warning with the following note: Resident with medications of Vitamin D as a dietary supplement and [MEDICATION NAME] for generalized [MEDICAL CONDITION]/AFIB/pulmonary HTN. admitted with [MEDICAL CONDITION] to LT LE and which has now resolved. Resident admitted with diet Regular diet and then changed to NAS per RD. Resident #2's nutritional care plan dated 04/26/17 was reviewed on 06/06/17 at approximately 2:00 p.m. The care plan established a goal that the resident would maintain a stabilized weight with no significant changes for the next 90 days. The care plan also directed staff to weigh per protocol and alert dietitian and physician to any significant loss or gain. There had been no subsequent nutrition notes since the 04/26/17 initial nutrition assessment despite a significant decline in weight (152.6 pounds to 134.2 pounds / an 18.4 pound loss from 05/03/17 to 05/30/17). Interview with the DON #44 on 06/07/17 at 11:00 a.m. identified diuresis as the primary cause of the weight loss. While diuresis might explain the weight loss, the resident's care plan which directed staff to alert the dietitian and physician had not been implemented. During interview with the Resident #2 on 06/07/17 at 11:30 a.m., she stated she had recently regained her appetite, was no longer in as much pain related to her fractures and found the meals to be tasty. c) Resident #117 During review of the clinical record on 06/06/17 at 11:00 AM., it was noted Resident #117 had an order dated 05/12/17 which stated, Weigh weekly x 4 from date of admission then monthly. Among the resident's [DIAGNOSES REDACTED]. The actual weights recorded in the Vitals section of the electronic medical record for the resident were: --05/17/17 = 195.0 --05/19/17 = 173.0 --06/02/17 = 159.6 During a 06/06/17 at 2:00 p.m. interview with the ADON #37, she stated the resident had not refused to be weighed per the ordered schedule. The first weight was obtained 5 days after admission and subsequent weights did not comply with the ordered weekly weights for the first month following admission. The resident's nutritional care plan developed on 05/17/17 and reviewed on 06/06/17 at 11:00 a.m. stated to, Monitor for changes in nutritional status (changes in intake, ability to feed self, unplanned weight loss/gain, abnormal labs) and report to food and nutrition/physician as indicated. There had been no subsequent nutrition notes to acknowledge the 35 pound weight loss since admission. During interview with Resident #117 on 06/07/17 at 3:00 p.m., she stated that staff had used a hoyer lift for her transfers and a scale was available on the lift. She recalled that she had asked staff to tell her the weight, but she could not recall when or what the weight had been.",2020-09-01
3072,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2017-06-08,365,D,0,1,FLLM11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview, observation, record review and policy review, the facility failed to provide thickened liquids in accordance with physician orders. This affected two (2) of five (5) residents residents in the facility ordered to receive thickened fluids at the onset of the survey on 6/05/17. Resident identifiers: #72 and #68. Facility census: 59. Findings include: a) Resident #72 The clinical record for Resident #72 was reviewed on 06/06/17 at 1:20 p.m. Resident #72 was admitted to the facility on [DATE] and had a [DIAGNOSES REDACTED]. The physician's orders [REDACTED].#72 was to receive honey thick liquids. On 06/05/17 at 12:40 p.m., an observation of the lunch meal was conducted. Resident #72's liquids were noted to be a normal consistency and not thickened. Her tray card noted she was to have honey thick liquids. An interview was completed on 06/05/17 at 3:15 p.m. with Nursing Assistant (NA) #3. NA #3 stated, We mix the thickener. We put in 2 packs per cup. In the dining room, we have a bowl. We use a spoon and eyeball it. They (liquids) all end up the same thickness. On 06/06/17 at 8:30 a.m., Resident #72 was observed eating breakfast. The breakfast tray was noted with thin liquids. There were 2 souffle cups of powder thickener on the tray labeled honey thick. A family member was noted to be feeding Resident #72. The family member reported that staff usually add thickener when tray is brought in; not always; like this morning and lunch yesterday, but she is doing well with thin liquids. An observation of the lunch meal was completed on 06/06/17 at 12:10 p.m. NA #26 delivered Resident #72's lunch tray and added the thickener from a souffle cup labeled honey thick to lemonade. NA #26 was interviewed at the time of the observation and stated that they have cups labeled honey thick and nectar thick and that she adds whatever powder is in the cup to the liquids to get the ordered consistency. She stated that the powder is measured in the kitchen and there are no instructions on how the nursing assistants use the powder. NA #26 stated that milk doesn't thicken as well so she adds a honey and a nectar powder to make a honey consistency. On 06/06/17 at 1:55 p.m., an interview was completed with the Assistant Director of Nurses (ADON) #37. The ADON reported that she was familiar with Resident #72. She was on a dysphagia, advanced texture (soft foods) with honey thick liquids. Nurses and nursing assistants thicken liquids on the floor. There are directions on the thickener cups. It says pudding, honey or nectar. They would add that (pre-poured powder) to the liquid and stir it. If they aren't sure, they would ask the nurse. It doesn't take a different amount of thickener to get the consistency, but hotter liquids take longer to thicken. Staff should mix the liquids for the resident. The kitchen staff have directions to oversee how to put the powder in the cups. I'm not sure why we don't buy any pre-thickened liquids. We don't have them. On 06/06/17 at 3:15 p.m., a review of an undated and untitiled document identified as a current in-service being done with all nurses and nursing assistants was completed. Written directions note that 15cc cubic centimeters) of thickening powder is to be added to 8 ounces of liquids for nectar and 45cc of thickened powder is to be added to 8 ounces of thinned liquids for honey thickness. A measurement of the amount of liquids seen in beverage cups being given to residents noted that each glass contained approximately 6 ounces of fluids. A review of the Dysphagia Diet-Liquids policy dated 10/31/16 was reviewed on 06/07/17 at approximately 11:00 AM. The policy noted, Cold beverages on the menu for nectar-like and honey-like are purchased commercially thickened in bulk. Commercially thickened water for nectar-like and honey-like consistency is available on the nursing unit. b) Resident #68 During dining room observations on 06/05/17 at 12:00 p.m., it was observed that Resident #68, who had an order for [REDACTED]. Facility Staff #31 was interviewed about the consistency of the lemonade. The lemonade was checked by Facility Staff #31 and found it to be unthickened and took the glass of lemonade to the beverage cart in the dining room. From the beverage cart she took an unlabeled 8 ounce glass filled with white powder and shook approximately two teaspoons into the glass of lemonade and stirred it with a coffee stir stick. She returned the lemonade to the resident, offered her a drink which the resident accepted, and left the table to continue with meal service. The resident was then observed to independently take sips of lemonade. Assistant Director of Nursing (ADON) #37 was interviewed on 06/06/17 at 2:00 p.m. about staff training regarding thickened fluids. She stated that it is covered in new employee orientation but could provide no materials to confirm it was part of the curriculum. On 06/07/17 at 11:00 a.m., Facility Staff #79, the Speech and Language Pathologist, was interviewed regarding whether she had been involved in development of a facility policy for thickened liquids. She stated she had not been involved in the policy development or training and it would be her preference that a gel product would be used rather than the powder the facility is using.",2020-09-01
3073,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2018-08-30,656,D,0,1,UDIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify and develop a care plan related to a resident's risk for opiate-related constipation. This was evident for one (1) of twenty-four (24) sampled residents. Resident identifier: #49. Facility census: 56. Findings included: a) Resident #49 Medical record review on 08/27/18 found this resident had orders for both scheduled and as needed (prn) opiate pain medication. --On 07/18/18 the physician ordered [MEDICATION NAME] five (5) milligrams (mg) sublingually three (3) times daily for severe pain. --On 06/06/18 the physician ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. every six (6) hours as needed (prn) for severe pain. Manufacturer's guidance for these opiod pain medications includes the risk that opiod induced constipation is the most common and debilitating side effect of opiods. The concentration of opiod receptors in the gastrointestinal tract is highly dense. Activation of these receptors inhibits gastric emptying, reduces mucosal secretions and increases fluid reabsorption. These factors cause stool to be hard and dry, and constipation may ultimately develop. Review of the (MONTH) Medication Administration Record [REDACTED]. orally. Review of the care plan on 08/28/18 found that the care plan did not address the risk of opiate related constipation. On 08/29/18 at 10:40 AM an interview was conducted with the director of nursing (DON) and the assistant director of nursing (ADON). The ADON said the risk for opiate related constipation should have been identified and care planned, and it was not. At 11:00 AM on 08/29/18 the DON said the constipation risk related to opiate use is now care planned.",2020-09-01
3074,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2018-08-30,684,D,0,1,UDIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to implement physician's orders for bowel protocol for a resident who went greater than three (3) consecutive days without a bowel movement. This was evident for one (1) of twenty-four (24) sampled residents. Resident identifier: #49. Facility census: 56. Findings include: a) Resident #49 Medical record review on 08/27/18 found this resident had orders for both scheduled and as needed (prn) opiate pain medication. --On 07/18/18 the physician ordered [MEDICATION NAME] five (5) milligrams (mg) sublingually three (3) times daily for severe pain. --On 06/06/18 the physician ordered [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. every six (6) hours as needed (prn) for severe pain. Manufacturer's guidance for these opiod pain medications includes the risk that opiod induced constipation is the most common and debilitating side effect of opiods. The concentration of opiod receptors in the gastrointestinal tract is highly dense. Activation of these receptors inhibits gastric emptying, reduces mucosal secretions and increases fluid reabsorption. These factors cause stool to be hard and dry, and constipation may ultimately develop. Review of the (MONTH) medication administration record (MAR) found he received fifty-two (52) doses of [MEDICATION NAME] sulfate five (5) milligrams (mg) sublingually, and he received nine (9) doses of [MEDICATION NAME]-[MEDICATION NAME] 5-325 mg. orally. This resident's bowel movement (BM) record, medication administration record, and nurse progress notes were reviewed. There were three (3) separate weeks in August, (YEAR), where he went greater than three (3) consecutive days with no evidence of having had a bowel movement. There was no evidence that he received medication(s) to treat those absences of bowel movements after three (3) consecutive days as follows: --Per the daily BM sheet, this resident had a BM on 08/06/18. There was no evidence that he had a BM during the first five (5) days of August. Review of the medication administration record (MAR) and nurse progress notes found no evidence that any treatment was offered and/or provided for the absence of BM's during this five (5) consecutive day period of time. --Per the daily BM sheet, this resident had an extra large BM during the day shift on 08/11/18, but none again until day shift on 08/19/18. This amounted to seven (7) consecutive days without a BM. The letters MOM (abbreviation for Milk of Magnesia) was written on the the BM sheet on 08/18/18, which was the seventh consecutive day with no evidence of having had a BM. There was no mention of the time of day the MOM was given. He had a large BM on 08/19/18 on the evening shift. --Per the daily BM sheet, he had a large BM during the evening shift on 08/19/18. The next BM was described as large, and occurred on 08/24/18 on the day shift. Review of the MAR and nurse progress notes found no evidence that any treatment was offered and/or provided for the absence of BM's during this four (4) consecutive day period of time. Review of the facility's standing orders for constipation stated the following four (4) point protocol: --If no bowel movement (BM) in three (3) days, give Milk of Magnesia thirty (30) milliliters (ml) orally one dose at bedtime. --If no BM within the next shift, give one (1) dose of [MEDICATION NAME] suppository per rectum. --If no BM within two (2) hours, give a Fleet enema --If no results from Fleet enema, call the physician for further orders. Review of this resident's daily BM sheet found directives to record BM's daily. Following that directive was the above referenced four (4) point protocol to follow if there was no BM in three (3) days. Review of the Activities of Daily Living (ADL) book for August, (YEAR), found that through all three (3) shifts he was assessed as either having had no transfers, limited assist or extensive assist for transfers, or dependent for transfers. Review of the ADL book for August, (YEAR), found that through all three (3) shifts he was assessed as either dependent on staff for toileting, or limited assist or extensive assist for toileting. One time noted toileting with supervision on 08/15/18 day shift. [DIAGNOSES REDACTED]. An interview with nursing assistant Employee #20 (E#20) was conducted on 08/29/18 at 9:30 AM. She said she was familiar with this resident and often worked with him. She said he walks with the therapy department staff. She said he is capable of going into the bathroom by himself, but he is a fall risk and is not supposed to go by himself. She said he must be supervised. She said he has bed and wheelchair alarms that he sometimes removes. Upon inquiry, she said that in the past month she has not seen him go into the bathroom by himself. She said some days when staff take him to the bathroom he stays in there alone and pulls the call bell cord when he's finished. She said that on other days staff stay in the bathroom with him until he finishes. She said this all depends on his abilities on a given day. She said he has been better asking for help going into the bathroom since his fall with major injury in June, (YEAR). She said they write in the ADL book whenever he has a BM. An interview was conducted with the assistant director of nursing (ADON) on 08/29/18 at 10 AM. She reviewed the August, (YEAR), BM sheet and the gaps between the BM's. She reviewed the August, (YEAR), ADL sheets. She said she will look for evidence of BMs elsewhere in the medical record. On 08/29/18 at 10:40 AM an interview was conducted with the director of nursing (DON) and the ADON. They said that he has behaviors, does not like to be told what to do, and has been known to remove alarms and go to the bathroom alone. The DON said his sister works here part-time and is aware of those behaviors and allegedly gets onto him about it. They said that even though he should not do so, that he can sneak to the bathroom after removing his alarm from the bed or the wheelchair. They said they thought perhaps that he had BM's that no one knew about. Upon inquiry, they said that he has the cognitive ability to say at the end of a shift, if asked, if his bowels moved or not. They acknowledged that someone should have been asking him, then documenting each shift. Prior to exit on 08/30/18, they were unable to provide evidence of BM's during the month of August, (YEAR), other than those identified on the daily BM sheet. They were unable to provide evidence that the physician's standing orders for bowel protocol was offered or initiated in (MONTH) (YEAR) on those occasions in (MONTH) when he went three (3) consecutive days with no evidence of having had a BM.",2020-09-01
3075,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2018-08-30,759,D,0,1,UDIG11,"**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 medication error rate not greater than five percent (5%). Based on two (2) medication administration errors out of twenty-seven (27) opportunities, the facility's medication error rate was 7.41%. This affected one (1) of three (3) residents observed during medication pass. Resident identifier: #43. Facility census: 56. Findings included: a) Resident #43 On 08/28/18 at 8:41 AM, licensed nurse employee #30 (E#30) poured a twenty-five (25) milligram (mg) [MEDICATION NAME] (anti-hypertensive medication) for Resident #43. The label on the blister pack of medication said this card of pills were each 25 mg. pills. The label directed to give three (3) tablets to equal 75 mg. The nurse then poured the next medication for this resident. After surveyor intervention, E#30 checked the electronic record and found the order for [MEDICATION NAME] was fifty (50) mg. at this time, which amounted to two (2) tablets. E#30 acknowledged that she had only poured 25 mg. when the physician's order called for 50 mg. At 9:00 AM on 08/28/18, E#30 gave a Breo Ellipta inhaler to Resident #43. He asked where his [MEDICATION NAME] inhaler was. E#30 told him this was what the pharmacy sent for him. He then took one (1) inhalation of the Breo Ellipta. The box which contained the Breo Ellipta had previously been opened. The date in which the inhaler was first opened for use had previously been inscribed on the Breo box with black marker. On 08/28/18 at 9:25 AM during reconciliation of the medications observed during medication pass, it was found that this resident had no physician's order for Breo Ellipta. Instead, the physician ordered [MEDICATION NAME] Diskus Aerosol Powder 250-50 one inhalation twice daily for [MEDICAL CONDITION], which he did not receive this morning. An interview was conducted with the assistant director of nursing (ADON) on 08/28/18 at 9:30 AM. It was discussed that the pharmacy label on Resident #43's blister pack of [MEDICATION NAME] directed to give three (3) twenty-five (25) mg. tablets to make a 75 mg. dose, whereas the physician's order directed to give fifty (50) mg. Prior to surveyor intervention, the nurse poured only one (1) twenty-five mg. dose. This was corrected prior to administering the medication to the resident. It was also discussed that the physician ordered [MEDICATION NAME] Diskus inhaler twice daily for Resident #43. However, E#30 instead administered a Breo Ellipta inhaler to the resident, but not the [MEDICATION NAME] inhaler. The ADON said that the pharmacy probably substituted Breo for the [MEDICATION NAME] inhaler. On 08/28/18 at 9:35 AM an interview was conducted with E#30. She said the Breo Ellipta belonged to Resident #19. She said she gave Resident #19's Breo inhaler to Resident #43 this morning in error. This finding was immediately relayed to the ADON by the surveyor at this time. During exit on 08/30/18, the DON provided further evidence to attest that the pharmacy included a warning/alert label on the blister pack of [MEDICATION NAME] for Resident #43 after the physician had ordered a dosage change on 08/07/18 from seventy-five (75) mg. three (3) times daily down to fifty (50) mg. three (3) times daily.",2020-09-01
3076,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2018-08-30,880,D,0,1,UDIG11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to administer an inhaler while using appropriate infection control procedure. This was evident for one (1) of three (3) residents observed for medication administration. Resident identifier: #43. Facility census: 56. Findings included: a) Resident #43 At 9:00 AM on 08/28/18, licensed nurse Employee #30 (E#30) gave a Breo Ellipta inhaler to Resident #43 (R#43). He asked where his [MEDICATION NAME] inhaler was. E#30 told him this was what the pharmacy sent for him. He then took one (1) inhalation of the Breo Ellipta. The box which contained the Breo Ellipta had previously been opened. The date in which the inhaler was first opened for use had previously been inscribed on the Breo box with black marker. On 08/28/18 at 9:25 AM during reconciliation of the medications observed during medication pass, it was found that R#43 had no physician's order for Breo Ellipta. Instead, the physician ordered [MEDICATION NAME] Diskus Aerosol Powder 250-50 one inhalation twice daily for [MEDICAL CONDITION], which he did not receive this morning. An interview was conducted with the assistant director of nursing (ADON) on 08/28/18 at 9:30 AM. It was discussed that the physician ordered [MEDICATION NAME] Diskus inhaler twice daily for R#43. However, E#30 instead administered a Breo Ellipta inhaler to the resident, but not the [MEDICATION NAME] inhaler. The ADON said that the pharmacy probably substituted Breo for the [MEDICATION NAME] inhaler. On 08/28/18 at 9:35 AM an interview was conducted with E#30. She said the Breo Ellipta belonged to Resident #19 (R#19). She said she gave R#19's Breo inhaler to R#43 this morning in error. It was immediately relayed to the ADON by the surveyor at this time that R#43 used an inhaler this morning which was used by R#19. Review of R#19's medical record on 08/28/18 at 10:00 AM found that R#19 had no signs or symptoms or [DIAGNOSES REDACTED].",2020-09-01
3077,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,561,D,0,1,MFEO11,"Based on staff interview, resident interview and record review, the facility failed to accommodate the Resident's preferences for showers. This was true for one (1) of two (2) Residents reviewed in the care area of choices. Resident identifier: #9. Facility census: 61 Findings included: a) Resident #9 During an interview on 10/07/19 at 1:52 PM, Resident #9 stated she did not get her baths on scheduled her days, they are often short staffed and put it off until the next day or even later. The Resident stated, They tell me they will be back later to get me (for shower) but they never do come back. On 10/08/19 at 12:15 PM review of shower logs and Activity Daily Living (ADL) record with Director of Nursing (DON) revealed documentation does not match between the two records. DON stated they get in hurry and go down through (ADL sheet) and mark it up. DON agreed that some shower dates are missing and she cannot say for sure that the Resident received a shower on these dates. Record review indicated the Resident's shower scheduled days were Tuesday and Friday evening. In (MONTH) of 2019 the Resident had 9 opportunities for showers for dates of: 08/02/19, 08/06/19, 08/09/19, 08/13/19, 08/16/19, 08/20/19, 08/23/19, 08/27/19, 08/30/19. Shower log indicates Resident only received showers for five (5) out of (9) opportunities on the following dates in (MONTH) 2019: 08/06/19, 08/13/19, 08/16/19, 08/20/19, 08/23/19. ADL record for (MONTH) 2019 indicates no showers given, bed baths only. In (MONTH) of 2019, the Resident had seven (7) opportunities for showers for the dates of: 09/03/19, 09/06/19, 09/10/19, 09/13/19, 09/17/19, 09/20/19, 09/24/19, 09/27/19. Shower log for (MONTH) 2019 indicates Resident only received showers four (4) showers in (MONTH) for the following dates: 09/2/19, 09/13/19, 09/20/19, 09/27/19. ADL record sheet for (MONTH) revealed a shower was given on 09/13/19 with only bed bathes the rest of month, and no bathing on 09/07/19. Review of Grievance and Concern Forms on 10/09/19 at 12:00 PM indicated the Resident had filed a grievance and concern on 05/13/19 that stated her showers were not being offered to her at the time she preferred. Resolution of Grievance indicated staff were re-educated regarding the Residents preference of shower times and the importance of ensuring preferred times were adhered to, in accordance with communicating changes with the Resident's shower schedule in advance if times need adjusted so Resident is aware.",2020-09-01
3078,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,584,D,0,1,MFEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the staff failed to maintain a clean, safe comfortable environment for residents. room [ROOM NUMBER]A had exposed sheetrock beside resident's bed. The foot board on the bed in room [ROOM NUMBER]B had no protective covering which exposed the wood. This practice had the potential to affect a limited number. Rooms identifiers: 406A, 405B. Facility census: 62. Findings included: a) room [ROOM NUMBER]A Observed on 10/07/19 at 12:48 PM, chunks of sheet rock missing from the wall beside resident's bed. b) room [ROOM NUMBER]B Observed on 10/07/19 at 1:00 PM, the protective covering on the footboard of resident's bed in room [ROOM NUMBER]B was peeled away and wood was exposed. In interview with the Maintenance Director on 10/09/19 at 3:25 PM, he stated that he was aware of the sheet rock issue in room [ROOM NUMBER]A and would check out the condition of the bed in room [ROOM NUMBER]B and replace the foot board.",2020-09-01
3079,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,600,K,0,1,MFEO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on policy and procedure review, incident report review, resident interview, and staff interview, the facility failed to ensure residents were free from verbal, psychological and physical abuse when confronted with resident to resident altercations. This practice caused actual harm to Resident #307 and #5. Resident #307 experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by crying shaking, and showing signs of sadness. Resident #5 was experienced actual harm, by Resident #8 through verbal and mental abuse, as evidenced by expressing feealings of fear and being unsafe. The actual harm and immediate jeopardy was further evident by the fact the facility did not report, investigate, nor put protections in place to safeguard residents from Resident #8, who had exhibited numerous incidents of verbal, mental and physical aggression towards residents and staff. The Centers for Medicare and Medicaid Services determined this deficient practice was an immediate jeopardy. State Agency surveyors notified the facility administrator of the immediate jeopardy on 11/04/19 at 12:32 PM. The facility abatement plan was approved through verification of implementation on 11/04/19 at 4:50 PM. The facility's abatement plan included: 1. Resident # 8 no longer resides in the facility. Resident #s 5, 2, 13, 22, and 45 were seen by facility Nurse Practitioner on 10/14/2019 to evaluate residents for emotional and psychological harm. Resident #s 5, 2, 13, 22, and 45 have not experienced any negative outcomes. On 11/1/2019 Resident #5 denied concerns, anxiety, fear related to any additional residents in the facility. Resident # 307 no longer resides in the facility. 2. All residents of the facility have the potential to be affected. On 10/16/19 all incident reports and resident council minutes from 04/01/2019 to current were audited by the Administrator to ensure all potential incidents of abuse, including resident to resident altercations, were thoroughly investigated, reported to the appropriate state agencies, and that protective safeguards were put into place to protect residents from the verbal, mental, and physically aggression of other residents. The Social Worker/designee will interview interviewable residents and the Director of Nursing/designees will conduct body audits of non-interviewable residents by 11/07/2019 to ensure other residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations. No other residents are exhibiting verbal, mental, and physical aggression towards residents or staff. 3. By 11/07/2019 all facility staff, including contracted and agency will receive abuse prohibition reeducation by the Director of Social Services/ designee to ensure all residents are 1) free from abuse including verbal, psychological, and physical abuse, 2) that timely reporting to appropriate state agencies occurs, 3) a thorough investigation is conducted, 4) involved residents' reactions are assessed and 5) interventions/safeguards are initiated to protect the residents when confronted by resident to resident altercations, with a post-test to validate understanding. Facility staff, including contracted and agency staff not available during this time frame will receive reeducation including a post-test by the Director of Nurses/designee upon day of return to work. New facility staff, including contracted and agency staff will be provided education with a posttest to validate understanding during orientation by the Director of Nurses/designee. Starting 10/30/2019 all incident reports and resident council minutes will be reviewed by the Administrator/designee and 10% of residents will be interviewed daily including weekends X 2 weeks, then 3X week X 2 weeks, then randomly thereafter to ensure all residents are free from verbal, psychological, and physical abuse when confronted by resident to resident altercations; ensuring timely reporting to the appropriate state agencies, a thorough investigation is completed, involved residents' reactions are assessed and that interventions are initiated to protect involved residents with immediate corrective action. 4. Results of these audits will be reported by the Administrator /designee monthly to the QAPI committee for any additional follow up and/or in-servicing until the issue is resolved and randomly thereafter as determined by the QAPI committee. Upon verification of the implementation of the facility abatement plan, the deficient practice was reduced to a D. Resident identifiers: #307, #2, #5, #13, #45, , #8. Facility census: 62. Findings included: a) Findings for 11/04/19 Interviews with [NAME] residents were conducted on (MONTH) 4, 2019. Residents were asked about their overall feelings in the facility, specifically, if they feel safe. Below are the replies: At 1:55 PM, Resident #5 stated she had been afraid of another resident, who is no longer in the facility. She was referring to resident #8. Resident #5 added that she was verbally abused by resident #8, in the past. She added that she is glad he is out of the facility. Resident #5 did report that resident #45 has threatened her. This was resolved when resident #5 reported this to nursing staff. Resident #5 reported that she feels safe in the facility. At 2:06 PM, Resident #13 was unable to answer questions. She was pleasantly confused and began discussing her birthday, company housing, her husband's death and her six children. At 2:19 PM, Resident #22 stated she is safe. Resident #22 reported resident #8 threw coffee during Bingo, at one point. She added that nothing like that has happened, since. Resident #22 is glad that resident #8 is no longer in the facility. Resident #22 reported Resident #45 has referred to her as a [***] . She does not feel threatened or abused. At 2:28 PM, Resident #2 stated she feels safer without Resident #8 in the facility. She added that when she has reported issues to nursing staff, they assist. At 2:35 PM, Resident #45 was unable to answer questions. She was confused and appeared agitated. During her continual chatting, she said she was happy and sad. She added that she writes books and it is how you are raised. Abuse training has begun for Staff. [NAME] Administrator plans to have all staff trained by (MONTH) 7, 2019. On (MONTH) 4, 2019, several staff members were interviewed, regarding. Below are their replies: At 3:30 PM, Employee #12, Activities Director, reported that the facility has done a lot of education regarding abuse. Employee #12 stated she has been trained to protect the residents, first, if there is an abusive situation. Employee #12 identified step two is to contact her supervisor, regarding the situation. Employee #12 has handled abusive situations with this protocol. Employee #12 added that she would call OHFLAC, if necessary. At 3:40 PM, Employee #84, Licensed Practical Nurse, stated she has not been working for the past few days. She stated that she would report an abusive situation to her supervisor. According to [NAME] Center's inservice sign in sheet, regarding Abuse Policy, Employee #84 has not been trained, as the signature line is empty. At 3:45 PM, Employee #59, Nursing Assistant, reported she has received the inservice. Employee #59 stated she would stop the abusive behavior, initially. She would follow up by reporting to her supervisor. Employee #15, Nursing Assistant, was interviewed with #59. She also had the inservice. She reported she would stop the abuse, then report it to her supervisor. At 3:50 PM, Employee #15, from the Maintenance Department, acknowledged that he has been trained. Employee #15 stated that he would stop the abusive situation and then report it to his supervisor. He added that he would report to OHFLAC, if nobody else was available to report. An employee from the Laundry Department, was interviewed at 3:55. Employee #86 stated she would report the situation to her supervisor. Employee #86 added that she would not get in the middle of that. There is no evidence that Employee #86 has received the Abuse Policy inservice. Employee #72, Clerk, acknowledged the inservice. At 4:00 PM, Employee #72 reported she would try to stop the abuse and report to a nurse. At 4:05, Registered Nurses #82 and #52, stated they would protect the residents, first. #82 stated she would then report to OHFLAC, Adult Protective Services and the Ombudsman. #52, would report to her supervisor and complete a change in condition. At 4:09 PM, Employee #8 from Physical Therapy, stated the most important thing is to protect the residents. That is what Employee #8 would do, before notifying supervisor. At 4:15 PM, Dietary employees #34 and #20 reported they would protect the residents and follow up with notifying supervisor. Employee #34 would then follow up with OHFLAC. At 4:40 PM, DON was made aware of complaints regarding Resident #45. She is aware of issues with this resident. She added that Resident #45 had a Urinary Tract Infection and was treated. In addition, resident #45 had [MEDICATION NAME] discontinued through a gradual dose reduction. They have evaluated the resident and believe she would benefit from [MEDICATION NAME], at her maintenance dosage. DON added that they will be obtaining orders to begin giving her [MEDICATION NAME]. b) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. c) Resident #307 On 10/08/19 at 11:00 AM, a review of an incident report dated 05/18/19 at 6:50 PM stated that Resident #307 was sitting in the common area in front of the Nurses Station. When Resident #8 started yelling racial slurs and calling him (Resident #307) vulgar names. Resident #307 started shaking and crying asking, Why is he call me names? I didn't do anything to him. I don't like to be called names and I don't like to be hollered at. What did I do to him to talk to me like that? Resident #307 was removed from the situation and consoled. The incident report noted resident-to-resident-NO ABUSE. Injury Psych (psychological), harm. An additional incident on 05/19/19 at 14:40 (2:40 PM) Resident #307 was in the common area when another resident (Resident #8) from the adjoining TV room started yelling and cursing and calling him N*****. Resident #307 started crying and expressing feelings of sadness and repeatedly stating why does he say that to me and why does he call me names? What did I do for him to talk to me like that. Resident #307 was harmed by showing signs of emotional distress of crying and being cursed and insulting name calling. d) Resident #2 In an interview with Resident #2 on 10/08/19 at 12:17 PM revealed she had observed Resident #8 yell, cuss and scream at other residents. Resident #2 stated other residents had told her without revealing other residents names, that they were afraid of Resident #8. Resident #2 stated she had seen Resident #8 go after other residents and had stepped in to protect other residents. She stated she is not afraid of Resident #8. e) Resident #5 A review of incident report dated 10/07/19 5:30 PM revealed Resident #5 was confronted by Resident #8 who was sitting on the table next to her. Resident #8 wanted the TV on. Resident #5 stated that the TV was only for Bingo. Resident #8 continued to argue with the other resident who then raised fists at Resident #5 and moved closer. Resident #8 continued to yell at Resident #8 raising fists while staff tried to pulled Resident #8 away. Resident #5 continued to yell and stated that if you hit me you will go to prison. During the Resident Council meeting on 10/08/19 at 2:30 PM Resident #5 stated that Resident #8 continually curses at her and calls her names. Resident #5 stated she does not feel safe and Resident #8 scares her. f) Resident #13 A review of the incident report dated 04/29/19 at 3:30 PM revealed Resident #8 was in dining room and began to yell and scream and threw his glasses, cards and a plastic flower vase which hit Resident #13 in the right side of face. Both residents were removed from the dining room for safety. No injury noted to Resident #13. A nurses note dated 04/30/19 Resident #13 has stayed away from Resident #8. g) Resident #45 A review of incident report dated 10/05/19 at 10:15 PM, Resident #8 was sitting at table coloring in common area. Resident #45 rolled over to the common area and started pecking Resident #8 on the shoulder. Resident #8 turned around and hit R#45 multiple witnessed times with closed fist before staff could separate them. Resident #45 removed from situation and placed in a safe environment while the aggressor #8 continued to pursue other unidentified residents and staff members. The incident report indicated there was no injury. No evidence was found as to the emotional status of this resident after the altercation. No further evidence was presented prior to exiting the facility as to this resident emotional status. h) Resident #8 An incident report on 09/14/19 at 6:14 PM review found the Director of Nursing (DON) was called to the dining room where Resident #8 was yelling and screaming. He was served his food and had asked for a salt and pepper shaker. The aide in the dining room handed him the shakers and he immediately stated to scream that he wanted the glass shakers. He became mad and threw the shakers at the aide leaving a mark on her arm. He continued to yell at residens and staff. The DON told him that he could not eat in the dining room as he was scaring residents. The Dietary Manager (DM) told him that she would serve his meal at the table in the TV lounge. He then grabbed a knife and a fork (plastic) and moved to the table fist raised utensils in his hand. He then moved to the DON and tried to stab with the utensils. The DON told him that he was not able to eat in the dining room in this state and she asked him to leave. In the meantime the DM had called the police. He continued to scream and yell until the police came and continued to call the officer names. The police officers called EMT (Emergency Medical Team) to see if any intervention was possible. Resident #8's guardian came in and talked to the officers. The Guardian stated she would like to have him evaluated by psychiatry. EMT could not take him in and the police officers left. Corrective actions noted on the incident report were to observe closely, try to remove from any triggers that start aggressive behavior. An interview with the DON on 10/08/19 at 3:25 PM found that no investigation of the incidents, witness statements, how other residents and victims were protected from this resident. The DON confirmed they did not follow their policy and procedure to report, investigate and assess resident reactions when the residents were involved and/or were victims of the abuse. The DON stated it would require another person just to notify other agencies and to conduct the investigations.",2020-09-01
3080,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,607,F,0,1,MFEO11,"Based on policy and procedure review, incident report review, and staff interview, the facility failed to implement the facility abuse policy. This practice had the potential to affect all residents residing in the building. Facility census: 62. Findings included: a) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. b) Incident Report Review A review of incident reports dated 04/29/19, 05/18/19, 09/04/19, 09/14/19 and 10/05/19 revealed resident to resident altercations involving Resident #8 as the aggressor. An interview with the NHA on 10/09/19 at 9:03 AM revealed the facility failed to implement their abuse policy by not reporting, investigating or assessing attacked residents with each incident. The NHA explained the use of the reporting requirements dated 2011 from OHFLAC stated the incidents did not need to be reported as their were no injuries or physician invention was required. The survey team member explained the Federal Regulations changed in (MONTH) (YEAR) and the 2011 reporting requirements were no longer valid. In addition, the review of the facility policy and procedure titled WV Abuse Prohibition was current and reflected the current regulations. The facility did not provide any further evidence of the implementation of the facility abuse policy and procedure by reporting, investigating and/or assessing the residents involved in the altercations.",2020-09-01
3081,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,609,F,0,1,MFEO11,"Based on policy and procedure review, incident report review and staff interview, the facility failed to report resident to resident altercations as required. This practice had the potential to affect all residents residing in the building. Facility census: 62. Findings included: a) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. b) Incident Report Review A review of incident reports dated 04/29/19, 05/18/19, 09/04/19, 09/14/19 and 10/05/19 revealed resident to resident altercations involving Resident #8 as the aggressor. An interview with the NHA on 10/09/19 at 9:03 AM revealed the facility failed to report to the appropaite state agencies of the resident to resident abuse. The NHA explained the use of the reporting requirements dated 2011 from the Office of Health FacilitiesLicensing and Certification (OHFLAC) stated the incidents did not need to be reported as their were no injuries or physician invention were required. The survey team member explained the Federal Regulations changed in (MONTH) (YEAR) and the 2011 reporting requirements were no longer valid. In addition, the review of the facility policy and procedure titled WV Abuse Prohibition was current and reflected the current regulations. The facility did not provide any further evidence of reporting any of the resident to resident altercations to the appropriate state agencies.",2020-09-01
3082,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,610,F,0,1,MFEO11,"Based on policy and procedure review, incident report review and staff interview, the facility failed to thoroughly investigate resident to resident altercations as required. This practice had the potential to affect all residents residing in the building. Facility census: 62. Findings included: a) Policy and Procedure Review A review of the facility policy and procedure titled WV Abuse Prohibition with effective date of 06/01/96, review date of 10/10/16 and revision date of 11/28/16 was conducted. The policy stated that anyone who witnesses an incident of suspected abuse is to tell the abuser to stop immediately and report the incident to their supervisor immediately. Additionally, the incident is to be reported to OHFLAC (Office of Health Facilities, Licensure and Certification), APS (Adult Protective Services), and the Ombudsman. If the resident sustains serious bodily injury, the Nursing Home Administrator (NHA) or designee is to be notified and reported within two (2) hours. Conduct and immediate and thorough investigation that focuses on whether abuse or neglect occurred and to what extent; clinical examination for signs of injuries, if indicated; causative factors; and interventions to prevent further injury. The investigation will be thoroughly documented and recorded. Ensure that documentation of witnessed interviews is included. If witnesses were noted on the incident report no evidence was provided that a witness interview had been conducted prior to exiting the facility. b) Incident Report Review A review of incident reports dated 04/29/19, 05/18/19, 09/04/19, 09/14/19 and 10/05/19 revealed resident to resident altercations involving Resident #8 as the aggressor. An interview with the NHA on 10/09/19 at 9:03 AM revealed the facility failed to interview witnesses to the incidents. The NHA explained the use of the reporting requirements dated 2011 from the Office of Health Facilities Licensure and Certification (OHFLAC) stated the incidents did not need to be reported as their were no injuries or physician invention were required. The survey team member explained the Federal Regulations changed in (MONTH) (YEAR) and the 2011 reporting requirements were no longer valid. In addition, the review of the facility policy and procedure titled WV Abuse Prohibition was current and reflected the current regulations. The facility did not provide any further evidence of investigations and/or witness statements of any of the resident to resident altercations prior to exiting the facility.",2020-09-01
3083,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,676,D,0,1,MFEO11,"Based on record review, staff interview, and resident interview the facility failed to ensure a resident was given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living. This deficient practice was true for one (1) of two (2) Residents reviewed in the care area of Activities of Daily Living. Resident identifier: #27. Facility census: 61. Findings included: a) Resident #27 During an interview on 10/07/19 at 12:50 PM, Resident #27 stated that she does not her get Restorative therapy on a routine basis like she should. Resident stated. If they (the facility) are short staffed they pull the therapy aide to help out and I don't get my therapy at all that day. Resident stated she had not had therapy in over 2 weeks. Resident tearfully specified, Therapy is not consistent at all, leg exercises are very important to me and I need them (staff) to help me with those. I can do arm exercises, but I need help with leg exercises. I can see a big difference in myself, even rolling in bed when they are helping clean me up (bathing) and dressing me, I am now weaker and can't do as much. I am more dependent on staff and I hate that. Record review on 10/08/19 at 11:00 AM revealed the following active order for Restorative Nursing Therapy: Restorative Nurse Program (RNP) three (3) times per week x fifteen minutes for Bilateral Upper Extremities, left leg and passive range of motion to right lower extremity to increase physical functioning. On 10/08/19 at 11:08 AM documentation regarding the Residents Restorative Therapy was requested from the Director of Nursing (DON). The DON stated. She hasn't been getting that much for the past two weeks, is that what she told you? Review of Restorative Nursing Record on 10/08/19 at 11:55 AM indicated the Resident only received Restorative Therapy once in (MONTH) for the date of 10/08/19. The Resident had not received any Restorative Therapy since 09/20/19. In (MONTH) of 2019, the Resident only received Restorative Therapy a total of five (5) out of thirteen (13) opportunities on: 09/09/19, 09/12/19, 09/16/19, 09/17/19, and 09/20/19. During an interview on 10/08/19 at 12:15 PM, the DON was asked why the Resident had not received Restorative Therapy as ordered and DON stated, We (the facility) pull staff from Restorative and use them on the floor to give care, we have to make sure the Resident's basic needs are met first. No sense in lying about it, that's why. Some days we just don't have the staff. Record review on 10/09/19 at 8:35 AM indicated the Resident was deemed to have capacity to make health care decisions and informed choices regarding her health care on 03/8/19 by the facility's physician.",2020-09-01
3084,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,725,D,0,1,MFEO11,"Based on resident interview, staff interview and record review, the facility failed to have sufficient nursing staff in order to provide restorative nursing services to a resident. This deficient practice was evident for one (1) of (2) Residents reviewed in care area of Activities of Daily Living. Resident identifier: #27. Facility census: 61. Findings included: a) Resident #27 During an interview on 10/07/19 at 12:50 PM, Resident #27 stated that she does not her get Restorative therapy on a routine basis like she should. Resident stated. If they (the facility) are short staffed they pull the therapy aide to help out and I don't get my therapy at all that day. Resident stated she had not had therapy in over 2 weeks. Resident tearfully specified, Therapy is not consistent at all, leg exercises are very important to me and I need them (staff) to help me with those. I can do arm exercises, but I need help with leg exercises. I can see a big difference in myself, even rolling in bed when they are helping clean me up (bathing) and dressing me, I am now weaker and can't do as much. I am more dependent on staff and I hate that. Record review on 10/08/19 at 11:00 AM revealed the following active order for Restorative Nursing Therapy: Restorative Nurse Program (RNP) three (3) times per week x fifteen minutes for Bilateral Upper Extremities, left leg and passive range of motion to right lower extremity to increase physical functioning. On 10/08/19 at 11:08 AM documentation regarding the Residents Restorative Therapy was requested from the Director of Nursing (DON). The DON stated. She hasn't been getting that much for the past two weeks, is that what she told you? Review of Restorative Nursing Record on 10/08/19 at 11:55 AM indicated the Resident only received Restorative Therapy once in (MONTH) for the date of 10/08/19. The Resident had not received any Restorative Therapy since 09/20/19. In (MONTH) of 2019, the Resident only received Restorative Therapy a total of five (5) out of thirteen (13) opportunities on: 09/09/19, 09/12/19, 09/16/19, 09/17/19, and 09/20/19. During an interview on 10/08/19 at 12:15 PM, the DON was asked why the Resident had not received Restorative Therapy as ordered and DON stated, We (the facility) pull staff from Restorative and use them on the floor to give care, we have to make sure the Resident's basic needs are met first. No sense in lying about it, that's why. Some days we just don't have the staff. Record review on 10/09/19 at 8:35 AM indicated the Resident was deemed to have capacity to make health care decisions and informed choices regarding her health care on 03/8/19 by the facility's physician.",2020-09-01
3085,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,812,E,0,1,MFEO11,"Based on observation and staff interview, the facility failed to store ice in a safe and sanitary manner. The ice machine water drain line touched the floor allowing for the potential for contaminants to enter the line and travel to the ice machine. This practice has the potential to affect more than a limited number. Facility census: 61. Findings include: a) On 10/07/19 at 12:45 PM observation of the kitchen ice machine drain line found the drain pipe laying on/touching the floor drain. The dietary manager observed the same and expressed she was not aware the drain line was touching the floor.",2020-09-01
3086,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2019-11-04,921,F,0,1,MFEO11,"Based on observation and staff interview, the facility failed to provide a safe, comfortable and sanitary environment for staff and visitors. The public restroom had exposed rotting wood around the base board and bubbling paint. This practice had the potential to affect a limited number of visitors and staff. Facility census: 62. Findings included: a) Public Restroom On 10/08/19 at 10:01 AM, an observation found in the Public restroom used by visitors and staff, there was rotting wood around the baseboard and the paint was bubbling. In interview with the Maintenance Director on 10/09/19 at 3:25 PM, he stated that he was aware of the condition of the public restroom and that the wall would be repaired.",2020-09-01
4278,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,249,E,0,1,WJYE11,"Based on record review and staff interview the facility failed to employee a qualified professional to head the Activity Program. This had the potential to effect all residents. Facility census: 61. Findings include: a) When the Administrator provided the entry-requested documentation at 2:30 p.m. on 03/14/16, she said Employee #11, identified as the Activity Director was not licensed or certified in West Virginia as an Activities Professional, although she was enrolled in a Certification program. A review of the personnel file of Employee #11 at 9:00 a.m. on 03/16/16, verified Employee #11 was hired on 08/27/15 as the Activity Director and had enrolled in a National Certification Council for Activity Professionals (NCCAP) approved Home Study program in (MONTH) (YEAR). There was evidence in the record reviews of Residents #27 and #53 that Employee #11 had initiated their care plans and was doing the revisions. There was no evidence in the records of the involvement of an approved professional. Employee #11 was on vacation during the survey and could not be interviewed. During an interview with the Administrator at 10:00 a.m. on 03/16/16, she said the Activities Director from a sister facility had visited to audit the program and was available as needed; and provided verification of her professional status. There was no evidence of the audit or its findings. The Administrator had no information of the present status of the employee in the training program or an approximate completion date.",2020-02-01
4279,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,253,E,0,1,WJYE11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly,and comfortable interior, including resident care equipment. This was found for five (5) of thirty-five (35) resident rooms with loose floor cove molding, stained and discolored tile around base of toilets, jagged sink edges and loose laminate sink counter tops. Two (2) of thirty-five (35) resident wheelchairs/cushions were found unclean and/or in disrepair. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #6 and #29. Facility census: 61. Findings include: a) Resident Rooms On 03/17/16 at 8;35 a.m., accompanied by Maintenance Supervisor #8 and the Administrator, a tour of the facility identified the following issues: 1. Room 103 The baseboard cove molding was loose from the wall on the right side of the exterior bathroom door in the resident room and in the resident bathroom between the sink and tub. 2. Room 108 The resident's bathroom had stained and discolored tile surrounding the toilet base. 3. Room 109 The underneath edge of the sink counter top in the resident room was jagged and rough to the touch. The resident's bathroom had stained and discolored tile surrounding the toilet base. 4. Room 110 The lower edge of the sink counter top in the resident's room had three (3) areas measuring 2.5 inches by 3 inches with missing laminate exposing the pressed wood base with jagged edges. The three (3) drawer storage cabinet under the sink had scratched, marred and missing finish. 5. Room 305 The laminate edge of the sink counter top was loose and not adhered to the edge of the sink. The three (3) drawer storage cabinet under the sink had scratched, marred and missing finish. At the conclusion of the tour, Maintenance Supervisor #8 agreed the issues needed repaired and/or replaced. He also commented the tile around the toilet bases needed to be cleaned and would speak with the Housekeeping Supervisor. Maintenance Supervisor #8 also stated, tours of the rooms are not done routinely and we depend on the other staff to tell us or write it in the maintenance repair book, but will start doing tours again. During an interview with Environmental Director #24 on 03/17/16 at 8:55 a.m., she stated, its that glue stuff that needs scraped off and cleaned around the toilets. b. Resident Wheelchairs During an observation, on 03/14/16 at 3:20 p.m., Resident #6's wheelchair was found to have food crumbs, tiny shreds of paper and dirt particles under the wheelchair cushion. At this time, Resident #6 reported the facility does not routinely clean his wheelchair. On 03/15/16 at 11:30 a.m., Resident #29's wheelchair arm rests were found to be rough to touch with multiple cracks in the vinyl surface. The zipper side of the wheelchair seat cushion cover was torn open exposing the foam interior. In addition, a second cushion in the shape of a bicycle seat had been tucked inside the seat cushion cover, creating an uneven surface for sitting. Licensed Practical Nurse (LPN) #6 was interviewed on 03/15/16 at 11:32 a.m. and confirmed Resident #29's wheelchair was in disrepair. The arm rests and seat cushion required replacement. The Administrator acknowledged the facility currently does not perform routine maintenance and/or cleaning of the residents' wheelchairs during an interview on 03/17/16 at 8:40 a.m.",2020-02-01
4280,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,272,D,0,1,WJYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed conduct an accurate initial comprehensive assessment for a resident receiving Hospice services. This practice was found for one (1) of one (1) Hospice residents reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifier: #18. Facility census: 61. Findings include: a) On 03/17/16 at 9:45 a.m. a medical record review revealed Resident #18 was admitted to the facility on [DATE] under Hospice Services. The admission minimum data set (MDS) with a assessment reference date (ARD) of 04/09/15 revealed section J, item J1400 does the resident have a condition or chronic disease that may result in a life expectancy of less than 6 months was coded as NO. According to the Resident Assessment instrument (RAI) 3.0 user's manual version 1.13, item J1400 is to be coded yes, if the medical record includes physician documentation: 1) that the resident is terminally ill; or 2) the resident is receiving hospice services. After reviewing the admission MDS for Resident #18 on 03/17/16 at 9:45 a.m., Registered Nurse (RN) #15 agreed and stated, it is incorrect because she (Resident #18) is and has been on Hospice since her admission.",2020-02-01
4281,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,279,D,0,1,WJYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to develop a comprehensive care plan based on a resident's current health condition/status that includes measurable objectives and timetables to meet a resident's medical, nursing and psychosocial needs. This practice was identified for one (1) of two (2) residents reviewed for urinary incontinence. Resident identifiers: #89. Facility census: 61. Findings include: a) Resident #89 Review of the medical record, on 03/16/16 at 3:00 p.m., revealed Resident #89 was admitted to the facility on [DATE], with occasional urinary incontinence. The quarterly minimum data set (MDS) assessment with an assessment reference date (ARD) of 02/20/16 revealed Resident #89's urinary incontinence progressed to an always incontinent status. The current care plan with a revision date of 03/01/16 is silent in regards to urinary incontinence. The clinical reimbursement coordinator Employee #76 reviewed the care plan during an interview on 03/17/16 at 9:25 a.m. and confirmed the care plan does not address Resident #89's urinary incontinence.",2020-02-01
4282,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,323,E,0,1,WJYE11,"Based on record review, observation and staff interviews, the facility failed to provide an environment free of accident hazards as possible and/or adequate supervision to prevent avoidable accidents by failing to secure dirty utility room and by failing to visually monitor the front exit door to dispel elopement for a 90 minutes time period when the front door alarm was disarmed. This had the potential to affect more than a limited number of residents. Facility census: 61. Findings include: At 11:30 a.m. on 03/16/16, the 15-second delay on two (2) exit doors was not working and the doors would not open. The door alarms on the exit door at the end of the 400 hall and the front door were disabled so the doors would open. The Administrator was informed and a maintenance person was contacted to repair the problem. The maintenance personnel were present at the 400 hall exit, but the front door was not being observed during this time. The facility had at least four (4) identified wanderers whose pictures were posted in the reception office. There was also cameras monitoring the exit via TV screens located at the nurses' station. Observation of the TV screens during this time revealed that no one was monitoring them. The location of the desk in the front office prevented that person from viewing the front door. A review of the incident reports revealed three (3) elopement attempts in the past seven (7) days. At 1:05 p.m. on 03/16/16, a resident wearing pajamas was observed approaching the front door. She stood and pushed the key pad several times and looked around before exiting the door. A surveyor went to the administrator's office and informed her of the exit. The Administrator immediately came out of her office and asked the receptionist if she had seen who left. Employee #41, sitting at her desk, said she had seen no one. The Administrator proceeded to the front porch and identified the resident as one who was allowed to exit independently. The administrator was informed the door should have been monitored until the locking mechanism was repaired. She stated the staff had been cautioned to monitor the identified wanderers, but acknowledged no one had been assigned to visually monitor the front door. b) An initial tour of the facility on 03/14/16 at 12:40 p.m., found the door to the soiled utility room could be entered without using a code on the push button lock. The soiled utility room contained two (2) soiled linen containers, two (2) trash containers, an oxygen concentrator with a plastic bag over it labeled broken. a centrifuge for spinning blood tubes and a refrigerator containing a residents blood specimen (tube). On 03/14/16 at 12:43 p.m., Licensed Practical Nurse (LPN) #3 verified the soiled utility room door was unlocked. She stated, it is always to be locked for resident safety and not to be opened by just turning the door handle. At 12:48 p.m. on 03/14/16, Maintenance Assistant #7 stated, someone had turned the lock off from the back of the door, but it is locked now.",2020-02-01
4283,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,329,D,0,1,WJYE11,"**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 ensure the consultant pharmacist identified irregularities in a residents' medication regimen, with potential drug interactions, time constraints and monitoring of a resident on antihypertensive medication per physician orders. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #107 and #26. Facility census: 61. Findings include: a) Resident #107 During a medication administration observation, on 03/16/16 at 8:00 a.m., Licensed Practical Nurse (LPN) #1 was observed to administer Resident #107's scheduled 8:00 a.m. oral (po) medications while the resident was in the process of consuming her breakfast meal. Resident #107's medications included; Calcium [MEDICATION NAME]-Vitamin D (Calcium supplement) tablet 600-200 mg units and [MEDICATION NAME] sodium (Snythroid) 112 micrograms (mcg) tablet. A medical record review on 03/16/16 at 9:05 a.m. revealed Resident #107 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Assistant Director of Nursing (ADON) #25 stated during an interview on 03/16/16 at 10:40 a.m., Calcium and [MEDICATION NAME] should not be given together or with meals, everyone knows that. The facility is trying to go to a twice a day med pass to increase efficiency. On 03/16/16 at 10:50 a.m., a review of the facility Lippincott drug reference handbook (YEAR) for manufacture guidelines under the medication Levothryroxine sodium ([MEDICATION NAME]) revealed: --Under INTERACTIONS, . Antacids, calcium [MEDICATION NAME] . (MONTH) impair [MEDICATION NAME] absorption. Separate doses by 4 to 5 hours. --Under EFFECTS ON LAB RESULTS, (MONTH) decrease [MEDICAL CONDITION] function test results . --Under PATIENT TEACHING, Teach patient the importance of compliance. Tell him to take drug at the same time each day, preferably 1/2 to 1 hours before breakfast, to maintain constant hormone levels and help prevent [MEDICAL CONDITION]. A review of the Pharmacy Policies and Procedures manual, on 03/16/16 at 9:35 a.m., revealed: --Under POLICY, a medication administration schedule is established by the Center Pharmacy Committee . --Under PURPOSE, To provide uniform and efficient practices in safe medication administration. To provide safe and accurate medication administration in Centers utilizing a BID (twice a day) Medication Administration or BID Med Pass Schedule.\ --Under Drug Administration Recommendations regarding Meals, Brand name [MEDICAL CONDITION], Generic Name Levothryroxine, Meal Reference: Before Meals . On 03/16/16 at 11:00 a.m. during an interview with LPN #1 stated, [MEDICATION NAME] are given at 6:00 a.m. by the treatment nurse unless the resident prefers it or has always taken their [MEDICATION NAME] with breakfast. She did not reply when inquired if the resident had been interviewed for when she normally takes her [MEDICATION NAME]. LPN #1 reported on 03/16/16 at 11:12 a.m. the MAR (medication administration record) has been corrected with the [MEDICATION NAME] to be given at 6:00 a.m. She also stated, I checked the nursing medication handbook and it ([MEDICATION NAME]) should not be given with calcium. During a phone interview with consulting Pharmacist #89 in the presence of the ADON #89, the Administrator and Surveyor # , on 03/16/16 at 11:55 a.m., she commented she reviews each medication, interaction, indications and that they are properly monitored during her monthly reviews and on a resident's admission. Consulting Pharmacist #89 also stated, I reviewed her (Resident #107) MAR and did not make any changes with the time which coincides with breakfast and receiving the calcium at the same time. Yes, it can cause absorption problems and the time was not discussed with Resident #107 by me. I would obtain an TSH ([MEDICAL CONDITION] Stimulating Hormone laboratory test) and adjust the time if a problem. Yes, it could be a potential problem but if a problem happens then I would adjust the medication accordingly and the time. I would wait for a problem to occur before making any changes. Yes, I guess it should be corrected before instead of waiting for any problems occur. These are recommended manufacture guidelines to administer on a empty stomach and not with calcium, but not always followed because they are recommendations. She did not reply when inquiry if the medication [MEDICATION NAME] was given outside of recommended manufacture guidelines. On 03/16/16 at 2:40 p.m. during an interview Resident #107 stated, At home I take my [MEDICAL CONDITION] pill as soon as I get up in the morning by itself before any other pills. Yes, I take Calcium at home but take it later with all my other pills not with my [MEDICATION NAME]. My Doctor told me that when I started taking it ([MEDICATION NAME]), take it on an empty stomach when I get up and never to take it with my Calcium. In summary the medication [MEDICATION NAME] was administered outside of the manufacture's recommendations during meal time and with the supplement medication Calcium. This was not identified by the consultant Pharmacist as an irregularity and has the potential for adverse reactions and/or resulting in mal-absorption of the medication. Also the resident was not interviewed by either the facility or the Pharmacist regarding the time or with what medication combination she had routinely taken her medication, to maintain her medication routine and effectiveness. b) Resident #26 Review of the medical record, on 03/16/16 at 8:40 a.m., revealed Resident #26 was admitted to the facility on [DATE]. Her plan of care included [MEDICATION NAME] 25 milligrams (mg) daily and Losartan Potassium-HCTZ 50-12.5 mg daily for the treatment of [REDACTED]. The weights and vital signs summary sheet lacks any blood pressure (BP) values between 01/15/16 and 03/03/16. Resident #26's record is silent in regards to any blood pressure monitoring during this time frame. ADON #25 reviewed the medical record during an interview, on 03/16/16 at 10:50 a.m., she confirmed Resident #26 has a [DIAGNOSES REDACTED]. ADON #26 acknowledged the chart lacked any BP values between 01/15/16 and 03/03/16.",2020-02-01
4284,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,356,C,0,1,WJYE11,"Based on observation and staff interview, the facility failed to post nurse staffing data in a clear and readable format in a prominent place readily accessible to residents and visitors. This had the potential to affect all residents. Facility census: 61. Findings include: a) During the initial tour of the facility at 12:45 p.m. on 03/14/16, an observation of the daily staff posting of the direct care staff was made. The posting form was located in the upper left corner of a bulletin board in the resident common lounge area. The information occupied an 8 inch x 11 inch sheet of sheet of paper in a typed form filled in with small typed font information. The form could not be easily read by residents and/or visitors and could not be read by anyone in a wheelchair. This was acknowledged by the Assistant Director of Nursing (ADON) at 12:50 p.m. on 03/14/16. On 3/15/16 at 8:30 a.m. Scheduler #28 reported she had corrected the staff posting. The posting is now located on the outer left side of the nurses station desk approximately 3 feet from the floor at the w/c residents' eye level, in dark ink, easily readable. In addition the original posting remains high up on the bulletin board in case the other posting disappears.",2020-02-01
4285,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,371,F,0,1,WJYE11,"Based on observation, staff interview, policy review and review of the Food and Drug Administration (FDA) food code the facility failed to store, prepare, and/or serve food in a safe and sanitary manner. Kitchen staff did not prepare foods under sanitary conditions; the residents' snack refrigerator temperature was not routinely monitored and foods were outdated. In addition a prolonged lunch distribution resulted in unsafe food temperatures at the point of service. This practice has the potential to affect all residents. Facility census: 61. Findings include: a) An observation of the snack refrigerator, on 03/14/16 at 1:10 p.m., revealed an incomplete daily temperature log. The Food and Nutrition Services Refrigerator/Freezer Temperature Log dated (MONTH) (YEAR) was incomplete on 03/03/16, and 03/10/16 through 03/13/16. The back page of the Food and Nutrition Services Refrigerator/Freezer Temperature Log contains the facility policy titled: 4.2 Refrigeration/Freezer Temperatures Standards. Part 1 of the section titled Process states: Director of Dining Services/Director of Culinary Services or designee observes and records all of the temperatures of the refrigerators on a daily basis using the Refrigerator/Freezer Temperature Log. In addition, the following outdated foods were identified during this observation on 03/14/16 at 1:10 p.m.: --Clear pitcher half filled with orange juice with a small white sticker saying: use by 2/27/16. --Three peach yogurts labeled: Canterbury Center Food Label, Name (Resident #101), Date 2-26, Items without a preprinted date, will be discarded 3 days after the date listed. Items may also be discarded for inappropriate packaging. --A clear plastic container with strawberries dated 2/28/16 (Resident #26). --A Styrofoam container with leftover foods dated 3/3/16 (Resident #61). During an interview with the Food Service Director #67, on 03/14/16 at 1:25 p.m., she reported it is the facility policy to check the residents' snack refrigerator temperature daily and record the results on the Refrigerator/Freezer Temperature Log. Employee #67 stated refrigerator foods are to be discarded three (3) days after the assigned date and agreed the above list of foods should have been discarded. b) During an observation of meal preparation, on 03/14/16 at 4:50 p.m., Cook #77 and Dining Services Director #67 were observed placing pieces of cake on individual plates and covering with plastic wrap. Cook #77 wore a gold watch and a large gold ring on his left hand and no gloves. Employee #67 had one glove on her left hand covering her silver ring with multiple stones. On 03/14/16 at 5:18 p.m. Cook #86 repeatedly touched her eye glasses while checking food temperatures on the tray line; and at one point laid her eye glasses down on the steam table adjacent to the hot foods. The FDA U.S. Public Health Service Food Code, dated 2013, states under section 2-303.11: Except for a plain ring such as a wedding band, while preparing FOOD, FOOD EMPLOYEES may not wear jewelry including medical information jewelry on their arms and hands. The above findings were reviewed with the Dining Services Director #67, on 03/16/16 at 9:42 a.m. She acknowledged the kitchen staff wore jewelry during meal prep and had no reply in regards to the FDA current guidelines. c) On 03/15/16 at 12:12 p.m., the first meal cart was observed leaving the kitchen. The last tray was removed from the non-electric cart at 12:36 p.m. by nurse aide (NA) #52 and immediately carried to the kitchen. Food temperature checks by Cook #87 revealed the following temperatures in Fahrenheit: Tuna sandwich 56 degrees, green beans 58 degrees, fruit 57 degrees, and ice tea 43 degrees. Cook #87 acknowledged the foods were at improper temperatures and a new tray was prepared.",2020-02-01
4286,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,425,F,0,1,WJYE11,"Based on observation, staff interview and review of the pharmacy services policies and procedures, the consulting pharmacist failed to identify the improper storage of a medication subject to abuse (Ativan) during monthly pharmacy reviews. This practice has the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) An observation of the medication storage area, on 03/15/16 at 4:20 p.m., in the company of Registered Nurse (RN) #14 and the Assistant Director of Nursing (ADON), revealed a clear plastic box with a red zip tie closure containing liquid and injectable Ativan (Schedule IV controlled substance/benzodiazepine). The clear plastic box was secured to a removable rack inside the locked refrigerator. A demonstration revealed both the rack and the locked container could easily be removed from the refrigerator. Both the ADON and RN #14 agreed the shelf was not secured to the refrigerator. The ADON reported she would contact maintenance and have the shelf secured to the refrigerator and obtain a locked clear plastic box for the Ativan. A review of the pharmacy services policies and procedures, on 03/17/16 at 10:00 a.m., revealed: --Under POLICY, A pharmacy representative will perform a regular nursing unit inspection for each nursing station . --Under PURPOSE, To ensure proper storage and labeling of all drugs and biological's . --Under PR[NAME]ESS, 1. A pharmacy representative assists Center with compliance with obligations pursuant to applicable law relating to . 1.2 Proper storage of drugs in medication carts, drawers, cupboards, refrigerators, interim drug supplies . On 03/17/16 at 11:00 a.m. a review of the consultant pharmacist summary for the months of (MONTH) (YEAR), (MONTH) (YEAR) and (MONTH) (YEAR) revealed, Evaluation Controlled Substances* (F425, F431) . YES . a) Controlled substances are properly and securely stored, per regulation .",2020-02-01
4287,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,428,D,0,1,WJYE11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, resident interview and policy review, the pharmacist failed to identify irregularities for potential medication interactions with time constraints and/or inconsistent drug monitoring as prescribed by the Physician during the medication regimen reviews. This was found for one (1) of five (5) residents reviewed for unnecessary medications and for one (1) of four (4) residents during medication administration observation during Stage 2 of the Quality Indicator Survey (QIS). This practice has the potential to affect more than a limited number of residents. Resident identifiers: # 107 and #26. Facility census: 61. Findings include: a) Resident #107 During a medication administration observation, on 03/16/16 at 8:00 a.m., Licensed Practical Nurse (LPN) #1 was observed to administer Resident #107's scheduled 8:00 a.m. oral (po) medications while the resident was in the process of consuming her breakfast meal. Resident #107's medications included; Calcium Carbonate-Vitamin D (Calcium supplement) tablet 600-200 mg units and Levethyroxine sodium (Snythroid) 112 micrograms (mcg) tablet. A medical record review on 03/16/16 at 9:05 a.m. revealed Resident #107 was admitted on [DATE] with [DIAGNOSES REDACTED]. The Assistant Director of Nursing (ADON) #25 stated during an interview on 03/16/16 at 10:40 a.m., Calcium and Synthroid should not be given together or with meals, everyone knows that. The facility is trying to go to a twice a day med pass to increase efficiency. On 03/16/16 at 10:50 a.m., a review of the facility Lippincott drug reference handbook (YEAR) for manufacture guidelines under the medication Levothryroxine sodium (Levothroid, Synthroid) revealed: --Under INTERACTIONS, . Antacids, calcium carbonate . (MONTH) impair Levethyroxine absorption. Separate doses by 4 to 5 hours. --Under EFFECTS ON LAB RESULTS, (MONTH) decrease thyroid function test results . --Under PATIENT TEACHING, Teach patient the importance of compliance. Tell him to take drug at the same time each day, preferably 1/2 to 1 hours before breakfast, to maintain constant hormone levels and help prevent insomnia. A review of the Pharmacy Policies and Procedures manual, on 03/16/16 at 9:35 a.m., revealed: --Under POLICY, a medication administration schedule is established by the Center Pharmacy Committee . --Under PURPOSE, To provide uniform and efficient practices in safe medication administration. To provide safe and accurate medication administration in Centers utilizing a BID (twice a day) Medication Administration or BID Med Pass Schedule.\ --Under Drug Administration Recommendations regarding Meals, Brand name Synthyroid, Generic Name Levothryroxine, Meal Reference: Before Meals . On 03/16/16 at 11:00 a.m. during an interview with LPN #1 stated, synthroids are given at 6:00 a.m. by the treatment nurse unless the resident prefers it or has always taken their Synthroid with breakfast. She did not reply when inquired if the resident had been interviewed for when she normally takes her Synthroid. LPN #1 reported on 03/16/16 at 11:12 a.m. the MAR (medication administration record) has been corrected with the Synthroid to be given at 6:00 a.m. She also stated, I checked the nursing medication handbook and it (Synthroid) should not be given with calcium. During a phone interview with consulting Pharmacist #89 in the presence of the ADON #89, the Administrator and Surveyor # , on 03/16/16 at 11:55 a.m., she commented she reviews each medication, interaction, indications and that they are properly monitored during her monthly reviews and on a resident's admission. Consulting Pharmacist #89 also stated, I reviewed her (Resident #107) MAR and did not make any changes with the time which coincides with breakfast and receiving the calcium at the same time. Yes, it can cause absorption problems and the time was not discussed with Resident #107 by me. I would obtain an TSH (Thyroid Stimulating Hormone laboratory test) and adjust the time if a problem. Yes, it could be a potential problem but if a problem happens then I would adjust the medication accordingly and the time. I would wait for a problem to occur before making any changes. Yes, I guess it should be corrected before instead of waiting for any problems occur. These are recommended manufacture guidelines to administer on a empty stomach and not with calcium, but not always followed because they are recommendations. She did not reply when inquiry if the medication Synthroid was given outside of recommended manufacture guidelines. On 03/16/16 at 2:40 p.m. during an interview Resident #107 stated, At home I take my thyroid pill as soon as I get up in the morning by itself before any other pills. Yes, I take Calcium at home but take it later with all my other pills not with my Synthroid. My Doctor told me that when I started taking it (Synthroid), take it on an empty stomach when I get up and never to take it with my Calcium. In summary the medication Synthroid was administered outside of the manufacture's recommendations during meal time and with the supplement medication Calcium. This was not identified by the consultant Pharmacist as an irregularity and has the potential for adverse reactions and/or resulting in mal-absorption of the medication. Also the resident was not interviewed by either the facility or the Pharmacist regarding the time or with what medication combination she had routinely taken her medication, to maintain her medication routine and effectiveness. b) Resident #26 Review of the medical record on 03/16/16 at 8:40 a.m. revealed Resident #26 was admitted to the facility on [DATE]. Her plan of care included Aldactone 25 milligrams (mg) daily and Losartan Potassium-HCTZ 50-12.5 mg daily for the treatment of [REDACTED]. The weights and vital signs summary sheet lacks any blood pressure (BP) values between 01/15/16 and 03/03/16. Resident #26's record is silent in regards to any blood pressure monitoring during this time period. The Assistant Director of Nursing #25 reviewed the medical record during an interview on 03/16/16 at 10:50 a.m. She confirmed Resident #26 has a [DIAGNOSES REDACTED]. ADON #26 acknowledged the chart lacked any BP values for Resident #26 for the time period of 01/15/16 through 03/03/16. The monthly medication regimen review form indicates the facility pharmacist #89 reviewed Resident #26 s medical records on 02/16/16 and 03/10/16 and noted no irregularities in the record. The pharmacist failed to identify the omission of blood pressure monitoring for a resident on antihypertensive medications with an order for [REDACTED]. A telephone interview was conducted with Pharmacist #89 on 03/16/16 at 12:00 p.m. in the presence of the ADON and the Administrator. Pharmacist #89 reported her monthly medication reviews include the medication ordered, drug interactions, proper monitoring and indications for use. Pharmacist #89 stated her review does not include the residents' vital sign sheets or blood pressures for a resident on antihypertensive medications. The pharmacist runs a computer report for hypertensives and then selects a sample of 5% of the residents on antihypertensive meds. Pharmacist #89 reported she is unaware if the same residents are reviewed every month and stated If they were not on the sample she did not review their vital signs. The pharmacist acknowledged she was unware Resident #26's BP was not monitored between 01/15/16 and 03/03/16.",2020-02-01
4288,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,431,E,0,1,WJYE11,"Based on observation and staff interview, the facility failed to ensure the secure permanently affixed non-removable storage of a medication subject to abuse (Ativan). This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) An observation of the medication storage area on 03/15/16 at 4:20 p.m., in the company of Registered Nurse (RN) #14 and the Assistant Director of Nursing (ADON), revealed a clear plastic box with a red zip tie closure containing liquid and injectable Ativan (Schedule IV controlled substance/benzodiazepine). The clear plastic box was secured to a removable rack inside the locked refrigerator. A demonstration revealed both the rack and the locked container could easily be removed from the refrigerator. Both the ADON and RN #14 agreed the shelf was not secured to the refrigerator. The ADON reported she would contact maintenance and have the shelf secured to the refrigerator and obtain a locked clear plastic box for the Ativan.",2020-02-01
4289,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,441,F,0,1,WJYE11,"Based on observation, staff interview and policy review, the facility failed to maintain an Infection Control Program designed to provide a safe and sanitary environment and to help prevent the development and transmission of disease and infection. Two (2) employees were observed failing to perform hand hygiene during meal tray pass to residents' rooms. This practice has the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) During an observation of the lunch meal pass, on 03/15/16 at 12:21 p.m., Nurse Aide (NA) #9 carried a meal tray into Resident #24's room, tucked the bed sheets into the foot of the bed and returned to the meal cart and retrieved another tray without washing or sanitizing her hands. When questioned immediately after this observation, NA #9 stated: I am new. She acknowledged she had made no attempt to clean or sanitize her hands after adjusting Resident #24's bed linen. At 12:29 p.m. on 03/15/16, NA #81 carried coffee into Resident #8's room, helped reposition her in bed, and returned to the meal cart for another tray without washing or decontaminating her hands. During an interview immediately after this observation, NA #81 agreed she had failed to wash or sanitize her hands after leaving Resident #8's room and before pulling another tray from the meal cart. b) The Assistant Director of Nursing was interviewed at 12:45 p.m. on 03/15/16, she reported staff is to wash/sanitize their hands between tray passes in resident rooms. c) A review of the facility hand hygiene policy, on 03/16/16, revealed staff is to: Decontaminate hands using an alcohol based hand rub or wash hands with soap and water in the following situations, 2.1 Before any direct contact with patient . and 2.7 after contact with inanimate objects in the immediate vicinity of the patient.",2020-02-01
4290,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2016-03-22,465,F,0,1,WJYE11,"Based on observation and staff interview the facility failed to ensure a safe, functional, sanitary and comfortable environment for residents and staff. The shower room on the 400 hall had multiple areas of cracked floor tile in three (3) of three (3) shower stalls. This has the potential to affect all residents that use this shower room. Facility census: 61. Findings include: a) An observation of the shower room on the 400 hall on 03/14/16 at 12:30 p.m. found multiple areas of cracked floor tiles in all three (3) shower stalls. The Assistant Director of Nursing viewed the 400 hall shower room on 03/14/16 at 12:50 p.m. and confirmed all three (3) shower stalls are used by the residents and all three (3) shower stalls have cracked floor tiles which need to be replaced.",2020-02-01
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
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
5562,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2015-02-12,386,E,0,1,7Y3Y11,"Based on medical record review and staff interview, the facility failed to ensure the physician took an active role in the supervision of care for five (5) of 35 Stage 2 sample residents. Written telephone orders, monthly orders, and/or monthly summary reports were not signed and dated to indicate they were reviewed by the physician. Resident identifiers: #76, #9, #64, #60, #50 and #38. Facility census: 57. Findings include: a) Resident #76 Medical record review, on 02/11/15, revealed this resident's attending physician was Physician #93. The clinical record contained verbal physician orders, dated 12/12/14, 01/11/15, and 01/21/15, which were not signed by Physician #93. The clinical record also contained (MONTH) 2014, (MONTH) 2014, and (MONTH) (YEAR) monthly physician orders which were not signed by Physician #93. During an interview, on 2/11/15 at 10:30 a.m., Nurse Consultant #92 stated the facility had a problem with Physician #93 seeing residents and signing the physician orders since (MONTH) 2014. b) Resident #9 Review of this resident's clinical record revealed Physician #93 was her attending physician. The clinical record contained verbal physician orders dated 9/10/14, 9/11/14, and 9/17/14 which had not been signed by Physician #93. The clinical record also contained monthly physician orders for (MONTH) 2014, (MONTH) 2014, and (MONTH) (YEAR) which had not been signed by Physician #93. c) On 2/11/15 at 11:05 a.m., the Director of Nursing (DON) stated the facility provided a list of residents for Physician #93 to see during her visits to the facility. The DON stated Physician #93 had been seeing residents weekly until (MONTH) 2014. The DON stated since (MONTH) 2014, she had to call Physician #93 to come to the facility to see residents. The DON stated Physician #93 had last been in the facility on 01/29/15. The DON could not explain why Physician #93 had not seen all her residents or signed the physician orders. During an interview, on 2/11/15 at 11:15 a.m., Medical Records Staff #14 stated she looked for orders needing signed by physicians, including Physician #93, and flagged the orders. Staff #14 stated she had a notebook with a list of all Physician #93's residents in the facility. Staff #14 stated the facility had a problem since (MONTH) 2014 with Physician #93 seeing her residents and signing the physician orders. Staff #14 stated she notified the physician office of the problem in (MONTH) 2014. Staff #14 said an office staff member stated they were aware of the problem. Staff #14 stated she informed the DON of the concern regarding Physician #93 in (MONTH) 2014. d) Resident #64 Review of the medical record, on 02/10/15 at 8:45 a.m., found the resident's primary care physician, Employee #93, failed to sign the following physician reports and orders for the resident during her visits: -- Monthly order summary reports dated 10/29/14, 11/26/14, 12/29/14, and 01/28/15 -- Physician's telephone orders dated 11/14/14, 12/14/14, and 1/15/15. During a staff interview with the Director of Nursing (DON), on 02/11/15 at 11:00 a.m., she reported the physician's orders should be signed at least monthly. She stated Physician #93 was in the facility visiting residents on 01/29/15. e) Resident #50 Resident #50's medical record was reviewed on 02/10/15 at 9:05 a.m. Monthly order summary reports dated 09/29/14, 10/29/14, 11/26/14, 12/26/14, and speech therapy orders dated 12/03/14, 12/08/14, 12/10/14 and 12/17/14 were not signed by the Medical Director, the resident's attending physician. During an interview on 02/11/15 at 8:30 a.m., the administrator acknowledged the physician orders were not signed in a timely manner. According to the administrator, the Medical Director visited the facility several times a week, but often gets behind, even when the staff reminds him. f) A medical record review was conducted for Resident #38 on 02/11/15 at 10:40 a.m. This review revealed unsigned physician orders dated 12/26/14, 01/12/15 and 01/13/15. Also there were unsigned physician order summaries for the months of (MONTH) 2014, (MONTH) 2014 and (MONTH) (YEAR). The resident's physician was Physician #93. On 02/11/15 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON). She verified and agreed Physician #93 had not signed the telephone orders and order summaries for the identified dates. The DON stated, The orders and summaries should be signed at least monthly by the attending Physician. She further stated, We have had a problem with Physician #93 seeing her residents since (MONTH) 2014 and have had to call her to come in and visit residents, I just called her and yelled at her about this. I was unaware of her not signing her orders or the order summaries until this morning and she only has nine (9) residents in the facility, so there is no excuse for it.",2018-10-01
5563,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2015-02-12,387,D,0,1,7Y3Y11,"Based on clinical record review and staff interview, the facility failed to ensure three (3) of 35 residents reviewed in Stage 2 of the survey had a face-to-face visit by a physician at 60 day intervals. Resident identifiers #76, #9, and #38. Facility census: 57. Findings include: a) Resident #76 Medical record review, on 02/11/15, revealed this resident's attending physician was Physician #93. There was no evidence the resident was seen by the physician since 09/30/14, the date of the last physician's progress note. During an interview, on 02/11/15 at 10:30 a.m., Nurse Consultant #92 stated since (MONTH) 2014, the facility had a problem with Physician #93 seeing residents. The consultant confirmed the last physician's note (evidence of a visit) for Resident #76 was dated 09/30/14. b) Resident #9 Review of this resident's clinical record, on 02/11/15, revealed Physician #93 was her attending physician. There was no evidence the resident was seen by the physician since 11/29/14, the date of the last physician's progress note. c) On 02/11/15 at 11:05 a.m., the Director of Nursing (DON) stated the facility provided Physician #93 a list of residents to see during her visits to the facility. The DON stated Physician #93 had been seeing residents weekly until (MONTH) 2014. The DON stated since (MONTH) 2014, she had to call Physician #93 to come to the facility to see residents. The DON stated Physician #93 was last in the building on 01/29/15. The DON could not explain why Physician #93 had not seen all her residents as required. . d) Resident #38 A medical record review was conducted for Resident #38 on 02/11/15 at 10:40 a.m. This review revealed the last documented physician's visit was 11/13/14. On 02/11/15 at 11:00 a.m., an interview was conducted with the Director of Nursing (DON). The DON stated, No, the physician has not seen the resident since (MONTH) 2014 and I just called and yelled at her about it. We have had a problem with Physician #93 seeing her residents since (MONTH) 2014, and have had to call her to come in and visit residents. The DON said Physician #93 used to visit her residents every thirty (30) days. She stated before October, Physician #93 visited her residents weekly. The DON said, I was unaware of her not having visited Resident #38 until this morning, and she only has nine (9) residents in the facility, so there is no excuse for it. In addition, the DON stated, We have not had to monitor physician visits before . She stated the facility's process was to provide the physicians with a list of the residents who were to be seen during their visits. She said Physician #93 was notified the week of 01/29/15 that she needed to visit her residents, and she visited the following day. The DON said Resident #38 must have been one (1) of the residents Physician #93 did not visit that day.",2018-10-01
5564,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2015-02-12,431,F,0,1,7Y3Y11,"Based on observation and staff interview, the facility failed to ensure the secure storage of a medication subject to abuse (Ativan). This practice had the potential to affect more than an isolated number of residents. Facility census: 57 Findings include: a) An observation of the medication storage area was completed, on 02/10/15 at 12:15 p.m., in the company of the Director of Nursing (DON). Multiple Carpuject syringes (pre-filled syringes) of injectable Ativan and a bottle of liquid Ativan were stored in a clear plastic lock box inside a locked refrigerator. The DON stated the refrigerator was used for storage of medications for all the units. The plastic container was not secured to the glass shelves. A demonstration revealed it was easily removed from the refrigerator. The DON stated, Yes, I know that it was to be secured, but we got a new refrigerator and I didn't think of it. She further stated she did not know how to secure it to the glass shelves. The DON said, I will take the blame because I forgot about it. She said she would contact maintenance to have the container secured.",2018-10-01
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
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
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
7050,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,241,E,0,1,GJXP11,"Based on observation and staff interview, the facility failed to provide care in a manner that maintained or enhanced each resident's dignity. On two (2) occasions, on 09/09/13 and again on 09/12/13, facility staff members were overheard referring to residents who required assistance to eat as feeders. This practice had the potential to affect more than an isolated number of residents. Facility census: 61. Findings include: a) On 09/09/13, during the evening meal, facility staff was transferring dinner trays from one cart to another. When asked why they did this, an aide answered, Those are the feeders. This occurred in the open central area outside of the nursing station. Several residents were sitting in the area within hearing distance. Again on 09/09/13, during the evening meal, Employee #77, a nursing assistant (NA), was on the 200 hall and was overheard speaking to two (2) other facility employees,referring to residents as feeders. On 09/12/13 at 8:35 a.m., Employee #32, a NA, referred to a cart of trays by stating those are for feeders. This occurred in the open central area outside of the nursing station with several residents sitting within hearing distance. During an interview with the facility administrator on 09/12/13 at 2:05 p.m., she stated she had overheard the expression of feeder used earlier in the day and agreed it was a dignity issue and was not to be used. .",2017-09-01
7051,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,247,D,0,1,GJXP11,"Based on record review, resident interview, and staff interview, the facility failed to notify the resident and/or family member of the reasons for room changes within the facility. This was the case for two (2) of five (5) residents sampled. Resident identifiers: #16 and #54. Facility census 61. Findings include: a) Resident #16 During an interview with Resident #16 at 2:00 p.m. on 09/11/13, she was asked if she had a room change while at the facility. She responded she had. When asked why she had been moved, she stated she did not know. She stated a staff member just came in and told her she was being moved. She acknowledged she had no objection and was satisfied with the new room and roommate, but did wonder why she was moved. A review of the records revealed a room transfer form indicating a room change on 05/10/13, from 110 a to 104 b. There was a check-mark to indicate the resident, who had capacity to make her own decisions, was notified. There was no explanation on this form or in the nurses' notes to indicate a reason for the move. b) Resident # 54 A review of the records revealed a room change for Resident #54 from 104 a to 109 a on 05/10/13. The record indicated notification of the resident and of his family, but there was no reason given for the move on either the transfer form or in the nurses' notes. Resident #54 was asked at 10:30 a.m. on 09/10/13, why he was moved. He stated he did not know. c) During an interview with Employee #7 (social worker) at 11:30 a.m. on 09/12/13, she reviewed the records of both residents and acknowledged there was no documentation of a reason for either move. She stated from memory she recalled a need for an appropriate bed for a new admission and thinks both residents were moved to accommodate this need, although she was sure they both agreed.",2017-09-01
7052,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,249,E,0,1,GJXP11,"Based on record review and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The facility did not have an activity director to plan, direct, or oversee an ongoing program of activities designed in accordance with the comprehensive assessments, the interests of the residents, and the physical, mental, and psychosocial well-being of the residents. This had the potential to effect all residents who participated, or wished to participate, in the activities program at the facility. Facility census 61. Findings include: a) During the entrance interview with the Administrator at 2:00 p.m. on 09/09/13, she stated the facility did not have an activities director at the present time. She explained the person filling the position for the past several months was under an agreement of fulfilling the qualifications required in the state. She had not done so, and resigned in August 2013. The position of the corporate consultant, who was overseeing her work and education, was eliminated in July 2013. In an interview with Employee #39 (Recreation aide) at 11:15 a.m. on 09/10/13, she stated there were currently three (3) recreation aides. She and Employee #38 (recreation aide) had been employed at the facility since 2007. A third recreation aide (Employee #72) had been there since February 2013. None of the three (3) had the training approved by the state to work in the capacity of an activities director. Employee #39 stated the three (3) provided day to day activities as set up in the program which was established prior to the previous director leaving. If there was a problem, she stated she would consult either the Social Worker or the Administrator. During independent interviews on 09/10/13, Employees #72 and #38 related the same information as Employee #39. In a follow-up interview with the Administrator at 5:00 p.m. on 09/12/13, she stated a replacement had been found for the position, but the person was not yet available to begin work at the facility.",2017-09-01
7053,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,272,D,0,1,GJXP11,"Based on record review and staff interview, the facility failed to ensure the accuracy of the minimum data set (MDS) assessment related to the fall history for one (1) of three (3) residents reviewed for falls in Stage 2 of the Quality Indicator Survey. Resident identifier: #62. Facility census: 61. Findings include: a) Resident #62 Review of the medical record and the facility's resident/patient incident reports, on 09/12/13 at 1:32 p.m., revealed Resident #61 fell out of his wheelchair on 06/04/13 and 06/08/13. The quarterly MDS assessment with an assessment reference date (ARD) of 07/16/13, was coded as 0 under section J1800. This code indicated the resident had not had any falls since admission/entry or reentry or the prior assessment. During an interview with a registered nurse (RN), Employee #11, on 09/12/13 at 2:55 p.m., she agreed the resident/patient incident reports dated 06/04/13 and 06/08/13 verified Resident #61 had experienced two (2) falls. She confirmed the MDS assessment was inaccurate.",2017-09-01
7054,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,278,D,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure the minimum data set (MDS) assessment, for one (1) of nineteen (19) residents reviewed in Stage 2 of the survey, accurately reflected his status. The MDS for this resident was certified accurate by the appropriate qualified health professionals; however, the assessment was not accurate. Resident identifier: #62. Facility census 61. Findings include: a) Resident #62 Review of the medical record and the facility's resident/patient incident reports on 09/12/13 at 1:32 p.m. revealed Resident #62 fell on [DATE] and 06/08/13. The quarterly MDS assessment with an assessment reference date (ARD) of 07/16/13, was coded as 0 under section J1800, indicating the resident had not had any falls since admission/entry or reentry or the prior assessment. During an interview with a registered nurse (RN), Employee #11, on 09/12/13 at 2:55 p.m. she confirmed the MDS was inaccurate.",2017-09-01
7055,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,280,D,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, resident interview, and staff interview, the facility failed to ensure the care plan was revised for one (1) of nineteen (19) Stage 2 residents, and failed to ensure one (1) of nineteen (19) residents was afforded the opportunity to make decisions regarding the provision of care and treatment. The care plan for Resident #28 was not revised after the POST form was updated and changed. In addition, Resident #26 was not afforded the right to participate in her care planning, nor was the resident consulted about care and treatment changes. Resident Identifiers: #28 and #26. Facility census 61. Findings include: a) Resident #28 Closed record review performed on [DATE] at 11:00 a.m., revealed the resident was initially admitted to the facility on [DATE]. The resident's medical record contained a POST form dated [DATE] requesting the resident to have cardiopulmonary resuscitation (CPR) with limited additional interventions. This form was signed by a physician and by the Medical Power of Attorney; however, the form had the word VOID in large letters across it. The care plan, dated [DATE] also had the resident's code status listed as CPR. Further review of the medical record revealed a revised POST form signed and dated [DATE] by the Medical Power of Attorney and signed by the physician on the same date. The code status on this form was changed to do not resuscitate (DNR) with comfort measures. The change in code status was not revised in the care plan. This information was discussed with Employee #11, the clinical records registered nurse, on [DATE] at 2:00 p.m. She said she updated the care plans quarterly. Employee #11 said the nurses were responsible for updating care plans with each new order, and the social worker was responsible for immediately updating the care plan when a POST was signed or updated. Employee #11 agreed this resident's care plan did not accurately reflect the resident's code status. b) Resident #26 A medical record review was conducted on [DATE] at 10:30 a.m. for Resident #26. The Resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] indicated the resident's Brief Interview for Mental Status (BIMS) score was 13. The previous MDS, dated [DATE], contained a BIMS score of 9. This indicated an improvement in cognition. Review of the resident's care plan meeting progress notes, dated [DATE], revealed the daughter-in- law and the resident were in attendance. The note also indicated the resident was alert with periods of confusion. The care plan meeting progress notes, dated [DATE], stated the family was invited and did not attend. On [DATE] at 11:10 a.m. an interview was conducted with Resident #26. During the interview she commented she had not been invited to a care plan meeting since this past Spring, which she had attended with her daughter-in- law. At 12:45 p.m. on [DATE] an interview was conducted with Employee #32, a Nurse Aide (NA). Employee #32 stated she usually was the NA for Resident #26. She stated the Resident .does have periods of confusion but she knows what is going on. At 12:50 p.m. an interview was conducted with Employee #43, a Licensed Practical Nurse (LPN). She stated she was usually the nurse for Resident #26 on the day shift. Employee #43 stated, The resident is confused at infrequent times but the rest of the time she is very sharp concerning her care and her environment. An interview was conducted with Employee #7, the Social Services Director on [DATE] at 12:55 p.m. She explained the process for the care plan meeting was to send out written invitations to the residents who had capacity and to send written invitations to the family of residents who lacked capacity. During the interview she said, There was no documentation to show that Resident #26 was invited to her August care plan meeting or that she was notified of the changes regarding her care. Upon further discussion, Employee #7 agreed even though the resident was noted to lack capacity, that did not mean she was not aware of her care needs and her environment. She also commented, since there was an improvement in the Resident's BIMS score, she made a mistake in not inviting the resident to attend her care meeting.",2017-09-01
7056,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,282,D,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to follow the care plan for one (1) of five (5) residents reviewed in Stage 2 for unnecessary medications. The staff failed to observe for the effectiveness and side effects of the antianxiety medication [MEDICATION NAME] ([MEDICATION NAME]). Resident identifier: #58. Facility census: 61. Findings include: a) Resident #58 Review of the medical record, on 09/11/13 at 1:30 p.m., revealed Resident #58 was prescribed [MEDICATION NAME] ([MEDICATION NAME]) 0.5 mg for anxiety on 01/24/13, the day she was admitted . On 02/20/13 the dose was increased to twice a day for behaviors such as repetitive health concerns, crying episodes and fear of being alone. The current care plan, with a revision date of 07/11/13, identified the resident's current [DIAGNOSES REDACTED]. Observe for effectiveness and side effects - drowsiness, sedation, unsteadiness. Document any incidents of concern and update MD prn (as needed). The facility form titled: Monthly Behavior Monitoring Flowsheet listed crying, fear of being alone, and repetitive health concerns as the targeted behaviors to be monitored every shift by staff. The forms were completed for March 2013, April 2013, May 2013, June 2013 and July 2013. The Monthly Behavior Monitoring Flowsheets for August and September were completely blank. There were no targeted behaviors identified or documentation indicating staff had observed the resident for behaviors or medication side effects. During an interview with the assistant director of nursing (ADON), Employee #45, on 09/11/13 at 3:50 p.m., she reported the facility's policy for residents on antianxiety medications was to monitor and document behaviors on the facility form titled Monthly Behavior Monitoring Flowsheet. Upon review of Resident #58's record, she confirmed the flow sheet for September was blank. The ADON was then informed the behavior flow sheet for August 2013 was also blank. .",2017-09-01
7057,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,329,D,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview and policy and procedure review, the facility failed to ensure one (1) of five (5) residents reviewed for unnecessary medications was free from unnecessary medications. Resident #23 was receiving [MEDICATION NAME] (a tetracyclic antidepressant) without an attempt at a gradual dose reduction (GDR). Resident #23. Facility Census 61 Findings include: a) Resident #23 A record review was conducted for Resident #23 on 09/12/13 at 9:45 a.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. The resident was also receiving palliative care. She received 15 mg of [MEDICATION NAME] at night. A pharmacy consultation report, dated 05/15/13, indicated the resident's [MEDICATION NAME] was due for an initial GDR in the first year. The attending physician declined the pharmacist's recommendation. On 09/12/13 at 10:45 a.m. a phone interview was conducted with Employee #88, the consulting pharmacist. Employee #88 stated she made GDR recommendations based on State and Federal guidelines. The recommendation for a dose reduction for [MEDICATION NAME] was based on these guidelines. At 11:20 a.m. on 09/12/13, a review of the Psychopharmacologic Medication Use, Pharmacy Services Policies and Procedures was conducted. It noted, If a GDR is contraindicated, the physician/prescriber documents the clinical rationale for why any additional dose reduction at that time would be likely to impair the patient's function or increase distressed behavior. The physician did not provide a clinical rationale for declining the GDR for this resident; therefore, providing no evidence a GDR was contraindicated for Resident #23.",2017-09-01
7058,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,371,F,0,1,GJXP11,"Based on observation and staff interview the facility failed to ensure sanitation practices to prevent contamination and ensure food was safe for consumption. The ceiling intake vent and an air conditioning filter in and/or near the food preparation area were soiled. This created a potential for debris to fall off the vent and/or blow off the air conditioning filter and contaminate food. This practice had the potential to affect all residents who received nourishment from the kitchen. Facility census: 61. Findings include: a) On 09/10/13 at 4:10 p.m., the intake ceiling vent was observed soiled with debris that could potentially fall off and contaminate food being prepared and served in the kitchen. On this same date, the dietary office door was observed open. The air conditioner filter in the dietary office was observed soiled with debris that could potentially blow off into the kitchen area and contaminate food being prepared and served in the kitchen. The dietary office door was observed open on 09/09/13, 09/10/13, 09/11/13 and 09/12/13, with the air conditioning filter noted to be soiled each day. On 09/10/13 at 4:10 p.m., Employee #86, the regional dietary manager, agreed the ceiling intake vent was soiled with debris. At 10:10 a.m. on 09/12/13, Employee #86 stated the ceiling intake vent had been cleaned. Observation revealed it no longer posed a potential for contamination of food. At 9:00 a.m. on 09/13/13, Employee #86 was informed the soiled air conditioning filter in the office also created a potential for food contamination since the office door was being left open to the kitchen. Employee #86 immediately requested maintenance staff clean the air conditioning filter.",2017-09-01
7059,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,428,D,0,1,GJXP11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and review of policies and procedures, the facility failed to ensure the physician acted upon the pharmacist's recommendation for a gradual dose reduction for one (1) of five (5) residents whose medical records were reviewed for unnecessary medications during Stage 2 of the Quality Indicator Survey. Resident identifier #23. Facility Census 61. Findings include: a) Resident #23 A record review was conducted for Resident #23 on 09/12/13 at 9:45 a.m. The resident was admitted on [DATE] with [DIAGNOSES REDACTED]. She was also receiving palliative care. A pharmacy consultation report, dated 05/15/13, was reviewed. It indicated the resident's mirtazapine was due for an initial gradual dose reduction (GDR). The resident was currently receiving 15 mg of mirtazapine each night. The attending physician declined the recommendation. but did not provide a reason the GDR was not accepted for the resident. At 11:20 a.m. on 09/12/13, a review of the facility's Psychopharmacologic Medication Use, Pharmacy Services Policies and Procedures was conducted. It noted, If a GDR is contraindicated, the physician/prescriber documents the clinical rationale for why any additional dose reduction at that time would be likely to impair the patient's function or increase distressed behavior. On 09/12/13 at 11:25 a.m. an interview was conducted with Employee #8, the Director of Nursing (DON). She confirmed the physician should have written a rationale which provided some basis for declining the pharmacist's recommendation for a GDR.",2017-09-01
7060,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,441,F,0,1,GJXP11,"Based on observation, staff interview, and policy/procedure review, the facility failed to ensure the implementation of an Infection Prevention and Control Program to prevent and control, to the extent possible, the onset and spread of infection. Personnel did not handle and process linens in a manner to prevent the spread of infection. This practice had the potential to affect all residents. Facility Census 61 Findings include: a) A review of the Soiled Linen Handling Policy/Procedure on 09/11/13 at 11:00 a.m. revealed a directive which stated, Laundry employees wear proper personal protective equipment (PPE) to sort linen. b) On 09/11/13 at 2:05 p.m. Employee #62, a floor tech, was observed placing soiled linens in the washing machines in the Laundry. He was wearing gloves while sorting and placing soiled linen into the two (2) washing machines Upon inquiry, Employee #62 stated I should be wearing a gown but I was in a hurry to unload my cart and didn't put it on. He then put on a gown and continued to sort and load soiled linen into the washing machines. c) At 2:15 p.m. on 09/11/13, an interview was conducted with Employee #16, the Housekeeping Supervisor. She confirmed Employee #62 should wear a gown and gloves when unloading soiled linen into the washing machines.",2017-09-01
7061,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,465,F,0,1,GJXP11,"Based on observation and staff interview, the facility failed to provide a safe, functional, sanitary and comfortable environment for the residents, staff and visitors. Observations of the airflow intake and output vents in the main hallways and the main dining room revealed gray debris on the vents and the ceiling surrounding the vents in the dining room. This debris had the potential to fall on residents, staff members, or visitors in the hallways and in the dining room. This practice had the potential to affect all residents. In addition, a bathroom heater did not have a cover in place, creating the potential for exposure to electrical shock, burns, and/or cuts. This practice had the potential to affect any resident who used this particular bathroom. Facility census: 61. Findings include: a) On 09/11/13 at 2:50 p.m., an observation of the airflow intake and output vents revealed gray debris filled intake vents and the same gray debris on the output vents in all the main hallways and the dining room. The gray debris in the output vents in the dining room ceiling had an additional area of debris, approximately three (3) feet in length, clinging to the spackling on the ceiling. In addition, the gray debris filled the first two (2) rows of the light fixture located beside an output vent at the nurses station. At 3:15 p.m. on 09/11/13, the administrator was shown the intake and output vents in the main hallways and the dining room. She agreed the vents, as well as the dining room ceiling, needed to be cleaned. She stated she would notify the maintenance department. Observations revealed the vents and the dining room ceiling were cleaned prior to exiting the facility on 09/13/13. b) On 09/10/13 at 9:10 a.m., an observation was conducted of the bathroom for room 109. A wall heater was located on the right side of the room above the floor baseboard. The heating flanges (prongs) were exposed and the front protective metal covering was lying on top of the heater. At 9:15 a.m. on 09/10/13, this observation was verified by Employee #49, a Registered Nurse (RN). Employee #49 agreed the wall heater was in disrepair and did not provide a safe and functional environment for the residents utilizing the bathroom. She further commented she would notify Maintenance to repair the wall heater. At 9:30 a.m. a maintenance employee was observed repairing the wall heater in the bathroom of room 109. .",2017-09-01
7062,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,490,F,0,1,GJXP11,"Based on observation, record review, and staff interview, the facility was not administered effectively to attain and/or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Maintenance and housekeeping problems throughout the facility were not identified and corrected. In addition, the facility did not have qualified department heads employed for two (2) departments which provided facility-wide services. This had the potential to affect all residents. Facility census 61. Findings include: a) Heating/air conditioning vents and/or air intake vents located throughout the facility (hallways, dining room, nurses' station, and kitchen) were observed with hanging and/or soiled loose debris. In the main dining room a wide area of the sloped ceiling surrounding the output vent was soiled and discolored. The administrator observed these areas in the presence of two (2) surveyors at 3:15 p.m. on 09/11/13. She agreed the vents needed immediate cleaning. b) During the entrance interview with the Administrator at 2:00 p.m. on 09/09/13, she stated the facility did not have a Certified Dietary Manager (CDM) at the present time. The administrator said she was aware the state required employment of a full time qualified dietary manager in all facilities who do not employ a full time licensed dietitian. The administrator stated the contracted licensed dietitian was present one (1) to two (2) times (Tuesdays and Thursdays) weekly and a regional corporate consultant visited on a weekly basis. She stated the corporate consultant was not a CD. She added the facility had hired a chef who had not yet started to work at the facility. This individual will be eligible to sit for the certification test when in it offered in 2014. c) During the entrance interview with the Administrator at 2:00 p.m. on 09/09/13, she stated the facility did not have a qualified activity director to plan, direct, or oversee an ongoing program of activities designed in accordance with the comprehensive assessments, the interests of the residents, and the physical, mental, and psychosocial well-being of the residents. She explained the person filling the position for the past several months, under an agreement of fulfilling the qualifications required by the state, had not done so and had resigned in August 2013. The position of the corporate consultant, who was overseeing her work and education, was eliminated in July 2013. The facility had three (3) activities aides employed full time, two (2) of them had been employed at the facility since 2007, but none had the qualifications to direct the program. A review of the CMS-2567 from the previous survey, which ended on 04/19/12, revealed the facility was cited for not having a certified activities director during that survey. The Plan of Correction submitted and accepted by the state was, An offer has been extended and accepted by a Certified Activities Director who has approximate start date of June, 2012. During an interview with the Administrator at 4:30 p.m. on 09/12/13, she stated a qualified person had been hired, but had not yet started in the position of activities director.",2017-09-01
7063,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2013-09-13,492,C,0,1,GJXP11,"Based on staff interviews, the facility failed to ensure their compliance with State regulations and codes which require a full-time dietary manager when the facility does not employee a full-time licensed dietitian. This had the potential to affect all residents. Facility census 61. Findings include: a) During the entrance interview with the Administrator, at 2:00 p.m. on 09/09/13, she stated the facility did not have a Certified Dietary Manager (CDM) at the present time. She stated the contracted licensed dietitian was present 1 - 2 times weekly (Tuesdays and Thursdays) and a regional corporate consultant also visited on a weekly basis. The administrator said the facility had hired a chef who had not yet started to work at the facility. This individual would be qualified to sit for the certification test when it is offered in 2014. When interviewed at 10:30 a.m. on 09/11/13, Employee #85, the contracted dietitian, verified she was at the facility weekly. She stated she could be contacted as needed. During an interview with Employee #86, a regional consultant, at 2:00 p.m. on 09/12/13, she stated she was assisting with managerial duties until a new CDM was hired.",2017-09-01
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
7213,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2014-07-10,225,E,1,0,E6P811,"Based on staff interview, review of the facility's concern and grievance files, record review, and policy review, the facility failed to investigate and/or report allegations of abuse and/or neglect for four (4) of nine (9) residents reviewed. The facility failed to investigate and report an allegation of sexual abuse of Resident #25. Resident #67 alleged staff had purposefully bumped his head against the bed backboard while providing care. Resident #66 was reported to have been hit in the face during a transfer with a lift. The family of Resident #65 alleged the resident's fingerstick blood sugars were not monitored as ordered. Resident identifiers: #27, #67, #66, and #65. Facility census: 62 Findings include: a) Resident #27 Review of concern and grievance files, on 07/08/14 at 12:16 p.m., revealed a concern, voiced by another party, indicating a black male had entered Resident #27's room, removed his clothing, and climbed on top of her. However, Resident #27 had been unable to confirm the incident. Review of the medical record provided no evidence a physical and/or visual assessment had been completed by a licensed nurse or physician. Review of the weekly skin assessments, located on the treatment administration record (TAR), indicated a skin assessment was completed on 05/02/14 (prior to the allegation) and again on 05/09/14, five (5) days after the alleged incident. An interview with the director of nursing (DON) at 1:45 p.m., on 07/10/14, revealed a physical assessment was not completed by a licensed nurse or physician, when the incident was reported. She related nursing assistants would have reported any abnormality during peri care. The DON related the resident denied the allegation, and she did not want to put her through the trauma of a vaginal exam. She confirmed a visual and/or physical exam was not completed by any licensed staff or physician. The administrator acknowledged a male staff member worked in the dietary department at that time, but related dietary staff left the facility at 8:30 p.m. She related the individual had completed nurse aide training and was currently working at another facility. During a family interview on 07/09/11 at 3:30 p.m., the family member indicated staff had a camera monitoring system, which alerted staff of people entering and exiting the facility. He related staff reviewed the film, and based on the forensic evidence was not concerned. An interview with the administrator and social worker, on 07/09/14 at 3:00 p.m., revealed they were unaware whether the complaint had been reviewed by adult protective services (APS). Another interview with the social worker, on 07/09/14 at 3:45 p.m., revealed she did not review the camera regarding the alleged incident reported on 05/05/14. The administrator was interviewed on 07/09/14 at 3:50 p.m. She related she was not in the facility at the time of the alleged incident, and was not aware whether the facility reviewed the film. The DON, interviewed on 07/09/14 at 3:55 p.m., confirmed the films were not reviewed. She said they had to be looked at screen by screen and it was a very time consuming process. The DON related a nurse monitored the screen and an alarm went off at night indicating someone entered the building. The camera system was reviewed with the director of nursing, who acknowledged an individual could walk past the screen before being visualized, if someone was not constantly watching the camera screen. The screen was located at the back of the room at the nurses' station. The alarm was located outside the room by the hallway. She also confirmed no evidence was present to indicate the physician was notified or clinical assessment was completed. Another interview with the social worker on 07/09/14 at 4:44 p.m., revealed she did not remember a conversation with the POA. She reviewed the statement she had written and said, Oh, yes, I remember this conversation, but I don't remember saying anything about the cameras. I do remember a nurse saying they would have seen on the monitor, if someone entered the building. Review of the abuse prohibition policy, on 07/09/14 at 9:30 a.m., revealed the facility would conduct an immediate and thorough investigation that focused on whether abuse or neglect occurred and to what extent, and clinical examination for signs of injuries as indicated Although staff reported the incident, and investigated the incident through interviews, the allegation was not thoroughly investigated. The director of nursing and social worker confirmed staff did not review the monitoring system to ensure no one had entered the facility; nor did a licensed nurse and/or physician complete a visual and/or physical exam, to assess whether the resident may have been sexually violated. b) Resident #67 Concern and grievance reports were reviewed on 07/09/14 at 3:50 p.m Resident #67 alleged he had received a suppository because his bowels had not moved. He indicated about an hour later he rang his call bell for assistance. He related I pushed the light for help and they didn't come quick enough so I messed myself. I think they were upset they had to clean me and feel like they purposefully bumped my head on the headboard when cleaning me up. He also indicated it was the first time he had to have the head bandage changed in a long time and it's because they bumped it. An investigation note indicated the resident did receive a suppository. It noted when staff returned to the room, Resident #67 had smeared feces on his bed side table and other places. It indicated staff did not remember bumping the resident's head, but the bandage was changed by the treatment nurse per order. Review of the progress notes, revealed a note dated 01/07/14 at 11:48 a.m., which indicated he had a small amount of blood on the outside of bandage site, and the nurse assured him the treatment nurse would take care of him. Review of physician's orders indicated the resident had a malignant mass on his head, which was covered with a bandage. An interview with the administrator, on 07/10/14 at 11:30 a.m., revealed the allegation was not reported to State agencies. She related the resident had been unable to remember what happened the afternoon of the incident, and therefore, because the nursing assistant denied it, the incident did not occur. She also confirmed she did not report the alleged incident of abuse, nor was the physician notified. Review of the abuse prohibition policy on 07/10/14 at 12:45 p.m., revealed the definition of abuse included the affliction or threat to inflict physical pain or injury . Section 5 noted all reports of suspected abuse must also be reported to the attending physician. The policy also indicated, upon receiving information concerning a report of suspected or alleged abuse, the administrator or designee would report to the appropriate state agencies. Interviews with the social worker on 07/10/14 at 11:50 a.m., and the DON, on 07/10/14 at 12:30 p.m., confirmed neither had reported the incident to the appropriate State agencies. c) Resident #66 On 07/08/14 at 9:47 a.m., a review of the facility grievance/concern forms was completed. A grievance/concern form was completed by the social worker on 02/09/14 for Resident #66. A family member stated when coming to visit Resident #66, this resident was found with her pants twisted around to side. The resident had been incontinent and had no bra on. The nursing aides immediately provided a bed bath per family member request and while using a Hoyer lift, the bar of lift hit the aide (resident) in the face and the aide did not apologize to the resident or even address with this resident. In the investigation section of the grievance/concern form, Describe action(s) taken to investigate grievance/concern: after SS (social service) was informed on concern, aides were asked if the hoyer lift did hit resident and aides stated, yes- asked if anyone had apologized and aide stated no and then did apologize to resident. 02/12/14. In an interview with the nursing home administrator (NHA), on 07/09/14 at 3:35 p.m., the NHA was asked if she had any information as to Resident #66 being hit with the lift, and whether this allegation of abuse had been reported to the appropriate State agencies. The NHA stated she did not have the answers to the questions but would investigate the matter. When the social worker was asked if there was an error in the grievance/report regarding an aide being hit with the lift or Resident #66 being hit in the face by the lift, the social worker agreed the resident had been hit by the lift. In addition, the social worker agreed the family member was present when this resident was hit in the face by the lift. When the NHA was asked if this incident was reported as an allegation of abuse, she stated she did not understand and thought there was something in the regulations about intent in the regulations. After explaining this was an allegation by Resident #66's family member of abuse and needed to be investigated and reported to the appropriate State agencies, the NHA stated she did not understand. No evidence was provided by the facility prior to exit on 07/10/14 at 3:15 p.m this allegation was reported to the appropriate State agencies. d) Resident #65 A review of the facility grievance/concern form was completed on 07/09/14 at 10:30 a.m. for Resident #65. The grievance/concern form, dated 06/10/14, revealed (family member) reporting with other family members present, that on Sunday the family had their father outside from 10:30 until later in day. Family reports around 4-5 pm they informed nurse that noone (sic) had checked their father's sugar - they report nurse said she checked it at 11:30 and it was 213. They report that nurse also checked sugar after their request and nurse told them again it was 213. Family report no nurse checked his sugar at 11:30 and no one gave him insulin after first reading. On 07/09/14 at 9:47 a.m., a review of the facility policy Abuse Prohibition revealed 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 (Office of Health Facilities and Certification) Department of Health and Human Resources (DHHR) using the . On 07/10/14 at 10:20 a.m., an interview with the NHA and DON was conducted. When the NHA was asked about the reporting of this allegation of neglect to the appropriate State agencies, she stated the incident had been investigated and there was no neglect. This writer explained when an allegation was reported to any staff member, the alleged incident was to be reported and the investigation was the next step in the process. The NHA stated she felt the incident had been investigated and the resident had received the blood sugar checks and insulin and did not understand why this would have to be reported.",2017-07-01
7214,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2014-07-10,309,D,1,0,E6P811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, review of the facility's concern/grievance file, and staff interview, the facility failed to ensure each resident was provided with the necessary care and services to maintain the highest practicable level of well-being for each resident. This was found three (3) of the nine (9) sample residents. There was no evidence Resident #66 was assessed for injury after being hit in the face with a lift. Resident #67 alleged staff intentionally hit his head against the backboard of the bed when providing incontinence care. There was no evidence this resident, who had an existing metastic lesion with a dressing on his head, was assessed and monitored at the time of the alleged incident. Resident #27 had an alleged inappropriate sexual encounter in which no physical assessment was completed immediately after the alleged event. Resident identifiers: #66, #67, and #27. Facility census: 62. Findings include: a) Resident #67 Concern and grievance reports were reviewed on 07/09/14 at 3:50 p.m. Resident #67 reported he had received a suppository because his bowels had not moved. He indicated about an hour later he rang his call bell for assistance. He alleged, I pushed the light for help and they didn't come quick enough so I messed myself. I think they were upset they had to clean me and feel like they purposefully bumped my head on the backboard when cleaning me up. He also indicated it was the first time he had to have the head bandage changed in a long time and it's because they bumped it. An investigation note on the concern grievance form, dated 01/07/14, indicated the resident did receive a suppository. The investigative note indicated staff did not remember bumping the resident's head, but the bandage was changed by the treatment nurse per order. Review of the progress notes revealed a note dated 01/07/14 at 11:48 a.m., which indicated he had a small amount of blood on the outside of bandage site, and the nurse assured him the treatment nurse would take care of him. (Review of physician's orders [REDACTED].) In an interview with the administrator on 07/09/14 at 3:50 p.m., she related the resident had been unable to remember what happened the afternoon of the incident, and therefore, because the nursing assistant denied it, the incident did not occur. The administrator confirmed an assessment was not immediately completed, because of the scheduled treatment. An interview with Employee #62, a licensed practical nurse (LPN), on 07/10/14 at 12:00 p.m., revealed when an accident occurred staff assessed the resident, completed a progress note, completed an incident report if an injury occurred, and completed every shift follow-up for three (3) days. During an interview with DON at 12:10 p.m., she said, he didn't hit his head. b) Resident #27 Review of concern and grievances, on 07/08/14 at 12:16 p.m. Review of reportable allegations revealed a concern, indicating a black male had entered Resident #27's room, removed his clothing, and climbed on top of her. However, Resident #27 had been unable to confirm the incident. Review of the medical record provided no evidence a physical and/or visual assessment had been completed by a licensed nurse or physician. An interview with the director of nursing (DON) at 1:45 p.m., on 07/10/14, confirmed a physical assessment was not completed by a licensed nurse or physician, when the incident was reported. She related nursing assistants would have reported any abnormality during peri care. The DON related the resident denied the allegation, and she did not want to put her through the trauma of a vaginal exam. She confirmed neither a visual and/or physical exam was not completed by any licensed staff or physician in an attempt to determine whether the resident had been sexually violated. Review of the medical record revealed the resident had both short term and long term memory impairment. An interview with the resident on 07/10/14 at 8:30 a.m., revealed she did not know the name of the city of location, nor where her son lived. She said she could not go home because her parents were in heaven and she just went from place to place to live. During the interview with the director of nursing, she also related the resident had denied being aware of anyone being in her room. She related she thought the resident may remember, but acknowledged the resident did have memory impairment. An interview with Employee #43, a nursing assistant (NA), on 07/10/14 at 9:00 a.m., revealed the resident's mental status varied. The NA related the resident's level of confusion varied day to day. She related the resident may or may not be able to remember what occurred in the past 24 hours. c) Resident #66 On 07/08/14 at 9:47 a.m., a review of the facility grievance/concern forms found a grievance/concern form completed by the social worker on 02/09/14 for Resident #66. A family member stated the nurse aides, while using a Hoyer lift, the bar of the lift hit the resident in the face No evidence was found indicating the resident was assessed for the extent of injury. The facility did not provide any further evidence of assessing this resident when hit in the face with a Hoyer lift prior to exiting the facility on 07/10/14 at 3:15 p.m",2017-07-01
7215,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2014-07-10,514,D,1,0,E6P811,"Based on medical record review and staff interview, the facility failed to maintain a complete and accurately documented medical record for one (1) of nine (9) records reviewed. The Medication Administration Record [REDACTED]. Resident identifier: #67. Facility census: 62. Findings include: a) Resident #67 Concern and grievance reports were reviewed on 07/09/14 at 8:30 a.m Resident #67 reported he had received a suppository because his bowels had not moved. An investigation note on the concern grievance form, dated 01/07/14, indicated the resident did receive a suppository. Review of the Medication Administration Record [REDACTED]. On 07/10/14 at 11:00 a.m., the director of nursing reviewed the medical record, including the MAR, and confirmed no evidence was present in the medical record to indicate the resident had received the suppository, nor the effectiveness of the medication. She acknowledged it did not reflect an accurate clinical picture.",2017-07-01
8584,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,225,D,0,1,KWL711,"Based of review grievance/concern documents and staff interview, the facility failed to ensure all allegations involving neglect were reported immediately to officials in accordance with State law through established procedures. Review of grievance/concern reports for the past six (6) months revealed allegations of neglect for two (2) of thirty-three (33) Stage II sample residents which were not reported to the Office of Health Facility Licensure and Certification (OHFLAC), Adult Protective Service (APS), or the Ombudsman as indicated by the nature of the occurrence. Resident identifiers: #43 and #99. Facility census: 60. Findings include: a) Resident #99 Review of a grievance/concerns form, dated 01/27/12, revealed Resident #99 had complained she was left unattended to bathe in the bathroom. According to the complaint, the call bell was not placed within her reach. The resident reported that as a result of not being able to call for staff, she became cold and upset. During an interview with the social worker and the administrator, on 04/19/12, at approximately 12:30 p.m., they said they did not report this to state agencies because they did view this as an allegation of neglect. b) Resident #43 Review of a customer and family concerns form, with the date of contact 04/02/12, revealed the sister of Resident #43 had left a letter in the social services office with multiple concerns. In one instance, the sister made an allegation the resident's teeth do not appear to be cleaned regularly. Another concern was noted as family reports that hair has looked unclean past couple visits. During an interview with the social worker and the administrator, on 04/19/12, at approximately 12:30 p.m., they said they did not report this to state agencies because they did not view this as an allegation of neglect.",2016-05-01
8585,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,249,C,0,1,KWL711,"Based on review of requested documentation and staff interview, the facility failed to ensure the activities program was directed by a qualified professional. The facility did not have an activities director to plan, direct, or oversee an ongoing program of activities designed in accordance with the comprehensive assessments, the interests of the residents, and the physical, mental, and psychosocial well-being of the residents. The facility failed to employ a qualified professional to oversee the activities program for a period of approximately seven (7) months. This had the potential to affect all residents. Facility census: 60. Findings include: a) On the day of entry to the facility, on 04/16/12, the administrator (Employee #45) provided the requested the Key Personnel form which indicated the position of activities director was vacant. This was verified during an interview with a recreation aide (Employee #80) at 9:15 a.m. on 04/18/12. Employee #80 stated the previous activities director had gone on disability leave in either July or August 2011 and returned in March 2012, but had resigned shortly after her return. She stated the facility had acquired an interim director who had left at the first of 2012. She stated she had no knowledge of the credentials of the interim director. Employee #80 also stated she had been assembling the monthly activity calendars and presenting them to the administrator for approval. She stated Employee #68 (another recreation aide) completed the new admission assessment forms and gave them to the Clinical Reimbursement Coordinator (Employee #43). Employee #80 stated the recreation aides continued their daily duties based on previous practices. She knew of no plans for hiring an activity director. A third recreation aide, Employee #24, as well as Employee #80, had been in their positions for five (5) years each, but neither possessed the qualifications to serve as the activities director. During an interview with the administrator, at 10:30 a.m. on 04/19/12, she stated the former activity director had take a leave due to illness in August 2011. She had been replaced with an interim director who was a recent graduate of a qualifying program, but that individual left at the end of the year when she failed her licensing exam. The administrator stated the former director had returned in February 2012, but quit without notice on 02/15/12. She had not been replaced although the corporation was attempting to hire someone through an agency. She acknowledged the calendars were being prepared by Employee #80 and approved by herself. She stated, when asked, that there had been no activities consultant service hired during this time (August 2011 - present) to oversee the activities program.",2016-05-01
8586,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,279,D,0,1,KWL711,"Based on medical record review and staff interview, the facility failed to develop a care plan with interventions for the prevention of skin breakdown for a resident identified as being at high risk for developing pressure ulcers and who had a recent history of healed pressure ulcers. This was true for one (1) of thirty-three (33) sampled residents in stage II of the Quality Indicator Survey (QIS). Resident identifier: #53. Facility census: 90. Findings include: a) Resident #53 At the time of the resident's admission to the facility, on 12/30/11, the facility identified two (2) stage II pressure areas to the coccyx. A care plan was established addressing the pressure areas. On 02/02/12, both areas were noted to have healed and the care plan was discontinued. The resident's minimum data set (MDS) assessments, with assessment reference dates (ARD) of 02/17/12 and 04/03/12 were reviewed. These assessments were completed after the pressure areas present on admission had healed. According to these assessments, the resident was still at risk of developing pressure ulcers. Review of the Braden scale for predicting pressure ulcers, completed on 04/03/12, found the resident was assessed as being at high risk for developing pressure ulcers. Review of the resident's skin integrity report, completed on 04/15/12, found the resident had developed a deep tissue injury to the left outer heel. This was measured as being 2.5 cm (centimeters) in length by 1.8 cm. in width. The surrounding tissue was identified as inflamed with healthy wound edges. Review of the current care plan found the facility had failed to address the resident's risk for developing pressure ulcers/skin breakdown, from 02/02/12 until 04/15/12, when the new area of breakdown to the left outer heel was discovered. On 04/18/12 at 10:10 a.m., the care plan was reviewed with Employee #43, the registered nurse clinical reimbursement coordinator. She verified the care plan failed to address the potential for the development of pressure areas from 02/02/12 until 04/15/12. There were no care plan interventions put in place from 02/02/12 to 04/15/12 in an attempt to prevent further development of pressure areas/skin breakdown. Despite the known history of pressure ulcers and the resident continuing to be assessed as being at high risk for developing pressure ulcers, no care plan was established until 04/15/12, when a new area of tissue breakdown was found on the left outer heel.",2016-05-01
8587,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,312,D,0,1,KWL711,"Based on medical record review, observation, and staff interview, the facility failed to ensure a dependant resident received staff assistance to maintain good person hygiene as evidenced by a malodorous smell emanating from the resident's feet. This was true for one (1) of thirty-three (33) residents reviewed in Stage II of the Quality Indicator Survey. Resident identifier: #53. Facility census: 60. Findings include: a) Resident #53 On 04/18/12 at 2:00 p.m., a dressing change to the left outer heel was observed with Employee #32, a licensed practical nurse. The resident was in bed with her socks off and Employee #32 stated, I need to clean her feet before I do the dressing, I didn't know they smelled so bad. Observation revealed the resident's toes on both feet were pressed tightly against each other. The toes were deformed and curled under. Employee #32 verified the odor was not from the deep tissue injury on the resident left outer foot, but was coming from the areas between the resident's toes. Review of the skin integrity report, completed on 04/15/12, identified the deep tissue injury on the left outer heel as having no odor. The resident's care plan included a problem identified as, I am dependent for bathing and all ADL's (activities of daily living) due to cognitive loss/dementia. There are times I am resistant to care yelling, scratching and spitting on staff when care is attempted. The goal associated with this problem was, My care needs will be anticipated and met every day as evidence by my care flow sheet and me presenting well groomed every day. Review of the shower scheduled, on 04/18/12, found no documentation the resident had refused showers. Interview with the director of nursing (DON), on 04/19/12 at 10:00 a.m., found the DON could not explain the reason for the odor emanating from the resident's feet. She verified the resident had showers or bed baths as needed, but no further information regarding the cause of the odor was provided.",2016-05-01
8588,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,314,D,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, staff interview, and observation, the facility failed to ensure interventions were in place to prevent the development of additional pressure areas for a resident who had a history of [REDACTED]. This was true for one (1) of thirty-three (33) residents reviewed in Stage II of the Quality Indicator Survey (QIS). Resident identifier: #53. Facility census: 90. Findings include: a) Resident #53 This resident was admitted to the facility from the hospital on [DATE]. She had a surgical wound secondary to repair of a [MEDICAL CONDITION], and two (2) Stage II pressure ulcers on her coccyx. The resident's admission minimum data set (MDS) assessment, with an assessment reference date (ARD) of 01/06/12, identified the resident as being totally dependent on staff for bed mobility, she did not walk, and she had limitations in the range of motion in one of her lower extremities. A care plan had been developed upon admission addressing the pressure areas that were present at that time. This care plan was discontinued on 02/02/12, when both areas had healed. A new care plan was not developed at that time to address the prevention of recurrence of the healed pressure ulcers or prevention of new pressure areas. Review of the resident's skin integrity report found the resident had developed a deep tissue injury to the left outer heel on 04/15/12. The area measured 2.5 cm (centimeters) in length and 1.8 cm in width. The surrounding tissue was documented as being inflamed with healthy wound edges. Employee #32, a licensed practical nurse, was observed performing a dressing change to the resident's heel at 2:00 p.m. on 04/18/12. The area was noted to have intact skin, was purple in color, and slightly reddened around the edges. stated she felt the area could have occurred when the resident's heel rubbed against a molded foot rest on the resident's wheelchair. She stated the footrest was hard and rounded around the resident's outer foot. Review of the resident's minimum data set (MDS) assessments, with assessment reference dates (ARD) of 02/17/12 and 04/03/12, found section M-0150 was coded to indicate the resident was at risk of developing pressure ulcers. These assessments had been completed after the pressure areas present on admission had healed. Review of the Braden scale for predicting pressure ulcers, completed on 04/03/12, found the resident was assessed as being at high risk for developing pressure ulcers. On 04/18/12 at 10:10 a.m., the care plan was reviewed with Employee #43, the registered nurse clinical reimbursement coordinator. She verified the care plan failed to address the potential for development of a new pressure area from 02/02/12 until 04/15/12. A care plan was not developed until the resident was identified as having a, deep tissue trauma to the left outer heel. Further review of the care plan found a problem statement, created by the dietitian on 04/17/12: . I have increased nutrient needs related to DTT (deep tissue trauma), stage IV pressure sore of left heel, outer aspect. (Note: the area, according to current definitions of the National Pressure Ulcer Advisory, and the minimum data set assessments instructions, did not meet the definition of a Stage IV pressure ulcer.) Although the resident had a known history of pressure ulcers, no interventions were put in place from 02/02/12 to 04/14/12, in an effort to prevent the development of new, or recurring, pressure ulcers. The assessments completed by staff identified the resident as being at high risk for developing pressure ulcers. The resident subsequently developed a deep tissue injury to the left outer heel that was identified on 04/15/12.",2016-05-01
8589,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,329,D,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and medical record review, the facility failed to: (1) identify the targeted behaviors for use of a PRN (as needed) medication, [MEDICATION NAME]; (2) implement non-pharmacological interventions before administration; (3) monitor for potential adverse side effects; and (4) monitor the residents' response to the medication. This was true for two (2) of thirty-three (33) residents sampled in Stage II of the Quality Indicator Survey who received PRN doses of the benzodiazepine, [MEDICATION NAME]. Resident identifiers: #30 and #53. Facility census: 60. Findings include: a) Resident #30 Medical record review found the resident was receiving [MEDICATION NAME] 0.5 mg by mouth, PRN three (3) times a day, since 08/17/11 for nervousness and anxiety. Review of the Medication Administration Record [REDACTED]. These included 03/06/12, 03/09/12, 03/10/12, 03/13/12, 03/14/12, 03/17/12, 03/18/12, 03/20/12, 03/22/12, 03/23/12, 03/25/12, 03/27/12, 03/28/12, 03/29/12 and 03/20/12. Review of the monthly behavior monitoring flow sheet for March 2012 found the resident was receiving [MEDICATION NAME] for multiple medical complaints. The entire flow sheet was blank for each of the fifteen (15) days the medication was administered. The directions on the flow sheet required nursing staff to indicate the day the medication was used, identify the non-pharmacological interventions implemented before administration, and to document the outcome and any possible side effects associated with the medication. During an interview with the director of nursing (DON), Employee #72, on 04/18/12 at 4:30 p.m., she reviewed the behavior monitoring flow sheet, nurses' notes and nursing assessments. The DON was unable to locate any information to verify the behaviors exhibited by the resident warranted the medication. In addition, she was unable to provide evidence of attempts at non-pharmacological interventions, descriptions of the outcome of the medications, or evidence of monitoring for possible side effects associated with the medication. b) Resident #53 Review of the physician's orders [REDACTED]. Review of the MAR found the resident received [MEDICATION NAME] on 03/05/12, 03/20/12 and 03/28/12 without evidence of: (1) the targeted behaviors exhibited; (2) the non-pharmacological interventions implemented before usage; (3) the outcome of the medications; and (4) monitoring of possible side effects associated with the medication. An interview with the DON, on 04/18/12 at 11:50 a.m., found she was unable to find the needed documentation for administration of [MEDICATION NAME]. No further information was provided before close of the survey.",2016-05-01
8590,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,371,E,0,1,KWL711,"Based on observation and staff interview, the facility failed to ensure food was prepared under sanitary conditions. Two (2) peanut butter and jelly sandwiches were being prepared beside a wet dish cloth. Both the cloth and the cleaning solution on the cloth created a potential for food contamination. This had the potential to affect more than a limited number of residents who received nourishment from the dietary department. Facility census: 60. Findings include: a) On 04/17/12 at 11:24 a.m., four (4) slices of white bread, two (2) of which had peanut butter on them, were observed on the preparation table in the kitchen. A cleaning cloth was lying beside the four (4) slices of bread. This was brought to the attention of the food service director (Employee #14) and the cook (Employee #67). Employee #67 stated the cloth was on the preparation table in order to clean the table after the sandwiches were made. Employee #67 confirmed the cloth should have been in the sanitizing solution. Furthermore, Employee #14 agreed the cloth was not to be on the preparation table when food was being prepared, and should have been stored in the sanitizing solution until needed.",2016-05-01
8591,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,425,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, pharmacist interview, and record review, the facility failed to properly dispose of medications after discharging residents and/or after expiration of the medication. The facility's pharmacy policy contained directives for medication disposal which were not implemented by the facility. This had the potential to affect all residents, as there was only one (1) medication preparation/storage area. Facility census 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, the following medications were found in the refrigerator in the shelf of the door: - One (1) opened and resealed bottle labeled Ativan intensol 2mg/ml with a name handwritten across the label. There was no date to indicate when it was opened. The previous name on the label was blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. - One (1) bottle of Novolin R insulin and one (1) bottle of Novolin N insulin whose labels indicated they were opened on 03/15/12. According to facility policy, these should have been disposed of on 04/11/12. They were labeled for Resident #1002 who was discharged on [DATE]. - One (1) opened bottle of Lantus insulin labeled as opened on 03/24/12. It belonged to Resident #1003, who was discharged on [DATE]. - One (1) opened bottle of Novolog insulin labeled as opened on 03/16/12. It belonged to Resident #69, a current resident. According to facility policy, this medication should have been discarded on 04/12/12. Observation revealed a sign, posted above the refrigerator in the medication storage/preparation room, which stated, OPENED VIALS TO BE DISCARDED AFTER 28 DAYS. The director of nursing (DON) was present, and verified this was facility policy. She acknowledged all these medications should have been discarded prior to the observations on 04/18/12. During a telephone interview with the facility's consultant pharmacist, at 10:15 a.m. on 04/19/12, he stated he was unaware of the label changes on the Ativan. He stated, as a controlled substance, Ativan could not be retained in the facility without a written, signed order from the physician received in the pharmacy. He further stated, No medications can be transferred in the facility. When a resident was discharged , all medications were to be pulled from the cart, stock, or refrigerator, and disposed of appropriately. The pharmacist had no answer why the medications of discharged residents and/or outdated medications had not been discovered during pharmacy inspections. He and the director of nurses both stated there had been a pharmacy review the preceding week.",2016-05-01
8592,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,428,D,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review, consultant pharmacist interview, and staff interview, the consultant pharmacist failed to identify medication irregularities for two (2) of thirty-three (33) Stage II sample residents. The residents each received Xanax PRN (as needed) without: (1) identification of targeted behaviors for use; (2) implementation of non-pharmacological interventions before deciding to use the medication; (3) monitoring for potential adverse side effects; and (4) monitoring each resident's response to the medication. Resident identifiers: #30 and #53. Facility census: 60. Findings include: a) Resident #30 Medical record review found the resident was receiving Xanax 0.5 mg by mouth three (3) times daily as needed. This order was written 08/17/11 for nervousness and anxiety. Review of the Medication Administration Record [REDACTED]. These included 03/06/12, 03/09/12, 03/10/12, 03/13/12, 03/14/12, 03/17/12, 03/18/12, 03/20/12, 03/22/12, 03/23/12, 03/25/12, 03/27/12, 03/28/12, 03/29/12 and 03/20/12. Review of the monthly behavior monitoring flow sheet for March 2012 found the resident received the Xanax for multiple medical complaints. The entire flow sheet was blank. The directions on the flow sheet required nursing staff to indicate the day the medication was used, identify the non-pharmacological interventions implemented before administration, and to document the outcome and any possible side effects associated with the medication. During an interview with director of nursing (DON), Employee #72, on 04/18/12 at 4:30 p.m., she reviewed the behavior monitoring flow sheet, nurses notes, and nursing assessments. She was unable to locate any information which indicated the resident exhibited any behaviors which warranted the medication and was unable to verify non-pharmacological interventions were attempted prior to medication use. Additionally, the DON was unable to locate monitoring for the outcome of the medications or monitoring of possible side effects associated with the medication. On 04/19/12 at 10:30 a.m., the DON verified the pharmacist reviewed the resident's medication regimen on 4/11/12 and 4/12/11, and failed to report the irregularity to the physician. The consultant pharmacist was interviewed by telephone, on the afternoon of 04/19/12, and was unable to provide any further information. b) Resident #53 Review of the physician's orders [REDACTED]. Review of the MAR found the resident received Xanax on 03/05/12, 03/20/12 and 03/28/12 without documentation of (1) the targeted behaviors exhibited; (2) the non-pharmacological interventions implemented before usage; (3) the outcome of the medications; and (4) monitoring of possible side effects associated with the medication. An interview with the DON, on 04/18/12 at 11:50 a.m., found she was unable to find the needed documentation for administration of Xanax and no further information was provided before close of the survey. On 04/19/12 at 10:30 a.m., the DON verified the pharmacist reviewed the resident's medication regimen on 4/11/12 and 4/12/11, and failed to report the irregularity to the physician. On the afternoon of 04/19/12, the consultant pharmacist was interviewed by telephone and was unable to present any further information.",2016-05-01
8593,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,431,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, consultant pharmacist interview, and record review, the facility failed to reconcile controlled medications and/or ensure that a controlled medication was appropriately labeled in accordance with currently accepted professional principles and facility policy. This had the potential to affect more than an isolated number of residents, as there was only one (1) medication storage room. Facility census: 60. Findings include: a) During observation of medication storage, in the sole medication storage and preparation room, accompanied by the director of nurses (Employee #72) at 3:00 p.m. on 04/18/12, an opened and resealed bottle of Ativan intensol 2 mg/ml was found in the the refrigerator on a shelf in the door. A resident's name was handwritten across the label. There was no date to indicate when the medication was opened. The previous name on the label had been blackened out with a marker. Employee #72 confirmed the medication belonged to Resident #1001, who was discharged on [DATE]. A second bottle of the same medication, unopened, and labeled by the pharmacy for Resident #1001, was also found on a shelf of the refrigerator. The DON stated the facility's practice was to mark out the resident's name on a label if the resident was discharged , and keep it a locked container inside the refrigerator, until it was needed by a resident with a new order. According to the DON, this ensured a resident with a new order had immediate access to the medication. The process eliminated waiting for a written signed order to be delivered to the pharmacy and the medication then delivered to the facility. When asked, the DON acknowledged this was not in accordance with state pharmacy guidelines. Observation revealed she discarded the opened bottle, marked out the resident's name on the unopened bottle, and placed it in the locked container in the refrigerator. During a telephone interview with the facility's consultant pharmacist, at 10:15 a.m. on 04/19/12, he stated he was unaware of the label changes on the Ativan. He stated, as a controlled substance, Ativan could not be retained in the facility without a written, signed order from the physician received in the pharmacy. He further stated, No medications can be transferred in the facility. When a resident was discharged , all medications were to be pulled from the cart, stock, or refrigerator, and disposed of appropriately. The pharmacist had no answer why the medications of discharged residents and/or outdated medications had not been discovered during pharmacy inspections. He and the director of nurses both stated there had been a pharmacy review the preceding week.",2016-05-01
8594,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,441,E,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility failed to ensure an infection control program which helped prevent the development and transmission of disease. Clean linens and hydroculator covers were not stored in a manner to prevent contamination. Additionally, nursing personnel failed to practice effective hand hygiene. These practices had the potential to affect more than an isolated number of residents. Facility census: 60 Findings include: a) Linens On 04/17/12 at 9:00 a.m., clean linen was found on the sink countertops in rooms 301 through 308. The linens included towels, wash cloths, sheets and reusable pads. The linens were placed on both sides of the sinks. An additional tour of the 300 Hall, on 04/17/12 at 11:15 a.m., revealed additional clean linens had been placed on the countertops. The items included fitted and flat sheets. Employee #72, the director of nursing (DON), was informed of these findings at 11:30 a.m. She was taken to room [ROOM NUMBER] to see the manner in which the linen was stored. Upon seeing the clean linen on the countertop, she stated staff knew the clean linen should not be stored on the sink and she would take care of this. b) Hydroculator covers Observation, on 04/16/12 at 1:00 p.m., revealed the soiled linen hamper and the uncovered cart containing clean hydroculator covers were side by side in the rehabilitation room. An additional observation, on 04/17/12 at 2:00 p.m., found the carts in the same location. Another observation, on 04/19/12 at 9:30 a.m., found the same situation. An interview, on 04/19/12 at 1:15 p.m., with the certified occupational therapist (Employee #87) revealed staff were not aware of the need to separate the clean covers from the soiled linen hamper. Employee #87 stated this would be corrected immediately. c) Handwashing - Observation during the lunch meal, on 04/17/12 at 12:14 p.m., found a nursing assistant (Employee #23) washed her hands and dried her hands with paper towels. After turning off the water faucet with the paper towels, she finished drying her hands with the same contaminated paper towels. She then proceeded to serve residents drinks, silverware, and the lunch meal. - Observation during the mid-day meal found Employee #42, a nursing assistant, failed to wash or sanitize her hands after using a lift sheet to help pull Resident #40 up higher in the bed. Immediately after assisting Resident #40, and without washing her hands, Employee #42 obtained and delivered a tray to Resident #27. She placed a towel over the resident's chest as a clothing protector, opened the milk carton and silverware, and handed the resident a fork. Further observation revealed Employee #42 then handled the central coffee dispenser on a cart in the hallway with her unclean hands. She poured a cup of coffee, obtained a plastic lid and placed it on the cup of coffee, then delivered a tray to Resident #108. Employee #42 assisted another nursing assistant to pull Resident #108 up in the bed, then set up his tray before she washed her hands and left the room. During an interview with the director of nursing on 04/19/12, at approximately 8:00 a.m., she acknowledged the nursing assistant did not follow correct hand-washing protocols. d) Employee #42 Observation of the mid-day meal found that nursing assistant #42 failed to wash or sanitize her hands after helping to pull Resident #40 up higher in the bed, using a lift shift the resident was lying on to lift her. Observation revealed that Employee #42 then immediately obtained and delivered a tray to Resident #27 in room [ROOM NUMBER]. She placed a towel over his chest as a clothing protector, opened his milk carton and silverware, and handed him his fork with unwashed hands. Further observation revealed Employee #42 then handled the central coffee dispenser on a cart in the hallway with her unclean hands, poured a cup of coffee, obtained a plastic lid and placed it on the cup of coffee, then delivered a tray to resident #108 in room [ROOM NUMBER]. Employee #42 assisted another aide to pull Resident #108 up in the bed, then set up his tray before she washed her hands and left the room. During interview with the Director of Nursing on 04/19/12 at approximately 8:00 a.m. she acknowledged the aide did not follow correct hand-washing protocols.",2016-05-01
8595,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2012-04-19,492,C,0,1,KWL711,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure each dietary employee had a valid food handlers permit as required by county regulations. Two (2) dietary employees did not have a current food handlers card. This practice had the potential to affect all residents who received nourishment from the dietary department. Facility census: 60 Findings include: a) Upon entrance, facility personnel were asked to provide evidence of food handlers permits, if the county in which the facility was located required them. On [DATE] at 11:40 a.m., a review of the food handlers permits, with the food service director (Employee #14), revealed the cooks (Employees #67 and #8) did not have valid food handlers permits. Inspection of the food handlers permits for these two (2) revealed each had expired in [DATE]. Employee #14 stated both employees had renewed their food handlers permits, but had not provided their cards. At the time of the survey, the facility had no evidence these employees had fulfilled the requirements to renew their food handlers permits. .",2016-05-01
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
10348,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,241,D,0,1,5TIO11,"Based on observation, record review, and staff interview, the facility failed to provide care with dignity by discussing care issues in the presence of an alert resident and in an area that did not assure auditory privacy for one (1) of thirteen (13) sampled residents. Resident identifier: #30. Facility census: 58. Findings include: a) Resident #30 During the provision of wound care by two (2) nurses (Employees #34 and #74) for Resident #30 in the resident's room at 11:10 a.m. on 10/06/09, Employee #74 stood by the resident's head at the top of the bed during the procedure. The resident was on the window bed farthest from the door, and the privacy curtain was pulled between the beds, but the door was not closed. The room was located on the main hallway from the front entrance, and several staff members and others were seen passing in the hall. While the resident could not be seen from the open door, the overbed table and its supplies were visible, making it obvious that wound care was being done. This surveyor stood against the wall across from the foot of the bed. At the start of the wound care, the resident was turned to face the inside of the room. At that time she said, on three (3) separate occasions and in a voice audible to this surveyor, that she needed to use the bathroom. Neither nurse acknowledged this request the first two (2) times; on her third try, when she said she had to ""go bad"" and apologized by saying, ""I'm sorry"", Employee #74 told her, ""It's OK. This won't take long."" At one point, Employee #74 asked the resident if she was having pain, and the resident replied that she was, but the nurse said nothing, and they continued with the procedure. During the procedure, Employee #34 related to this surveyor information which included the status of the wounds present, the care being given, and traits that the resident had that impeded the healing process. She stated the resident was refusing to eat, would not let them turn her off of the affected side often enough, and that she would not heal as long as she did this. The resident was alert and aware of her surroundings. She spoke clearly and made requests during the dressing change, but Employee #34 never spoke to her throughout the procedure, and none of her observations were directed to the resident. The surveyor could easily hear the nurse, and when the surveyor, at one point, walked to the doorway, Employee #34 could still be heard. During an interview with Employee #74 and the facility's wound care nurse (Employee #62) at 10:30 a.m. on 10/07/09, they both acknowledged Resident #30 was alert and aware of those around her. This resident was identified by the facility as being interviewable. Employee #74 acknowledged the resident had made the requests repeated above but did not comment about her failure to address them. .",2015-05-01
10349,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,272,E,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the accuracy of the minimum data set (MDS) assessments for four (4) of the thirteen (13) sampled residents. Resident identifiers: #49, #21, #42, and #10. Facility census: 58. Findings include: a) Resident #49 Medical record review revealed Resident #49 was an [AGE] year old female who was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Her admission MDS revealed, in Section M.1., the presence of two (2) Stage I, one (1) Stage II, and one (1) Stage IV pressure ulcers. A review of the significant change in status MDS, dated [DATE], indicated in Section M.1. the presence of one (1) Stage II and one (1) Stage IV pressure ulcers, but there was no entry in Section M.3. to indicated there were any resolved ulcers. This made the status of the resident unclear. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/10/07/09, she acknowledged there should have been an entry in Section M.3., as she was sure two (2) of the ulcers had healed. b) Resident #21 Medical record review revealed Resident #21 had been receiving a diuretic ([MEDICATION NAME]) daily since at least November 2008, but the significant change in status MDS, dated [DATE], failed to indicate this in Section O.4. The MDS nurse, when questioned at 3:45 p.m. on 10/07/09, stated this was an oversight. c) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: ""Resident at times sits up all night not allowing staff to put her to bed."" She was ordered [MEDICATION NAME] 25 mg each night for sleep, and this medication was increased to 50 mg on 08/15/09, after a psychiatric consult on 08/13/09, when the physician noted she was ""somnolent"" during the examination. A review of the annual MDS, dated [DATE], and the quarterly MDS, dated [DATE], found not mention, in Section E.1., of any ""sleep-cycle issues"", although the care plan dated 07/27/09 stated: ""Resident continues to sit up at night at times, refusing to go to bed, falling asleep in wheelchair."" During an interview with the MDS nurse at 3:45 p.m. on 10/07/09, she acknowledged there should have been an entry in Section E, because she and other nurses were aware the resident did have sleeping issues and would stay up at night and then be sleepy during the day. d) The MDS nurse reported to this surveyor, on 10/08/09, that she had corrected the inaccuracies noted above. e) Resident #10 Review of Resident's #10 medical record, on 10/06/09, revealed the MDS was completed on 09/16/09, with Section N. (Activity Pursuit Patterns) identifying the resident as not awake any time during the last seven (7) days. Observations at the time of this survey, and interview on 10/07/09 with the MDS nurse, revealed the resident stayed in bed most of the time watching TV and reading. The MDS nurse acknowledged this was an inaccurate assessment. .",2015-05-01
10350,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,274,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to complete a comprehensive assessment minimum data set (MDS) for one (1) of thirteen (13) sampled residents who exhibited a significant change in health status. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The facility completed an annual MDS on 05/04/09 and a quarterly MDS on 07/26/09. A comparison of these assessments revealed following changes: Section E1 (indicators of depression, anxiety, sad mood) - repetitive verbalizations and repetitive anxious complaints / concerns increased from less than six (6) times a week to daily or almost daily, and repetitive movements increased from non to less than six (6) times a week. Section E2 (mood persistence) - changed from present and easily altered to present and not easily altered. Section 4 (behavioral symptoms) - the frequency of resisting care increased from occurring one (1) to three (3) days in the last seven (7) days to occurring four (4) to six (6) days in the last seven (7) days. Section O4b - the resident was now receiving a medication for antianxiety. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she acknowledged, after reviewing the record, that the 07/26/09 MDS should have been a comprehensive significant change in status assessment instead of an abbreviated quarterly assessment. .",2015-05-01
10351,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,279,E,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to initiate a care plan and/or adequately address all problems identified through the comprehensive resident assessment for nine (9) of fifteen (15) sampled residents, by either not establishing measurable goals and/or by the lack of nursing interventions designed to meet the goals. Resident identifiers: #3, #4, #13, #42, #59, #36, #24, #48, and #57. Facility census: 58. Findings include: a) Residents #3, #13, #42, #59, #36, #24, and #48 Each of these seven (7) residents was receiving one (1) or more psychoactive medications on a continuing basis including [MEDICATION NAME], [MEDICATION NAME], and/or [MEDICATION NAME]. These medications were identified in their comprehensive minimum data set (MDS) assessments, which triggered the resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use. In each case, the interdisciplinary care team identified on the resident's RAP summary that the team would proceed with care planning the medication use to observe for the effectiveness of medication, potential medication side effects, and potential dosage reductions. However, none of residents' care plans contained a problem, under the column headed ""Focus"", for [MEDICAL CONDITION] drug use and there were no measurable goals established for this. The only entries found were the following statement under ""Interventions"": ""Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects."" This intervention was usually addressing a behavioral or cognitive problem. In none of these residents' care plans were any of the side effects listed, although, in the documentation of the care plan meeting, at times, mentioned potential safety issues. During a meeting with the MDS nurse (Employee #47), the assistant director of nursing (Employee #74), and the administrator at 4:00 p.m. on 10/07/09, the MDS nurse acknowledged she did not address the use of a [MEDICAL CONDITION] drug as a problem and admitted that the wording in the RAP summaries did indicate this would be addressed for these residents. She said that they would have to discuss this. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she had a [DIAGNOSES REDACTED]. The admission MDS, dated [DATE], identified in Section O (Medications) that the resident was receiving a daily diuretic. The RAP summary, completed on 08/06/09, was triggered for dehydration / fluid maintenance, and the care planning decision was checked to indicate this would be addressed on the resident's care plan. Review of the current care plan found it did not address the potential problem / risk of dehydration. In an interview on the afternoon of 10/07/09, the MDS nurse there was no care plan to address this risk. c) Resident #57 Review of Resident #57's medical record, on 10/06/09, revealed a [DIAGNOSES REDACTED]. d) Resident #4 Review of Resident #4's medical record, 10/07/09, revealed she had a current physician order [REDACTED]. In an interview at about 10:00 a.m. on 10/08/09, the MDS nurse acknowledged there had been no care plan developed for dehydration. .",2015-05-01
10352,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,280,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to review and/or revise the care plan to include changes in health care needs including a significant weight loss due to poor intake for one (1) of thirteen (13) sampled residents. Resident identifier: #21. Facility census: 58. Findings include: a) Resident #21 A review of the significant change in status minimum data set (MDS), dated [DATE], revealed Resident #21 had a weight loss of 5% or more in the last thirty (30) days or 10% or more in the last one hundred eighty (180) days (Section K3a), and that she left twenty-five percent (25%) or more of food uneaten at most meals (Section K4c). The care plan meeting notes for 08/19/09 stated: ""MDS and Careplan reviewed for significant change in status on 8/12/09. Significant change due to weight loss, ..."" and ""Resident has exhibited a weight loss over past months. She is taking a regular no added salt diet with sugar substitute. Resident is able to feed self but needs much encouragement."" These changes in the MDS triggered the resident assessment protocol (RAP) for nutritional status, which included the above assessment information, and the interdisciplinary care team indicated that care planning would be done to address this. A review of the care plan, with a print date of 08/17/09, revealed the following entry on page 6 as an addition under the problem of dehydration: ""8/17/09 Res (resident) has exhibited significant weight loss over past review. At risk for additional weight loss due to poor intakes. Continue with POC (plan of care)."" There was no goal associated with this entry and no nursing interventions as suggested in the care plan meeting. During an interview with the MDS nurse (Employee #47) at 3:45 p.m. on 10/07/09, she reviewed the care plan and agreed it contained no interventions, possibly due to an oversight. .",2015-05-01
10353,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,285,B,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the mental health status of a new resident had been evaluated under the Pre-Admission Screening and Resident Review (PASRR) program prior to the resident being admitted into the facility for three (3) of fifteen (15) sampled residents. Resident identifiers: #60, #36, and #49. Facility census: 58. Findings include: a) Resident #60 Review of Resident #60's medical record, on 10/07/09, revealed he was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 06/19/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. b) Resident #36 Review of Resident #36's medical record, on 10/06/09, revealed she was admitted to the facility on [DATE]. The PASRR determination was not made, as indicated by the dated signature in Section V, until 07/27/09. In an interview on 10/08/09, the social service director acknowledged the resident was admitted prior to the determination of the PASRR.. c) Resident #49 A review of the clinical record revealed Resident #49 was admitted to the facility on [DATE]. However, the Level II determination was not made, as indicated by the dated signature in Section V of the PASRR, until 07/15/09. During an interview with the administrator and the social worker at 10:15 on 10/08/09, they acknowledged the dates noted above were correct. .",2015-05-01
10354,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,329,D,0,1,5TIO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure the medication regimen of one (1) of thirteen (13) sampled residents was free of unnecessary drugs. There was a lack of monitoring for sleeplessness to ascertain the effectiveness of [MEDICATION NAME] in treating [MEDICAL CONDITION], and there was a lack of monitoring for the presence of adverse side effects associated with the use of the [MEDICATION NAME]. Resident identifier: #42. Facility census: 58. Findings include: a) Resident #42 Medical record review revealed Resident #42 was an [AGE] year old female with [DIAGNOSES REDACTED]. The resident's care plan contained a problem initiated on 05/10/09, stating: ""Resident at times sits up all night not allowing staff to put her to bed."" Her physician ordered [MEDICATION NAME] 25 mg each night to promote sleep. The dosage of this medication was increased on 08/15/09 to 50 mg after a psychiatric consult on 08/13/09, during which the physician noted, ""She's still having problems with decreased sleep at night"" and that she was ""somnolent during the examination"". Review of the resident's annual comprehensive assessment, dated 05/04/09, and the most recent abbreviated quarterly assessment, dated 07/26/09, found no entries in Section E1 to indicate the resident exhibited signs of ""sleep-cycle issues"". The resident assessment protocol (RAP) for [MEDICAL CONDITION] drug use stated: ""Will proceed with care plan to observe effectiveness of medication, potential medication side effects and for potential dosage reductions."" However, the only entry in the care plan was: ""Administer antipsychotic and antidepressant per MD orders. Observe for effectiveness and side effects."" A review of seventeen (17) interdisciplinary team progress notes, written between 07/27/09 and 08/10/09, only revealed one (1) entry (on 07/27/09) which addressed her problem of not sleeping, stating, ""Resident continues to sit up at night at times, refusing to go to bed, falling asleep in wheelchair."" A review of August and September 2009 nursing notes failed to reveal any monitoring of her sleeplessness or its decline or improvement after the addition of [MEDICATION NAME] medication therapy. Her monthly behavior monitoring flowsheets did not include sleeplessness as a behavior to be monitored daily. The care plan identified the problem of the resident sitting up all night with several nursing interventions, but there was no mention of the need to conduct any behavioral monitoring, and there was no evidence that such monitoring occurred. There was no evidence in the record of any behavioral monitoring or monitoring for the onset of adverse side effects. During a meeting with the MDS nurse (Employee #47), the assistant director of nursing (Employee #74), and the administrator at 4:00 p.m. on 10/07/09, they were asked where the information about the resident's not sleeping, as mentioned in the care plan meeting notes of 08/05/09, was recorded. They all stated they were aware the resident stayed up at night, and they stated they thought her sleeplessness may contribute to her behaviors and refusal of baths, but they could produce any documentation to support this. At the time of exit, there had been no additional monitoring documentation presented. .",2015-05-01
10355,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-10-08,386,D,0,1,5TIO11,"Based on record review and staff interview, the facility failed to assure a physician signed and dates all orders received for the care of one (1) of thirteen (13) sampled residents in a timely manner. Resident identifier: #49. Facility census: 58. Findings include: a) Resident #49 A review of the clinical record for Resident #49 revealed the attending physician's last required visit was on 09/16/09, with progress notes entered by him into the record and signed and dated. But there were five (5) verbally received treatment orders from August and eight (8) from September (prior to his visit date) that were not signed or dated to reflect his review. The monthly recapitulation of physician orders for September was on the record on 08/31/09, and these were also not signed or dated. During an interview with the administrator at 10:20 a.m. on 10/08/09, when informed of the physician's failure to sign the orders, she stated all orders should have been signed and she would review the chart. At the time of exit, no additional information had been received regarding this concern.",2015-05-01
10356,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-12-03,514,D,0,1,5TIO12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to assure the clinical information in one (1) of eight (8) sampled residents' records was accurate, by having physician's orders [REDACTED]. Resident identifier: #15. Facility census: 56. Findings include: a) Resident #15 A review of Resident #15's clinical record revealed a medication order handwritten onto the computer generated physician's orders [REDACTED]. The order was written adjacent to the PRN Medication area and read: ""[MEDICATION NAME] 2.5 mg po (by mouth) @ 4 pm & HS (bedtime)"". The order was undated, unsigned, and did not identify the [DIAGNOSES REDACTED]. The physician orders [REDACTED]."" The Medication Administration Record [REDACTED]@ 4 pm and HS"", and the resident was routinely receiving the medication twice daily on a regular basis. During an interview with the director of nurses at 3:05 p.m. on 12/03/09, she stated she had spoken to the nurse who transcribed the order, and the nurse reported the physician instructed her to make the medication order continuous instead of PRN. She acknowledged the order had not been transcribed per facility policy (Taking Medication and Treatment Orders) onto a verbal / telephone order form.",2015-05-01
10357,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-12-03,428,D,0,1,5TIO12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure irregularities reported by the pharmacist during the drug regimen review were acted upon for one (1) of eight (8) sampled residents. Resident #53 was receiving Ativan and Ambien, and the pharmacist identified these medications had sedative side effects and asked the physician to evaluate the need for both medications. The physician was notified of this irregularity on 09/29/09 and failed to act upon the pharmacist's recommendation. Facility census: 56. Findings include: a) Resident #53 Review of the current physician's orders [REDACTED]. A review of the Pharmacy Consult Report (dated 09/27/09) found the pharmacist identified a drug irregularity, in that both drugs had sedative side effects. The recommendation stated, ""Please provide documentation in your progress notes why this resident needs two sedating drugs at HS (bedtime). If dual drug therapy is to continue, it is recommended that: a) the prescriber document an assessment of risk versus benefit, indicating that it continues to be a valid therapeutic intervention for this individual..."" The physician signed the report on 10/13/09 but did not record any response. A review of the physician's progress notes for 10/17/09 and 11/23/09 failed to find evidence the physician addressed the pharmacist's recommendations. In an interview with the director of nursing on 12/03/09 at 4:00 p.m., she could not find any additional information. .",2015-05-01
11285,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-05-21,279,D,1,0,JD6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review and staff interview, the facility failed to develop a comprehensive care plan for one (1) of eight (8) sampled residents. A resident was admitted to the facility with an antibiotic-resistant respiratory infection and was ordered antibiotic therapy by the physician. The facility did not address the respiratory infection on the resident's care plan. Resident identifier: #59. Facility census: 56. Findings include: a) Resident #59 Resident #59's closed medical record, when reviewed on 05/20/09, revealed the resident was admitted to the facility on [DATE], with [DIAGNOSES REDACTED]. On 02/05/09, the physician ordered, ""[MEDICATION NAME] 600 milligrams BID (twice daily) [MEDICAL CONDITIONS]-resistant Staphylococcus aureus)."" The resident's admission minimum data set assessment (MDS), dated [DATE], in Section I, 2., indicated the resident had an antibiotic-resistant infection. Review of the resident's care plan, dated 02/05/09, found no mention of the resident's antibiotic-resistant respiratory infection. The assistant director of nursing (ADON - Employee #1), when interviewed on 05/21/09 at 10:20 a.m., stated she was the facility's infection control nurse and confirmed the resident's care plan did not address the respiratory infection. The ADON further stated it was the facility's policy to [MEDICAL CONDITION] infections on the care plan. .",2014-07-01
11286,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-05-21,323,G,1,0,JD6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, family interview, and staff interview, the facility failed to assure the safety of one (1) of eight (8) sampled residents, by not providing adequate supervision to prevent an accident with injury requiring emergency medical intervention. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, ""Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards."" While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as ""2+"" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or total dependence of staff for bed mobility, transfers, and toileting. The daughter's concern about the lack of adequate staff assistance when the fall occurred (an allegation of neglect) was not reported to the appropriate State agencies, and there was no documentation to indicate the facility conducted a thorough investigation into the daughter's concerns even though the nurses' notes indicated the resident's daughter returned to the facility with the resident and spoke to the director of nursing (DON) about the fall. During an interview with the administrator at 11:05 a.m. on 05/21/09, she acknowledged the daughter had been upset at the fact that there were not two (2) persons assisting Resident #57 at the time of the fall, but the administrator stated there was a nursing assistant in the room and the resident had a walker. She also stated the resident had gotten herself out of bed, although there was no evidence of this, and it was not mentioned in either the nurses' notes or the incident report. The administrator did acknowledge, after reviewing the record, there should have been two (2) nursing assistants present to assist the resident whenever she was out of bed. .",2014-07-01
11287,CANTERBURY CENTER,515179,80 MADDEX DRIVE,SHEPHERDSTOWN,WV,25443,2009-05-21,225,D,1,0,JD6Y11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on closed record review, family interview, and staff interview, the facility failed to immediately report and/or thoroughly investigate an allegation of neglect, when one (1) of eight (8) sampled residents, who did not receive the assistance of two (2) staff members with transfer or ambulation, fell and sustained an injury. Resident identifier: #57. Facility census: 56. Findings include: a) Resident #57 Review of Resident #57's closed medical record revealed a [AGE] year old female with [DIAGNOSES REDACTED]. The resident fell in her room on 06/04/08, striking her head and requiring an emergency transport to the hospital for closure of the laceration. The resident's daughter, when interviewed, reported the resident was standing at the sink while a nursing assistant was making her bed when she fell , although her mother was supposed to have the assistance of two (2) staff members when up. The resident's daughter stated she questioned the facility about the lack of assistance at the time of the fall. Documentation on the incident report of the fall stated, ""Pt. (patient) was ambulating in walker and CNA (certified nursing assistant), lost balance and fell backwards."" While the description of the circumstances surrounding the fall varied between these two (2) sources, both the incident report and the resident's daughter indicated only one (1) staff member was present at the time of Resident #57's fall. A review of Resident #57's care plan revealed a nursing intervention indicating the resident required the assistance of two (2) staff members when getting out of bed. An activities of daily living (ADL) assistance form communicated to the nursing assistants, on 09/26/07 and again on 04/24/08, that the number of staff Resident #57 required for bed mobility, transfers, and toileting as ""2+"" (two (2) or more). Documentation by the nursing assistants on the ADL flow sheet, for 06/04/08, recorded Resident #57 required maximum physical help or total dependence of staff for bed mobility, transfers, and toileting. The daughter's concern about the lack of adequate staff assistance when the fall occurred (an allegation of neglect) was not reported to the appropriate State agencies, and there was no documentation to indicate the facility conducted a thorough investigation into the daughter's concerns even though the nurses' notes indicated the resident's daughter returned to the facility with the resident and spoke to the director of nursing (DON) about the fall. During an interview with the administrator at 11:05 a.m. on 05/21/09, she acknowledged the daughter had been upset at the fact that there were not two (2) persons assisting Resident #57 at the time of the fall, but the administrator stated there was a nursing assistant in the room and the resident had a walker. She also stated the resident had gotten herself out of bed, although there was no evidence of this. When asked why the allegation of neglect by the daughter had not been reported and investigated, she stated they did not recognize it as an allegation at the time, although she admitted there should have been two (2) nursing assistants present. .",2014-07-01
3012,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-02-14,689,E,1,0,29JE11,"> Based on observations, staff interviews, review of water temperature logs and policy review, the facility failed to monitor safe water temperatures accurately on 1 of 2 halls (A hall). The facility failed to consistently perform weekly water temperatures for 1 of 2 halls. This had the potential to affect more than an isolated number of residents. Facility census 56. Findings included: a) Accurate monitor of water temperatures Review of water temperature logs, conducted on 02/12/18 at 3:15 PM, revealed on 02/05/18: --A 1 room water temp 119.6 --A 2 room water temp 116.9 --A-5 room water temp 117.1 --A-7 room water temp 118.1 --B-18 room water temp 118.1 During an interview, on 02/12/18 at 12:00 PM, Maintenance Director (MD) #51 stated the facility had problems with mixing valve in (MONTH) and on 02/05/18 installed a new circulating valve in the building to raise water temperatures. The facility had been having problems with cold water complaints since his date of hire 01/08/18. MD #51 stated he and the normal water temperature in resident rooms is to be between 100-110 degrees. During an interview, on 02/12/18 at 3:25 PM, with the Administrator and MD #51 stated the water temperatures were only elevated for a short while. The administrator stated the facility took no precautions to limit resident access to hot water on 02/05/18. The facility provided documentation of water temps done on 02/06/18 and 02/12/18. Water temperatures were within state guidelines. On 02/12/18 at 3:40 PM to 3:45 PM, water temperatures were obtained by MD #51 utilizing a digital thermometer. --Room A 9 was 112. MD #51 stated oh that is hot. --Room A 10 was 114. --Room A 15 was 117 --Shower room (on A hall) was 99.5. At 3:50 PM, MD #51 stated the thermometer was self calibrating. MD #51 stated he had never calibrated the thermometer or changed the batteries since his date of hire. MD #51 was instructed on obtaining a cup of ice mixed with water. The thermometer only dropped to 42 degrees after immersion in ice slurry. At 4:03 PM, Regional Senior VP of Clinical Operations obtained a second thermometer. The thermometer was calibrated in ice slurry. The thermometer dropped to 32 degrees. On 02/12/18 at 4:05 PM, water temperatures were performed by VP of Clinical operations. --Room A 9 water temp was 110 --Room A 10 water temp was 106 --Room A 15 water temp was 100 At 4:15 PM on 02/12/18, MD #51 stated he had turned the mixing valve down. MD #51 stated he had informed the Administrator of his interventions. At 4:20 PM on 02/12/18, Maintenance Assistant (MA) #10 stated he did water temperatures on a weekly basis. MA #10 stated he did not do any more frequent monitoring of water temperatures after the installation of the circulating valve on 02/05/18. MA #10 stated he had never calibrated a thermometer prior to taking water temperatures. MA #10 stated he started to work at the facility on 01/15/18. MA #10 stated he had performed water temperatures since his date of hire which he did not document. MA #10 was unable to provide any evidence that water temperatures had been performed. Review of water temperature logs performed on 02/12/18 at 7:45 PM and 02/13/18 at 5:05 AM revealed water temperatures on both the A hall and B hall and shower room ranged 100 degrees to 109 degrees. Nursing was notified, on 02/12/18 at 8:00 PM that water temperatures were in the safe range. b) Consistent monitoring of water temperatures Review of facility policy entitled Hot Water Temperatures: inspection. revised 06/01/07 stated hot water temperatures will be tested weekly. Process is to conduct tests in at least 3 locations. Inspection forms are to be filed and maintained for one year. Review of water temperature logs revealed water temperatures had not been monitored from 10/02/17 until 01/19/18. During an interview, on 02/12/18 at 3:25 PM, with the Administrator and MD #51 stated the water temperatures were monitored on a weekly basis. The administrator was unaware of the lack of documentation of water temperature inspections performed from 10/02/17 until 01/19/18. The Administrator stated she could provide no further evidence that water temperature inspections had been completed.",2020-09-01
3013,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-03-22,655,E,1,0,GXSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to provide the residents and/or responsible parties with written summaries of the residents' baseline care plans which were developed within forty-eight (48) hours of admission. This was evident for four (4) of five (5) sampled residents. Resident identifiers: #61, #16, #5, #6. Facility census: 59. Findings included: a) Resident #61 Review of the medical record on 03/20/18 found this resident first came to the facility on [DATE], and had some baseline careplanning done in the first forty-eight (48) hours of admission. There was no evidence that the resident and/or the responsible party was provided a written summary of the baseline care plan, and/or a copy of the baseline care plan. Further review of the medical record found he lacked capacity to make medical decisions. Review of the State operation manual (SOM) found that residents and/or their responsible parties must receive a written summary of the baseline careplan that was developed within forty-eight (48) hours of the resident's admission. At a minimum, this summary must include initial goals, summary of medications and dietary instructions, any services and treatments to be administered by the facility and personnel acting on behalf of the facility, physician's orders [REDACTED]. During an interview with the director of nursing (DON) and registered nurse clinical reimbursement coordinator (CRC) Employee #44 on 03/20/18 at 10:09 a.m., they said their initial care plan is always a verbal summary rather than a written summary. They said they try to conduct their first post-admission patient-family conference within seventy-two (72) hours of admission. They said when the twenty-one (21) day care plan is completed, they give the resident and/or responsible party the option of having a copy of the care plan if they want one. On 03/20/18 at 11:30 a.m., E#44 provided a copy of their post-admission patient-family conference form which was dated 02/07/18, which was sixteen (16) days after admission. The resident attended this meeting, but not the family. An interview was completed with the licensed social worker (LSW) on 03/22/18 at approximately noon, while in the presence of the DON and E#44. They agreed the resident first came to the facility on [DATE]. The LSW said she reached out to the family representative on 01/31/18, but found that the telephone was out of service. The LSW said she found another telephone number on a particular document in the medical record and called that number. She said there was no answer, so she left a message on the voicemail. The LSW said on 02/07/18 they held the family conference, and included the family representative by telephone. Employee #44, the DON, and the LSW showed that they began the initial baseline care plan within 48 hours of admission with goals, and that they added to it all along. They were all in agreement that they have not been giving copies of the baseline care plan, or a written summary of the baseline care plan, that identifies goals and services, to their residents and/or representatives. b) Resident #16 Review of the medical record on 03/20/18 found this resident first came to the facility on [DATE], and had some baseline careplanning done in the first forty-eight (48) hours of admission. There was no evidence that the resident and/or the responsible party was provided a written summary of the baseline care plan, and/or a copy of the baseline care plan. Further review of the medical record found although he had capacity to make medical decisions, he experienced episodes of confusion. During an interview with the director of nursing (DON) and registered nurse clinical reimbursement coordinator (CRC) Employee #44 on 03/20/18 at 10:09 a.m., they said their initial care plan is always a verbal summary rather than a written summary. They said they try to conduct their first post-admission patient-family conference within seventy-two (72) hours of admission. They said when the twenty-one (21) day care plan is completed, they give the resident and/or responsible party the option of having a copy of the care plan if they want one. On 03/20/18 at 11:30 a.m., E#44 provided a copy of the post-admission patient-family conference from which was dated 03/01/18, which was seventy-two (72) hours after admission. The resident and the family attended this meeting. There was no evidence that the resident and/or the family who attended was offered a written summary of the baseline care plan. An interview was conducted with the resident on 03/20/18 at 2:00 p.m. He said he has never received a written summary or copy of his baseline care plan that he was aware of. A telephone call was also made at this time to the family member who attended the 03/01/18 family conference. Upon inquiry, he said he has never been given a written summary or copy of the baseline care plan. An interview was completed with the licensed social worker (LSW) on 03/22/18 at approximately noon, while in the presence of the DON and E#44. They agreed the resident first came to the facility on [DATE]. Employee #44, the DON, and the LSW showed that they began the initial baseline care plan within 48 hours of admission with goals, and that they added to it all along. They were all in agreement that they have not been giving copies of the baseline care plan, or a written summary of the base line care plan, that identifies goals and services, to their residents and/or representatives. c) Resident #5 Review of the medical record on 03/20/18 found this resident first came to the facility on [DATE], and had some baseline careplanning done in the first forty-eight (48) hours of admission. There was no evidence that the resident and/or the responsible party was provided a written summary of the baseline care plan, and/or a copy of the baseline care plan. Further review of the medical record found that he lacked capacity to make medical decisions due to dementia. During an interview with the director of nursing (DON) and registered nurse clinical reimbursement coordinator (CRC) Employee #44 on 03/20/18 at 10:09 a.m., they said their initial care plan is always a verbal summary rather than a written summary. They said they try to conduct their first post-admission patient-family conference within seventy-two (72) hours of admission. They said when the twenty-one (21) day care plan is completed, they give the resident and/or responsible party the option of having a copy of the care plan if they want one. On 03/20/18 at 11:30 a.m., E#44 provided a copy of the post-admission patient-family conference from which was dated 02/09/18, which was eight (8) days after admission. The resident and the family attended this meeting. There was no evidence that the resident and/or the family who attended was offered a written summary of the baseline care plan. An interview was completed with the licensed social worker (LSW) on 03/22/18 at approximately noon, while in the presence of the DON and E#44. They agreed the resident first came to the facility on [DATE]. Employee #44, the DON, and the LSW showed that they began the initial baseline care plan within 48 hours of admission with goals, and that they added to it all along. They were all in agreement that they have not been giving copies of the baseline care plan, or a written summary of the base line care plan, that identifies goals and services, to their residents and/or representatives. d) Resident #6 Review of the medical record on 03/20/18 found this resident first came to the facility on [DATE], and had some baseline careplanning done in the first forty-eight (48) hours of admission. There was no evidence that the resident and/or the responsible party was provided a written summary of the baseline care plan, and/or a copy of the baseline care plan. Further review of the medical record found that he was deemed to have capacity to make medical decisions. During an interview with the director of nursing (DON) and registered nurse clinical reimbursement coordinator ( CRC) Employee #44 on 03/20/18 at 10:09 a.m., they said their initial care plan is always a verbal summary rather than a written summary. They said they try to conduct their first post-admission patient-family conference within seventy-two (72) hours of admission. They said when the twenty-one (21) day care plan is completed, they give the resident and/or responsible party the option of having a copy of the care plan if they want one. On 03/20/18 at 11:30 a.m., E#44 provided a copy of the post admission patient family conference from which was dated 03/09/18, which was seven (7) days after admission. The resident and the family attended this meeting. There was no evidence that the resident and/or the family was offered a written summary of the baseline care plan. An interview was conducted with the resident on 03/20/18 at noon. Upon inquiry, he shook his head to signify that he has never received a written summary or copy of his care plan that he was aware of. An interview was completed with the licensed social worker (LSW) on 03/22/18 at approximately noon, while in the presence of the DON and E#44. They agreed the resident first came to the facility on [DATE]. Employee #44, the DON, and the LSW showed that they began the initial baseline care plan within 48 hours of admission with goals, and that they added to it all along. They were all in agreement that they have not been giving copies of the baseline care plan, or a written summary of the base line care plan, that identifies goals and services, to their residents and/or representatives.",2020-09-01
3014,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-03-22,656,D,1,0,GXSO11,"> Based on medical record review and staff interview, the facility failed to develop a care plan focus and goals for a resident admitted with urinary incontinence. This was evident for one (1) of five (5) sampled residents. Resident identifier: #61. Facility census: 59. Findings included: a) Resident #61 The medical record was reviewed on 03/20/18. Review of the activities of daily living (ADL) flow sheets for (MONTH) and (MONTH) (YEAR) found that all of the documentation showed incontinence of urine. Review of the admission minimum data set (MDS) with assessment reference date (ARD) 01/29/18, found nursing assessed him as frequently incontinent of urine. Review of the care plan found there was no focus or goals pertaining to this resident's problem of urinary incontinence. An interview was completed with clinical reimbursement coordinator (CRC) registered nurse Employee #44 (E#44) at 9:25 a.m. on 03/22/18. She reviewed the care plan and the ADL flow sheets and the initial nursing assessment. She said this resident was incontinent of urine at the time of admission, and throughout his stay. She said the admission nursing assessment contained information that he was frequently incontinent of urine. She said in the ADL look-back period of seven (7) days prior to the 01/29/18 MDS, he was incontinent of urine on all shifts for all seven (7) days except for one shift which was left blank. She said because of the one (1) blank entry, and the nursing assessment information, she assessed him on the initial MDS as frequently incontinent of urine rather than as always incontinent of urine. E#44 referred to page twenty-eight (28) of the care plan related to the resident being at risk for skin breakdown as related to immobility. She stated, usually I put incontinence. I don't know why I didn't put it there. She agreed the care plan should have identified the problem area of urinary incontinence, along with person-centered goals and interventions related to the urinary incontinence, and it was not done.",2020-09-01
3015,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-03-22,686,D,1,0,GXSO11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** > Based on medical record review and staff interview, the facility failed to ensure it followed physician's orders for treatment changes when a Stage I pressure ulcer evolved into a Stage II pressure ulcer. This was evident for one (1) of five (5) sampled residents, and one (1) of two (2) residents with documented Stage II pressure ulcers. Resident identifier: #61. Facility census: 59. Findings included: a) Resident #61 The medical record was reviewed on 03/20/18. This resident first came to the facility on [DATE]. According to the skin integrity reports dated 01/22/18 he had a Stage I to the coccyx/buttocks, a Stage I to the left heel, and a Stage I to the right heel. Nursing completed weekly skin assessments on 01/22/18, 01/29/18, 02/05/18, 02/12/18, and 02/19/18, and there were no changes assessed for either heel. On the day of admission, and throughout his stay at the facility, the physician ordered sure prep to both heels each night and as needed for redness. Nursing completed weekly skin assessments of the coccyx on 01/22/18, 01/29/18, 02/05/18, and 02/12/18. There were no changes assessed in the Stage I to the coccyx. Each time nursing described it as spread diffusely. On the day of admission, and through 02/18/18, the physician ordered protective cream to the bilateral buttocks and coccyx every shift related to redness. The weekly skin assessment dated [DATE] assessed that the reddened coccyx developed a small opened area measuring 0.8 centimeters (cms) by 0.2 cms by 0.1 cm., and it was now deemed a Stage 2 pressure ulcer. A physician's order dated 02/18/18 directed to cleanse the Stage 2 pressure ulcer on the coccyx with wound cleanser, apply hydrogel, cover with adhesive [MEDICATION NAME], and change every three (3) days and prn (as needed). Review of the treatment administration record (TAR) found there were blank spaces left open on 02/18/18 and on 02/21/18 to document the treatment for [REDACTED]. However, there was no evidence on the TAR that the treatment was completed on either of those dates, or anytime in February. On 03/22/18 at 8:30 a.m., the director of nursing (DON) provided copies of the progress notes from 02/16/18 through the date of discharge on 02/22/18. Review of the progress notes found no mention of the change in treatment orders for the Stage 2 pressure ulcer, and found no mention that the new treatment orders were completed. During an interview with the DON on 03/22/18 at 8:30 a.m. she agreed there was no evidence on the TAR on either 02/18/18 or on 02/21/18 to support that the new treatment order for the Stage 2 pressure ulcer was done. She agreed there was no documentation in the nurse progress notes about the worsening of the pressure ulcer from Stage I to Stage II, or of the change in treatment ordered by the physician on 02/18/18.",2020-09-01
3016,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-03-22,880,D,1,0,GXSO11,"> Based on observation, staff interview, and policy review, the facility failed to maintain its infection control program to help prevent the potential transmission of organisms and disease to the extent possible over which it had control. When providing incontinence care to a resident, a nursing assistant threw soiled linens and a used incontinence product directly onto the floor in the resident's room. Resident identifier: #49. Facility census: 59. Findings included: a) Resident #49 Observation on 03/22/18 at 09:20 a.m. found the door to this resident's room was open, and his privacy curtain was pulled around his bed. On the floor between his bed and his room-mate's bed lay a disposable brief that was folded numerous times, a blue plastic pad that looked like chux incontinence pad, and soiled linens which included washcloths and a towel. At this time, nursing assistant #15 (E#15) pushed back the privacy curtain. E#15 picked up the disposable items from the floor and placed them into a clear plastic trash bag, then picked up the soiled linens from the floor and placed them into another clear plastic bag. E#15 carried the two (2) bags down the hall to the soiled utility room. An interview was conducted with the director of nursing (DON) on 03/22/18 at 9:45 a.m. She said nursing is supposed to bag linens and used incontinence products in plastic bags, then take them to the soiled utility room. She said nursing staff know not to throw those contaminated items onto the floor. On 03/22/18 at 10:20 a.m. the DON provided a copy of their infection control policy on linen handling, the purpose of which was to provide effective containment and reduce potential for cross-contamination from soiled linen. She said the same was true for the disposal of trash and incontinence products. The DON said she has already begun staff re-education on infection control measures related to disposal of briefs and soiled linen.",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
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
3019,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,253,E,0,1,CPO811,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. A resident shower in the bathroom had dirt and grime on the floor tile and wall. Walls needed repaired and/or painting. An air conditioner unit needed repaired. A nightstand had a door that was hanging down, and an over-bed table had missing veneer on its edges exposing particle board. Doors had gouges and marred areas and/or doors and door facings had cracked and peeling paint around edges. Loose cove molding was noted in a resident room. These finding affected nine (9) of thirty-six (36) rooms observed. Room Numbers: #23, #24, #25, #26, #27, #28, #31, #32, and #37. Facility census: 52. Findings include: a) Observation of the facility during Stage 1 Quality Indicator Survey (QIS) revealed the following rooms had environmental concerns and cosmetic imperfections. 1. Room #23 There were gouges two (2) inches deep in the wall behind the headboard of the bed and the wood bar on the wall was loose and hanging down. The wall to the left side of a resident room entry way was scraped with missing paint. 2. Room #24 The bathroom had a one and a half inch (1-1/2) hole in the wall above the toilet. 3. Room #25 There was loose cove molding on the right side of the wall by the bathroom entrance door. 4. Room #26 The air conditioner unit was in disrepair with the unit separated from the wall and missing a vent grate covering. 5. Room #27 A nightstand in this room was in disrepair with front door loose and hanging down. The over-bed table had missing veneer on edges exposing particle board. 6. Room #28 The exterior entry door had gouges and marred areas exposing the wood beneath finish. 7. Room #31 The bathroom exterior door and door facing had cracked and peeling paint around the edges. 8. Room #32 A one and one-half inch (1-1/2) hole was in the bathroom wall above the toilet. The bathroom exterior door and facing had cracked and peeling paint around edges. 9. Room #37 The bathroom shower had dirt and grime on the floor tile and in the grout of the shower floor, that extended into the left corner one-third (1/3) of the way up the shower wall from the shower floor. b) A tour with the Administrator, Maintenance Director, and Environmental Services Director, beginning at 2:55 p.m. and concluding at 3:15 p.m. on 07/12/17, confirmed all of the identified issues needed repaired and/or replaced. They also agreed the shower needed deep cleaned or resurfaced.",2020-09-01
3020,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,279,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews, observations, and staff interviews, the facility failed address Resident #49's dental status in the resident's care plan, and failed to develop a care plan for Resident #44's depression. Two (2) of sixteen (16) residents whose care plans were reviewed were affected. Resident identifiers: #49 and #44. Facility census: 52. Findings include: a) Resident #49 A Stage 1 observation on 07/10/17 at 10:15 a.m., revealed Resident #49 was edentulous. He was not wearing dentures, and none were visible in the room. The minimum data set (MDS) with an assessment reference date (ARD) of 05/15/17 also noted the resident was edentulous. Nurse Aide (NA) #17, interviewed on 07/11/17 at 12:45 p.m., voiced Resident #14 was edentulous and did not wear dentures. The care plan, reviewed on 07/12/17, did not indicate the resident's dental status. The nurse aide Kardex was also silent for dental status. On 07/13/17 at about 8:45 a.m., the Center Nurse Executive (CNE) reviewed the resident's care plan and Kardex and confirmed they did not reflect Resident #49's current dental status. b) Resident #44 On 07/12/17 at 9:23 a.m., a medical record review revealed Resident #44 had [DIAGNOSES REDACTED]. She was prescribed the medication [MEDICATION NAME] 100 mg (milligrams) po (by mouth) daily for major [MEDICAL CONDITION] on 09/12/16. Review of the resident's care plan found it did not address the resident's depression, that the resident received an antidepressant medications, and did not identify nonpharmacologic interventions for depression. After review of the care plan for Resident #44 on 07/12/17 at 9:59 a.m., the Clinical Records Coordinator (CRC) #60 commented that she does the care plans for the facility. She stated, There is a mention about the antidepressant medication under falls, but no interventions for the medication, and no, the care plan does not contain anything about Resident #44's [DIAGNOSES REDACTED].",2020-09-01
3021,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,280,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to revise the care plan for one (1) of sixteen (16) sample residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident #49's care plan was not revised to reflect actual falls. Resident #11's care plan was not revised when the resident experienced weight loss. Resident identifiers: #49 and #11. Facility census: 52. Findings include: a) Resident #49 During a stage one interview, on 07/10/17 at 2:23 p.m., with Registered Nurse (RN) #60, the nurse verbalized Resident #49 had fallen two (2) times. The nurse said the resident fell on [DATE] and again on 06/30/17. Review of the resident's electronic medical record (EMR) on 07/11/17, found progress notes related to falls that correlated with incident accident reports dated 06/29/17 and 06/30/17. The care plan, reviewed on 07/12/13, noted Resident #49 had a potential for falls, but did not indicate the resident had actual falls. On 07/13/17 at 8:45 a.m., the Center Nurse Executive reviewed the care plan and confirmed it did not reflect the actual falls. b) Resident #11 The resident's care plan created on 06/05/17, with a revision by the Dietitian on 06/15/17, did not reflect the resident's 16% weight loss until brought to the facility's attention by the surveyor on 07/17/17. Resident #11, admitted to the facility on [DATE], had been losing weight since her admission. The following weights were recorded: -- 06/02/17 - 127 pounds (#) -- No weight recorded on 06/09/17. -- 06/09/17 - her previous weight was listed as 135#, but that weight was for another resident -- On 06/16/17 - 117# -- On 06/23/17 - 113.2#. On 06/21/17, the dietitian recorded Resident #11's weight loss as 7.5% in two (2) weeks. The explanation for the weight loss given by the dietitian was that the diuretic [MEDICATION NAME] had begun on 06/12/17 due to a history of [MEDICAL CONDITIONS]. During a telephone interview, with the resident's daughter, she stated her mother had been on [MEDICATION NAME] for more than [AGE] years for high blood pressure, not [MEDICAL CONDITION] as stated on her weight loss sheet. Further medical record review revealed Resident #11 did not have a diagnosis (Dx) of [MEDICAL CONDITION]. The medical record also revealed this resident received [MEDICATION NAME] as a antihypertensive medication due to a [DIAGNOSES REDACTED]. By 07/09/17, Resident #11 had a weight loss of 16% in 5 weeks. The resident was on a heart healthy diet and percentages of meal consumption were recorded as 100% with only three (3) meals record at 75%. Weekly weights were ordered to start on 06/16/17. A review of the resident's care plan created on 06/05/17, found Resident #11 was at nutritional risk due to needing a therapeutic diet to assist in management of cardiac issues and having increased nutritional needs for healing a pressure ulcer and a body mass index that was in normal range. The weight goal was for maintenance of her current weight. The care plan also stated the resident would maintain a stabilized weight of 127# +/- 5# (pounds) through the next review. However, the facility failed to revise the resident's care plan to address her weight loss when her weight went below 127 pounds by more than 5 pounds.",2020-09-01
3022,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,282,E,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on resident interview, observation, medical record review, and staff interview, the facility failed to provide care in accordance with the written plan of care. The facility failed to provide evidence Resident #49 received snacks, failed to ensure evaluations of pain were completed with each administration of pain medication and/or failed to ensure application of nonpharmacological interventions for pain for Resident #45, failed to monitor Resident #26's [MEDICAL TREATMENT] shunt for thrill and bruit, and failed to obtain laboratory tests as ordered by the physician for Resident #56. These findings affected four (4) of sixteen (16) residents whose care plans were reviewed during Stage 2 of the Quality Indicator Survey. Resident identifiers: Resident #49, #45, #26, and #56. Resident census: 52. Findings include: a) Resident #49 The current care plan related to nutritional status, reviewed on 07/11/17, noted Resident #49 was at nutritional risk related to multiple medical issues. The goal was for the resident to consume greater than 75% (percent) of meals, snacks, and supplements. The care plan intervention dated 05/10/17 required staff offer snacks. The paper transcribed activity of daily living records (ADLs), reviewed for the months of May, June, and (MONTH) (YEAR), had multiple omissions of data. During an interview with the Center Nurse Executive on 07/12/17 at 1:45 p.m., the nurse reviewed ADL records for May, June, and (MONTH) (YEAR). The CNE also reviewed facility intake records dated 07/01/17 to 07/11/17. She verbalized confirmation the records provided no evidence the resident had received snacks as ordered. The ADL records noted Resident #49 did not receive and/or was not offered snacks as follows: -- (MONTH) (YEAR) - eleven (11) of eleven (11) opportunities -- (MONTH) (YEAR) - twenty-seven (27) of thirty (30) opportunities. -- (MONTH) (YEAR) - thirteen (13) of twenty (20) opportunities Additionally, the CNE reviewed meal percentage sheets dated 07/01/17 through 07/11/17 and found no evidence was present to indicate Resident #49 received a snack for 07/01/17, 07/02/17, 07/03/17, 7/04/17, 07/05/17, 07/06/17, 07/07/17, 07/08/17, 07/09/17, or 07/10/17. b) Resident #45 During a random observation on 07/10/17 at 2:26 p.m., Resident #45 voiced pain and asked Registered Nurse (RN) #60 for pain medication. The nurse did not ask the resident to rate her pain level, and did not offer non-pharmacological interventions. Resident #45, interviewed at 2:29 p.m. on 07/10/17, voiced she had left leg and foot pain, and phantom pain in her right leg. Observation revealed a [MEDICAL CONDITION] (BKA). The resident said she had a procedure at the hospital where they punctured her artery, and it was causing pain. The resident said medication helped her pain, but it was never eliminated completely. At the lowest level of pain, the resident said it still bothered her, but she might have to live with it, being a diabetic. The resident voiced staff did not offer warm or cold compresses as a non-pharmacological intervention. The minimum data set (MDS) with an assessment reference date (ARD) of 05/29/17, reviewed on 07/11/17, noted a brief interview for mental status (BIMS) score of 14 which indicated the resident was cognitively intact. [DIAGNOSES REDACTED]. The pain assessment indicated the resident received pain medication, but had not received nonpharmacological interventions. The care plan, reviewed at 12:06 p.m. on 07/11/17, noted Resident #45 exhibited an alteration in comfort related to a BKA, chronic back pain, and [MEDICAL CONDITION]. Interventions included to evaluate pain characteristics, quality, severity, locations, precipitating factors/relieving factors; utilize the pain scale, assist to position of comfort utilizing pillows and appropriate positioning devices, and offer hot/cold therapy as ordered and document effectiveness. Nurse Aide (NA) #17, #NA #46, NA #29, NA #74, and NA #41, interviewed on 07/11/17 at 2:49 p.m., denied knowledge the resident verbalized pain and/or exhibited signs or symptoms of pain. NA #17 voiced Resident #45's pain was resolved. Licensed Practical Nurse (LPN) #26, interviewed on 07/11/17 at about 2:55 p.m., said Resident #45 complained of pain, but she did not utilize heat because of the high temperatures. Upon inquiry, as to whether something such as a warm wash cloth/towel had been attempted to relieve pain, the nurse replied, No. During an observation of Resident #45's foot wound with Licensed Practical Nurse (LPN) #43, the resident verbalized she had informed the surveyor yesterday (07/10/17) that she always had pain and that it never went away. The LPN did not evaluate Resident #45's pain prior to exiting the room. With further discussion, the resident voiced staff did not follow-up after administration of medication to evaluate the effectiveness of the pain medication. The resident said they would sometimes ask her the location of the pain and to rate it. Upon inquiry, as to how she expressed her pain, the resident said she would tell the nurse aide and the NA would notify the nurse, and sometimes she would tell the nurse herself. The Center Nurse Executive (CNE), interviewed at 5:15 p.m. on 07/11/17, confirmed the resident exhibited pain daily and voiced the nurse aides should have been aware Resident #45 experienced pain and that the resident asked nurse aides to inform nurses of her pain. Upon review of the pain flow sheets, the CNE confirmed the resident experienced pain daily. During another interview with the CNE on 07/13/17 at 8:45 a.m., the CNE reviewed pain flow sheets dated 07/01/17 through 07/12/17 compared to the controlled substance records, and confirmed no evidence was present to indicate a pain assessment and/or nonpharmacological intervention had been completed with each administration of pain medication. The resident received pain medication on: -- 07/03/17 at 9:30 p.m., -- 07/06/17 at 9:00 p.m., -- 07/07/17 at 6:00 a.m., -- 07/10/17 at 2:30 p.m., and -- 07/12/17 at 8:00 a.m. The CNE confirmed no evidence was present to indicate the facility implemented the care plan as directed. c) Resident #26 During an interview with Resident #26 on 07/11/17 at 12:09 p.m., he commented that he went to [MEDICAL TREATMENT] every Monday, Wednesday, and Friday. He proceeded to explain that he had a left forearm fistula that was accessed by the [MEDICAL TREATMENT] center for his treatment. On 07/11/17 at 12:14 p.m. a medical record review revealed Resident #26 [DIAGNOSES REDACTED]. Review of the resident's care plan found it included, (typed as written) Focus: Resident is at risk for impaired renal function and is at risk for complications related to [MEDICAL TREATMENT] . The interventions included, .Monitor [MEDICAL TREATMENT] access for +bruit/+thrill (positive bruit/positive thrill) q (every) shift and prn (as needed). Shunt/fistula is in left forearm . On 07/11/17 at 2:20 p.m., when asked where nurses documented the monitoring of the fistula for Resident #26, Registered Nurse #39 stated, It is documented in the TAR (treatment administration record), I will show it to you. Upon opening the TAR for Resident #26, there was no record present. She stated, As you can see there is nothing there to record the assessment on. So, it doesn't look like there is any documentation of monitoring his fistula. After review of the care plan for Resident #26 and review of the TAR on 07/11/17 at 2:30 p.m., the Director of Nursing (DON) verified there was no documentation for monitoring his fistula as directed by his care plan. She stated, No, the care plan was not followed for monitoring his [MEDICAL TREATMENT] fistula. d) Resident #56 Review of the resident's medical record on 07/12/17 at 12:21 p.m., found her monthly orders included, CBC (complete blood count), CMP (comprehensive metabolic panel), BMP (basic metabolic panel), HGB (hemoglobin) A1c on admission then every 3 months. (Feb/May/Aug/Nov) A CBC, CMP, BMP, and HGB A1c were drawn on 02/20/17 (3 days after admission), but the lab tests ordered drawn every three months, due in (MONTH) (YEAR), were not found in the resident's medical record. The care plan with a revision date of 03/08/17, included an intervention for diabetes of, Labs as ordered and report results to MD (medical doctor). Under the interventions for dehydration risk related to diuretic/antihypertensive medications the care plan stated, Monitor lab work as ordered and report as indicated. Licensed Practical Nurse (LPN) #26 reviewed the medical record during an interview on 07/12/17 at 1:00 p.m. and agreed Resident #56's orders included orders for a CBC, CMP, BMP, and Hgb A1c every three (3) months. The labs should have been drawn in (MONTH) (YEAR), but no lab results were in the resident's chart to indicate the tests were done as ordered. LPN #26 reported the Assistant Director of Nursing (ADON) made the arrangements for scheduled labs to be drawn, and put the forms in the monthly lab book when they were due to be drawn. The Director of Nursing (DON) reviewed Resident #56's orders during an interview on 07/12/17 at 1:20 p.m. The DON confirmed the quarterly labs should have been drawn in (MONTH) and they were not. The Clinical Record Coordinator (CRC) #60 reviewed the medical record and care plan during an interview on 07/12/17 at 1:29 p.m. The CRC acknowledged the care plan directed to do lab work as ordered and agreed the care plan was not followed - that Resident #56's quarterly scheduled labs were not drawn.",2020-09-01
3023,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,309,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, resident interview, record review, and staff interview the facility failed to ensure effective pain management for one (1) of four (4) residents reviewed for pain management. Resident #45 stated her pain was never relieved, that no nonpharmacologic interventions were offered/provided, and staff did not evaluate the nature of her pain or the effectiveness of pain medications. Resident identifier: #45. Facility census: 52. Findings include: a) Resident #45 During a random observation on 07/10/17 at 2:26 p.m., Resident #45 voiced pain and asked Registered Nurse (RN) #60 for pain medication. The nurse did not ask the resident to rate her pain level, and did not offer nonpharmacological interventions. Resident #45, interviewed at 2:29 p.m. on 07/10/17, said she had left leg and foot pain, and phantom pain in her right leg. Observation revealed a [MEDICAL CONDITION] (BKA). The resident verbalized that she had a procedure at the hospital and they had punctured her artery, and it was causing pain. The resident said medication helped her pain, but it was never totally eliminated. At the lowest level of pain, the resident said it still bothered her, but she might have to live with it, being a diabetic. The resident voiced staff did not offer warm or cold compresses as a non-pharmacological intervention. The resident's minimum data set (MDS) assessment, with an assessment reference date (ARD) of 05/29/17, reviewed on 07/11/17, noted a Brief Interview for Mental Status (BIMS) score of 14 which indicated the resident was cognitively intact. Her [DIAGNOSES REDACTED]. The pain assessment indicated the resident received pain medication, but had not received nonpharmacological interventions. The care plan, reviewed at 12:06 p.m. on 07/11/17, noted Resident #45 exhibited an alteration in comfort related to a BKA, chronic back pain, and [MEDICAL CONDITION]. Interventions included to evaluate pain characteristics, quality, severity, locations, precipitating factors/relieving factors, utilize the pain scale, assist to position of comfort utilizing pillows and appropriate positioning devices, and offer hot/cold therapy as ordered and document effectiveness. Nurse Aide (NA) #17, #NA #46, NA #29, NA #74, and NA #41, when interviewed on 07/11/17 at 2:49 p.m., each denied knowledge the resident verbalized pain and/or exhibited signs or symptoms of pain. NA #17, voiced Resident #45's pain was resolved. Licensed Practical Nurse (LPN) #26, interviewed on 07/11/17 at 2:55 p.m., said Resident #45 complained of pain, but she did not utilize heat because of the high temperatures. Upon inquiry as to whether something such as a warm washcloth/towel had been attempted to relieve pain, the nurse replied, No. On 07/11/17 at 4:03 p.m. during an observation of Resident #45's foot wound with Licensed Practical Nurse (LPN) #43, the resident stated she had informed the surveyor yesterday (07/10/17) that she always had pain and that it never went away. The LPN did not evaluate Resident #45's pain prior to exiting the room. With further discussion, the resident voiced staff did not follow-up after administration of medication to evaluate the effectiveness of the pain medication. The resident said they would sometimes ask her the location of the pain and to rate it, but not always. When asked how she expressed her pain, the resident said she would tell the nurse aide and the NA would notify the nurse, and sometimes she would tell the nurse herself. The Center Nurse Executive (CNE), interviewed at about 5:15 p.m. on 07/11/17, confirmed the resident exhibited pain daily and commented the nurse aides should have been aware Resident #45 experienced pain and that the resident asked nurse aides to inform nurses of pain. Upon review of the pain flow sheets, the CNE confirmed the resident experienced pain on a daily basis. During another interview with the CNE on 07/13/17 at 8:45 a.m., the CNE reviewed pain flow sheets dated 07/01/17 through 07/12/17 compared to the controlled substance records, and confirmed no evidence was present to indicate a pain assessment and/or non-pharmacological intervention had been completed with each administration of pain medication. Additionally, the follow-up assessments after administration of medication noted the non-medication interventions of repositioning/breathing as ineffective prior to administration of medication; and noted medication as effective with a pain rating of zero (0). The CNE confirmed no evidence was present to indicate the facility assessed and/or accurately assessed Resident #45's pain.",2020-09-01
3024,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,323,E,0,1,CPO811,"Based on a random observation, staff interview, policy review, and record review, the facility failed to ensure an environment as free of accidents hazards as was possible. The facility stored an Automated External Defibrillator (AED) within easy access of residents and visitors. In addition, the door to a common shower room and utility room was left unlocked and accessible to residents and visitors. These findings had the potential to affect more than a limited number of residents. Facility census: 52 Findings include: a) Automated External Defibrillator A random observation on 07/10/17 at 8:50 a.m., revealed an automated external defibrillator (AED) machine on top of the crash cart located in the alcove on A-Hall near the nurses' station. (A defibrillator is a device used to deliver a shock to the chest for certain heart problems.) The device was readily accessible to residents. The Center Nurse Executive (CNE), interviewed at that time, picked up the machine and verified it was not secured. She said the machine was placed there for easy access in case of an emergency. When asked what would happen if a resident accessed the machine, the CNE said she had not thought about it, but would find somewhere else to place the defibrillator. During the discussion, the CNE easily opened the battery operated AED machine, by pulling apart the snaps of the cover. She pushed a button which opened the device, and green lights flashed indicating the machine was ready to function and a voice provided instructions for use. On 07/10/17 at 12:28 p.m., the CNE reported a new lock had been placed on the clean utility door, and the AED machine placed inside. The Automated External Defibrillator Program policy, with a revision date of 05/01/13, noted the AED machine would be maintained in accordance with state regulations and the manufacturer's recommendations. The policy indicated AED would be used to treat persons who experienced suspected sudden cardiac arrest, and Use of the AED is authorized only for staff certified in use of the AED. b) Resident common shower room On 07/10/17 at 8:20 a.m., while conducting the initial tour of the facility, an open/unlocked common shower room was found. In the shower room was a sixteen (16) ounce (oz) bottle labeled as, Germicidal cleanser and deodorant with a precaution on the label to Keep out of reach of children sitting on the shower room counter top. At 8:23 a.m., when shown to Regional Consultant #6, she immediately removed to bottle. She stated, It should not be sitting out where any resident could access it and should be in a locked cabinet. Yes, it is an accident hazard. c) Soiled Utility Room On 07/10/17 at 8:25 a.m., it was found the door to the soiled utility room could be entered without using a code on the push button lock. The soiled utility room contained two (2) large trash cans and two (2) large containers for soiled linen and a hopper. Nurse Aide #61, who was standing in the hallway, stated, That door is always supposed to be locked for safety of the residents. An observation at 8:50 a.m. on 07/10/17, again found the door to the soiled utility room could be entered without using a code on the push button lock. When shared with Regional Consultant #6 at 8:52 a.m., she stated, The door is supposed to be locked, I will have the lock repaired by maintenance. The Maintenance Director reported on 07/10/17 at 11:30 a.m., The door lock on the soiled utility room has been replaced.",2020-09-01
3025,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,325,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation, and staff interviews, the facility failed to address Resident #11's weight loss. Resident #11 experienced a 16 percent (%) weight loss before interventions were implemented. This was found for one (1) of four (4) residents reviewed for nutrition. Resident identifier: #11. Facility census: 52. Findings include; a) Resident #11 The resident's care plan created on 06/05/17, with a revision by the Dietitian on 06/15/17, did not reflect the resident's 16% weight loss until brought to the facility's attention by the surveyor on 07/17/17. Resident #11, admitted to the facility on [DATE], had been losing weight since her admission. The following weights were recorded: -- 06/02/17 - 127 pounds (#) -- No weight recorded on 06/09/17. -- 06/09/17 - her previous weight was listed as 135#, but that weight was for another resident -- On 06/16/17 - 117# -- On 06/23/17 - 113.2#. On 06/21/17, the dietitian recorded Resident #11's weight loss as 7.5% in two (2) weeks. The explanation for the weight loss given by the dietitian was that the diuretic [MEDICATION NAME] had begun on 06/12/17 due to a history of [MEDICAL CONDITIONS]. During a telephone interview, with the resident's daughter, she stated her mother had been on [MEDICATION NAME] for more than [AGE] years for high blood pressure, not [MEDICAL CONDITION] as stated on her weight loss sheet. Further medical record review revealed Resident #11 did not have a diagnosis (Dx) of [MEDICAL CONDITION]. The medical record also revealed this resident received [MEDICATION NAME] as a anithypertensive medication due to a [DIAGNOSES REDACTED]. By 07/09/17, Resident #11 had a weight loss of 16% in 5 weeks. The resident was on a heart healthy diet and percentages of meal consumption were recorded as100% with only three (3) meals record at 75%. Weekly weights were ordered to start on 06/16/17. A review of the resident's care plan created on 06/05/17, showed Resident #11 was at nutritional risk due to needing a therapeutic diet to assist in management of cardiac issues and having increased nutritional needs for healing a pressure ulcer and a body mass index that was in normal range. The weight goal was for maintenance of her current weight. The care plan also stated the resident would maintain a stabilized weight of 127# +/- 5# (pounds) through the next review. However, the facility failed to develop a care plan for the resident's weight loss when her weight went below 127 pounds by more than 5 pounds. During an interview on 07/12/17 at 12:22 p.m., LPN #26 said the resident had been on the weight loss list and this had been given to the dietitian. She also verified that on 06/16/17, Resident #11 had another resident's weight listed as her pervious weight which would have made the weight loss even greater. During an interview with the Director of Nursing on 07/12/17 at 3:15 p.m., she stated she had copies of all the dietitian's notes along with the weight loss percentages. Resident #11 was on these lists for weight loss, however, the first percentage given was attributed to [MEDICATION NAME] for [MEDICAL CONDITION] which was not a [DIAGNOSES REDACTED]. During the telephone interview with dietitian on 07/17/17 at 4:50 p.m., she stated she was not sure where she saw a Dx of [MEDICAL CONDITION], but it was probably from a hospital discharge. She stated a care conference was held on 07/17/17 with the Resident #11's two daughters' where they discussed the resident's weight loss. Resident #11's diet was changed to regular and supplements were started on 07/14/17. The dietitian stated the resident's weight was up 2 pounds that week.",2020-09-01
3026,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,332,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, medical record review, review of manufacturer's instructions, and policy review, the facility failed to ensure a medication error rate of less than five percent (5%). A nurse would have administered an extra dose of a blood pressure medication had not the surveyor intervened, an extended release medication was crushed, and eye drops were administered incorrectly. There were three (3) errors identfied in thirty-five (35) opportunities for error. This practice affected three (3) of six (6) residents observed with a medication error rate of 8.5 percent. Resident identifiers: #56, #21, and #67. Facility census: 52. Findings include: a) Resident #56 During a medication administration observation on 07/12/17 at 8:12 a.m., Licensed Practical Nurse (LPN) #26 placed [MEDICATION NAME] 25 mg into the medication cup from a unit dose packaged card. Continued observation revealed the nurse continued to hold the card in her hand with another card, and placed another dose in the medication cup. After the nurse finished pouring the medications, and prior to administration, upon request the nurse counted the pills in the medication cup. When asked whether the resident should receive two (2) doses of the same medication, the LPN assured the medication was correct, but again reviewed the medications against the record. LPN #26 removed one tablet from the cup stating two (2) doses had been poured, and confirmed it was [MEDICATION NAME] (blood pressure medication). b) Resident #67 1. On 07/12/17 at 8:20 a.m., Licensed Practical Nurse (LPN) #26 poured medications for Resident #67. The nurse placed a large white pill into a separate cup and identified the tablet as potassium chloride. When asked if the resident had an order allowing the medication to be crushed, the nurse replied, Yes. The nurse further added, That is the only way she will take it. Reconciliation of the medication observation, on 07/12/17 at 8:35 a.m., revealed a physician's orders [REDACTED]. Physician #1, interviewed at 8:42 a.m. on 07/12/17, voiced if the resident was unable to take medications as directed that he should be contacted for instructions and/or new orders. c) Resident #21 During a medication observation on 07/12/17, Licensed Practical Nurse (LPN) #43 administered [MEDICATION NAME] eye drops, one (1) drop in each eye at 8:56 a.m. The nurse administered [MEDICATION NAME] eye drops, one (1) drop in each eye at 8:57 a.m. The facility's medication administration eye (drops and ointments) policy, reviewed on 07/12/17 at 11:45 a.m., instructed, If administering multiple eye medications, wait at least five (5) minutes between medications. The manufacturer's frequently asked questions posting includes, How do I use [MEDICATION NAME](R)? Take [MEDICATION NAME](R) ophthalmic solution exactly as your eye care professional prescribed .If more than 1 topical ophthalmic product is to be used, the different products should be instilled at least 5 minutes apart. d) A follow-up interview with the Center Nurse Executive, on 07/12/17 at 1:30 p.m., confirmed the medications were not administered correctly.",2020-09-01
3027,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,356,C,0,1,CPO811,"Based on facility record review and staff interview, the facility failed to maintain completed copies of all daily staff postings for a minimum of 18 months. This had the potential to affect all residents residing in the facility. Facility census: 52. Findings include: a) Review of daily postings on 07/11/17 at 2:30 p.m. for the period of 04/13/17 through 07/10/17 revealed there were no postings for: -- 04/14/17, -- 05/01/17, -- 05/11/17, -- 05/13/17, -- 05/15/17, -- 05/16/17, -- 05/21/17, -- 05/26/17, -- 05/29/17, and -- 06/04/17. The Administrator acknowledged the missing staff posting forms during an interview on 07/11/17 at 4:32 p.m. The Administrator stated, That is why that person no longer works here.",2020-09-01
3028,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,428,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, staff interview, and policy review, the pharmacist failed to identify missing laboratory (lab) studies ordered by the physician to be completed quarterly as an irregularity. Routine scheduled labs were not drawn as ordered for one (1) of five (5) residents reviewed for unnecessary medications. Resident identifier: #56. Facility census: 52. Findings include: a) Resident #86 Review of the medical record on 07/12/17 at 12:21 p.m., revealed resident #56 was initially admitted to the facility on [DATE]. Her monthly routine orders included CBC (complete blood count), CMP (comprehensive metabolic panel), BMP (basic metabolic panel), HGB (hemoglobin) A1c on admission then every 3 months. (Feb/May/Aug/Nov) Dx (diagnoses) HTN, DM2, [DIAGNOSES REDACTED]. The initial CBC, CMP, BMP, and Hgb A1c were drawn on 02/20/17, three days after admission. The next lab studies, due in (MONTH) (YEAR) were not found in the resident's record. The monthly pharmacy reviews dated 05/23/17 and 06/22/17 did not identify the absence of the labs due to be completed in (MONTH) (YEAR). Licensed Practical Nurse (LPN) #26 reviewed the medical record during an interview on 07/12/17 at 1:00 p.m. and agreed Resident #56's orders included for a CBC, CMP, BMP, and Hgb A1c to be competed every three (3) months, but no lab results were in the chart indicating these tests were not done as ordered. LPN #26 reported the Assistant Director of Nursing (ADON) made the arrangements for scheduled labs to be drawn, and put the forms in the monthly lab book when they were due to be drawn. The Director of Nursing (DON) reviewed Resident #56's orders during an interview on 07/12/17 at 1:20 p.m., and confirmed the quarterly labs should have been drawn in (MONTH) and they were not. During a follow-up interview on 07/12/17 at 2:57 p.m. the DON reviewed the pharmacy medication regimen review forms and agreed there was no indication the pharmacist had identified Resident #56's lab work had not been drawn as ordered. The facility pharmacist was called on 07/12/17 at 3:04 p.m. A telephone message was left requesting the pharmacist call the surveyor or contact the facility with further information. The pharmacist did not respond to this request. The facility's policy titled 9.1 Medication Regimen Review with a revision date of 12/15/08 included The consultant pharmacist conducts and completes the medication regimen review at least monthly by: 1.1 Reviewing the medical record including .1.1.3 physician's orders [REDACTED].",2020-09-01
3029,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,431,E,0,1,CPO811,"Based on observations, review of sheets for controlled medications, review of pharmacy reports, review of the State Operations Manual Appendix PP, staff interview, and policy review, the facility failed to ensure controlled substance records were complete and contained information to show complete reconciliation by on-coming and off-going nurses. This was found for three (3) of three (3) narcotic books reviewed during medication storage review. In addition, during a random observation, a medication cart was found unlocked when not in the direct line of sight of the nurse. This practice had the potential to affect more than a limited number of residents. Facility census: 52. Findings include: a) Review of the three (3) shift change controlled substance inventory logs dated 11/04/16 through 07/11/17 at 9:18 a.m. on 07/11/17 found there were sixty-two (62) blank signature spaces for reconciliation of the controlled medication counts at the change of shifts identified. On 07/11/17 at 9:25 a.m., Licensed Practical Nurse (LPN) #26 explained the procedure/process for shift to shift reconciliation. She commented, every on-coming and off-going nurse was to count the narcotics and then each nurse was to sign the shift reconciliation sheets. After reviewing the three (3) shift change controlled substance inventory logs dated 11/04/16 through 07/11/17 at 9:55 a.m. on 07/11/17, the Director of Nursing (DON) stated, No there are not supposed to be any blanks. The oncoming and the off going nurse are both supposed to sign for the shift to shift count. Back in (MONTH) we had a lot of agency nurses but still there should not be any blanks and that is not an excuse. A review of the facility's Controlled Drugs: Management of Policy and Procedure on 07/11/17 at 10:30 a.m. revealed on page 5, Titled 5. Ongoing Inventory of controlled Drugs (Shift Count): .5.1.3 Both licensed nursing staff participating in the count must: 5.1.3.1 Confirm that the Inventory Page reflects the quantity of drugs present in the container, and that the integrity of each container is intact. 5.1.3.2 Verify the amount remaining as noted in the Amount Left column on each Inventory Page. 5.1.3.3 Both licensed nursing staff sign the Shift Count page in the Controlled Substances book to acknowledge completion of the shift count A review of the monthly audits conducted by the Consultant Pharmacist from 11/16/17 to 06/05/17 at 12:10 p.m. on 07/12/17 revealed the evaluation was marked No for .b) Controlled substance inventory is reconciled according to facility procedures (Shift counts are done with 2 nurse signatures every shift) . for the dates specified on the audit. During a follow-up interview with the DON on 07/12/17 at 12:25 p.m., she stated, I have been employed at this facility since March. I receive the information from the audits, but due to staffing issues have only attended one of the exit meetings with the Pharmacist. When asked whether she was aware of the information regarding the shift to shift reconciliation not being completed with two (2) nurses' signatures. She stated, Yes I have received the information and thought it was being done. The DON provided an education in-service signature sheet for education provided to the nurses regarding shift to shift narcotic inventory requiring both on-coming and off-going nurse signatures on 07/12/17 at 3:00 p.m. b) A random observation of the B Hall medication cart on 07/12/17 at 2:35 p.m., found the cart stored unlocked. The lock on the cart protruded and had a red marking on the right inner side of the lock. A corporate advisor was standing in the office with other staff. When asked whether the cart was locked, the advisor walked up to the cart, pushed in the lock, and said, The nurse was just here. Upon inquiry as to whom the cart was assigned, Licensed Practical Nurse (LPN) #43 replied it was assigned to LPN #26. Immediately prior to the observation of the unlocked cart, LPN #26 was observed walking up A-Hall toward the front door. The State Operations Manual, Appendix PP, Chapter 483.45 (h), Storage of Drugs and Biologicals, required the facility to store all drugs and biologicals in locked (1) compartments, and permit only authorized personnel to have access to the keys. An interview with the Center Nurse Executive (CNE) and Administrator at 3:30 p.m. on 07/12/17, confirmed the facility practice required the cart be locked when unattended.",2020-09-01
3030,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,441,F,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview, review of Centers for Disease Control and Prevention guidelines, medical record review, and policy review, the facility failed to maintain an effective infection control program to prevent the transmission and spread of disease and infection to the extent possible. Staff handled medications incorrectly, did not maintain aseptic technique with a wound dressing treatment, failed to utilize proper hand hygiene, failed to ensure isolation requirements were maintained, failed to handle clean linens properly, failed to maintain standard precautions when storing bed pans, failed to store and/or maintain resident equipment in a sanitary manner, failed to perform surveillance and investigation, failed to use records of infection incidents to improve its infection control processes and outcomes by taking corrective actions as indicated, and failed to report, track and/or trend infections adequately. The facilty also failed to ensure bedpans/urinals were properly stored and that wheelchairs had surfaces that could be sanitized. These practices had the potential to affect all residents. Resident identifiers: #2, #56, #67, #21, #40, #87, #46, and #84. Facility census: 52. Findings include: a) Resident #2 During a medication administration observation on 07/11/17 at 4:15 p.m., Registered Nurse (RN) #15 entered the room of Resident #2 to administer an insulin injection. The nurse placed the Quik Pen on the over-the-bed table without a barrier, and after administering the medication returned the pen to the cart without first cleaning it. b) Resident #56 On 07/12/17 at 8:12 a.m., a medication observation revealed Licensed Practical Nurse (LPN) #26 poured medication for Resident #56. When punching-out the medication from the card, the pill fell on to the top of the medication cart. The LPN picked the medication up with a tissue and placed it in the cup with the resident's other medications. c) Resident #67 When administering medications to Resident #67 on 07/12/17 at 8:20 a.m., Licensed Practical Nurse (LPN) #26 placed the inhaler on the over-the-bed table without a barrier. Without performing hand hygiene, the nurse exited the room, placed the inhaler back in the medication cart without cleaning it, signed the medication administration record, then began pouring medications for another resident. d) Resident #21 Licensed Practical Nurse (LPN) #43 administered medications to Resident #21 at 8:45 a.m. The nurse entered the room and placed eye drops, nasal spray, and tissues from the medication cart on the over-the-bed table without a barrier. LPN #43 washed her hands for a count of nine (9) seconds, donned gloves and administered a [MEDICATION NAME] eye drop in each eye. While wearing the same gloves, the nurse administered saline nasal spray in each of the resident's nostrils, and without changing gloves, administered a [MEDICATION NAME] eye drop in each eye, then administered [MEDICATION NAME] nasal spray in each nostril. Upon completion of the medication administration, the medications, the nurse picked up the thermometer and took Resident #21's temperature by scanning the resident's forehead. LPN #43 removed her gloves, picked up the eye drops and nasal sprays and returned them to the medication cart without wiping them off. The nurse returned to the room and washed her hands for a count of seven (7) seconds. e) The facility's hand hygiene policy, with a revision date of 11/28/16, and Centers for Disease Control and Prevention guidelines required staff wash hands vigorously for 20 seconds, covering all surfaces of the hands and fingers f) Resident #87 During a random observation on 07/10/17 at 3:19 p.m., Licensed Practical Nurse (LPN) #14 entered the room of Resident #87 and said she needed to change her dressing. Without sanitizing her hands, the LPN donned gloves, opened the sterile dressing package and touched the inside of the dressing (part next to the wound bed) with her gloved fingers. The nurse utilized scissors to cut the dressing in half. LPN #14 picked up the dressing again with her finger on the inside of the dressings. After placing tape on the outside of the dressing to make a border, the nurse rolled the resident to her left side, placed a blue barrier pad beneath her, and pulled down Resident #14's pants revealing a border dressing with brown stain on the inferior aspect. LPN removed the dressing and commented the substance was stool. LPN #14 removed her gloves, washed her hands, and donned clean gloves. Using a circular motion the nurse cleansed the open area on the right buttock. The nurse cleansed the resident's buttocks and placed a small ball of stool on the right side of the blue barrier pad. LPN #14 repositioned the resident, then placed the bag containing wound care supplies on the barrier pad, in the same area as the ball of stool. The nurse sprayed the coccyx area with wound cleanser then laid the spray bottle on the pad, outside of the bag. The nurse cleansed the coccyx wound and buttock wound with the same gauze, obtained a new four by four (4x4) gauze and dried each wound with the same gauze. Without changing gloves, LPN #14 opened a tube of medication which she identified as [MEDICATION NAME]. Without changing gloves, the nurse placed [MEDICATION NAME] onto her then contaminated gloved finger and applied it onto the wound bed on the coccyx area. The LPN then poured another dollop of [MEDICATION NAME] onto the same gloved finger and applied it directly onto the wound bed on the right buttock. The aseptic (free of infectious organisms) wound dressing policy revised 11/30/15, noted to clean the over-the-bed-table, place a clean barrier on the table and place supplies on the barrier .if a patient had multiple wounds, treat each wound as a separate procedure .if a break in aseptic technique occurred, stop the procedure, remove gloves, cleanse hands, and apply clean gloves .open dressing(s) without contaminating .prepare medication/ointment by placing on inner sterile package .expose area to be treated, apply clean gloves, place bed protector under or adjacent to wound site and remove soiled dressing, discard dressing and gloves. Cleanse hands and apply clean gloves .cleanse wound .using swab or applicator, apply treatment medication .apply and secure clean dressing. Remove gloves and discard .apply prepared label, cleanse hands The Center Nurse Executive, interviewed on 07/12/17 at about 5:15 p.m., agreed the nurse failed to maintain aseptic technique and confirmed the technique created a potential for cross contamination. g) Laundry An observation of the laundry area on 07/10/17 at 8:44 a.m. with Laundry Worker #10, revealed the fan in the upper right corner of the clean linen side of the room, upon entry to the room from the corridor, needed cleaned. A layer of dust covered the fan and there were multiple dust balls in the wire casing. The fan was turned on and blowing across the clean linen. Upon inquiry as to who cleaned the fans, Laundry Worker #10 said she thought it was maintenance. She did not know when it was last cleaned. Registered Nurse (RN) #21, interviewed on 07/12/17 at 9:40 a.m., verbalized the dirty fan created a potential for contamination of the clean linen. During a follow-up observation and interview with Laundry Worker #10 on 07/12/17 at 2:30 p.m., she reported maintenance staff had cleaned the fan that morning. h) Resident #40 On 07/11/17 at 4:24 p.m., Registered Nurse (RN) #15 donned personal protective equipment (PPE) and entered the room of Resident #40. The nurse said the resident required contact precautions related to Clostridium difficile (C-diff), a drug resistant organism. A curtain was pulled around the end of the bed and two (2) bins were located at the foot of the bed for disposal of contaminated items such as PPE. A dust covered fan sat at the right foot of the resident's bed and was blowing across the room toward the hallway. A nurse aide (name unknown) was in the room and assisted RN #15 reposition the resident in bed. Upon completion, the NA opened the lid of the hamper, removed her gloves and as she was placing them in the bin, the lid closed between her hand and the soiled PPE gowns. The NA washed her hands and while exiting the room used bare hands to pull back the curtain to the edge of the bed. The NA did not wash her hands again prior to exiting the room. RN #15 also disposed of his PPE, washed his hands, then touched the curtain prior to exiting the room. During an interview immediately following the observation, the Center Nurse Executive agreed there was potential for cross contamination when staff touched the curtains while exiting the room. The Clostridium difficile policy, revised 11/28/16 required staff maintain stringent handwashing On 07/12/2017 at 9:15 a.m., Registered Nurse #21 said the dusty fan blowing across containers of contaminated items created a potential for cross contamination and spread of disease and infection as it blew across isolation carts toward hallway. i) Residents #46 and #87 A Stage 1 observation on 07/10/17 at 3:50 p.m., noted bedpans stored in plastic bags hanging over the toilet paper roll in the bathroom. Both Residents #46 and #87 utilized the bathroom. During an interview with the Center Nurse Executive (CNE) on 07/12/17 at 4:06 p.m., the nurse confirmed the bedpans posed a potential for cross-contamination. j) Resident #84 On 07/10/17 at 9:52 a.m., a Stage 1 observation revealed the resident's geri chair positioned at the foot of the bed. The vinyl on the outer edge of the right chair arm was torn with a shredded appearance from the back of the armrest to the front of the armrest exposing fabric and wood beneath. The fall mat located on the left side of the bed was torn, exposing the fabric beneath, and the right floor mat had a shredded appearance with long threads. During an interview at 4:06 p.m. on 07/10/17, the Center Nurse Executive acknowledged the items could not be cleansed properly and created a potential for cross contamination. k) Facility acquired infections The handwritten infection control line listing, reviewed on 07/11/17, noted ongoing respiratory infections and urinary tract infections between (MONTH) (YEAR) and (MONTH) (YEAR). The computerized trending forms did not provide information related to location in the facility and did not correlate with the number of residents who received antibiotic therapy in accordance with the written line listing. Further review of the records noted trends for urinary tract infections (UTI) and respiratory infections (RESP) from (MONTH) (YEAR) to (MONTH) (YEAR). On 07/12/17 at 9:40 a.m., after reviewing the infection control information, Registered Nurse (RN) #21 said the ESBL (extended-spectrum beta lactamases) in-house acquired infections should have been reported to the health department in (MONTH) (YEAR). The nurse said she acknowledged an ongoing trend of infections based on the handwritten report, including urinary tract infections and respiratory infections. On 07/13/17 at about 8:45 a.m., Registered Nurse (RN) #65 verified the trending report and tracking reports did not correlate. The nurse said that only diagnoses/symptoms meeting McGeer's criteria were placed on the trending report. The RN verbalized the other infections treated with antibiotics did not meet the criteria of a true infection. The nurse reviewed the handwritten line listing forms and acknowledged ongoing issues with urinary tract infections and respiratory infections. The nurse said no communication had been initiated with the local health department, and the facility had not developed an action plan to address the infections. RN #65 said she had not analyzed data related to month to month infections, and had not looked at data from the perspective of residents' symptoms. When asked what the facility did to prevent respiratory symptoms from spreading throughout the facility, the nurse said no special precautions had been taken because the symptoms did not meet the infection criteria. The tracking forms were again reviewed with the RN, and she acknowledged an increase from six (6) residents with respiratory symptoms in (MONTH) (YEAR) to twenty-two (22) residents in (MONTH) (YEAR), and fluctuations continuing through (MONTH) (YEAR). RN #65 confirmed no evidence was present to indicate staff had been educated other than the hand hygiene in-service completed 02/08/17. Only nurse aides on the day shift and evening shift were noted as educated. No evidence was presented to indicate staff on the 11:00 p.m. to 7:00 a.m. morning shift were educated. Additionally, no evidence was present to indicate the facility monitored staff for hand hygiene, aseptic technique, proper perineal/incontinence care, or linen handling. Upon exit of the facility, no additional information was provided. The Outbreak Investigation/Management policy, with a revision date of 11/28/16, note an outbreak would be defined as an excess over expected (usual) level of disease within the Center or according to defined clinical parameters or state regulations. Case definitions included: -- Influenza: One (1) or more laboratory proven cases (patient and staff) of influenza, along with other cased of a respiratory infection in a Unit within a seven (7) day period -- Pneumonia: Two (2) or more patients with nosocomial cases of non-aspiration pneumonia within a seven (7) day period should be reviewed for outbreak potential, and -- MDROs (multidrug resistant organisms) - an increase from baseline of healthcare acquired infections required additional surveillance to determine the source of transmission. The infection control monthly line listing noted two (2) or more residents were diagnosed with [REDACTED]. The facility's outbreak investigation policy, with a revision date of 11/28/16, section 1.1.4 noted Pneumonia: Two (2) or more patients with nosocomial cases on non-aspiration pneumonia within a seven (7) day period should be reviewed for outbreak potential. Registered Nurse (RN) #65 verbalized the identified cases met the criteria, but the respiratory outbreak had not been reported to the local health department or other Stage agency. Additionally, RN #65 verbalized two (2) residents had been identified with a history of ESBL, therefore, no further action was taken with the newly identified infections. The nurse verified evidence could not be provided of an ongoing, systematic analysis with corrective actions, if warranted, based on the data collected, to improve resident health status. h) Bedpan storage An observation of the bathroom between rooms [ROOM NUMBERS] on 07/10/17 at 2:30 p.m. revealed the following: -- a bedpan in a plastic bag hanging over the toilet paper roll -- a bedpan and urinal in a plastic bag sitting on the floor beside the commode and below the toilet paper -- a urinal with urine sitting on the baseboard heater on the left side of the toilet -- an unlabeled and uncovered bedpan on the dirty shower floor -- a strong odor of urine with an open air-freshener sitting on the back of the commode On 07/10/17 at 2:32 p.m., Resident #43 reported he used this restroom and often had difficulty getting toilet paper because the bedpan bags were always hanging over the toilet paper rolls. The Director of Nursing (DON) observed the bathroom during an interview on 07/10/17 at 2:41 p.m. and confirmed the restroom had a strong smell of urine, the shower area needed cleaned and there should not be items sitting on the shower floor, the bed pan bags should not be obstructing the toilet paper rolls, nor resting on the floor, and the urinal should not be sitting on the heater. The DON agreed this was an infection control concern related to improper storage. Arrangements were made to clean the bathroom and shower and to adjust the storage hooks to keep bedpan bags off the floor and allow free access to the toilet paper rolls. i) Wheelchairs On 07/10/17 at 10:56 a.m., Resident #56's wheelchair was found in disrepair. The seat cushion was missing a large portion of the covering in the back corner exposing a rough inner lining, tears in both upper outer corners of the back support also exposing the rough inner lining, and there was rust around the front leg support holders. During this observation, Resident #56 confirmed she used this wheelchair and stated I am blind, I can't see so they gave me any old chair. I had a nicer one when I came and they took it. On 07/11/17 at 8:57 a.m., Resident #5's wheelchair was noted to be frayed along the top edges of the wheelchair armrests. One armrest was repaired with electric tape. During this observation, Resident #5 confirmed this was the wheelchair he used daily and added, I use to have a nicer chair, they took it one night and gave me this one. The DON and Facility Administrator agreed both wheelchairs were a sanitary concern during an interview on 07/12/17 at 3:43 p.m. The Administrator stated she would order new wheelchairs for both residents.",2020-09-01
3031,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,490,F,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, resident interview, medical record review, review of the Centers for Disease Control and Prevention guidelines, policy review, review of infection control tracking and trending reports, and staff interview, the facility failed to utilize its resources effectively and efficiently to attain or maintain the highest practicable physical, mental and or psychosocial well-being of each resident. The facility failed to ensure an effective infection control program to prevent the transmission and spread of disease and infection to the extent possible. The facility failed to utilize surveillance data to improve its infection control processes and outcomes by taking corrective actions as indicated, failed to report, and/or trend infections adequately. The failed to ensure an environment as free of accident hazards as was possible by storing an automated external defibrillator (AED) machine within easy access of residents and not ensuring residents did not have access to potentially harmful chemicals and/or soiled areas. The facility also failed to ensure conveyance of funds upon the resident's death or discharge, and failed to provide housekeeping and maintenance services to maintain a sanitary, orderly, and comfortable environment. These practices had the potential to affect all residents. Facility census: 52. Findings include: a) Infection Control The facility failed to maintain an effective infection control program to prevent the transmission and spread of disease and infection to the extent possible. Staff handled medications incorrectly, did not maintain aseptic technique with a wound dressing treatment, failed to utilize proper hand hygiene, failed to ensure isolation requirements were maintained, failed to handle clean linens properly, failed to maintain standard precautions when storing bed pans, failed to store and/or maintain resident equipment in a sanitary manner, failed to perform surveillance and investigation, failed to use records of infection incidents to improve its infection control processes and outcomes by taking corrective actions as indicated, and failed to report, track and/or trend infections adequately. 1. Resident #2 During a medication administration observation on [DATE] at 4:15 p.m., Registered Nurse (RN) #15 entered the room of Resident #2 to administer an insulin injection. The nurse placed the Quik Pen on the over-the-bed table without a barrier, and after administering the medication returned the pen to the cart without first cleaning it. 2. Resident #56 On [DATE] at 8:12 a.m., a medication observation revealed Licensed Practical Nurse (LPN) #26 poured medication for Resident #56. When punching-out the medication from the card, the pill fell on to the top of the medication cart. The LPN picked the medication up with a tissue and placed it in the cup with the resident's other medications. 3. Resident #67 When administering medications to Resident #67 on [DATE] at 8:20 a.m., Licensed Practical Nurse (LPN) #26 placed the inhaler on the over-the-bed table without a barrier. Without performing hand hygiene, the nurse exited the room, placed the inhaler back in the medication cart without cleaning it, signed the Medication Administration Record, [REDACTED]. 4. Resident #21 Licensed Practical Nurse (LPN) #43 administered medications to Resident #21 at 8:45 a.m. The nurse entered the room and placed eye drops, nasal spray, and tissues from the medication cart on the over-the-bed table without a barrier. LPN #43 washed her hands for a count of nine (9) seconds, donned gloves and administered a [MEDICATION NAME] eye drop in each eye. While wearing the same gloves, the nurse administered saline nasal spray in each of the resident's nostrils, and without changing gloves, administered a [MEDICATION NAME] eye drop in each eye, then administered [MEDICATION NAME] nasal spray in each nostril. Upon completion of the medication administration, the medications, the nurse picked up the thermometer and took Resident #21's temperature by scanning the resident's forehead. LPN #43 removed her gloves, picked up the eye drops and nasal sprays and returned them to the medication cart without wiping them off. The nurse returned to the room and washed her hands for a count of seven (7) seconds. 5. The facility's hand hygiene policy, with a revision date of [DATE], and Centers for Disease Control and Prevention guidelines required staff wash hands vigorously for 20 seconds, covering all surfaces of the hands and fingers 6. Resident #87 During a random observation on [DATE] at 3:19 p.m., Licensed Practical Nurse (LPN) #14 entered the room of Resident #87 and said she needed to change her dressing. Without sanitizing her hands, the LPN donned gloves, opened the sterile dressing package and touched the inside of the dressing (part next to the wound bed) with her gloved fingers. The nurse utilized scissors to cut the dressing in half. LPN #14 picked up the dressing again with her finger on the inside of the dressings. After placing tape on the outside of the dressing to make a border, the nurse rolled the resident to her left side, placed a blue barrier pad beneath her, and pulled down Resident #14's pants revealing a border dressing with brown stain on the inferior aspect. LPN removed the dressing and commented the substance was stool. LPN #14 removed her gloves, washed her hands, and donned clean gloves. Using a circular motion the nurse cleansed the open area on the right buttock. The nurse cleansed the resident's buttocks and placed a small ball of stool on the right side of the blue barrier pad. LPN #14 repositioned the resident, then placed the bag containing wound care supplies on the barrier pad, in the same area as the ball of stool. The nurse sprayed the coccyx area with wound cleanser then laid the spray bottle on the pad, outside of the bag. The nurse cleansed the coccyx wound and buttock wound with the same gauze, obtained a new four by four (4x4) gauze and dried each wound with the same gauze. Without changing gloves, LPN #14 opened a tube of medication which she identified as [MEDICATION NAME]. Without changing gloves, the nurse placed [MEDICATION NAME] onto her then contaminated gloved finger and applied it onto the wound bed on the coccyx area. The LPN then poured another dollop of [MEDICATION NAME] onto the same gloved finger and applied it directly onto the wound bed on the right buttock. The aseptic (free of infectious organisms) wound dressing policy revised [DATE], noted to clean the over-the-bed-table, place a clean barrier on the table and place supplies on the barrier .if a patient had multiple wounds, treat each wound as a separate procedure .if a break in aseptic technique occurred, stop the procedure, remove gloves, cleanse hands, and apply clean gloves .open dressing(s) without contaminating .prepare medication/ointment by placing on inner sterile package .expose area to be treated, apply clean gloves, place bed protector under or adjacent to wound site and remove soiled dressing, discard dressing and gloves. Cleanse hands and apply clean gloves .cleanse wound .using swab or applicator, apply treatment medication .apply and secure clean dressing. Remove gloves and discard .apply prepared label, cleanse hands The Center Nurse Executive, interviewed on [DATE] at about 5:15 p.m., agreed the nurse failed to maintain aseptic technique and confirmed the technique created a potential for cross contamination. 7. Laundry An observation of the laundry area on [DATE] at 8:44 a.m. with Laundry Worker #10, revealed the fan in the upper right corner of the clean linen side of the room, upon entry to the room from the corridor, needed cleaned. A layer of dust covered the fan and there were multiple dust balls in the wire casing. The fan was turned on and blowing across the clean linen. Upon inquiry as to who cleaned the fans, Laundry Worker #10 said she thought it was maintenance. She did not know when it was last cleaned. Registered Nurse (RN) #21, interviewed on [DATE] at 9:40 a.m., verbalized the dirty fan created a potential for contamination of the clean linen. During a follow-up observation and interview with Laundry Worker #10 on [DATE] at 2:30 p.m., she reported maintenance staff had cleaned the fan that morning. 8. Resident #40 On [DATE] at 4:24 p.m., Registered Nurse (RN) #15 donned personal protective equipment (PPE) and entered the room of Resident #40. The nurse said the resident required contact precautions related to [MEDICAL CONDITIONS], a drug resistant organism. A curtain was pulled around the end of the bed and two (2) bins were located at the foot of the bed for disposal of contaminated items such as PPE. A dust covered fan sat at the right foot of the resident's bed and was blowing across the room toward the hallway. A nurse aide (name unknown) was in the room and assisted RN #15 reposition the resident in bed. Upon completion, the NA opened the lid of the hamper, removed her gloves and as she was placing them in the bin, the lid closed between her hand and the soiled PPE gowns. The NA washed her hands and while exiting the room used bare hands to pull back the curtain to the edge of the bed. The NA did not wash her hands again prior to exiting the room. RN #15 also disposed of his PPE, washed his hands, then touched the curtain prior to exiting the room. During an interview immediately following the observation, the Center Nurse Executive agreed there was potential for cross contamination when staff touched the curtains while exiting the room. The [MEDICAL CONDITION] policy, revised [DATE] required staff maintain stringent handwashing On [DATE] at 9:15 a.m., Registered Nurse #21 said the dusty fan blowing across containers of contaminated items created a potential for cross contamination and spread of disease and infection as it blew across isolation carts toward hallway. 9. Residents #46 and #87 A Stage 1 observation on [DATE] at 3:50 p.m., noted bedpans stored in plastic bags hanging over the toilet paper roll in the bathroom. Both Residents #46 and #87 utilized the bathroom. During an interview with the Center Nurse Executive (CNE) on [DATE] at 4:06 p.m., the nurse confirmed the bedpans posed a potential for cross-contamination. 10. Resident #84 On [DATE] at 9:52 a.m., a Stage 1 observation revealed the resident's geri chair positioned at the foot of the bed. The vinyl on the outer edge of the right chair arm was torn with a shredded appearance from the back of the armrest to the front of the armrest exposing fabric and wood beneath. The fall mat located on the left side of the bed was torn, exposing the fabric beneath, and the right floor mat had a shredded appearance with long threads. During an interview at 4:06 p.m. on [DATE], the Center Nurse Executive acknowledged the items could not be cleansed properly and created a potential for cross contamination. 11. Facility acquired infections The handwritten infection control line listing, reviewed on [DATE], noted ongoing respiratory infections and urinary tract infections between (MONTH) (YEAR) and (MONTH) (YEAR). The computerized trending forms did not provide information related to location in the facility and did not correlate with the number of residents who received antibiotic therapy in accordance with the written line listing. Further review of the records noted trends for urinary tract infections [MEDICAL CONDITION] and respiratory infections (RESP) from (MONTH) (YEAR) to (MONTH) (YEAR). On [DATE] at 9:40 a.m., after reviewing the infection control information, Registered Nurse (RN) #21 said the ESBL (extended-spectrum beta lactamases) in-house acquired infections should have been reported to the health department in (MONTH) (YEAR). The nurse said she acknowledged an ongoing trend of infections based on the handwritten report, including urinary tract infections and respiratory infections. On [DATE] at about 8:45 a.m., Registered Nurse (RN) #65 verified the trending report and tracking reports did not correlate. The nurse said that only diagnoses/symptoms meeting McGeer's criteria were placed on the trending report. The RN verbalized the other infections treated with antibiotics did not meet the criteria of a true infection. The nurse reviewed the handwritten line listing forms and acknowledged ongoing issues with urinary tract infections and respiratory infections. The nurse said no communication had been initiated with the local health department, and the facility had not developed an action plan to address the infections. RN #65 said she had not analyzed data related to month to month infections, and had not looked at data from the perspective of residents' symptoms. When asked what the facility did to prevent respiratory symptoms from spreading throughout the facility, the nurse said no special precautions had been taken because the symptoms did not meet the infection criteria. The tracking forms were again reviewed with the RN, and she acknowledged an increase from six (6) residents with respiratory symptoms in (MONTH) (YEAR) to twenty-two (22) residents in (MONTH) (YEAR), and fluctuations continuing through (MONTH) (YEAR). RN #65 confirmed no evidence was present to indicate staff had been educated other than the hand hygiene in-service completed [DATE]. Only nurse aides on the day shift and evening shift were noted as educated. No evidence was presented to indicate staff on the 11:00 p.m. to 7:00 a.m. morning shift were educated. Additionally, no evidence was present to indicate the facility monitored staff for hand hygiene, aseptic technique, proper perineal/incontinence care, or linen handling. Upon exit of the facility, no additional information was provided. The Outbreak Investigation/Management policy, with a revision date of [DATE], note an outbreak would be defined as an excess over expected (usual) level of disease within the Center or according to defined clinical parameters or state regulations. Case definitions included: -- Influenza: One (1) or more laboratory proven cases (patient and staff) of influenza, along with other cased of a respiratory infection in a Unit within a seven (7) day period -- Pneumonia: Two (2) or more patients with nosocomial cases of non-aspiration pneumonia within a seven (7) day period should be reviewed for outbreak potential, and -- MDROs (multidrug resistant organisms) - an increase from baseline of healthcare acquired infections required additional surveillance to determine the source of transmission. The infection control monthly line listing noted two (2) or more residents were diagnosed with [REDACTED]. The facility's outbreak investigation policy, with a revision date of [DATE], section 1.1.4 noted Pneumonia: Two (2) or more patients with nosocomial cases on non-aspiration pneumonia within a seven (7) day period should be reviewed for outbreak potential. Registered Nurse (RN) #65 verbalized the identified cases met the criteria, but the respiratory outbreak had not been reported to the local health department or other Stage agency. Additionally, RN #65 verbalized two (2) residents had been identified with a history of ESBL, therefore, no further action was taken with the newly identified infections. The nurse verified evidence could not be provided of an ongoing, systematic analysis with corrective actions, if warranted, based on the data collected, to improve resident health status. 12. Bedpan storage An observation of the bathroom between rooms [ROOM NUMBERS] on [DATE] at 2:30 p.m. revealed the following: -- a bedpan in a plastic bag hanging over the toilet paper roll -- a bedpan and urinal in a plastic bag sitting on the floor beside the commode and below the toilet paper -- a urinal with urine sitting on the baseboard heater on the left side of the toilet -- an unlabeled and uncovered bedpan on the dirty shower floor -- a strong odor of urine with an open air-freshener sitting on the back of the commode On [DATE] at 2:32 p.m., Resident #43 reported he used this restroom and often had difficulty getting toilet paper because the bedpan bags were always hanging over the toilet paper rolls. The Director of Nursing (DON) observed the bathroom during an interview on [DATE] at 2:41 p.m. and confirmed the restroom had a strong smell of urine, the shower area needed cleaned and there should not be items sitting on the shower floor, the bed pan bags should not be obstructing the toilet paper rolls, nor resting on the floor, and the urinal should not be sitting on the heater. The DON agreed this was an infection control concern related to improper storage. Arrangements were made to clean the bathroom and shower and to adjust the storage hooks to keep bedpan bags off the floor and allow free access to the toilet paper rolls. 13. Wheelchairs On [DATE] at 10:56 a.m., Resident #56's wheelchair was found in disrepair. The seat cushion was missing a large portion of the covering in the back corner exposing a rough inner lining, tears in both upper outer corners of the back support also exposing the rough inner lining, and there was rust around the front leg support holders. During this observation, Resident #56 confirmed she used this wheelchair and stated I am blind, I can't see so they gave me any old chair. I had a nicer one when I came and they took it. On [DATE] at 8:57 a.m., Resident #5's wheelchair was noted to be frayed along the top edges of the wheelchair armrests. One armrest was repaired with electric tape. During this observation, Resident #5 confirmed this was the wheelchair he used daily and added, I use to have a nicer chair, they took it one night and gave me this one. The DON and Facility Administrator agreed both wheelchairs were a sanitary concern during an interview on [DATE] at 3:43 p.m. The Administrator stated she would order new wheelchairs for both residents. b) The facility failed to ensure an environment as free of accidents hazards as was possible. The facility stored an Automated External Defibrillator (AED) within easy access of residents and visitors. The device's battery was charged, and capable of delivering a charge that could result in harm or even death if activated by an unauthorized person. 1. Automated External Defibrillator A random observation on [DATE] at 8:50 a.m., revealed an automated external defibrillator (AED) machine on top of the crash cart located in the alcove on A-Hall near the nurses' station. (A defibrillator is a device used to deliver a shock to the chest for certain heart problems.) The device was readily accessible to residents. The Center Nurse Executive (CNE), interviewed at that time, picked up the machine and verified it was not secured. She said the machine was placed there for easy access in case of an emergency. When asked what would happen if a resident accessed the machine, the CNE said she had not thought about it, but would find somewhere else to place the defibrillator. During the discussion, the CNE easily opened the battery operated AED machine, by pulling apart the snaps of the cover. She pushed a button which opened the device, and green lights flashed indicating the machine was ready to function and a voice provided instructions for use. On [DATE] at 12:28 p.m., the CNE reported a new lock had been placed on the clean utility door, and the AED machine placed inside. 2. Resident common shower room On [DATE] at 8:20 a.m., while conducting the initial tour of the facility, an open/unlocked common shower room was found. In the shower room was a sixteen (16) ounce (oz) bottle labeled as, Germicidal cleanser and deodorant with a precaution on the label to Keep out of reach of children sitting on the shower room counter top. At 8:23 a.m., when shown to Regional Consultant #6, she immediately removed to bottle. She stated, It should not be sitting out where any resident could access it and should be in a locked cabinet. Yes, it is an accident hazard. 3. Soiled Utility Room On [DATE] at 8:25 a.m., it was found the door to the soiled utility room could be entered without using a code on the push button lock. The soiled utility room contained two (2) large trash cans and two (2) large containers for soiled linen and a hopper. Nurse Aide #61, who was standing in the hallway, stated, That door is always supposed to be locked for safety of the residents. An observation at 8:50 a.m. on [DATE], again found the door to the soiled utility room could be entered without using a code on the push button lock. When shared with Regional Consultant #6 at 8:52 a.m., she stated, The door is supposed to be locked, I will have the lock repaired by maintenance. The Maintenance Director reported on [DATE] at 11:30 a.m., The door lock on the soiled utility room has been replaced. d) 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. 1. 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. 2. 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 3. 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. 4. 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. e) The facility failed to provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable environment. A resident shower in the bathroom had dirt and grime on the floor tile and wall. Walls needed repaired and/or painting. An air conditioner unit needed repaired. A nightstand had a door that was hanging down, and an over-bed table had missing veneer on its edges exposing particle board. Doors had gouges and marred areas and/or doors and door facings had cracked and peeling paint around edges. Loose cove molding was noted in a resident room. Observation of the facility during Stage 1 Quality Indicator Survey (QIS) revealed the following rooms had environmental concerns and cosmetic imperfections. 1. room [ROOM NUMBER] There were gouges two (2) inches deep in the wall behind the headboard of the bed and the wood bar on the wall was loose and hanging down. The wall to the left side of a resident room entry way was scraped with missing paint. 2. room [ROOM NUMBER] The bathroom had a one and a half inch (1-,[DATE]) hole in the wall above the toilet. 3. room [ROOM NUMBER] There was loose cove molding on the right side of the wall by the bathroom entrance door. 4. room [ROOM NUMBER] The air conditioner unit was in disrepair with the unit separated from the wall and missing a vent grate covering. 5. room [ROOM NUMBER] A nightstand in this room was in disrepair with front door loose and hanging down. The over-bed table had missing veneer on edges exposing particle board. 6. room [ROOM NUMBER] The exterior entry door had gouges and marred areas exposing the wood beneath finish. 7. room [ROOM NUMBER] The bathroom exterior door and door facing had cracked and peeling paint around the edges. 8. room [ROOM NUMBER] A one and one-half inch (1-,[DATE]) hole was in the bathroom wall above the toilet. The bathroom exterior door and facing had cracked and peeling paint around edges. 9. room [ROOM NUMBER] The bathroom shower had dirt and grime on the floor tile and in the grout of the shower floor, that extended into the left corner one-third (,[DATE]) of the way up the shower wall from the shower floor. b) A tour with the Administrator, Maintenance Director, and Environmental Services Director, beginning at 2:55 p.m. and concluding at 3:15 p.m. on [DATE], confirmed all of the identified issues needed repaired and/or replaced. They also agreed the shower needed deep cleaned or resurfaced.",2020-09-01
3032,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,502,D,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to ensure laboratory services were obtained timely for one (1) of five (5) residents reviewed for unnecessary medications. Routine scheduled labs for Resident #56 were not drawn as ordered. Resident identifier: #56. Facility census: 52. Findings include: a) Resident #56 Review of the resident's medical record on 07/12/17 at 12:21 p.m., found her monthly routine orders included a, CBC (complete blood count), CMP(comprehensive metabolic panel), BMP (basic metabolic panel), HGB (hemoglobin) A1c on admission then every 3 months. (Feb/May/Aug/Nov) Dx (diagnosis). HTN, DM2, [MEDICAL CONDITION]. A CBC, CMP, BMP, and Hgb A1c were drawn on 02/20/17, three (3) days after the resident's admission, but no laboratory results were found for the tests due in (MONTH) (YEAR). Licensed Practical Nurse (LPN) #26 reviewed the resident's medical record during an interview on 07/12/17 at 1:00 p.m. and agreed Resident #56's orders included a CBC, CMP, BMP, and Hgb A1c every three (3) months. She said the labs should have been drawn in May, but no lab results in the chart indicated the tests were not done as ordered. LPN #26 reported the Assistant Director of Nursing (ADON) made the arrangements for scheduled labs to be drawn, and puts the forms in the monthly lab book when they are due to be drawn. The Director of Nursing (DON) reviewed Resident #56's orders during an interview on 07/12/17 at 1:20 p.m., and confirmed the quarterly labs should have been drawn in (MONTH) and were not. The DON reviewed the ADON's lab book and tickler sheet with scheduled labs for the residents during this interview and confirmed Resident #56 was not on the master list for her scheduled quarterly labs.",2020-09-01
3033,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2017-07-14,514,E,0,1,CPO811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to maintain complete, accurately documented clinical records of each resident. The [MEDICAL TREATMENT] communication forms for one (1) of one (1) [MEDICAL TREATMENT] resident (#26) whose chart was reviewed during Stage 2 of the Quality Indicator Survey (QIS) were blank or incomplete. In addition, inaccurate and/or incomplete records related to meal and fluid and snack percentages for one (1) (#40) of five (5) records reviewed for unnecessary medications. This practice has the potential to affect more than an isolated number of residents. Resident identifiers: #26 and #40. Facility census: 52. Findings include: a) Resident #26 On 07/11/17 at 12:14 p.m., medical record review revealed Resident #26's [DIAGNOSES REDACTED]. Review of the [MEDICAL TREATMENT] Communication Record on 07/11/17 at 12:39 p.m. revealed the following: -- record dated 07/10/17 had blank areas for the resident's name, room, physician, and center nurse. The section titled, To be completed by licensed nurse for [MEDICAL TREATMENT] patient prior to [MEDICAL TREATMENT] treatment, was blank. -- record not dated or signed by nurse for section To be completed by licensed nurse for [MEDICAL TREATMENT] patient prior to [MEDICAL TREATMENT] treatment. and blank for section titled, To be completed by Licensed Nurse post-[MEDICAL TREATMENT] treatment. -- record dated 06/26/17 did not include the resident's name, room, Physician and center nurse. The section titled, To be completed by licensed nurse for [MEDICAL TREATMENT] patient prior to [MEDICAL TREATMENT] treatment, was blank. -- record dated 06/21/17 blank for section titled, To be completed by Licensed Nurse post-[MEDICAL TREATMENT] treatment. -- record dated 06/19/17 blank for section titled, To be completed by licensed nurse for [MEDICAL TREATMENT] patient prior to [MEDICAL TREATMENT] treatment. After review of the [MEDICAL TREATMENT] Communication Record on 07/11/17 at 12:39 p.m., Licensed Practical Nurse (LPN) #26 verified and agreed the records were incomplete and/or blank. She explained that the procedure was for the nurse to complete the top section (titled, To be completed by licensed nurse for [MEDICAL TREATMENT] patient prior to [MEDICAL TREATMENT] treatment) of the from prior to the Resident going to [MEDICAL TREATMENT], the middle section was completed by the [MEDICAL TREATMENT] center, but they sent their own form for this, and the bottom portion of the form was filled out when the resident returned to the facility. Sometimes the nurse was busy and they took him (to [MEDICAL TREATMENT]) before she could fill out the top portion. She stated, Yes, it is an incomplete medical record, and no, there should not be any blanks. b) Resident #49 Review of the resident's current care plan related to nutritional status on 07/11/17, noted Resident #49 was at nutritional risk related to multiple medical issues. The goal was for the resident to consume greater than 75 percent of meals, snacks, and supplements. The intervention, dated 05/10/17 required staff offer snacks. The paper transcribed activity of daily living records (ADLs), reviewed for the months of May, June, and (MONTH) (YEAR) had multiple omissions of data. The ADL records omitted data as follows: The ADL records noted Resident #49 did not receive and/or was not offered snacks as follows: -- (MONTH) (YEAR) - 13 of 20 opportunities -- (MONTH) (YEAR) - 27 of 30 opportunities -- (MONTH) (YEAR) - 11 of 11 opportunities Meal and fluid percentages were omitted as follows: -- (MONTH) (YEAR) - 56 of 67 opportunities -- (MONTH) (YEAR) - 90 of 90 opportunities -- (MONTH) (YEAR) - 11 of 11 opportunities During an interview on 07/12/17 at 1:45 p.m., the Center Nurse Executive reviewed the resident's ADL records for May, June, and (MONTH) (YEAR). She confirmed the medical record was incomplete, and did not have sufficient information to provide an accurate representation of Resident #49's nutritional intake.",2020-09-01
3034,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,550,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3035,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,558,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3036,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,584,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3037,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,641,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3038,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,656,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3039,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,684,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3040,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,690,D,0,1,GTWI11,Deficiency Text Not Available,2020-09-01
3041,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,697,G,0,1,GTWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, resident interview, staff interview and policy review, the facility failed to ensure a resident received the treatment and care in accordance with professional standards or practice, the comprehensive care plan, and the resident's choices, related to pain management. Resident #47 was not offered an as needed (prn) pain medication before or during pressure wound treatment prior to surveyor intervention. This resulted in actual harm to the resident. Also, the facility demonstrated a pattern of not assessing Resident #47's pain prior to prn pain medication and/or assessing its effectiveness following the prn pain medication administration. These practices were evident for one (1) of eighteen (18) sampled residents. Resident identifier: #47. Facility census: 60. Findings included: a) Resident #47 On 09/11/18 at at 11:30 AM, registered nurse (RN) #39 began treatment on a Stage 4 pressure wound to the resident's right buttock. She washed the right buttock wound with soap and water. The resident jumped when touched with the washcloth during cleansing, and complained of pain. RN #39 then applied Sureprep to the peri-wound surrounding skin. Next, she applied Santyl (an enzymatic debrider) to the wound bed by using the tip of her gloved index finger. The resident winced and complained of pain again when the wound bed was touched. Her facial expression was distorted and gave further evidence of pain beyond her stated words. RN #39 said it always hurts her like this during the dressing change. RN#39, when asked when she most recently received or was offered pain medication, said this resident received a scheduled dose of pain medication around 9:00 AM this morning. She said it is scheduled twice per day (at 9:00 AM and 9:00 PM). RN #39 said she wanted to get this dressing done before the resident left at 12:15 PM today for an appointment out of the facility. She said she got a bit behind today due to being observed with morning medication pass. Upon inquiry as to whether she gets as needed (prn) pain medication [MEDICATION NAME] prior to the pressure wound treatment, RN #39 replied that the resident does have a prn (as needed) pain medication order. At this time the resident verbalized that she thought the wound was supposed to be packed. RN #39 assured her that was no longer the case, but would go out to see if the physician who made rounds this morning may have changed the order. This writer asked if she also might want to check about prn pain medication while she was at the desk, to which the resident replied yes. RN #39 left the room, then returned quickly with a pain pill for the resident. Upon inquiry, she said it was a [MEDICATION NAME]. The resident took the [MEDICATION NAME]. RN #39 told the resident there were no new physician's orders [REDACTED]. RN #39 then covered the wound with an [MEDICATION NAME] dressing. RN #39 did not ask the resident to rate her pain level. The surveyor asked the resident the level of pain she was experiencing at this time. The resident said it was an eight (8) or nine (9) out of a scale of one (1) to ten (10). The resident then asked why a number was needed. It was explained that this would help the nurse understand the severity level of the pain, and would help the nurse assess how effective the pain medication was at treating her pain. An interview was conducted with the resident on 09/11/18 at 12:10 PM. She said it would be helpful if she could get her dressings changed soon after her scheduled pain medication. She said nurses sometimes are busy and cannot get to her dressing changes timely after the medication. She said sometimes the dressings become soiled and have to be removed at times other than around her scheduled 9:00 AM and 9:00 PM pain medications. She said sometimes nurses offer her pain medication before the dressing changes, and other times they just arrive in her room with the treatment supplies and ready to go. The medical record was reviewed on 09/11/18. According to the Medication Administration Record [REDACTED]. Of that number, nursing staff assessed the severity level of the pain prior to the pain medication only six (6) times out of sixty (60) opportunities. Nursing assessed the effectiveness of the prn [MEDICATION NAME] on only one (1) occasion out of sixty (60) opportunities. This resident also had physician orders [REDACTED]. every six (6) hours as needed for pain or fever. She received this medication four (4) times in August, (YEAR). On one (1) occasion the nurse assessed the pain level of nine (9) out of ten (10). There was no evidence of pain assessment following any of the four (4) doses. Review of the narcotic sign-out sheets for September, (YEAR), found she received [MEDICATION NAME] 5/325 mg. a total of sixteen (16) times. Review of the prn pain management flow sheet for (MONTH) found the [MEDICATION NAME] was recorded only eight (8) out of the sixteen (16) dose opportunities on the flow sheet. Of that total, those eight (8) did have a pre-medication pain level assessment, but only five (5) times was the post prn pain medication level assessed. Also in (MONTH) (YEAR), the resident received one (1) dose of [MEDICATION NAME] which was ordered at every six (6) hours prn for mild pain. There was no pre- or post- administration pain assessment. The resident also had physician orders [REDACTED]. every four (4) hours prn for moderate to severe pain. Per the MAR, this resident received twelve (12) doses of [MEDICATION NAME] in (MONTH) of (YEAR). Nursing completed one pain rating assessment out of twelve (12) opportunities, and did no post prn pain medication rating assessments. Page seventeen (17) of the care plan addressed pain related to a recent surgical procedure, stage 4 pressure ulcer, and [DIAGNOSES REDACTED]. -Evaluate pain characteristics of quality, severity, location, precipitating/relieving factors. -Utilize pain scale -Medicate resident as ordered for pain and monitor for effectiveness. -Complete pain assessment per protocol. An interview was conducted with the director of nursing (DON) on 09/12/18 at 2:30 PM. She said she would look to see if they have a policy about what is expected of a nurse related to assessing pain severity before and after prn pain medication. She wrote down the number of times in (MONTH) and (MONTH) (YEAR) where there were no assessments evident for pain relief following the prn medication, or for pain assessment prior to the prn pain medication. She said she would look elsewhere within the medical record, and would direct the ADON to do likewise, to try and produce evidence of pre- and post- prn pain medication assessments. On 09/12/18 at 4:20 PM another interview was conducted with the DON. She provided the facility's policy on pain management, with revision date of 03/01/18. Item number five (5) on the policy stated that if prn medications are given, to document on the back of the MAR indicated [REDACTED]. Item number eight (8) of the policy stated that patient receiving interventions for pain will be monitored for the effectiveness in providing pain relief. Staff are to document the effectiveness of PRN (pain) medications. The DON said this is typically done on the pain flow record. She agreed that for this resident, staff had dropped the ball and had not consistently assessed her pain before and/or after pain medication doses. She further stated that their policy does not specify how they would determine effectiveness, such as a lichter scale. She agreed that they would need to use some type of scale before treatment with pain medication, and then after the pain medication, as a measure of the change in comfort level. An interview was conducted with the administrator, the DON, and the corporate/regional administrator employee #500 (E#500) on 09/12/18 at 5:00 PM. No further information was provided related to the lack of pain assessments pre- and/or post- prn pain medication administration for this resident. E#500 asked if it would be considered harm when the resident was not given and/or offered prn pain medication prior to the pressure wound treatment and dressing change when observed on 09/11/18. Replied in the affirmative since the resident did have pain during the treatment, and the prn pain medication was not suggested prior to surveyor intervention.",2020-09-01
3042,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,730,D,0,1,GTWI11,"Based on staff interview and record review, facility failed to ensure 3 of 5 nurse aides had the required 12 hours of inservice training. Staff identifiers: #29, #45, #63. Facility Census 60. Findings included: a) Nurse Aide #29 Review of personnel and training records revealed her date of hire was 11/29/16. The records contained no evidence of 12 hours of annual inservice training for the last year. b) Nurse Aide #45 Review of personnel and training records revealed her date of hire was 08/25/2000. The records contained no evidence of 12 hours of annual inservice training for the last year. c) Nurse Aide #63 Review of personnel and training records revealed her date of hire was 02/02/15. The records contained no evidence of 12 hours of annual inservice training for the last year. During an interview, on 09/12/18 at 9:10 AM, the administrator confirmed the facility had no evidence of the actual inservice training time for the above employees. The administrator stated the facility had implemented a new procedure of online training for all employees for annual inservice training in the last several months.",2020-09-01
3043,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,761,E,0,1,GTWI11,"Based on random observation and staff interview, the facility failed to ensure the safe storage of items located in a treatment cart. This has the potential to effect more than a limited number of residents. Facility census 60. Findings included: Random observation of treatment cart on 9/12/18 at 10:45 am at A13a was unlocked. Wandering Residents #21 and #18 were on hall and in close proximity to this treatment cart. No staff member was present. LPN #17 came to cart stated is it unlocked. Removed items from bottom drawer, did not lock the cart walked down B hall. LPN #17 returned to treatment cart 3 minutes later and returned items to the cart. LPN #17 did not lock the cart. During an interview, on 9/12/18 at 12:45 PM, LPN #17 stated, I should have locked the cart but didn't because you (the surveyor) were standing there. The cart was brand new this morning. We didn't know what key locked the cart on A hall so I didn't lock it. I would have turned it to face the wall but I know that still isn't right.",2020-09-01
3044,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,842,D,0,1,GTWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to ensure a complete and accurate medical record. Physician orders for treatment of [REDACTED]. This was evident for one (1) of eighteen (18) sampled residents. Resident identifier: #47. Facility census: 60. Findings included: a) Resident #47 Review of the medical record on 09/11/18 found a physician's order dated 08/31/18 to treat the (Stage 4) pressure wound to the right buttock as follows: clean wound to right buttock with soap and water, pat dry, apply calcium alginate with silver, cover with border dressing, and change every other day and as needed (prn). It did not direct to use Santyl. The physician re-ordered the same treatment on 09/02/18. Physician's order dated 09/02/18 directed to treat the (Stage 2) left buttock pressure wound with soap and water, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME], and change every other day and prn. Physician's order dated 09/07/18 directed to cleanse the pressure wound to the left buttock with soap and water, Sureprep the peri-wound, apply Santyl to the wound bed, and cover with [MEDICATION NAME] every other day and as needed (prn). Further review of the medical record found the treatment administration record (TAR) contained an order dated 09/07/18 to cleanse the wound to the left buttock with soap and water, Sureprep the peri-wound, apply Santyl to the wound bed, and cover with [MEDICATION NAME] every other day and prn (as needed). Nurses initialed this was done on the day shift on 09/08/18, 09/09/18, 09/10/18, and 09/11/18. An interview was conducted with the assistant director of nursing (ADON) on 09/11/18 at 12:00 PM. She reviewed the physician orders for wound care. Relayed to her that the nurse completed treatment to the right buttock with Santyl on 09/11/18, when there was no order for Santyl for the right buttock. Rather, the physician's order directed Santyl to the left buttock pressure wound. The ADON said that in her opinion the Santyl order should have been for the right hip, not the left hip. She agreed that nursing documented on the treatment administration record (TAR) that Santyl treatment was done to the left hip on 09/08/18, 09/09/18, 09/10/18, and 09/11/18. The observed treatment on 09/11/18 was the Santyl treatment to the right buttock pressure wound, not the left buttock wound However, E#39 documented on the TAR that she did the Santyl treatment to the left buttock. The ADON said there is no slough or necrotic tissue on the left buttock Stage 2 pressure ulcer that would require Santyl. On 09/12/18 at 8:00 AM, an interview was conducted with the ADON. She said they contacted the physician yesterday and corrected the pressure ulcer treatment orders as follows: - Cleanse left buttock wound (Stage 2) with soap and water, rinse, pat dry, apply [MEDICATION NAME] AG, cover with [MEDICATION NAME] every other day and as needed (prn). -Cleanse right buttock wound (Stage 4) with soap and water, rinse, pat dry, Sureprep peri- wound, apply Santyl to wound bed, cover with [MEDICATION NAME] every other day and as needed (prn). Observation of the wound care for both the right and left buttock pressure wounds was done on 09/12/18 between 10:30 AM and 10:50 AM. Wound care was completed by the ADON, while E#39 assisted. The nurse practitioner (FNP) was also present. The ADON stated there was a bit of slough in a pocket on the left side of the right buttock pressure ulcer. The FNP and ADON opted to not use Santyl today on the right buttock pressure wound. Instead, the ADON packed the wound with [MEDICATION NAME] and covered it with [MEDICATION NAME]. The FNP said this resident has her weekly wound care appointment today at the wound care center (WCC) at 2:00 PM. The FNP stated the WCC would observe the right buttock pressure wound and would clean out that pocket of slough more thoroughly. She said it was possible that the WCC might change the wound care orders at that time. Per the ADON's measurement, this wound was a bit smaller than it was at the last measurement seven (7) days ago. Next, the ADON completed wound care to the left buttock pressure wound. After cleansing it, the ADON laid a small [MEDICATION NAME] on top of it and covered it with [MEDICATION NAME]. There was no slough or necrotic material observed. On 09/12/18 at 5:00 PM an interview was conducted with the administrator, the DON, and the corporate/regional administrator employee #500 (E#500.) They said there were no errors in the pressure ulcer treatments, rather, the order was written incorrectly on the TAR and on the hand-written physician order sheet.",2020-09-01
3045,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,867,E,0,1,GTWI12,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility to maintain an effective Quality Assurance Program to develop and implement appropriate plans of action to correct quality deficiencies of which it had or should of had knowledge. The facility failed to implement care plans related to pain monitoring, failed to assess pain prior and/or after as needed pain medication was given to residents, and failed to maintain accurate resident medical records. This is true for two (2) of thirteen (13) citations requiring a revisit survey. Resident identifiers: #36 and #600. Facility census: 64. Findings included: a) Resident #36 The medical record was reviewed on 11/26/18. The physician ordered [MEDICATION NAME] (an opiod pain mediation) 10-325 milligrams (mg) every four (4) hours prn (as needed) for severe pain. The resident received a total of thirty-seven (37) doses of [MEDICATION NAME] in November, (YEAR). The physician ordered Tylenol 325 mg. two (2) tablets every four (4) hours as needed for moderate pain. The resident received fourteen (14) doses of 650 mg. Tylenol in November, (YEAR). The physician also ordered Tylenol 325 mg. one (1) tablet every four (4) hours as needed for mild pain. The resident received five (5) doses of 325 mg. Tylenol in November, (YEAR). [DIAGNOSES REDACTED]. Review of the medication administration record (MAR) for (MONTH) (YEAR) found numerous instances where prn (as needed) pain medication was administered. Review of the the MAR and/or the prn pain management flow sheet found nursing staff did not evaluate the pain and/or utilize pain scale, and/or monitor effectiveness and/or complete pain assessment per protocol as follows: [MEDICATION NAME] 10-325 mg. administration - - 11/03/18 at 4:30 AM the level of pain was not assessed before the [MEDICATION NAME] administration, nor was the effectiveness of the prn pain medication assessed afterward. - 11/05/18 at 12:20 AM the level of pain was not assessed before the [MEDICATION NAME] administration, nor was the effectiveness of the prn pain medication assessed afterward. - 11/05/18 at 3:30 PM the level of pain was not assessed before the [MEDICATION NAME] administration, nor was the effectiveness of the prn pain medication assessed afterward. - 11/16/18 at 8:00 PM the level of pain was not assessed before the [MEDICATION NAME] administration, nor was the effectiveness of the prn pain medication assessed afterward. Tylenol 650 mg. administration - - 11/08/18 at 9:30 AM Tylenol 650 mg. was given for a pain rating scale level 7 out of 10, but the effectiveness of the pain medication was not assessed after the Tylenol administration. - 11/10/18 at 9:30 AM Tylenol 650 mg. was given for a pain rating scale level 4 out of 10, but the effectiveness of the pain medication was not assessed after the Tylenol administration. - 11/11/18 at 2:00 AM Tylenol 650 was given for a pain rating scale level 4 out of 10, but the effectiveness of the pain medication was not assessed after the Tylenol administration. - 11/22/18 at 9:00 AM the level of pain was not assessed before Tylenol administration, and the effectiveness of the pain medication was not assessed after the Tylenol administration. - 11/24/18 at 9:15 AM the level of pain was not assessed before Tylenol administration, and the effectiveness of the pain medication was not assessed after the Tylenol administration. Tylenol 325 mg. administration - - 11/19/18 at 7:00 PM the level of pain was not assessed before Tylenol administration, and the effectiveness of the pain medication was not assessed after the Tylenol administration. On 11/27/18 at 8:25 AM the lists of the missing pain assessments for the pre- and/or post- prn pain medications were given to the director of nursing (DON) and the administrator. They said they would look for the missing assessment information. At 2:30 PM on 11/27/18 the DON and the administrator said they were unable to find anywhere within the medical record the pre and/or post prn pain medication assessments for the dates and times listed above. The DON said she has educated nursing staff of the need to assess pain levels before and after prn pain medications. She said they have done audits and have reminded staff to complete those pain assessments as part of their plan of correction, but still the above instances were missed. b) Resident #600 The medical record was reviewed on 11/26/18. The physician ordered [MEDICATION NAME] (an opiod pain medication) 5-325 milligrams (mg) every four (4) hours as needed for severe pain. The resident received fifty-five (55) doses of [MEDICATION NAME] in November, (YEAR). [DIAGNOSES REDACTED]. Review of the medication administration record (MAR) for (MONTH) (YEAR) found numerous instances where prn (as needed) pain medication was administered. Review of the MAR and/or the prn pain management flow sheet found nursing staff did not evaluate the pain and/or utilize pain scale, and/or monitor effectiveness and/or complete pain assessment per protocol as follows: [MEDICATION NAME] 5-325 mg. administration- - 11/18/18 at 5:00 AM the level of pain was not assessed before [MEDICATION NAME] administration, nor was the effectiveness of the pain medication assessed afterward. - 11/18/18 at 9:00 PM the level of pain was not assessed before [MEDICATION NAME] administration, nor was the effectiveness of the pain medication assessed afterward. - 11/19/18 at 11:00 AM the level of pain was not assessed before [MEDICATION NAME] administration, nor was the effectiveness of the pain medication assessed afterward. - 11/19/18 at 2:30 PM the level of pain was not assessed before [MEDICATION NAME] administration, nor was the effectiveness of the pain medication assessed afterward. - 11/19/18 at 7:00 PM the level of pain was not assessed before [MEDICATION NAME] administration, nor was the effectiveness of the pain medication assessed afterward. - 11/20/18 at 10:40 PM the level of pain was assessed on a pain rating scale level 4 out of 10 when the [MEDICATION NAME] was administered, but the effectiveness of the pain medication was not assessed afterward. On 11/27/18 at 8:25 AM the lists of the missing pain assessments pre- and post- prn pain medications were given to the director of nursing (DON) and the administrator. They said they would look for the missing assessment information. At 2:30 PM on 11/27/18 the DON and the administrator said they were unable to find anywhere within the medical record the pre and/or post prn pain medication assessments for the dates and times listed above. The DON said she has educated nursing staff of the need to assess pain levels before and after prn pain medication administration. She said they have done audits and have reminded staff to complete those pain assessments as part of their plan of correction, but still the above instances were missed.",2020-09-01
3046,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,880,E,0,1,GTWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview the facility failed to maintain an infection prevention and control program to prevent the development and transmission of communicable disease and infection to the extent possible. Staff failed to wear a gown while providing care for a resident in isolation, failed to maintain a geriatric chair in a condition to prevent transmission of disease to the extent possible, and failed to follow appropriate hand hygiene practice during med pass. This practice has the potential to effect more than a limited number. Resident identifier: #62, #2 and #19. Facility census: 60. Findings included: a) Resident #62 Review of medical records found a physician order [REDACTED].#62 in isolation for ESBL ( Gram-negative bacteria that produce an enzyme; beta-lactamase that has the ability to break down commonly used antibiotics, such as [MEDICATION NAME] and cephalosporins and render them ineffective for treatment) in urine,and [MEDICAL CONDITION]-resistant Staphylococcus aureus (MRSA) in a wound on the right foot, second digit. On 09/13/18 at 10:05 AM licensed nurse (LPN) #34 completed wound care in the bilateral groin/gluteal folds and on a ulcer to the right foot second digit for Resident #62, without dawning a personal protective gown. Following the care LPN #34 explained Resident #62 had completed her antibiotic and she thought the resident was no longer on isolation. At this time the residents door had a sign to see the nurse before entering and a cart holding protective equipment. A blood draw for a complete blood count (CBC) with differential and a complete metabolic panel (CMP) was completed on 09/10/18. A nursing note with a date of 09/11/18 reveals a successful lab draw with STAT labs ordered. Results indicate several abnormal values, reviewed with (physician) office. Have stated they will get back to us wrt next steps. That there are abnormal labs reported to (physician). Results are on his clip board for detailed review. During an interview on 09/12/18 at 10:50 AM the director of nursing (DON) explained the infection control physician wanted Resident #62 to remain in isolation until labortory results were obtained. At the time of the wound care Resident #62 did not yet have an order to discontinue isolation. b) Resident #2 On 09/11/18 at 7:00 AM a geriatric chair sitting in the hallway between room #B33 and #B35 was observed to have both chair arms worn down to the padding on the outside edge. Housekeeper #11 and clinical coordinator #60 both expressed the chair belonged to Resident #2. Both observed the chair arms worn down until the padding was exposed causing an inability to clean the chair in a manner to prevent the spread of disease. At 3:40 PM on 09/12/18 the geriatric chair was observed sitting in the same area. Licensed nurse (LPN) #40 expressed the chair belonged to Resident #2 and observed the chair arms worn down causing the padding to be exposed. c) Resident #19 On 09/11/18 at 8:51 AM, Registered Nurse (RN) #39 was observed administering eye drops (gtts), oral medication, nasal spray, and eye gtts wearing the same gloves . 09/11/18 at 8:54 AM, when RN #39 was asked if gloves should have been changed between the different types of medication, she was in agreement. RN #39 stated, Oh, I am sorry. The DoN, on 09/11/18 at 1:00 PM, was informed of the observation with RN #39. The DoN acknowledged RN #39 failed to change her gloves during different types of medication administration.",2020-09-01
3047,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2018-09-13,883,F,0,1,GTWI11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on review of the medical record, staff interview, policy and procedure review, and review of Centers for Disease Control (CDC) recommendations, , the facility failed to ensure that each resident received pneumococcal vaccine in accordance with accepted guidelines . The facility failed to offer and/or administer the Prevnar 13 (PCV13) vaccine to 5 of 6 residents reviewed. Resident identifiers: Residents #29, #37, #34, #43, and #45. Facility census: 60. Findings included: a) A review of the medical record for Resident #29, revealed the resident had received one dose of pneumococcal vaccine (PPSV23- date not specified), but had not been offered Prevnar 13 (PCV13). An interview with the Nurse Practice Educator (NPE) , who is responsible for infection control duties, on 09/11/18, at 4:10 PM, verified that there was no finding of information about Prevnar 13 or the immunization being offered to the resident. b) A review of the medical record for Resident #37, revealed the resident received the pneumococcal vaccine (PPSV23) on 09/03/10. There was no indication that Prevnar 13 (PCV13) was offered to the resident. An interview with the NPE on 09/11/18, at 4:10 PM, verified the Prevnar 13 was not offered to the resident. c) A review of the medical record for Resident #34, revealed the resident was offered [MEDICATION NAME] (PPSV23) vaccine only. There was no evidence that Prevnar 13 was offered or information provided about Prevnar 13 to Resident #34. An interview with the NPE , on 09/11/18, at 4:10 PM, verified that Resident #34 was not offered Prevnar 13. d) A review of the medical record for Resident #43, revealed the resident had signed an informed consent to receive the Prevnar13 vaccine on 08/05/18. Further review of the medical record, including the Medication Administration Record, [REDACTED]. An interview with the NPE, on 09/11/18, at 4:30 PM, when questioned about whether the Prevnar13 was administered to residents, she stated I have never given 13, I can't tell you. [MEDICATION NAME] only is on our standing orders. We are not offering Prevnar 13. e) A review of the medical record for Resident #45, revealed the resident's responsible party had signed an informed consent for the pneumococcal vaccination series on 05/09/18. Further review of the medical record, did not show evidence the vaccine was given that included the Prevnar 13. An interview with the NPE, on 09/11/18, at 4:10 PM, it was stated , I am not finding information on Prevnar 13 being administered. The immunization record for pneumonia is blank. f) Further interviews with Administrative staff, on 09/12/18, at 8:55 AM, verified the following: --The NPE confirmed Prevnar 13 vaccinations were administered to residents on 09/12/18 after surveyor interviewed NPE and discussed findings on 09/11/18. --The Director of Nursing (DON) stated the Prevnar was ordered last night {9/11/18} and was given today. --The administrator stated we ordered it last night. It was not in the building at the time findings were discussed. g) A review of the policy and procedure IC601 revision date 11/28/17, notes a licensed nurse will provide pneumococcal immunizations to patients in adherence with the current recommendations of the Advisory committee on Immunization practices (ACIP) as set forth by the Centers of Disease Control and Prevention (CDC). h) Review of the current CDC guidelines found that CDC recommends routine administration of pneumococcal conjugate vaccine (Prenvar 13) first , followed one year later with a dose of [MEDICATION NAME]. If the patient already received one (1) or more doses of of [MEDICATION NAME] 23, the Prevnar 13 should be given at least one (1) year after they received the most recent dose of [MEDICATION NAME] 23. In accordance with CDC recommendations for adults aged 65 and older, both Prevnar 13 and [MEDICATION NAME] 23 are recommended to protect against pneumococal pneumonia and invasive pneumococcal disease.",2020-09-01
3048,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,550,D,0,1,Z6B811,"Based on observation, and staff interview, the facility failed to treat each resident with respect and dignity. Resident #56's body was exposed. Resident #49's urinal was not empted prior to meal time. This was a random opportunity for discovery. Resident Identifiers: #56 and #49. Facility census 65. Findings included: a) Resident #56 On 12/16/19 at 1:16 PM, observation found Resident #56 was laying in his bed, with the door wide open. The curtain was pulled back allowing visual access to anyone walking down the hall by his room. The resident's gown was pulled up exposing his hips/legs. He was wearing a brief over his private area. An interview and observation was conducted with Nurse #5 on 12/16/19 at 1:17 PM. Nurse #5 was standing outside in the hallway and stated, Oh yeah, Resident #56's (name) needs to be repositioned and his gown pulled back down. Nurse #5 entered the room and pulled down Resident #56's gown so not to expose his body any further. b) Resident # 49 An observation on 12/16/19 at 12:50 PM, found Resident #49's urinal, which was half full of urine, on the left upper side enabler of his bed. Resident # 49 was eating his lunch. Resident #49 stated to surveyor, It is a shame a person has to have this urine smell while he eats his lunch. An interview and observation was conducted with Nurse #5 on 12/16/19 at 12:55 PM. Nurse #5 observed the urinal half full on the left side enabler of Resident #49's bed. She confirmed this is a dignity issue. The Nurse empted the urinal. In an interview with the Administrator on 12/16/19 at 1:02 PM., the Administrator stated the resident is care planned to have his urinal close. The Administrator agreed the urinal should have been emptied when the staff came in to serve Resident #49 his lunch meal.",2020-09-01
3049,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,583,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on random observation and interview, the facility failed to ensure a Resident's Medication Administration Record [REDACTED]. Personal identifiers included, Resident's name, room number, medications, and [DIAGNOSES REDACTED]. Resident identifier: #23. Facility census: 65. Findings included: a) Resident #23 A random observation on 12/17/19 at 7:53 AM, revealed the MAR for Resident #23 was left open on top of the B-hall medication cart. The resident's information was in view of other residents, staff and visitors. On 12/17/19 at 7:54 AM, an interview with Licensed Practical Nurse (LPN) #72, confirmed the information was in view. LPN #72 stated resident information should never be in view of guests or visitors. She closed out the medication cart screen.",2020-09-01
3050,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,584,D,0,1,Z6B811,"Based on observation and staff interview, the facility failed to ensure maintenance services were provided a safe environment. The exhaust fan in Room B29 was not working properly. This had the potential to affect a limited number of residents. Resident identifier: #32. Room identifier: B29. Facility census: 65. Findings included: a) Resident #32 - Room B29 Observation of the fan in room B29, on 12/16/19 at 03:30 PM revealed the fan to be making a grating noise when turned on. During an interview on 12/16/19 at 03:30 PM, Resident #32, who resides in room B29, expressed concern the exhaust fan in the bathroom was not working properly and was noisy. An interview with the maintenance supervisor on 12/17/19 at 8:30 AM, verified the exhaust fan needed to be replaced.",2020-09-01
3051,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,623,D,0,1,Z6B811,"Based on record review and staff interview the facility failed to notify the residents representative in writing of the reason for transfer/discharge and send a copy to the Ombudsman. This was true for one (1) of one (1) residents reviewed for hospitalization for the closed record review. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 On 12/17/19 at 12:30 PM a review of the medical record revealed Resident #66 was transferred to a local acute care hospital for behaviors which were a danger to himself and other residents. No evidence was found that the facility notified the residents representative was notified in writing of the reason for transfer/discharge and a copy sent to the Ombudsman. In an interview with the Director of Nursing (DON) on 12/17/19 at 1:19 PM, the DON stated there was no evidence that a transfer notice and/or notification of the Ombudsman was found, therefore the transfer notices were not completed.",2020-09-01
3052,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,625,D,0,1,Z6B811,"Based on record review and staff interview, the facility failed to notify the resident's representative regarding the facility policy for bed hold, including reserve bed payment. This was true for one (1) of one (1) residents reviewed for hospitalization for the closed record review. Resident identifier: #66. Facility census: 65. Findings included: a) Resident #66 On 12/17/19 at 12:30 PM a review of the medical record revealed Resident #66 was transferred to a local acute care hospital for behaviors which were a danger to himself and other residents. No evidence was found that the facility notified the residents representative of the facility bed hold policy, including the reserve bed payment. In an interview with the Director of Nursing (DON) on 12/17/19 at 1:19 PM, the DON stated that there was no evidence that the residents representative was notified of the facility bed hold policy including the reserve bed payment.",2020-09-01
3053,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,656,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview, the facility failed to implement a comprehensive person centered care plan for pressure ulcer prevention, failed to ensure a Foley catheter was kept from coming into contact with the floor, and failed to apply a circular foot elevator to a resident's left lower extremity, This deficient practice was true for 2 of 30 resident's reviewed. Resident Identifiers #39, and #10. Facility census 65. a) Resident #39 Review of the person centered comprehensive care plan for R#39 noted a focus area identifying Resident #39 at risk for skin break down with an intervention to utilize positioning devices as appropriate to prevent pressure with an order to float heels every shift (QS) when in bed. An observation on 12/17/19 at 08:05 AM, in the presence of Licensed Practical Nurse (LPN) #52, revealed R#39 in bed with her heals directly on the bed. The heels were not floated as ordered. An interview with LPN #52, on 12/17/19 at 8:08 AM, verified the heels were not floated while in bed and should have been. Further review of the person centered comprehensive care plan for R#39 noted a focus area identifying the need for an indwelling catheter with an intervention to keep Foley off floor. An observation of R#39 on 12/17/19 at 8:05 AM, noted a Foley catheter in place and positioned on the bed frame allowing the catheter bag to come into contact with the floor without any barrier present. An interview with LPN #52, on 12/17/19 at 8:08 AM, verified the catheter bag was positioned allowing the catheter bag to lay directly on the floor. LPN #52 confirmed there was no barrier in place to prevent the catheter bag from having direct contact with the floor and should be kept off the floor. b) Resident #10 Review of the current care plan for Resident #10 revealed the following focus statement: (Resident #10's Name) was admitted with abraded areas to his thigh. Is at risk for further skin issues due to decrease in mobility, and incontinence. He has a [DIAGNOSES REDACTED]. The resident has reopened a pressure ulcer to right buttock- healed. 12/07/19 area to to right buttocks reopened. This focus statement was initiated on 12/16/19. The interventions related to this focus statement included: Resident to wear a circular foot elevator (a spiral cut foam ring that lifts the lower leg completely off the bed to help offload the heel and prevent and treat pressure ulcers.) This circular foot elevator is used while the resident is in his bed. The care plan said to assess the skin under the elevator every shift. This intervention was initiated on 11/15/19. Off load/ float heels while in bed. Treatment to heel per order. This intervention was initiated on 06/24/19. Observation of Resident #10 on 12/18/19 at 3:00 PM, found the resident lying in bed and his circular foot elevator to left lower extremity above ankle was not applied. Resident #10's heels were also not offloaded as directed by the care plan. Observation and interview with the director of Nursing (DON) and Licensed Practical Nurse (LPN) #60 on 12/18/19 at 3:51 PM., confirmed the staff were not implementing these interventions to help prevent pressure ulcers. The DON and LPN #60 then applied Resident #10's circular foot elevator to his left lower extremity above the ankle area. c) Resident #56 Record review for Resident #56 revealed a physician order [REDACTED]. The physician order [REDACTED]. Observation of Resident #56 on 12/16/19 at 1:16 PM, revealed Resident #56 did not have his bilateral anterior AFO splints to help decrease foot drop. A review of Resident #56's care plan found the following focus statement: (Resident #56's name) requires assistance with activities of daily living care (ADL) related to Amyotrophic Lateral [MEDICAL CONDITION] which is a chronic disease/condition. The resident is receiving palliative care/hospice. This care plan was initiated on 07/24/19, with a revision date of 10/08/19. The interventions related to this goal included: (Resident #56) has bilateral anterior AFO splint to decrease foot drop. The bilateral anterior AFO splints are to be put on in the morning at 6:00 AM, and off at 5:30 PM, per resident request daily. Assess skin condition underneath every shift. An observation of Resident #56 on 12/17/19 at 3:20 PM, revealed the resident was laying in bed and his bilateral AFO splints were not in place. A review of Resident #56's treatment administration record (TAR) found Resident #56 Bilateral Anterior AFO splints are to be applied every day at 6:00 AM, and removed at 5:30 PM. Nurse #52 documented Resident #56's bilateral AFO boot was on for the seven (7) to three (3) shift on 12/17/19. Observation and interview on 12/17/19 at 3:22 PM, with the Nurse Practice Educator (NPE) #40 confirmed Resident #56 was laying in his bed without his bilateral AFO splints on. The NPE said maybe the Nurse Aide (NA) for hospice had taken the boots (splints) off and did not report this to their nurses, but she was not sure why the splints were not in place. The NPE asked Nurse #52 on 12/17/19 at 3:24 PM why Resident #56's was not wearing his boots(splints). Nurse #52 stated, The shoes are to be placed on prior to the time she comes in, and they were on the resident a while ago, someone had taken them off. Nurse #52 confirmed the staff are not implementing the intervention on the care plan and the physician's orders [REDACTED].>NPE #40 was at the nursing station on 12/18/19 at 10:00 AM. The NPE was informed Resident #56's bilateral anterior AFO splints were not applied again today. The NPE looked over at Nurse #66 and asked why Resident #56 was not wearing his bilateral AFO boot (splints). Nurse #66 nodded her head and said she did not know why the boots (splints) were not on the resident. Surveyor and Nurse #66 walked to Resident #56's room. The nurse observed Resident #56 laying in his bed without his bilateral AFO splints. The nurse stated the night shift places the boot (splints) on during their shift and the boot (splints) are taken off at 5:30 PM. Nurse #66 stated the boots (splints) were not applied before she came on her shift this morning. Nurse #66 further stated the hospice nurse just needs to remove this order and I will write a note the resident refused to wear the boots (splints). When asked whether or not Resident #56 had refused to have the staff apply the splints. Nurse #66 stated, The resident has never asked for the boots(splints) to be taken off. Nurse #66 searched the resident's closet and found the bilateral anterior AFO splints in his closet. This observation revealed, the nurse did not ask Resident #56 if he wanted the splints left off. The Nurse placed the splints back in the closet and left the residents room.",2020-09-01
3054,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,657,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interviews and record reviews the facility failed to revise care plans to ensure residents' needs are met. The facility failed to revise care plans related to discontinued weight checks and to ensure assistance with activity of daily living. The failed practice affected two (2) of nineteen (19) residents. Resident identifiers #59 and #44. Facility census 65. Findings included: A policy titled, OPS416 Person-Centered Care Plan with revision date of 07/01/19, was reviewed on 12/18/19 at 4:15 PM. The policy stated, 7. Care plans will be: 7.2 Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments, as as needed to reflect the response to care and changing of needs and goals. a) Resident #59 A record review, on 12/17/19 at 11:46 AM, revealed a physician order [REDACTED]. Further record review, on 12/17/19 at 11:46 AM, revealed the current care plan that stated, Daily weights, notify MD for > 3 pounds weight gain, per orders and alert dietitian and LcNrs physician to any significant loss or gain. An interview with Registered Nurse (RN) #40, on 12/17/19 at 12:00 PM, confirmed the care plan should have been revised after the physician order [REDACTED]. b) Resident #44 - activities of daily living (ADL) care Observation on 12/16/19 at 3:43 PM, revealed Resident #44 in his room wearing a red shirt and a pair of black pants. Resident #44 had a strong and unpleasant body odor smell. A review of Resident #44's quarterly minimum data set (MDS) with the assessment reference date (ARD) of 11/15/19, revealed the resident has the ability to express ideas and wants, both verbal and non-verbal expression. The resident understands (clear comprehension) verbal content. The quarterly MDS finds Resident #44 does not exhibit behavior of rejection of care for his activity of daily living (ADL) assistance. The resident is identified as independent with no setup or physical help from the staff for his personal hygiene. A record review of Resident #44 care plan on /17/19 at 2:30 PM, revealed a care plan with a focus of the resident requires supervision with majority of has activity of daily living (ADL). The care plan revealed the resident has a [DIAGNOSES REDACTED]. This care plan focus was initiated on 12/20/18, and revised on 11/27/19. There was no intervention explaining how the staff are to assist the resident with his personal hygiene. There is a care plan addressing, (resident name), does not show potential for discharge to the community due to physical care needs exceed ability of family and community to care for him at home. This focus was initiated on 01/07/19 and revised on 11/25/19. Interventions included, Provide encouragement, supervision or assistance as needed to meet ADL needs of bathing, dressing/grooming, mobility, toileting, nutrition and hydration. This care plan was initiated on 02/20/19. On 12/17/19 at 2:40 PM, Nurse Aide #52 when asked to describe what the resident can do for his personal hygiene. The NA said the resident dresses himself, they do not assist him with changing his clothes. He takes himself to the bathroom, goes to the shower room to have a shower. No further comment was provided regarding how the staff assisted Resident #44 with changing his clothes. Observation of Resident #44 on 12/18/19 at 8:20 AM, found he was still wearing the same red shirt he had wore for the previous 2 days, 12/17/19 and 12/16/19. The resident wore the same pair of black pants for 12/16/19 and 12/17/19. Resident #44 had a strong and unpleasant body odor smell. Observation on 12/18/19 at 8:30 AM, with NA #12 found Resident #44 was in the shower room to receive his shower. The Resident looked at the surveyor and said, The dog is after me today. NA #12 said that means the resident does not like to change his clothes. NA #12 said the resident has to be assisted with changing his clothes or he will not change his clothes. This NA said the resident does not like for the nursing staff to change him, except for her. The NA was informed that Resident #44 has had the same red shirt on since Monday and he wore the same black pants on for two (2) days, Monday and Tuesday. The NA stated that the resident refuses to have someone change his clothes. She revealed the resident can get very mean about changing his clothes and not very many staff can get him to change his clothes. In an interview on 12/18/19 at 8:42 AM, with LPN #66 was asked to review Resident #44's ADL care plan. The Nurse was asked does Resident #44 refuse to change his clothes. LPN #66 stated, Yes he does. The LPN was asked should the care plan be revised to identify the refusal to have his clothes changed and what interventions are staff to implement when the resident refuses to change his clothes. The LPN agreed the care plan should be revised. Employee #22 was present at the nursing station on 12/18/19 at 12:42 PM, and stated that she knows Resident #44 will not change his clothes for the staff. It is a big hassle to get him to change his clothes, he gets mean with them. On 12/18/19 at 3:10 PM, the director of nursing (DON) revised Resident #44's care plan to reveal the resident refuses to change his clothes. c) Resident #44 - revision for alcohol withdrawal. A record review of Resident #44 care plan on 12/17/19 at 2:33 PM, found a focus problem: Resident requires supervision with majority of has activity of daily living (ADL). The care plan revealed the resident has a [DIAGNOSES REDACTED]. This care plan focus was initiated on 12/20/18, and revised on 11/27/19. An intervention to monitor conditions that may contribute to ADL decline included alcohol withdrawal. The date this intervention was was put in place was 12/20/18 and revised on 11/27/19. The resident was admitted on [DATE]. In an interview on 12/17/19 at 2:42 PM, with Nurse Practice Educator (NPE) #40, she was asked whether the resident continues to need to be monitored for alcohol withdrawals. NPE said this was a initial intervention when he was admitted to the facility. The NPE confirmed this intervention should have been revised on the care plan.",2020-09-01
3055,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,677,D,0,1,Z6B811,"Based on observation and staff interviews, the facility failed to assist a resident who is unable to carry out activities of daily living (ADL) receives the necessary services to maintain good personal hygiene. A resident's finger nails were not cleaned and trimmed. This had the potential to affect one (1) out of thirty residents reviewed during the annual Long Term Care Survey Process (LTCSP). Resident Identifier: #44. Facility census 65. Findings included: a) Resident #44 A review of Resident #44's quarterly minimum data set (MDS) with the assessment reference date (ARD) of 11/15/19, revealed the resident has the ability to express ideas and wants, both verbal and non-verbal expression. The resident understands (clear comprehension) verbal content. The quarterly MDS finds Resident #44 does not exhibit behavior of rejection of care for his activity of daily living (ADL) assistance. The resident is identified as independent with no setup or physical help from the staff for his personal hygiene. In an interview with Resident #44 on 12/16/19 at 3:43 PM, the resident said that his fingernails are long. The resident stated, No one here will cut my nails except for my daughter. She cuts my nails. Observation of Resident #44's fingernails on 12/16/19 at 3:44 PM, found his nails were long, the middle fingernails on both hands were uneven with jagged edges and debris was visible underneath all the nails. An interview on 12/17/19 at 4:00 PM, with NA #45, confirmed nail care is provided to Resident #44 when he receives his shower. Observation of Resident #44 in the shower room on 12/18/19 at 9:00 AM, with Nurse Aide (NA) #12, confirmed Resident #44's finger nails were long. The middle fingernail on both hands were uneven and had jagged edges with debris visible underneath all nails. The NA was asked whether the resident could trim and clean his own nails. The NA replied no, he is unable to trim or file his own nails. Then the NA was asked whether she trims and cleans underneath Resident #44's fingernails when she gives him his shower. The NA said, No, the nurses do that. On 12/18/19 at 9:05 AM, the Director of Nursing (DON) confirmed Resident #44's fingernails were long, uneven with jagged edges on both middle fingernails with debris underneath all the nails. The DON acknowledged that, Resident #44's nails needed to be trimmed. The DON revealed the nurses are to trim and clean Resident #44's fingernails. Surveyor informed the DON Resident #44's quarterly MDS with the ARD of 11/15/19 finds Resident #44 is independent with no setup or physical help from the staff for his personal hygiene. The DON confirmed that Resident #44 is unable to perform his own fingernail care. The DON was asked when was the last time a nurse provided fingernail care to Resident #44? The DON said she would have to go review Resident #44's record. The DON returned and stated, she could not find any evidence to indicate when the resident last received fingernail care. On 12/18/19, a new order was written directing nurses to trim and clean Resident #44's fingernails every week on Sunday.",2020-09-01
3056,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,684,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility failed to provide residents care and treatment in accordance with professional standards of practice, the comprehensive person centered care plan and the resident's choices. The facility failed to follow physician orders [REDACTED]. In addition the facility failed to implement interventions on the comprehensive person centered care plan to apply a circular foot elevator, and to off load/ float a resident heels while in bed. This practice affected three (3) of 30 sampled residents . Resident Identifiers #56, #10 and #39. Facility census 65. Findings included: a) Resident #56 Record review for Resident #56 revealed a physician order [REDACTED]. The physician order [REDACTED]. Observation of Resident #56 on 12/16/19 at 1:16 PM, revealed Resident #56 did not have his bilateral anterior AFO splints to help decrease foot drop. A review of Resident #56's care plan found the following focus statement: (Resident #56's name) requires assistance with activities of daily living care (ADL) related to Amyotrophic Lateral [MEDICAL CONDITION] which is a chronic disease/condition. The resident is receiving palliative care/hospice. This care plan was initiated on 07/24/19, with a revision date of 10/08/19. The interventions related to this goal included: (Resident #56) has bilateral anterior AFO splint to decrease foot drop. The bilateral anterior AFO splints are to be put on in the morning at 6:00 AM, and off at 5:30 PM, per resident request daily. Assess skin condition underneath every shift. An observation of Resident #56 on 12/17/19 at 3:20 PM, revealed the resident was laying in bed and his bilateral AFO splints were not in place. A review of Resident #56's treatment administration record (TAR) found Resident #56 Bilateral Anterior AFO splints are to be applied every day at 6:00 AM, and removed at 5:30 PM. Nurse #52 documented Resident #56's bilateral AFO boot was on for the seven (7) to three (3) shift on 12/17/19. Observation and interview on 12/17/19 at 3:22 PM, with the Nurse Practice Educator (NPE) #40 confirmed Resident #56 was laying in his bed without his bilateral AFO splints on. The NPE said maybe the Nurse Aide (NA) for hospice had taken the boots (splints) off and did not report this to their nurses, but she was not sure why the splints were not in place. The NPE asked Nurse #52 on 12/17/19 at 3:24 PM why Resident #56's was not wearing his boots(splints). Nurse #52 stated, The shoes are to be placed on prior to the time she comes in, and they were on the resident a while ago, someone had taken them off. Nurse #52 confirmed the staff are not implementing the intervention on the care plan and the physician's orders [REDACTED].>NPE #40 was at the nursing station on 12/18/19 at 10:00 AM. The NPE was informed Resident #56's bilateral anterior AFO splints were not applied again today. The NPE looked over at Nurse #66 and asked why Resident #56 was not wearing his bilateral AFO boot (splints). Nurse #66 nodded her head and said she did not know why the boots (splints) were not on the resident. Surveyor and Nurse #66 walked to Resident #56's room. The nurse observed Resident #56 laying in his bed without his bilateral AFO splints. The nurse stated the night shift places the boot (splints) on during their shift and the boot (splints) are taken off at 5:30 PM. Nurse #66 stated the boots (splints) were not applied before she came on her shift this morning. Nurse #66 further stated the hospice nurse just needs to remove this order and I will write a note the resident refused to wear the boots (splints). When asked whether or not Resident #56 had refused to have the staff apply the splints. Nurse #66 stated, The resident has never asked for the boots(splints) to be taken off. Nurse #66 searched the resident's closet and found the bilateral anterior AFO splints in his closet. This observation revealed, the nurse did not ask Resident #56 if he wanted the splints left off. The Nurse placed the splints back in the closet and left the residents room. b) Resident #10 Review of the current care plan for Resident #10 revealed the following focus statement: (Resident #10's Name) was admitted with abraded areas to his thigh. Is at risk for further skin issues due to decrease in mobility, and incontinence. He has a [DIAGNOSES REDACTED]. The resident has reopened a pressure ulcer to right buttock- healed. 12/07/19 area to to right buttocks reopened. This focus statement was initiated on 12/16/19. The interventions related to this focus statement included: Resident to wear a circular foot elevator (a spiral cut foam ring that lifts the lower leg completely off the bed to help offload the heel and prevent and treat pressure ulcers.) This circular foot elevator is used while the resident is in his bed. The care plan said to assess the skin under the elevator every shift. This intervention was initiated on 11/15/19. Off load/ float heels while in bed. Treatment to heel per order. This intervention was initiated on 06/24/19. Observation of Resident #10 on 12/18/19 at 3:00 PM, found the resident lying in bed and his circular foot elevator to left lower extremity above ankle was not applied. Resident #10's heels were also not offloaded as directed by the care plan. Observation and interview with the director of Nursing (DON) and Licensed Practical Nurse (LPN) #60 on 12/18/19 at 3:51 PM., confirmed the staff were not implementing these interventions to help prevent pressure ulcers. The DON and LPN #60 then applied Resident #10's circular foot elevator to his left lower extremity above the ankle area. b) Resident #39 A record review for R#39 showed a physician's orders [REDACTED]. An observation on 12/17/19 at 08:05 AM, in the presence of LPN #52, revealed R#39 in bed with her heals directly on the bed and were not floated as ordered. An interview with LPN #52, on 12/17/19 at 08:08 AM, verified the heels were not floated while in bed and should have been.",2020-09-01
3057,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,695,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, medical record review, and interview, the facility failed to deliver respiratory care services consistent with professional standards of practice. A physician's orders [REDACTED]. This practice affected one (1) of two (2)- residents reviewed for respiratory care during the Long-Term Care Survey Process (LTCSP). Resident Identifier: #28, Facility Census: 65 Findings included: a) Resident #28 A review of the facility's policy titled Oxygen: Nasal Cannula effective date 01/01/04 with revision date 11/01/19 revealed the following: Verify order. Connect to cannula to the nipple adapter to humidifier and set the flow rate to the prescribed liter rate. Document: Date and time; method of administration; and Liter flow. An observation of Resident #28, on 12/18/19 at 2:32 PM, revealed the Resident was receiving oxygen at one (1) Liter via nasal cannula (an oxygen delivery device) from an oxygen concentrator. A review of the Resident's physician order, revealed the order Oxygen two (2) Liters Per Minute (LPM), Route: nasal cannula to maintain oxygen saturation ninety (90) % or greater with an order date of 06/18/19. An interview with Licensed Practical Nurse (LPN) #52 on 12/18/19 at 2:34 PM, verified the Resident was receiving oxygen at (1) Liter Per Minute. LPN #52 confirmed Resident #28 was ordered oxygen at two (2) Liters via nasal cannula. The LPN verified the oxygen level was wrong. (LPN) #52 changed Resident #28's oxygen to two (2) LPM on the concentrator.",2020-09-01
3058,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,761,E,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview the facility failed to properly store medication in a locked compartment on the treatment cart. The failed practice was a random opportunity for discovery. The failed practice had the potential to affected more than an unlimited number of residents. Facility census: 65. Finding included: A policy titled 3.6 Medication Storage with review date 07/05/16 was reviewed on 12/18/19 at 4:00 PM. The policy stated, Medications administered by staff shall be kept in their original containers in a locked storage cabinet. 1.1 The cabinet shall be locked when not in use and the key carries by the person on duty in charge of medication administration. a) Treatment Cart A An observation, on 12/16/19 1:15 PM, revealed an open, unlocked and unattended Treatment Cart A sitting in hallway. The treatment cart contained multiple medications: [REDACTED] Four (4) eight (8) ounce bottles of Wound Cleansers titled skin integrity Four (4) boxes of 10 individually wrapped Preparation H Tablets Three (3) ounce tube of [MEDICATION NAME] 10% Five (5) ounce tube of Aspercreme 30 gram tube of [MEDICATION NAME] 2% 50 milliliter tube of [MEDICATION NAME] Propronale Topical Solution Three (3) ounce container of Phytoplex Antifungal Powder 40 pad container of Tucks Medicated Coding Pads Two (2) 30 gram containers of [MEDICATION NAME] Topical Powder One (1) 15 grams container of [MEDICATION NAME] Topical Powder Three (3) ounce container of [MEDICATION NAME] V 0.35 ounce 10 grams of Idosorb Iodine Gel An interview with Licensed Practical Nurse (LPN) #52, on 12/26/19 at 1:35 PM, confirmed the treatment cart should have been locked when unattended. LPN #52 stated, it was me, I'm the one that left it unlocked.",2020-09-01
3059,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,812,E,0,1,Z6B811,"Based on observation and staff interview, facility failed to store food in accordance with professional standards for food service safety. The facility failed to label and date stored food and complete the daily refrigerator temperature log. The failed practice had the potential to affect more than an unlimited number of resident receiving food from this central location. Facility census 65. Findings included: A policy titled Refrigerated/Frozen Storage with revision date of 06/15/19 was reviewed on 12/18/19 at 1:30 PM. The policy stated, 1. Refrigeration: 1.4 All foods are labeled with name of product and the date received and use by date once opened. 1.5 Prepared foods are labeled and dated with name of product, date prepared and use by date. 2. Freezer: 2.4 Food is dated when received and with use by date when opened. 2.5 Foods are kept in original container, foods are completely covered and labeled with name of product and use by date. a) Unlabeled/Undated Food An observation during the initial kitchen tour, on 12/16/19 at 12:30 AM, revealed unlabeled and undated food stored within the refrigerator. The following food items were not labeled or dated in the refrigerator: One (1) plate of pre-made salad not dated, sitting on cart One (1) hotdog in a metal container not dated One half (1/2) cucumber cut and wrapped sitting on shelf but not dated One (1) tomato not wrapped or dated sitting in a pan on shelf One (1) cucumber not wrapped or dated sitting in a pan on shelf Three (3) leaves of lettuce not wrapped or dated sitting in a pan on shelf Additional observation during the initial tour of the kitchen, on 12/16/19 at 12:40 PM, revealed unlabeled and undated food stored within the freezer. The following food items were not labeled or dated in the freezer: Five (5) pound bag of crinkle cut fries not in original box and not dated One (1) opened bag of fish squares, total nine (9) fish squares in bag not dated One (1) opened bag of hamburger patties, total nine (9) in bag not dated An interview with Dietary Manager (DM), on 12/16/19 at 12:50 PM, confirmed all items in the refrigerator and freezer should be labeled and dated. DM immediately went and labeled and dated all items unlabeled and undated in the refrigerator and freezer. An interview with Cook #18 , on 12/16/19 at 12:55 PM, confirmed all food in refrigerator and freezer should be wrapped, labeled and dated. Cook #18 stated, that is my fault I did not label the pre-made salad or wrap the salad ingredients in the pan. An observation during the follow-up kitchen tour, on 12/17/19 at 12:15 PM, revealed food items within the kitchen are that were not labeled or dated. The following food items that were not labeled or dated were: One (1) container of 63 individual servings of whipped spread butter, not in manufactures box and not dated One (1) Six (6) quart container of thickener, not in manufactured box, sitting on shelf not labeled or dated An interview with Dietary District Manager (DDM) , on 12/17/19 at 12:30 PM, confirmed all items not in original packaging should be labeled and dated. b) Refrigerator Temperature Log An observation, on 12/16/19 at 1:05 PM, revealed a refrigerator temperature log that was incomplete. Evidence revealed the temperature log was missing documented temperatures for the date of 12/14/19. An immediate interview with DM, on 12/16/19 at 1:05 PM, confirmed the refrigerator log was incomplete and should have been completed daily. An interview with DDM, on 12/17/19 at 12:30 PM, confirmed the refrigerator temperature log should have been completed daily with no missing information.",2020-09-01
3060,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,842,E,0,1,Z6B811,"Based on record review and staff interviews, the facility failed to maintain medical records on each resident that were complete and accurately documented. This was true for one (1) of thirty (30) resident's records reviewed during the annual Long Term Care Survey Process (LTCSP). Resident Identifier: #10. Facility census 65. Findings included: a) Resident #10 A review of the Residents medical record on 12/17/19 at 2:30 PM, found the support provided to Resident #10 on his activity of daily living (ADL) record was left blank for bed mobility for the following days and shifts. --Night shift 12/01/19, 12/02/19, 12/04/19, 12/10/19, 12/15/19. --Day shift for 12/01/19,12/14/19, 12/15/19, and 12/16/19. --Evening shift 12/01/19-12/04/19, 12/10/19, 12/14/19- 12/16/19. The ADL record showed the support provided to Resident #10 was left blank for transfer for the following days and shifts. --Day shift 12/14/19- 12/16/19. --Evening shift 12/02/19, 12/10/19,12/14/19-12/16/19. The ADL record showed the support provided to Resident #10 was left blank for bathing for the following days and shifts. --Night shift 12/10/19, 12/13/19-12/16/19. --Day shift 12/01/19,12/13/19. On 12/17/19 at 3:00 PM, Nurse Aide (NA) #45, verified NA's were not documenting the support the resident required for bed mobility, transfers, bathing. An interview with Nurse #52 on 12/17/19 at 3:37 PM., confirmed the (MONTH) 2019 ADL record was inaccurate related to the support provided to Resident #10.",2020-09-01
3061,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,880,D,0,1,Z6B811,"Based on observation, record review and staff interview, the facility failed to maintain an effective infection control program designed to ensure care was delivered in accordance with acceptable infection control practices for one (1) of one (1) resident reviewed with a Foley catheter. Resident identifier: #39. Facility census: 65. Findings included: a) Resident #39 An observation of R#39 on 12/17/19 at 08:05 AM, revealed a Foley catheter in place and positioned on the bed frame allowing the catheter bag to come into direct contact with the floor without any barrier present. An interview with LPN #52, on 12/17/19 at 08:08 AM, verified the catheter bag was positioned allowing the catheter bag to lay on the floor. LPN #52 confirmed there was no barrier in place to prevent direct contact with the floor.",2020-09-01
3062,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2019-12-18,883,D,0,1,Z6B811,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview the facility failed to follow a resident's health care decision makers wishes for her mother to not receive the Influenza vaccination. This was true for one (1) of five (5) resident reviewed for the facility task of Immunizations. Resident Identifier #51. Facility census 65. Findings included: a) Resident #51 Resident #51 was admitted to the facility on [DATE]. A review of Resident #51 influenza immunization consent form with the date of 11/21/19, revealed the resident's representative had refused the Influenza vaccination for the Flu season from (MONTH) 2019- (MONTH) 2020. The Resident's Representative had reported her mother had already received the Influenza vaccination in (MONTH) 2019. A physician order [REDACTED].#51 to receive Influenza half (0.5 milliliter -ML) to be injected intramuscularly (injection delivers medication into a muscle) one (1) time. A review of Resident #51's admission minimum data set (MDS) with the assessment reference date of 11/27/19 revealed the resident received the Influenza Vaccine on 11/22/19. A review of the Immunization report finds Resident #51 was administered the Influenza vaccination to her left deltoid (The deltoid muscle is the muscle forming the rounded contour of the human shoulder) on 11/22/19. The Medication Administration Record [REDACTED]. On 12/18/19 at 12:10 PM, an interview with the Director of Nursing (DON), confirmed her staff should not have administered the Influenza vaccination to Resident #51. The physician visited the resident on 12/18/19 at 1:20 PM. He stated, the facility notified him today about Resident #51 receiving the Influenza vaccination when her family Representative had refused for her to receive the vaccination. The facility's policy finds the center will provide the opportunity to receive the Influenza vaccination unless the patient has already has been immunized.",2020-09-01
4268,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-04-22,241,E,0,1,JPCR11,"Based on observations and staff interview, the facility failed to provide dining in a manner that promoted and enhanced each resident's dignity and respect in full recognition of his or her individuality. The staff did not interact and/or communicate with residents prior to, or during, meal service in the smaller dining room designated for residents requiring assistance with meals. In addition, staff referred to residents as feeders in the presence of residents. Facility census: 67. Findings include: a) Observations during lunch, in the small dining room reserved for residents requiring assistance with meals, on 04/18/16, 04/19/16, and 04/20/16 revealed for each meal the resident population consisted of nine (9) residents and three (3) staff members. No social interactions or conversing occurred between the staff and residents prior to, or during, each meal service. Staff consistently fed the residents their meals without verbal communications with the residents. Residents were not told what foods and beverages were on their trays. On 04/20/16 at 12:40 p.m., the Administrator observed and verified there were no interactions between the staff and residents during the meal service. She stated, Usually there is talking and laughter in here, but the State is here. The Administrator did not reply when asked if this interaction was between staff and residents or just between staff. b) On 04/18/16 at 12:35 p.m., during an interview with Nurse Aide (NA) #16 in the small dining room, when asked what meal service occurred in the small dining room, she replied, This room is used for the feeders. This was said in the presence of residents who were in the dining room. When asked to repeat her answer, she stated, I should say for residents who require assistance with meals. c) During an observation of breakfast on 04/20/16 at 08:00 a.m., Nurse Aide (NA) #66 was heard asking co-workers if there were any feeders left as she walked down Boyd's hall (B hall). This was said within hearing of residents who were in their rooms. During an interview on 04/20/16 at 1:10 p.m., NA #66 acknowledged she had used the word feeder when referring to residents that required assistance with meals.",2020-02-01
4269,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-04-22,253,E,0,1,JPCR11,"Based on observation and staff interview, the facility failed to provide housekeeping and maintenance services necessary to maintain a clean, sanitary, orderly, and comfortable interior as evidenced by numerous cosmetic imperfections. Resident rooms had scratched and marred walls, bathroom night lights in disrepair, and scratched and chipped wooden doors with exposed sections of bare wood. This had the potential to affect more than an isolated number of residents. Facility census: 67. Findings include: a) Resident rooms Observations during Stage 1 of the Quality Indicator Survey (QIS) found the following on 04/18/16 and 04/19/16: 1. Room 18a The plastic covering over the bathroom night light was pushed into the wall exposing rough edges of the dry wall. A four (4) inch by four (4) inch hole was found in the wall near the baseboard on the left side of the bathroom. 2. Room 14a A large scratched and marred area on the right side of the wall in the bathroom 3. Room 11a The bathroom night light cover was loose and the surrounding metal frame was rusted. In addition, the paint on the bathroom walls was peeling. 4. Room 13a There was a large gouged scratch measuring three (3) inches wide by ten (10) inches long found just inside the door of the resident's room on the left side. 5. Room 30b The paint was scratched off the bathroom walls and the paint and plaster were chipped off the outside corner of the wall near the residents' sink exposing drywall. 6. Doors The door between the residents' common shower room and bathroom, and multiple doors throughout the facility, had scratches and chipped areas from the door handles down and along the corner edges exposing rough chipped wood. b) A tour on 04/26/16 at 11:30 a.m., while reviewing the identified concerns with Housekeeping Supervisor #84, found the large gouged scratched area measuring three (3) inches by ten (10) inches inside room 13a had been painted. However, several small areas of chipped paint remained in the same area and plaster remained exposed. Housekeeping Supervisor #84 stated they had not painted the rooms in a while and agreed the issues needed repaired.",2020-02-01
4270,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-04-22,272,D,0,1,JPCR11,"Based on record review and staff interview, the facility failed to conduct an accurate comprehensive assessment for one (1) of twenty-six (26) Stage 2 residents reviewed during the annual Quality Indicator Survey. The comprehensive assessment did not identify Resident #29 received Hospice Services. Resident identifier: #29. Facility census: 67. Findings include: a) Resident #29 Review of the resident's medical record on 04/26/16 at 8:30 a.m., revealed Resident #29 requested a change in care during a family meeting with her physician. The physician's progress note dated 03/23/16, stated, Family meeting held, resident expressed wish to not have to continue living like this and family wants her to be comfort care. On 03/30/16, the physician ordered Hospice services for Resident #29 starting 03/30/16. The significant change Minimum Data Set (MDS) assessment with an assessment reference date (ARD) of 04/08/16, did not identify the resident's current Hospice care. During an interview on 04/26/16 at 11:20 a.m., Clinical Records Coordinator (CRC) #59 reviewed the significant change MDS and acknowledged Resident #29 was receiving Hospice services, and the significant change MDS did not reflect this.",2020-02-01
4271,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-04-22,282,D,0,1,JPCR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interview, the facility failed to provide care and services in accordance with each resident's written plan of care regarding constipation including monitoring and recording bowel movements, and documenting frequency and consistency of stools. This practice was found for two (2) of twenty-six (26) sample residents' whose care plan was reviewed during Stage 2 of the Quality Indicator Survey (QIS). Resident identifiers: #49 and #44. Facility census: 67. Findings include: a) Resident #49 On 04/25/16 at 11:00 a.m., medical record review revealed Resident #49, admitted to the facility on [DATE], had [DIAGNOSES REDACTED]. The care plan, dated 04/04/16, included a Focus of, Resident exhibits or is at risk for . constipation. The interventions included, Monitor and record bowel movements; Provide bowel regimen utilize pharmacological agents as appropriate i.e. stool softeners, laxatives, etc. document effectiveness; Document frequency and consistency of stools. A review of the bowel movement sheets for (MONTH) (YEAR) through (MONTH) (YEAR) for Resident #49 found multiple blank spaces for daily documentation of bowel movements during this period. b) Resident #44 On 04/20/16 at 3:35 p.m., medical record review revealed Resident #44 was admitted on [DATE] and readmitted on [DATE]. Her [DIAGNOSES REDACTED]. The care plan dated 04/04/16, included a focus statement of, Resident exhibits or is at risk for . constipation. The interventions included, Monitor and record bowel movements; Provide bowel regimen utilize pharmacological agents as appropriate i.e. stool softeners, laxatives, etc. document effectiveness; Document frequency and consistency of stools. A review of the bowel movement sheets for Resident #44 from (MONTH) (YEAR) through (MONTH) (YEAR) revealed multiple blank spaces for daily documentation of bowel movements during the time frame. c) During an interview on 04/21/16 at 10:40 a.m., Nurse Aide (NA) #50 commented, staff on all shifts documented bowel movements for each resident on the bowel movement sheets. If the resident did not have a bowel movement (BM) then the nurse was informed. d) In an interview on 04/21/16 at 10:45 a.m., Licensed Practical Nurse (LPN) #36, after reviewing the bowel movement sheets for Residents #44 and #49, stated the BMs were not documented. e) The Director of Nursing (DON) reviewed the bowel movement sheets during an interview on 04/26/16 at 11:45 a.m. The DON acknowledged the sheets did not contain complete documentation for bowel movements as directed by the resident's care plans.",2020-02-01
4272,CARE HAVEN CENTER,515178,2720 CHARLES TOWN ROAD,MARTINSBURG,WV,25401,2016-04-22,329,D,0,1,JPCR11,"**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on medical record review and staff interview, the facility failed to identify a potential drug interaction for Resident #34, who received calcium [MEDICATION NAME] and [MEDICATION NAME] ([MEDICATION NAME]) daily at 8:00 a.m. This was found for one (1) of five (5) residents reviewed for unnecessary medications during the annual survey. Resident identifier: #34. Facility census: 67. Findings include: a) Resident #34 Review of the resident's medical record on 04/21/16 at 8:30 a.m., found the Medication Administration Record [REDACTED]. Licensed Practical Nurse (LPN) #36 reviewed the MAR indicated [REDACTED]. She acknowledged the administration of a calcium supplement with [MEDICATION NAME] can inhibit the absorption of the [MEDICATION NAME] and they should be administered at separate times. During an interview on 04/21/16 at 11:30 a.m., the Director of Nursing (DON) reported there was a recent computer update and the medications previously given at 6:30 a.m. were moved to 8:00 a.m. The DON stated, The pharmacist says it doesn't matter if you give it ([MEDICATION NAME]) with other meds (medications) as long as you always give it at the same time. The DON had no response when asked what the pharmacist suggests when [MEDICATION NAME] is administered with calcium. The facility's Nursing (YEAR) Drug Handbook, reviewed on 04/25/16 at 1:30 p.m., included in the interactions section for [MEDICATION NAME], on page 847, . calcium [MEDICATION NAME], . (MONTH) impair [MEDICATION NAME] absorption. Separate doses by 4 to 5 hours. A follow up review of the MAR indicated [REDACTED].",2020-02-01